Ganser syndrome

Ganser syndrome is a rare and controversial condition, whose main and most striking feature is the production of approximate answers (or near misses) to very simple questions ¹. Ganser syndrome is characterized by the individual mimicking behavior they think is typical of a psychosis; usually by providing nonsensical or wrong answers to questions, and doing things incorrectly. For instance, asked how many legs a horse has, patients with Ganser syndrome will reply “5”, and answers to plain arithmetic questions will likewise be wrong, but only slightly off the mark (e.g., 2 + 2 = 3). This symptom was originally described by Sigbert Ganser in 1897 ² in prisoners on remand and labeled vorbeigehen (“to pass by” or beside the point, or giving approximate answers to questions within the patient’s range of knowledge), although the term vorbeireden (“to talk beside the point”) is also frequently used. A number of associated symptoms were also reported: “clouding of consciousness,” somatoform conversion disorder, hallucinations, sudden and spontaneous recovery, subsequent amnesia for the episode, premorbid traumatic psychosocial experience and/or (usually mild) head trauma. Enoch and Trethowan ³ state that the four essential clinical features of the Ganser syndrome are: approximate answers, somatic conversion symptoms, clouding of consciousness, and visual or auditory pseudohallucinations.

Ganser syndrome is also sometimes called nonsense syndrome, balderdash syndrome, syndrome of approximate answers, pseudodementia or prison psychosis. This last name, prison psychosis, is sometimes used because the syndrome occurs most frequently in prison inmates, where it may represent an attempt to gain leniency from prison or court officials.

Ganser syndrome is generally accepted in the literature as a type of dissociative disorder (a condition that involves disruptions or breakdowns of memory, awareness, identity and/or perception) and was previously classified as a factitious disorder. However Sigal et al state ⁴ that the underlying mechanisms are still under discussion, and the organic and/or psychotic nature of Ganser syndrome is still controversial. More recently, Fink and Taylor ⁵ suggested that the Ganser syndrome could be one of the forms of catatonia. Sigbert Ganser saw it as a form of “twilight hysteria,” whereas others suggested that malingering, psychosis or dissociation were more appropriate labels, oftentimes combined with organic impairment and a subjectively intolerable psychosocial context. A central conundrum of Ganser’s syndrome is whether it could simultaneously be a cultural and pathological representation of insanity, whereas cognitive, organic, affective, motivational and social factors would converge towards a naïve idea of what mental illness should look like, especially through the provision of approximate answers.

Etiological, epidemiological and diagnostic issues have never been resolved for Ganser’s syndrome ¹. Controversy has always surrounded the precise nosological status of the Ganser syndrome. Several authors such as Cocores et al. ⁶ have insisted on the relationship with malingering disorders, schizophreniform disorders, a hysterical dissociative state, or organic or toxic confusional states. Modern classifications subsume Ganser syndrome under the general heading of unspecified dissociative disorders as in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) ⁷. However, Ganser syndrome was removed in the Diagnostic and Statistical Manual of Mental Disorders,Fifth Edition (DSM-5).

Ganser syndrome may occur in persons with other mental disorders such as schizophrenia, depressive disorders, toxic states, paresis, alcohol use disorders and factitious disorders. A review of the literature (n=151) demonstrates however that Ganser’s syndrome is frequently associated with brain injury, although detailed imaging, neuropsychological, and neurological data of this for the most part do not exist ⁸. EEG data does not suggest any specific organic cause ⁹.

Ganser syndrome symptoms

Ganser syndrome has been observed frequently in conjunction with a marked psychosocial or physical stressor (ie, head injury, serious illness). Typically, the duration of symptoms is brief.

Enoch and Trethowan’s 4 identified symptoms for the syndrome are as follows ³:

• Approximate answers
• Clouding of consciousness
• Somatic conversion symptoms
• Hallucinations

Other commonly observed features include the following ¹⁰:

• A dreamy or perplexed appearance
• Memory or personal identity loss
• No recollection of the syndromal state upon recovery
• Perseveration
• No response to painful stimuli
• Catatonic posturing
• Echolalia
• Echopraxia

Ganser syndrome diagnosis

Diagnosing Ganser syndrome is very challenging, not only because some measure of dishonesty is involved but also because it is very rare.

Usually when giving wrong answers they are only slightly off showing that the individual understood the question. For instance, when asked how many legs a horse has they might say, “five.” Also, although subjects appear confused in their answers, in other respects they appear to understand their surroundings.

Ganser syndrome treatment

Consultation with a neurologist is advisable to rule out neurologic etiologic factors.

Consultation with a psychiatrist is recommended initially and in follow-up.

Inpatient treatment may be needed during the acute phase. This is often necessary to protect the patient from himself or herself considering his or her dissociation. Treat any underlying medical conditions.

Admit the patient to a psychiatric facility if the patient is a danger to self or others.

Simple supportive psychotherapy and monitoring for safety are the chief components of treatment. Limited evidence exists that hypnosis or electroconvulsive therapy (ECT) may be useful.

Medication rarely is necessary and may be contraindicated in medically ill patients. Low-dose benzodiazepines and antipsychotic medications have been used with limited success. Psychopharmacological interventions should be used with caution because they could result in masking an underlying organic disease.

Recovery usually is within days for most patients, especially if precipitating stress resolves.

References

1. Ganser Syndrome. Neurology. Front Neurol Neurosci. Basel, Karger, 2018, vol 42, pp 1-22 https://doi.org/10.1159/000475676
2. Ganser SJ. Über einen eigenartigen hysterischen Dammerszustand. Archiv Psychiatr Nervenkr. 1898;30:633–640. doi: 10.1007/BF02036039
3. Enoch MD, Trethowan WH. Uncommon psychiatric syndromes. Bristol, England: John Wright; 1978. The Ganser syndrome; pp. 50–62.
4. Ganser syndrome: a review of 15 cases. Sigal M, Altmark D, Alfici S, Gelkopf M. Compr Psychiatry. 1992 Mar-Apr; 33(2):134-8.
5. The catatonia syndrome: forgotten but not gone. Fink M, Taylor MA. Arch Gen Psychiatry. 2009 Nov; 66(11):1173-7.
6. The Ganser syndrome: evidence suggesting its classification as a dissociative disorder. Cocores JA, Santa WG, Patel MD. Int J Psychiatry Med. 1984; 14(1):47-56.
7. Spodenkiewicz M, Taïeb O, Speranza M, Moro MR, Révah-Levy A. Case report of Ganser syndrome in a 14-year-old girl: another face of depressive disorder?. Child Adolesc Psychiatry Ment Health. 2012;6(1):6. Published 2012 Feb 1. doi:10.1186/1753-2000-6-6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3292982
8. Wirtz, G; Baas, U; Hofer, H; Nyffeler, T; Seifritz, E; Müri, René Martin; Gutbrod, Klemens (2008). [Psychopathology of Ganser’s syndrome. Literature review and case report]. [Article in German] Nervenarzt, 79(5), pp. 543-547. Heidelberg: Springer-Verlag 10.1007/s00115-008-2411-8 https://boris.unibe.ch/27598/1/115_2008_Article_2411.pdf
9. A review of the EEG literature on Ganser’s syndrome. Int J Psychiatry Med. 1986-1987;16(1):59-65. https://www.ncbi.nlm.nih.gov/pubmed/3522461
10. Ganser Syndrome Clinical Presentation. https://emedicine.medscape.com/article/287390-clinical