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Colloquia Topics Index [link]Politics of Diagnosis Index

Ticktin's Syndrome, or, The 'Post-Psychiatric, Post Confusional State'

Stephen Ticktin, M.D.

My esteemed colleagues,

I bring to your medical attention, for purposes of careful critical evaluation, a new and rather bizarre disease entity. It was forced upon my awareness, rather circuitously, through my having been unsuccessful at the last sitting of the M.R.C. Psych. examinations. As a result, I set about doing a retrospective study of the situation, to see if I could elucidate some of the factors which might have played a part in my, presently, not being a member, in good standing, of the Royal College. With your most gracious forbearance, I will present my findings.

After conducting personal interviews (along with some standardized questionnaires) of some of my closest friends, who were able to observe me at close quarters during those limbically overactive days just prior to my examinations, it gradually came to light that, at the time, I was suffering from a rather unusual psychiatric disorder, which, to the best of my knowledge, has never before been reported in the literature. For want of a better term, I call it the 'post-psychiatric post confusional state', although my friends now refer to it eponymously as "Ticktin' s Syndrome". To give an exhaustive account of this condition, in all of its relevant parameters, is, at this stage of its investigation, virtually impossible. Certainly a more sedulous description awaits future developments. I will present here only a rough outline which I hope will stimulate fruitful discussion, followed by further research.

Probably the most prominent feature of this disorder - and really the basis of its present taxonomic title - is the fact that it appears to have a very circumscribed epidemiology. So far, it is unknown outside of the psychiatrically trained population. Its onset is usually insidious (although acute variants are known-particularly around exam time) and it seems to have a predilection for young graduates, though older ones are not necessarily immune. Usually, by the time a predisposed individual has finished his psychiatric training and is ready to sit his qualifying examinations, all of the cardinal features are present.

As with other confusional states, disorientation is a key sign (though obviously, not pathognemonic in and of itself). However, the disorientation in question is of a very unusual nature. The person with Ticktin's Syndrome is usually oriented to time and place (though habitually tends never to wear a wrist watch, and often is found living and working in foreign countries) but is profoundly dis­oriented to person. Although these people refer to themselves somewhat emblematically as psychiatric trainees, this merely marks an uncertainty as to whether they are really geneticists, biologists, pharmacologists, physicians, psychologists, psychoanalysts, sociologists, priests, or even sometimes philosophers. In an attempt to ward off the anxiety attendant upon such a state of affairs, they often claim to be all of these things simultaneously, with a sort of grandiose euphoria remiscent of the patient embarking on a manic episode. Although this tends to be the typical presentation, it can easily be seen that depressive variants may arise, if the original existential doubt and uncertainty about who one is remains in consciousness. The person in such a state, far from imagining himself to be a number different things simultaneously, realises, much to his or her chagrin, that he is not even one of them, and consequently depression ensues. Thus we can see that 'Ticktin's Syndrome" runs the full gamut of affective disorders.

Thought disorder also rears its ugly head in this syndrome and once again it often becomes difficult to differentiate it from schizophrenia, as consciousness (in some respects) is clear in both instances. The speech is highly suggestive and typically consists of a somewhat stilted mechanical flow of words liberally inter­spersed with neologisms of a psychological nature. This often presents as a sort of 'psychiatric verbigeration' virtually indistinguishable from jargon aphasia. In such instances the person's occupation may provide an invaluable clue to the correct diagnosis. Often one is simply left with the impression that one is listening to a psychiatrically updated recitation of Lewis Carroll's "Song of the Jabberwocky". In addition, the neologisms in this syndrome have one distinctive feature. They usually defy precise definition and many people will often exhibit "Ticktin's Sign" - a near catastrophic reaction, of the order of Goldstein, to any attempt made by the interviewer (or examiner as the case may be) to get the person to clarify his or her concepts.

Delusions (and sometimes hallucinations) may arise, but like Bleuler, I would consider these to be secondary symptons. The typical pathogenesis is as follows: The person with 'Ticktin's syndrome' begins talking to a patient of his who tells him that his mind is being controlled by forces over which he has no control. Our patient considers his patient to be deluded and as the delusion. in question constitutes a first rank sympton; he makes a diagnosis of schizopbrenia. When then asked to explain what causes schizophrenia he uses a model which refers to forces going on both inside and outside of the individual - forces over which the individual ofter has no control! (How does one control one's brain. Dopamine levels for example). Thus our patient's belief that his his patient is deluded is shown, by his own internal logic, to be a false one and therefore it is he, the person with the post-psychiatric post confusional state whi is himself deluded and therefore confused.

So far we have been talking about some of the striking features of the clinical presentation. Aetiological considerations enter next, but, alas, we are really at a loss at this stage to say very much about them. Certainly as we stated above it is noteworthy that the syndrome only occurs in the psychiatrically trained population. However, at the present moment, this has to remain at the level of an an empirical observation which still awaits the seal of statistical approval. And, as the philosophers are want to say, it is simply fallacious to argue "post hoc, ergo propter hoc". Just because night follows day, it does not mean that day causes night.

Yet, be that as it may, this does not prevent us from speculating about some of the reasons why a psychiatric training may give rise to this syndrome. In the first instance, the young trainee is exposed to a welter of new and overwhelmingly vague concepts (neurosis, psychosis, etc.) and is expected to assimilate reams of, often, conflicting data and ideas. The ethos of liberal eclecticism which pervades his world again forces him to weld together different heuristic models which cannot really be harmoniousl.y married. He learns, for example, that physical illness may cause mental illness, but equally that mental factors may be important in the aetiology of physical illness. Thus, he may find himself, in one instance, using drugs to treat a mental condition, and, in another, using psychotherapy to ameliorate a physical one. Again, if someone comes to him complaining that he is ill when he is patently not, he learns that this patient is ill (even though he isn't) because he thinks he is ill when he's not. He suffers from Hypochondriasis! It is consideratiohs such as these which would naturally lead one to think that a psychiatric training may be aetiologically linked to the disorder under question. However, at this stage, until the patho­genesis becomes clearer, it is better to talk about a syndrome than a disease entity per se.

The natural course and outcome of this syndrome requires further investigation. Those who present with an acute onset appear to have a self-limiting disorder, though recurrences are common, especially amongst those who persist in taking further psychiatric training posts. Those with a more insiduous onset however seem to be left with a chron-ic defect state, once any florid symptons (usually seen around examination time) have abated and their long-term course is more ominous. The presence of Ticktin's sign has a bad prognostic value.

Treatment, again, remains a somewhat dark and thorny area. Yet we must address ourselves to this question. Medications should be generally avoided in the initial stages as this often tends to accentuate the disorientation, but sometimes it may be useful in the management of more recalcitrant patients. Psychotherapy awaits further evaluation, though one intrinsic drawback to its use is the fact that typically these patients lack insight into the nature of their illness and this may also lead to problems in their general management. At present, the best treatment (the"drug of choice" as it were) is a change of occupation - or, at the very least - a "psychiatry holiday".

Gentlemen, are we not witness to some very strange and arcane disorder, whose very innards would have baffled Hippocrates and made Galen's black locks stand on end. And what of Kraepelin and Bleuler; would they not have racked their brains until they had come to scientific grips with this potentially monstrous disorder. For if there is an illness at the heart of our profession, let us, as physicians, spare no technology which will allow us to expose this tainted flower and nip it in the bud. Treatment, at all costs, should be our motto.

I will say no more.

"Ticktin's Syndrome, or, The Post-Psychiatric Post Confusional State"
by Stephen Jan Ticktin, M.D.
Asylum Magazine for Democratic Psychiatry
Vol. 3, No.2

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