Eponym

Case presentation

A 45-year-old South African man was admitted to aneurology ward with a left hemiparesis and a 4-dayhistory of amnesia and wandering. Physicalexamination was unremarkable, but a urine toxicologyscreen was positive for both cannabis and ecstasy.During admission his consciousness ﬂuctuated, andalthough extensive investigation revealed no organiccause for his symptoms he was given a course of intravenous acyclovir to treat possible encephalitis.After 3 weeks he was referred for psychiatricassessment. He was able to give a rational account of himself, disclosing that as a young man, he had foughtin the Rhodesian War, where he had been personallyinvolved in the murder and torture of the civilianpopulation. After the war he had become a teacher,emigrating to the UK in 2002. He then developedseveral symptoms related to his time in the RhodesianArmy. He reported intrusive visual hallucinations thatgave a “snapshot” of his experiences during the war, hebecame hypervigilant, and his performance at workbegan to suffer. He was unable to give any account of his activities for the 4-day period that correlated with hiswandering, but did recall his admission to hospital. Onexamination of his mental state, the only notableabnormality was his giving of approximate answers.When asked to spell WORLD backwards, he replied“EBOLG”. When asked to recall the words honesty,window, and lace, he replied “modesty, house, shoes”.The request to write a complete sentence was met withthe words “Where I’m I going to . . . ”. With the historyof visual hallucinations, conversion symptoms,approximate answers, and clouding of consciousness, adiagnosis of Ganser’s syndrome was made. Hissymptoms subsequently improved with no speciﬁcintervention and he was discharged.

Ganser’s syndrome

In 1897, the neurologist Sigbert Ganser ﬁrst describedthe syndrome that bears his name while working at apenal institution in Halle, Germany. He had noted asyndrome in three prisoners, the features of whichincluded approximate answers to simple questions,perceptual abnormalities such as visual and auditoryhallucinations, clouding of consciousness, andsymptoms of somatic conversion (also known asfunctional or hysterical symptoms).

Approximate answers refer to responses that areincorrect, but indicate that the question has beenunderstood. For example, when asked, “How manylegs does a cow have?”, the patient might reply “five”.Although clearly incorrect, this answer demonstratesan understanding of the question and requiredanswer. The unusual nature of this symptomcombined with the fluctuating level of consciousnesshas prompted extensive debate as to whether Ganser’ssyndrome represents organic brain impairment, anhysterical conversion disorder, or malingering. Assuch, the syndrome has frequently undergone reclas-sification, a fact reflected by its alternative titles—balderdash syndrome, prison psychosis, nonsensesyndrome.

Notably, the initial interest in this bizarrepsychopathology reﬂected a widespread fascinationwith the concept of hysteria in

ﬁn de siècle

Europe.Ganser’s syndrome is diagnosed on the basis of fourclinical features, all of which are required, although notsimultaneously (panel). Later writers struggled to makesense of the symptom approximate answers, coiningterms such as

vorbeireden

(meaning to talk at crossedpurposes) and paralogia. Ganser, however, withcharacteristic clarity, preferred the term

vorbeigehen

(topass by, meaning that the patient passes by the correctanswer to choose another) and stated that “The mostobvious sign which they present consists of theirinability to answer correctly the simplest of questionswhich are asked of them, even though by many of theiranswers they indicate that they have grasped, in a largepart, the sense of the question, and in their answersthey betray at once a bafﬂing ignorance and asurprising lack of knowledge which they most assuredlyonce possessed, or still possess.”

He described his second patient by way of example:“when asked to read the paper he read out in asenseless fashion, Bismarck, King Albert, Rothschild... He designated a dollar bill, a mark and a ﬁfty centpiece alike as a mark. A ﬁve-mark bill he described asprinted paper, whose value he was not able torecognise.”

The state of clouded consciousness is often marked,and the patient’s manner can ﬂuctuate greatly duringthe course of the illness, appearing agitated andaggressive, then later stuporose and placid. Varioussomatic conversion symptoms have been noted inGanser’s syndrome including gait abnormalities,rigidity, blindness, and hemiplegia. Ganser describes atypical presentation: “In one case widely extendinganalgesia spread over the entire body and over thetongue so that the deepest pin prick nowhere evoked asense of pain.”

Ganser’s syndrome

Justin Dwyer, Steven Reid

Lancet

2004; 364: 471–73Department of LiaisonPsychiatry, St Mary’s Hospital,London, UK

(J Dwyer MB,S Reid PhD)Correspondence to: Dr StevenReid, Department of LiaisonPsychiatry, Paterson Centre forMental Health, St Mary’sHospital, London W2 1PD, UK

steve.reid@nhs.net

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Vol 364 July 31, 2004 471

Panel:

Features of Ganser’s syndrome

Approximate answers

Somatic conversion symptoms

Clouding of consciousness

Perceptual disturbances

Eponym

Perceptual disturbances can take the form of eithervisual or auditory hallucinations, as vividly illustrated inanother of Ganser’s original cases: “One patient wasextremely agitated, often leaped out of his bed, assumeda pugilistic posture, stretched out his arm and suddenlyarose to seek cover behind the bed, and then again creptunder the mattress. While engaged in these activities hespoke a great deal about war with the Cossacks, abouthunting and so forth . . . It was clear that this behaviourwas completely his response to hallucinations . . .”.

The onset of the syndrome is sudden, and after avariable period of hours to weeks, it resolves abruptlywith a characteristic amnesia accompanied by perplexityfor the entire period.The incidence of Ganser’s syndrome is unknown,although the condition is thought to be exceedingly rare.Before 1955, only 14 cases had been described inEnglish medical publications.

A review of case reportsfound that 74% were male with a mean age of 32.

In a1973 survey of 1200 patients admitted to a psychiatrichospital in Singapore, Tsoi

reported ten cases fulﬁllingthe criteria for the diagnosis. In view of the setting of Ganser’s original series, an increased prevalenceamongst the prison population might be expected, if only due to reporting bias. However, McGrath andMcKenna

reported only 50 cases of what they describedas prison psychosis amongst 8000 military prisoners,and of these a small number would be judged to haveGanser’s syndrome. Scott

made the distinction betweenthe Ganser symptom of approximate answers andGanser’s syndrome, the former being common, andoften seen in psychiatric illnesses such as schizophreniaand depression.The cause of Ganser’s syndrome remains uncertain.Current psychiatric classiﬁcation categorises it as adissociative disorder, the symptoms of which are judgedas psychogenic in origin.

This view has been greetedwith scepticism by those who suspect deliberatesimulation and malingering, most notably Wertham

who stated that “a Ganser reaction is a hystericalpseudo-stupidity which occurs almost exclusively in jailsand old-fashioned German textbooks”. Ganser himself,although reporting the syndrome as “an unusualhysterical confusional state”, was less certain of theunderlying mechanisms and noted that in his threeoriginal cases, two patients had experienced a headinjury and the third typhus fever. An association withhead injury has been noted in subsequent case series,

and Lishman proposed that cerebral dysfunctionmight sometimes facilitate the development of thesyndrome, especially where ﬂuctuating impairment of consciousness is apparent.

Diagnosis

The diagnosis of Ganser’s syndrome is oftenproblematic, especially in view of the frequency withwhich the symptom of approximate answers arises inother psychiatric disorders. The identiﬁcation of malingering, in order to gain an obvious beneﬁt such asaccommodation, is important although not nearly asstraightforward as it might seem. The two are notmutually exclusive, a point emphasised by Ganserhimself. The original description of the syndrome in aprison population itself may have lent a spuriouscredibility to the notion of conscious simulation,although this particular constellation of symptomswould be an unusual choice for considered deception.The striking presentation, perceptual disturbances, andapproximate answers may suggest a psychotic illness,and Ganser’s syndrome has been described inprodromal schizophrenia. The formal thought disorder

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