Ganser syndrome is a rare dissociative disorder characterized by nonsensical or wrong answers to questions and other dissociative symptoms such as fugue, amnesia or conversion disorder, often with visual pseudohallucinations and a decreased state of consciousness. The syndrome has also been called nonsense syndrome, balderdash syndrome, syndrome of approximate answers, hysterical pseudodementia or prison psychosis.
The term prison psychosis is sometimes used because the syndrome occurs most frequently in prison inmates, where it may be seen as an attempt to gain leniency from prison or court officials. Psychological symptoms generally resemble the patient's sense of mental illness rather than any recognized category. The syndrome may occur in persons with other mental disorders such as schizophrenia, depressive disorders, toxic states, paresis, alcohol use disorders and factitious disorders.Knoblosh, F. (1986). Ganser Syndrome and DSM-III. American Journal of Psychiatry, 143(3), 393-393. Ganser syndrome can sometimes be diagnosed as merely malingering, but it is more often defined as a dissociative disorder.
The identification of Ganser syndrome is attributed to German psychiatrist Sigbert Ganser (1853–1931). In 1898, he described the disorder in prisoners awaiting trial in a penal institution in Halle, Germany. He named impaired consciousness and distorted communication, namely in the form of approximate answers (also referred to as Vorbeireden in the literature, German for "to talk past; to have a misunderstanding"), as the defining symptoms of the syndrome.Whitlock, F.A. (1967). The Ganser Syndrome. British Journal of Psychiatry, 113(494), 19-29. Vorbeireden involves the inability to answer questions precisely, although the content of the questions is understood.Weiner, H.; Brainman, A. (1955). The Ganser Syndrome: A Review and Addition of Some Unusual Cases. American Journal of Psychiatry, 111(10), 767-773.
Ganser syndrome is described as a dissociative disorder not otherwise specified (DDNOS) in the DSM-IV, and is not currently listed in the DSM-5. It is a rare and an often overlooked clinical phenomenon. In most cases, it is preceded by extreme stress and followed by amnesia for the period of psychosis. In addition to approximate answers, other symptoms include a clouding of consciousness, somatic conversion disorder symptoms, confusion, stress, loss of personal identity, echolalia, and echopraxia.
Cause To date, no definitive cause or reason of the disorder has been established.Mendis, S.; Hodgson, R.E. (2012). Ganser Syndrome: examining the aetiological debate through a systematic case report review. European Journal of Psychiatry, 26(2). The sources that classify the syndrome as a dissociative disorder or a factitious disorder conflict in their proposed aetiologies. As a result, there are differing theories as to why the syndrome develops.
Ganser syndrome was previously classified as a factitious disorder, explaining the symptoms as mimicking of what patients who do not experience psychosis believe is typical of the experience. However, the DSM-IV placed the syndrome under "Dissociative Disorders Not Otherwise Specified". There has been evidence of a strong correlation between approximate answers and amnesia, suggesting that these have an underlying dissociative mechanism.Cocores, J.A.; Santa, W.G.; Patel L, MD. (1985). The Ganser Syndrome: Evidence Suggesting its Classification as a Dissociative Disorder. The International Journal of Psychiatry in Medicine, 14(1), 47-56.
Both Ganser's syndrome and the broader category of dissociative disorders have been linked to histories of hysteria, psychosis, conversion, multiple personality and possible feigning. Despite this, the condition's aetiology remains under question due to associations with established psychiatric disorders, as well as organic states.
According to Stern and Whiles (1942), Ganser syndrome is a fundamentally psychotic illness. As evidence, they describe the case of a woman with recurrent mania and a head injury before being submitted to treatment and the report of a man with schizophrenia who suffered from alcoholism and had recently been in prison.
Ganser syndrome is also sometimes referred to as "prison psychosis", emphasizing its prevalence among prisoners, generating discussion about whether the disorder only appears in this population. In a study of prisoners, Estes and New concluded that escaping an intolerable situation, such as being incarcerated, prompted the syndrome's key symptoms. The study touched on the malingering controversy surrounding the syndrome, as well as the stress component that often precedes the disorder.
According to consultant psychiatrist F. A. Whitlock, Ganser syndrome is a hysterical disorder, on par with Ganser's description of the disorder. Whitlock pointed to the number of cases in which Ganser syndrome was reported in settings of organic brain disease or functional psychosis as evidence of its hysterical foundations. Kraepelin and Bumke also believed the syndrome to be of a hysterical nature. Bumke thought the syndrome hysterical because amnesia for a traumatic emotional event tends to occur in hysteria more than in other disorders. The giving of approximate answers is thought to be produced in hysterical personalities.
According to Mayer-Gross and Bleuler, Ganser syndrome occurs mainly in epileptic or schizophrenic patients.
Still others claim that an organic condition that could lead to the manifestation of Ganser syndrome symptoms would have to be at an advanced stage in which a diagnosis could be easily given.Koenig, T.; Lee, H.B. (2001). A Case of Ganser Syndrome: Organic or Hysterical?. General Hospital Psychiatry, 23(4), 230-231.
There have also been reports of trauma and stroke patients with the syndrome. A study investigating the neurological basis of Ganser syndrome described a patient with symptoms of the disorder who had a history of stroke and bifrontal infarcts.Ouyang, D., Duggal, H. S., & Jacob, N. J. (2003). Neurobiological Basis of Ganser Syndrome. Indian Journal of Psychiatry, 45(4), 255–256. They discovered that hyperglutamatergic states, which are caused by both strokes and stress, share a relationship with dissociative symptoms, suggesting a possible organic pathology that can predispose individuals to the syndrome. Wirtz and colleagues (2008) described a patient with Ganser syndrome after a left-hemispheric middle cerebral artery infarct. A neuropsychological examination revealed atypical lateralisation of cognitive functions, leading to the conclusion that the giving of approximate answers might be related to frontal-executive cerebral dysfunction.
Diagnosis Ganser syndrome was listed under Factitious Disorder with Psychological Symptoms in the DSM-III.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC. American Psychiatric Association, 1952. The criteria of this category emphasized symptoms that cannot be explained by other mental disorders, psychological symptoms under the control of the individual, and the goal of assuming a patient role, not otherwise understandable given their circumstances.
The DSM-IV-TR classified Ganser syndrome as a dissociative disorder defined by the giving of approximate answers to questions (e.g. '2 plus 2 equals 5' when not associated with dissociative amnesia or dissociative fugue).American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC. American Psychiatric Association, 2000. The ICD-10World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization. and DSM-IV do not specify any diagnostic criteria—apart from approximate answers—as a requirement for a Ganser syndrome diagnosis. Most case studies of the syndrome also depend on the presence of approximate answers and at least one of the other symptoms described by Ganser in his original paper. Usually when giving wrong answers, individuals are only slightly off, showing that the individual understood the questionBromberg, W. (1986). The neglect of Ganser Syndrome. The American Journal of Psychiatry, 143(7), 937-938. For instance, when asked how many legs a horse has, they might say, "five". Although subjects appear confused in their answers, in other respects they appear to understand their surroundings. Amnesia, loss of personal identity, and clouding of consciousness were among the most common symptoms apart from approximate answers.
Although there is currently no uniform way to diagnose the syndrome, a full neurological and mental state examination is recommended to determine its presence as well as tests that assess malingering.Epstein, R.S. (1991). Ganser Syndrome, Trance Logic, and the Question of Malingering. Psychiatric Annals, 21(4), 238-244. In addition to mental examination, other investigations should be done to exclude other underlying causes. These include computer tomography scans (CT) or magnetic resonance imaging (MRI) scans to exclude structural pathology, lumbar puncture to exclude meningitis or encephalitis, and electroencephalography (EEG), to exclude delirium or seizure disorder.Dwyer, J.; Reid, S. (2004). Ganser's Syndrome. The Lancet, 364(9432), 471-473.
Diagnosing Ganser syndrome is challenging because of its rarity and symptom variability. The manifested symptoms may be dependent on the individual's conception of what mental illness entails, creating the possibility of a wide range of combinations of symptoms present in an individual with Ganser syndrome.
Treatment In many cases, the symptoms seem to dwindle after a few days, and patients are often left with amnesia for the period of psychosis. Hospitalization may be necessary during the acute phase of symptoms, and psychiatric care if the patient is a danger to self or others.Carney, M.W.P.; Chary, T.N.K.; Robotis, P.; Childs, A. (1987). Ganser Syndrome and its Management. British Journal of Psychiatry, 151, 697-700. A neurological consult is advised to rule out any organic cause. Psychotherapy may also recommended for ensuring and maintaining safety.
Ganser patients typically recover quickly and completely.Enoch, M. D., & Irving, G. (1962). The Ganser syndrome. Acta Psychiatrica Scandinavica, 38(3), 213-222. Since Ganser syndrome can be a response to psychic deterioration, its resolution may be followed by other psychiatric symptoms, such as schizophreniaLieberman, A.A. (1954). The Ganser Syndrome in Psychoses. Journal of Nervous and Mental Disease, 120(1-2), 10-16. and depression,Haddah, P.M. (1993). Ganser Syndrome Followed by Major Depressive Episode. British Journal of Psychiatry, 161, 251-253. hence the rationale behind the recommendation of psychotherapy. Medication is usually not required.
Epidemiology