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10.1192/bjp.113.494.19Access the most recent version at DOI:
1967, 113:19-29.BJP
F. A. WHITLOCKThe Ganser Syndrome
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Brit. J. Piat, (1967), 113, 19-29
The Ganser SyndromeBy F. A. WHITLOCK
American textbooks seem somewhat less certain,for Arieti and his
co-authors (@g) list theGanser syndrome under the heading of
Rare,Unclassifiable, Collective and Exotic PsychoticSyndromes. The
writers in this book tend toregard the Ganser syndrome as
essentially atransient psychosis, although they admit thedifficulty
in deciding whether or not hysteria isthe more correct diagnosis.
Noyes and Kolb(1963) and Gregory (1961) both adhere to theusual
placement of Ganser states in the portionof their books devoted to
Hysterical Neuroses.Szasz (1961) dogmatically regards the
Gansersyndrome as a variant of either malingering orhysteria. He
quotes, with some approval,Wertham's (I94@) comment that
aGanserreaction is a hysterical pseudo-stupidity whichoccurs almost
exclusively in jails and in oldfashioned German textbooks. It is
now knownto be almost always due more to consciousmalingering than
to unconscious stupefaction.In his anxiety to equate the symptoms
of theGanser syndrome with the alleged impersonation of the sick
role in hysteria, Szasz, along withothers, overlooks the fact that
Ganser was quitecertain that his patients were not malingering.
Associated P.@ychiatricDisordersThe persistence of the opinion
that the Ganser
syndrome is an hysterical disorder is all the moreremarkable in
the light of the number of reportsof this condition occurring in
settings of organicbrain disease or functional psychosis.
AdmittedlyMayer-Gross and his colleagues have advisedcaution in the
diagnosis of this condition, for, asthey mention, Manyof these
patients havebeen found subsequently to be epileptic, or
thesubjects of an unsuspected schizophrenia, ororganic cerebral
disease. Similarly, Sim comments that organicbrain disease can
alsopresent a picture with certain features of theGanser syndrome.
He goes on to describe a
In 1897 Ganser delivered a paper entitledConcerningan Unusual
Hysterical ConfusionalStatein which he described three prisoners
whodeveloped transitory symptoms of mental illness.The main
features were disturbances of consciousness with subsequent amnesia
for theepisode, prominent hallucinations, sensorychanges of an
hysterical kind and, on questioning, peculiar verbal responses
which have cometo be regarded as the hallmark of the Ganserstate.
The illness terminated abruptly with fullrestoration of normal
mental function. DespiteGanser's designation of the condition as
hysterical, controversy over its precise nosologicalstatus has
persisted over the past sixty-oddyears. Is it in fact a form of
hysteria, or is it apsychotic illness of brief duration? Is
thehysterical pseudo-dementia described by Wernicke (1906)
identical with or distinct from theGanser syndrome? What is the
relationship, ifany, of the symptomatology of the Ganser
statetheoften-described vorbeiredenand approximate answerstothe
disordered thoughtof the schizophrenic and the dysphasia of
thepatient suffering from organic brain disease?Is it a fact that
the Ganser syndrome occursmost frequently in patients in military
or civilprisons and is rare in the non-delinquentpopulation? To
these and other problems thestandard textbooks of psychiatry return
confficting answers.
Current Textbook DescriptionsTraditionally the Ganser syndrome
is des
cribed in the majority of English textbooks ofpsychiatry under
the heading of HystericalDisorders. Mayer-Gross and his
colleagues(I96o), Henderson and Batchelor (1962),Curran and
Partridge (1963), Sim (1963),Skottowe (1964) and Anderson (1964),
to namebut a proportion of the authors of current textbooks, all
subscribe to this tradition. By contrast,
19
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20 THE GANSER SYNDROME
case in which the symptoms of the syndromedisappeared after the
removal of a largesagittal meningioma. Henderson and
Batchelormention the development of the Ganser syndrome in a case
of acute hallucinatory paranoidstate, and Curran and Partridge also
mentionthe concurrence of the syndrome with schizophrenia. By
contrast, Arieti claims that anorganic condition that might lead to
thesesymptoms (Ganser syndrome) would have tobe at a very advanced
stage;. . . there wouldbe no difficulty in making the diagnosis.
Noyesand Kolb regard the Ganser syndrome as analteration of
consciousness allied both tosimulation and the dissociative dream
state.
Functional and Organic SyndromesDespite the main consensus of
opinion in
psychiatric textbooks that the Ganser syndromeis predominantly
an hysterical disorder, reportsin English and American medical
journals aremainly concerned with pointing out the incidence of the
syndrome in a wide variety ofpsychiatric settings. Ganser states
have beendescribed in settings of functional and organicpsychoses,
after head injuries and in alcoholics.Bender (i@@) described a
29-year-old womanwho developed a Ganser syndrome during thecourse
of a post-partum schizophreniformillness. The features of the
Ganser state cleveloped after a suicidal attempt by
coal-gaspoisoning. This author also described anotherpatient who
died shortly after admission fortreatment of an acute
schizophreniform illnessdeveloping during the puerperium. The
evidence for the Ganser syndrome in this secondcase is somewhat
equivocal, and the death of thepatient shortly after admission
leaves one indoubt about her true state at the time. Thecause of
the death was not given. Anderson andMallinson (i@@i), after
stating that everyonehas agreed so far that the syndrome rests on
anhysterical basis,go on to describe three casesof their own
occurring during the course offunctional psychoses. The first
patient wasdiagnosed as suffering from depression, as wasthe
second, who perhaps would today be givena diagnosis of psychogenic
psychosis. The thirdcase was a schizophrenic with
strongpsychogenicfeatures at the time of onset.
Goldin and MacDonald (1955) provide auseful review of the
literature on the subject, andmention among other cases one
described byLieberman (i@5) who suffered from hysteriform,
epileptiform, alcoholic and diffuse organicdisorder, symptoms
indicative of a fairlyadvanced organic brain syndrome. Theseauthors
stress the symptom of disturbance ofconsciousness in the Ganser
syndrome and goon to describe a case of their own. This was aman of
62 who presented as a classic, agitateddepression; nevertheless,
the onset of the Gansersymptoms was preceded by a sudden loss
ofconsciousness associated with double incontinence; these and
other findings suggested thepossibility of organic cerebral
disease. Weinerand Braiman (1955) remark, Wehave notbeen able to
find any reports of patientssuffering of the Ganser syndrome who
weredemented as well,but they mention a case ofthe syndrome in an
alcoholic described by Voss(1908), and a further case following
head injurydescribed by Baumann (1906). They giveclinical details
of three of the six cases they hadexamined, remarking that the
other three weretypicallyhysterical. Of the three
patientsdescribed, one was a case of paretic neurosyphilis, another
was a schizophrenic whoseillness developed after an unsuccessful
suicidalattempt, and the third had had a preceding lossof
consciousness considered to be hysterical.In one of these cases at
least, there was unequivocal evidence of organic brain
disease.Tyndal (1956) also commented on the possibleorganic basis
for some cases of the Gansersyndrome.
Stern and Whiles (1942) support the theorythat the Ganser
syndrome is a psychotic illness,giving details of three cases of
their own insupport of this opinion. The first of these was awoman
suffering from recurrent mania orhypomania who had sustained a head
injuryshortly before admission. The second was a35-year-old male
schizophrenic, an alcoholicoften involved in brawls, who had
recently beenin prison. The third case, a probable schizophrenic,
showed features more strongly suggestive of pseudo-dementia or the
so-calledbuffoonerysyndrome than of a true Ganserstate. In the
first two cases there seemed to be
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BY F. A. WHITLOCK 2!
some possibility of organic brain disorder, eithertraumatic or
toxic, existing before the onset ofthe Ganser syndrome. McGrath and
McKenna(1961) review the literature, pointing out thatthe syndrome
has been described as occurringin schizophrenia, depression,
G.P.I., alcoholicpsychosis and following head injury. In
theiropinion, Ganser states are not to be equatedwith malingering,
but these authors prefer toavoid committing themselves to either
thehysterical or the psychotic hypothesis. Instead,they back both
possibilities by calling thecondition anhysterical psychosis after
Fernchel.Their own case was a 29-year-old malewho developed a
Ganser syndrome some eightmonths after head injury with concussion.
It isnot easy to say what part, if any, the head injuryplayed in
the production of the illness, and theauthors themselves felt that
the compensationissue was of greater importance. May and
hiscolleagues (1960) describe three cases developingafter severe
emotional stress. All three wouldqualify as psychogenic psychoses
with schizophrenic features and all showed acute onset ofillness
with clouding of consciousness. Finally,Enoch and Irving (1962)
describe a case of thesyndrome in a 55-year-old man admitted
forwhat was originally diagnosed as an organicconfusional state. At
the time of admission heshowed equivocal plantar responses, and
anX-ray of the skull showed a vascular defect inthe upper part of
the parietal region. Despitethese findings, the authors concluded
that thepatient manifested a pure hysterical reaction.
In summary, therefore, although a goodmany authors support the
belief that the Gansersyndrome is an hysterical disorder, it is
pertinentto point out the high incidence of organic braindisease in
the cases described. In this context itis worth recalling that, of
the three casesoriginally described by Ganser, two had
sufferedserious head injuries, and the third was recovering from a
severe bout of typhus withprolonged convalescence and psychic
alterations. If one adheres to Ganser's originaldescription, it
must be wrong to emphasize thefeatures of clouding of
consciousness, paralogiaand hallucinations while ignoring the
evident@organic brain disturbance which appeared tobe an essential
feature in his cases. However,
when the syndrome appears in the course of afunctional
psychosis, one is faced by theproblem of deciding whether the
Ganser-likesymptoms are part of the presenting illness orare
hysterical symptoms grafted on to theunderlying psychotic process.
The formerpossibility certainly seems simpler, and obviatesthe need
for a double diagnostic description ofsymptoms.
Hysterical Pseudo-DementiaThe question of whether the Ganser
syndrome
and Hysterical Pseudo-Dementia are one andthe same condition
appears to be an open one.Mayer-Gross and his colleagues,
Hendersonand Batchelor, Sim, Fish (1962) and Szasz allmaintain with
varying degrees of certainty thatpseudo-dementia and the Ganser
syndrome aretwo names for the same condition. In oppositionto these
authorities, (Jurran and Partridge andalso Anderson maintain that
pseudo-dementiais to be differentiated from the Ganser
syndromeprincipally on the basis that patients diagnosedas
suffering from hysterical pseudo-dementiashow no disturbance of
consciousness. Thisdifferential point was emphasized by
Bumke(1936), by Anderson and Mallinson (i @i),byAnderson and his
colleagues (i@@) and byother authorities. All three of Ganser's
originalcases had shown clouding of consciousness inassociation
with the onset of their symptoms,and it seems generally to be
agreed that theabsence of clouding makes the diagnosis of aGanser
state somewhat dubious. Ganser'soriginal description of the
condition as anhysterical twilight state also emphasized
theassociated disturbance of consciousness. Accountsof patients
suffering from pseudo-dementiacertainly note the absence of any
disturbance ofconsciousness, at the same time emphasizingthe
qualities of simulation or malingering whichare more apparent in
this class of condition.Anderson regards pseudo-dementia as a
disorderdeveloping in mentally dull persons who areusually in
trouble with authority. The differential diagnosis between
hysterical pseudo-dementia and straight malingering is not always
aneasy one to make, whereas the question ofmalingering in the
Ganser syndrome should notarise. Kioh (1961) also supports the
opinion
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22 THE CIANSER SYNDROME
that the Ganser syndrome and pseudo-dementiaare not one and the
same condition. Nevertheless, he tends to the opinion that the
Gansersyndrome itself is an hysterical disorder, sincewhether or
not functional or organic psychosisco-exists with the syndrome,
hystericalmechanismsare employed by the patient, Unfortunately,
Kiloh somewhat confuses the issue, as heuses the term
pseudo-dementiato describean apparent organic dementia occurring in
asetting of severe melancholia. This, of course, iswholly different
from the hysterical pseudodementia which usually develops, as
alreadyindicated, in persons of low intelligence who donot manifest
affective changes and who aredevoid of any evidence of disturbance
ofconsciousness.
Speech DisorderMuch consideration has been given to the
precise meaning of the terms vorbeiredenand approximate answers.
The similaritybetween the verbal statements of Ganserpatients and
patients suffering from schizophrenic thought disorder or organic
dysphasiahas been pointed out on more than one occasion.Anderson
and Mallinson mention the closesimilarity of the Ganser response to
schizophrenic thought disorder, and Fish commentsthat the symptoms
of vorbeireden or paralogiaare by no means uncommon in
schizophrenia.In some instances he feels that the nonsensicalnature
of the replies can be explained in termsof the patients adopting a
childish, playfulattitude, a condition which presumably isclosely
related to Bleuler's buffoonery syndrome.Alternatively, a Ganser
type of response canoccur as a catatonic phenomenon, explicablein
terms of the symptom of forced responsiveness.It is within the
experience of most psychiatriststo be puzzled by a patient's
apparently inconsequential replies, and to some extent it is
amatter of judgment and interpretation todecide whether a patient
is giving a Gansertype response, has a schizophrenic
thoughtdisorder, a nominal dysphasia, or is disorientedon account
of a toxic-confusional psychosis.
As far as dysphasia is concerned, Critchley(1964) has commented
upon the similaritybetween what he terms regressivemetonymy
and the vorbeireden symptom of the Gansersyndrome. In his
opinion, this phenomenon,occurring in the course of an organic
dementia,is the first symptom of a sensory or jargonaphasia. Some
of these problems will be considered again after describing the
symptomatology of patients who had shown featuressuggesting Ganser
states, but who on laterconsideration turned out to have an organic
orschizophrenic diagnosis. As far as the symptomof approximate
answers is concerned, it is noteasy to assess, from the
descriptions given in thepapers already cited, how approximate
ananswer needs to be before it is placed in thiscategory. Pick
(9,7) felt that only by forcingthe meaning of the term could some
of theanswers be regarded as approximate, and withthis view the
present writer whole-heartedlyconcurs. Even in Ganser's original
description,by no means all the answers are approximate.For
example, on being asked to add 2 and @,onepatient gave the answer
Three,but whenasked to add 3 and 2, he gave the answerSeven.When
asked to add 5 and 2, theanswer was Fourand when required
tosubtract i from 4, he gave the answer Fivebut corrected this to
Three.It seems,therefore, that it is not the approximation
ofanswers but their random nature which is sostriking. Furthermore,
not all the replies carrythe implication that the patients must
have hadan underlying understanding of the correctanswer.
Prison PsychosisThere has been considerable discussion on
whether or not the Ganser syndrome arises onlyor predominantly
in patients in prison awaitingtrial. No doubt the fact that
Ganser's threecases were prisoners, and the belief in the mindsof
some writers that the Ganser syndrome isclosely related to
malingering, have contributedto the opinion that the syndrome is
rare outsidea prison setting. Indeed, in a sense it could besaid
that, along with the other presentingfeatures in the cases
described by Ganser, thedevelopment of the illness in the prison
settingis an essential part of the syndrome. Opinionamongst the
authorities already quoted isdivided on the issue, but the majority
of authors
-
\BY F. A. WHITLOCK 23
discussed, and from the evidence so far presentedit is clear
that those suffering from Gansersyndrome are not malingerers, and
that adistinction can be drawn between hystericalpseudo-dementia
and the syndrome itself; themain differentiating feature, in the
opinion ofsome authors, is the absence of clouding ofconsciousness
in cases suffering from hystericalpseudo-dementia. The similarity
of some of theverbal responses to those of aphasics and
schizophrenics has been emphasized by a number ofauthors, and at
times difficulty is experiencedin deciding on the correct
diagnostic categoryto which the patient should be assigned.Finally,
although a number of examples of thesyndrome occurring in a prison
or militarysetting have been described, it is by no meansunusual
for the condition to develop in civilianpatients who are not in
trouble with the law.These and other points will be further
discussedfollowing the description of a number of clinicalcases,
all of whom manifested features of theGanser syndrome during the
course of theirillnesses.
CA@Cases. The patient, male, aged 26 years, a skilled
plumber
by trade, was admitted to a psychiatric ward three weeksafter
sustaining a closed head injury with concussion.Physically, he
showed inequality of the pupils and anextensorleft plantar
response.The EEG showed diffuseslow activity, an abnormality which
improved slowlythroughout the period of in-patient treatmel)t.
Mentally he was pleasant, somewhat facile, and haddifficulty in
concentrating on a given task. On questioninghe respondedas
follows:
Q. Whatis your name ?A. Itmay be the same as yours.Q. Howold are
you ?A. Howshould I know that?Later, he gave his correct age, but
gave the year of his
birth as 1922 instead of i@. When this inaccuracy wascommented
on, he replied in an offhand manner, Well,it's nearabouts. When
asked to give his address, he saidNewcastleupon Tyne, Newcastle.
Asked in what streethe lived, he replied, Itmay be the street we
have beentrying to find tonight. He was then asked to state
thecolour of his (blue) pyjamas and he replied that it mightbe red.
The colour of a red chair he gave as brown, butlater correctly as
red. He appeared to have some difficultyin naming objects correctly
and was disoriented in timeand place. When asked to say how long he
had been in theward, he replied Well,I could have come in this
minute,couldn't I?; he had some difficulty in distinguishing
between the words worldand ward.Throughout the
maintain that the syndrome is most likely todevelop in
prisoners. However, Sim, andHenderson and Batchelor, remark on
itsoccurrence in law-abiding patients, whileGoldin and McDonald,
Curran and Partridge,and Scott (1965) all support the view that it
israre in prison practice today. Of the eighteencases recently
described in the English literature(19341962) in which clinical
details areadequate, only four developed their illnesswhile in
prison, although a number of the othershad received prison
sentences in the past. Whatis particularly striking is the high
incidence ofsymptoms following some kind of trouble,either of a
domestic, sexual or financial kind.However, as a considerable
proportion ofpsychiatric illnesses of all kinds develop insomewhat
similar circumstances, there is noreason to believe that
situational stress of thiskind is necessarily a specific feature of
theGanser syndrome.
Sex IncidenceTyndal (1956) comments on the rarity of the
condition in female patients. Without givingany clinical
details, he mentions 25 cases of hisown, all males, in which he
felt the issue ofcompensation and pension played a prominentpart in
the pathogenesis. However, it is likelythat a proportion of these
cases could have beeninstances of hysterical pseudo-dementia
ratherthan true examples of the Ganser syndrome.Five of the
eighteen recently reported cases(1934-1962) were women, and a past
impressionof male preponderance may have been due moreto the
reported incidence in military and civilprisoners than to any
definite sex differentiation.
Summary of Previous AccountsIt seems clear that many traditional
textbook
accounts of the Ganser syndrome conflict withthe case reports
published in the psychiatricjournals. Further consideration will be
givenlater to the nosological status of the condition,but it is
evident that the Ganser syndrome canoccur in a variety of
psychiatric illnesses, themajority of which are due to injury or
organicdisease affecting the central nervous system.The
relationship of the syndrome to hystericalpseudo-dementia and
malingering has also been
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24 THE GANSPR SYNDROME
interview, he was cheerfW, off-hand and a little perplexed.The
great majority of his answers had the approximate andparalogic
quality of the Gamer symptoms.
Two days after admission, he was correctly oriented butstill
showed impaired powers of concentration and memorywith a tendency
to perseverate. He continued to giveparalogic answers; for example,
when asked to name theyear, he said 1938,when in fact it was 5958,
but hegave his age correctly as 24; he then looked at the dates
onhis case chart and said Why,that makes us five, it's1958.When
askedto say what he was drawing (a testpicture of a house), he
replied, It'san amalgamation ofbuilding materials. He could not
give any clearerdefinition of what he meant by this phrase. When
askedto turn over a piece of paper, he turned it round so thatthe
head of the sheet was now at the bottom. Psychologicaltesting,
using the Raven's Matrices, 5938, and the MillHill Verbal Scale,
revealed a marked deficit (Grade IV+).On discharge, he was
correctly oriented, was able to givethe correct answers to most
questions, but was stilldecidedly euphoric. He had a post-traumatic
amnesia offive weeks'duration.
Case2. The patient, a female, aged @,was admitted toa
psychiatric ward three days after falling off a ladder.She was
completely unconsciousfor a few minutes following the accident, but
managed to walk into the admissionward. At that time she was wholly
disoriented, was unableto give her name, and appeared to be
confused. Shortlyafter her admission, she walked out of the
hospital andreturned home. She was then re-admitted and
transferredto the psychiatric unit. At interview, she appeared
somewhat distraught and untidy. Physical examination andEEG studies
revealed nothing of significance. Mentallyshe appeared to be
somewhat confused; when addressedby her name, she looked over her
shoulder as if expectingto see someone of this name in another part
of the room.In reply to direct questions, she said she had four
legs andtwo heads. When a single finger was pointed at her, shesaid
there were two. She appeared wholly disoriented intime and place,
believing that she was staying in an hotel,and asked to see the
manager. Her capacity to sustain aconversation fluctuated
considerably, but over thesubsequent ten days, there was an
all-round improvementin her condition. She became correctly
oriented and wasfinally discharged. The duration of post-traumatic
amnesiawas not recorded in this case.
Case 3. The patient, a married salesman, aged 42, wasadmitted
some five days after an illness characterized byheadaches,
vomiting, insomnia and a subjective feeling offorced thinking. The
whole episode was initiated by anepileptic convulsion. There was no
previous history ofphysical or mental illness, but there was
evidence tosuggest that the patient had been under domestic
andfinancial stressfor some considerable time. At the time
ofadmission he did not show any obvious physical abnormality, but
the EEG report stated that there was adiffuse abnormality with
excess slow activity, maximalover the inferior surfaceof the left
temporal convexityandprobably rising from the left-mid-temporal
region. The
record suggested a destructivelesion in the brain. Mentallyhe
appeared somewhat puzzled, but claimed he did notfeel in any way
ill. He was disoriented in time and place,and tended to evade
giving a direct answer to any givenquestion, claiming that he was
not particularly interestedin the subject under discussion. He had
difficulty in namingobjects. However, he did not seem particularly
concernedby his failures. When asked to interpret the proverb
Astitch in time saves nine, he replied Well,a stitch issomething
under here, isn't it ?and pointed to hissub-costal margin. The
proverb Arolling stone gathersno moss he interpreted as
It'sgenerally very simple,isn't it? A rolling stone travelling
along doesn't pick upany moss, which they use on modern advertising
props, Ithink. We don't use a great deal. If they're going to
sendstones over to represent the miners as a committee, I knowwhat
you mean anyway. He mentioned that his wifehad been ill for many
years from an intractable skindisorder, and went on to say that she
had been in jail forthis condition; he later corrected himself and
said that shehad been in hospital. When asked where he was, he
saidhe was in a Department of Education in Illness, by
which,presumably, he meant a Teaching Hospital. His moodshowed an
overall flatness and detachment, but at timeshe appeared somewhat
irritated by the questions. A stockresponse to many of the
questions was Well,we don'tmake much use of that in our sort of
business.
On the following day he complained of an unusualodour of hot
metal in the room in which he was beingnursed. He still showedsome
degree of clouding, but afterthree days he was correctly oriented
and his speech hadreturned to normal A neurological examination at
thisstage revealed a slight impairment of power in the righthand,
and in view of this and the abnormal EEC, hewas transferred to a
neurological ward for further investigation. Straight X-ray of the
skull was normal, and a leftcarotid angiogram did not reveal any
obvious spaceoccupying lesion in the brain. Haematological
andbiochemical investigations did not show any abnormality.A
further EEG approximately a fortnight afteradmission showed that
activity of the right hemispherewas now almost normal; however,
there had been nosignificant change in the slow wave abnormality in
theleft mid-temporal region. On discharge the patient wasfree of
symptoms, but the precise diagnosis was uncertain.In all
probability he had sustained a cerebro-vascularaccident which had
led to the epileptic convulsion,disturbance of consciousness and
the subsequent psychiatric symptoms observed at the time of
admission.
On follow-up some two months later, he had nosubjective
complaints, but it was noted that he still hadsome slight
difficulty in putting a name to commonobjects. His speech was
normal, but he showed a mildeuphoria and pressure of talk which
were probablyfeatures of his premorbid personality.
Case @.This patient, a married 48-year-old prisonofficer, was
admitted shortly after the sudden onset of anillness characterized
by an inability to hold things in hishands and by odd and unusual
behaviour. For example,he was said to have tried to light a
cigarette, but placed
-
BY F. A. WHITLOCK 25
the match in his mouth instead of the cigarette. At thetime of
admission, he claimed not to be able to recognizeany friends, and
could not remember his own age andname, but was able to give quite
a lot of information abouthis home and family. At the time he
seemed quite placidand unconcerned by his symptoms. It was recorded
thathe seemed able to write replies to questions correctly butcould
not give a spoken answer. From time to time,however, it was stated
that whencaught unawares hedid in fact give correct replies.
Physically, apart from araised blood pressure of igo/i 10, no
abnormality wasdiscovered. In the course of history-taking from the
patientand his wife, it was discovered that he was greatly
dissatisfied with his work and recently had been very upsetby the
sudden deaths of two close friends. His wifementioned that for some
two weeks beibre the onset of theillness he had been out of sorts
and somewhat forgetful. Itwas felt at the time that these factors
played a major partin his illness, and a diagnosis of hysteria and
a differentialdiagnosis of Ganser syndrome or malingering was
made.Two days after admission he said he was well, and he wasable
to give a fair account of events leading up to hisillness. However,
he claimed that his memory for theillness itself was vague, and he
was still unable to givespoken answers to direct questions. For
example, whenasked to give the name of the day after Friday, he
couldnot give the correct answer verbally, though he wrotedown
Saturdaycorrectly. He was able to write the ageotlsis son (20
years) but was unable to spell it out aloud.
On the third day he was still unable to carry out simpletasks,
such as reciting the days of the week or the months ofthe year, to
giving his own name or counting up to 20.However, a fortnight after
admission his general capacitiesbegan to improve and he was able to
give some dates andfactual information correctly. It was noted that
at thisstage he had some features of the Gerstmann syndrome inthat
he manifested a right-left disorientation and fingeragnosia of his
right hand. An EEG at this time showed aleft temporal abnormality
characterized by a minordegree of asymmetry with increased slow
wave activity onthat side. Psychological testing using the W.A.I.S.
showeda performance scale of i o6, a verbal scale of 87 and a
fullscale of 95. The psychologist reported that in her opinionthis
result was compatible with an organic brain disturbance. Finally,
an angiogram showed obstruction of theleft internal carotid artery.
There was no evidence of aspace-occupying lesion, and all other
arterial brancheswithin the skull seemed normal. It was concluded
thatthe obstruction was probably due to thrombosis, and thatthe
features which initially had so strongly suggested anhysterical
illness were in fact due to dysphasia.
Cass 5. This patient, a married salesman, aged 47 anda known
alcoholic, was admitted to hospital shortly aftera head injury due
to a fall from the steps of his house. Fivedays after the fall he
was still partly unconscious and wasdescribed as being wholly
disoriented and talking rubbish.A month after his injury he became
noisy and restless,and for that reason was admitted to a
psychiatric ward forfurther assessment and treatment. At that time
it wasnoticed that he appeared to be confused and conf.abula
ting; he was unable to retain any piece of information formore
than a minute and seemed unable to recognizepeople correctly. As
far as one could tell, he was by nowfully conscious, but was quite
disoriented and unable togive any account of himself or of events
of the previousday. He showed classical confabulation symptoms.
Atentative diagnosis was made of Korsakoff syndrome in analcoholic
who had sustained a severe head injury. At thisstage it was noted
that some of his replies strongly suggesteda Gamer type of
response. For example, on 20 March,5965 he said it was 21 November,
1966; on 29 March, hegave the day correctly as Monday but stated it
was 25February, 1964. Later, he corrected the month to Marchbut
still insisted that it was i96@. He appeared to havesome difficulty
in naming objects, and in particular, whentested for visual acuity,
was unable to give the names ofsome of the letters on the testing
chart. At this stage hewas examined by the clinical psychologist;
his verbalscale on the W.A.I.S. was 152, his performance scale
6gand full-scale g@. There was marked impairment oflogical memory,
orientation and visual memory. On theBender-Gestalt test he had
great difficulty in copying aline of dots; at one stage, instead,
he gave a row of B's and9's, claiming that each dot looked
different. When askedto draw a row of small circles, he drew them
as stars.Other responses of a similar nature during his
testingstrongly suggested the paralogic kind of response observedin
the Ganser state. At this stage an air encephalogram,angiogram,
X-ray of skull, EEC and serology of thecerebro-spinal fluid were
all quite normal.
Case6. This male patient aged r6, was admitted shortlyafter the
acute onset of a typical schizophrenic psychosis.He had been out
with friends in the evtning@ and it wasnoticed that he was somewhat
anxious during this time.On returning home, he believed that
somebody had beenin the house, and, despite parental reassurance,
he spentthe night roaming around looking into cupboards. Onthe
following day he arranged some telephone apparatusbelonging to his
brother in a rather peculiar way. He saidthat everything was
wiredup,that there was electricityeverywhere and that his parents
were charged. Later thatday, being a Sunday, he went to church with
his family,but during the course of the service he walked into
thevestry and in a loud voice disowned his father. Later, athome,
he expressed suspicion of everyone and feared thathe was being
poisoned. The family history and previouspersonal history were
unremarkable. He was said to be anactive lad who had recently left
school after a somewhatindifferent performance there. He had a
number offriends, but tended to select them from somewhat
youngerage groups than himself. He was employed as an
apprenticecarpet-layer, and it was reported that he worked well,
andwas cheerful and friendly.
On admission he was mute, unco-operative, suspiciousand
manneristic, and appeared to have some disturbanceof conscious
awareness. When he did reply to questionshe would only say that he
should not be in hospital. Herefused to discuss his illness. Two
days later he becamemore communicative, and although he said be
could notclearly remember events prior to his admission, there
was
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26 THE GANSER SYNDROMEno evidence of clouding during this time.
He was off-handand casual in his manner. When asked why he had
spentsome time talking into an unconnected telephone, hereplied,
BecauseI like the sound of my own voice. Onthe third day he was
found lying on his bed gazing at adummy figure on the floor made up
of his pyjamas andunderclothes. He said it meant that he was two
people,one good one and one bad, and he went on to tell thedoctor
that if he (the doctor) took his hands out of hispockets he would
understand things better. When askedhow long he had been in the
ward, he remarked, Aboutfive years, how does that affect you ?When
asked toname the colours of certain objects in the room, he
gavesome correctly, but stated that a grey filing-cabinet wasbrown.
He appeared totally ur'concerned by his errors.Although some of his
replies had the quality of absurdityfound in the Ganser syndrome,
there could be no doubtthat this patient was suffering from an
acute schizophreniform psychosis, and this ce@ssed fairly abruptly
on theadministration of chlorpromazine and following
electroconvulsive therapy. Further enquiry disclosed that forsome
time the patient had been concealing considerableanxiety owing to
fear of police proceedings over a shootingincident of which he had
some knowledge. Fortunately,this matter was
resolvedsatisfactorily,and on attendanceas an out-patient one month
after discharge, the patientwas symptom-free.
DIscussIoNIt could be argued with good reason that none
of the cases described in this paper had all oreven the majority
of the symptoms described byGanser in his original paper. However,
thesame criticism could be applied to the casespresented by other
authors. Indeed, of thesixteen cases listed only one of those
describedby Weiner and Braiman showed the full pictureof clouding
of consciousness, hallucinations,paralogia, hysterical conversion
symptoms andan abrupt termination to the illness withamnesia for
the whole episode. Of the other twocases described by these
authors, one failed tomanifest hallucinations and the other showed
nohysterical symptoms, but by comparison withthe great majority of
the cases described thesethree met most of the requirements for
adiagnosis of Ganser syndrome. In fact, it isevident that to most
authors the only essentialsymptom for a diagnosis of Ganser
syndrome isthe presence of the vorbeireden symptom, andlittle
attention is paid to the presence or absenceof the other symptoms
described by Ganser.Consideration of the cases listed in this
papershould be sufficient to indicate how very
unreliable this symptom is, and how uncommonis its occurrence in
conjunction with all theother symptoms described by Ganser.
Certainlythe presence of vorbeireden alone is insufficientto
warrant a diagnosis of Ganser syndrome,which in the view of the
present author is acondition implying an acute psychosis with
atleast clouding of consciousness and a sudden orfairly brisk
termination with subsequent amnesia for the duration of the
illness.
Six of the cases previously described did not,on the evidence
presented, show clouding ofconsciousness, and one of those
presented byStern and Whiles did not even have very clearevidence
of the usual paralogia symptoms.Much, of course, depends on the
diagnosis ofclouding of consciousness, a condition by nomeans easy
to detect if the symptoms are slightor transitory. In the presence
of unequivocalorganic brain disease, the symptom is moreoften
diagnosed mainly on the basis of confusion,disorientation, failure
to sustain attention andsubsequent amnesia. By contrast, a
diagnosis ofpsychogenic clouding will more often be
maderetrospectively on the basis of amnesia, eventhough at the
height of the illness a condition ofwithdrawal, bewilderment and
vagueness mightwell make one suspect that the level of conscious
awareness is disturbed.
The symptoms of hallucinations, hystericalsymptoms, abrupt
termination to the disorderand amnesia were for the most part
absent inthe majority of cases described, as indeed theywere in the
cases described in this paper. Onlythe last in the present series
came reasonablyclose to Ganser's original description, althoughin
this case hysterical symptoms of a conversionkind were not
detected. The first two casesundoubtedly showed the characteristic
featuresof paralogia, approximate answers and disturbance of
consciousness. As far as could bediscovered at the time, neither of
them showedany hallucinations, but, in keeping with
Ganser'soriginal examples, both had sustained headinjuries shortly
before the onset of the illness.By contrast, the third case,
although showingsymptoms characteristic of the Ganser syndrome,
also had symptoms suggesting a nominaldysphasia in association with
a probable cerebrovascular accident. During his clouded phase
the
-
27BY F. A. WHITLOCK
chlorpromazine medication. His off-hand, almost contemptuous
manner of replying wasstrongly reminiscent of the disinterest
exhibitedin such marked degree by the first patient inthis
series.
Ganser Symptoms or Ganser Syndrome?Scott's (1965) suggestion
that a differentiation
should be made between Ganser ymptomsandthe Ganser syndrome has
much to commend it.For whereas the former are comparativelycommon,
the latter seems to be rare in theextreme. As already mentioned,
very few of thecases discussed came anywhere near to meetingthe
full criteria of the syndrome, and similarconsiderations apply to
the cases described inthis paper. What does seem certain is that
bothsymptoms and syndrome can occur in a widevariety of psychiatric
disorders. In a good manycases previous head injury or acute
functionalpsychosis figure prominently as settings conducive to the
development of the Gansersyndrome. However, the diagnosis of
thesyndrome cannot rest solely on the presence ofunusual verbal
responses, which when examinedclosely have little that is specific
about them.The belief that all the replies of the patients
areapproximate,in the sense that there is anunderstandable
relationship between the correctand the given answer, will not
stand up tocritical examination. A good many replies madedo not
correspond to this concept of approximation; it is the random and
absurd nature of thereplies which is much more striking.
Hence,difficulty is encountered in deciding whetherthe patient has
some form of dysphasia or aschizophrenic thought disorder, a
difficultywhich more often than not can only be
resolvedretrospectively after the end of the illness.
It remains to be decided how far one shouldcontinue to regard
the syndrome as an hystericaldisorder rather than a psychotic one.
Undoubtedly one great difficulty facing anyone wishingto clarify
this problem is the matter of nomenclature. Whereas a good many
psychiatricsymptoms can be defined with reasonableclarity, this
certainly is not so with hysteria.Slater (1965) has recently
commented on theproblem, arguing that hysteria has no
precisemeaning even though he is prepared to retain
diagnosis of Ganser syndrome seemed justifiablein the light of
his abnormal responses. Hisdesignation of the ward in the
TeachingHospital as aDepartment of Education inIllnesswas qulte
characteristic. In retrospect,the nominal dysphasia, persisting to
a veryslight degree some two months later, wouldjustify a partial
explanation of the clinicalpicture in terms of his central
disturbance ofspeech. This was, in fact, a good example of acase in
which it was extremely difficult todifferentiate a Ganser response
from an aphasicone. However, the fourth case more clearlyshowed a
nominal dysphasia, although initiallya diagnosis of Ganser syndrome
and even ofmalingering was considered. It was known thatthe patient
was unsettled in his job, and it wasthought that he might have some
reason tofeign an illness in order to leave his employment.
The fifth case was an undoubted example ofa Korsakoff syndrome
subsequent to alcoholismand head injury. Nevertheless, he
manifestedGanser-like responses in the course of hispsychological
testing. The relationship betweenthis class of phenomenon and the
more typicalconfabulation of the Korsakoff state is possiblya
fairly close one; but whereas the Korsakoffsymptoms can be
understood in terms of adislocation of time sense, the apparent
confabulation being in some cases a truly experienced event
relating to the wrong occasion,(Whitty and Lewin, 196o) the Ganser
responsehas a quality of randomness and absurditywhich is very
different from the factual andcircumstantial detail of the replies
of a confabulating patient.
Finally, in the sixth case, an acute schizophreniform psychosis,
the behaviour, thoughapparently absurd, could be interpreted
ashaving some specific symbolic meaning to thepatient. The vague,
off-hand replies werecertainly similar to the Ganser type of
response,but could have been interpreted in terms of theso-called
buffoonery syndrome of Bleuler. Inthis patient there was only
slight evidence ofclouding of consciousness, and at no time did
hemanifest any evidence of hysterical symptoms.Nevertheless, he was
partially amnesic for thewhole episode, which came to an
abrupttermination after a short course of E.C.T. and
-
28 THE GANSER SYNDROMEthe term hysterical.The so-called
conversionstates can be defined with reasonable exactness,but
dissociative states comprising fugues, amnesias and twilight
state&ail of which implysome disturbance of conscious
awarenesslackthat precise definition which would separatethem from
other psychogenic reactions. Where,for example, do the clouded
states occurring inacute psychogenic or schizophrcniform psychoses
end and hysterical twilight states begin?In both conditions intense
emotional upheavalprecedes the onset of the symptoms; and in
both,there is subsequent amnesia. Other hystericalsymptoms of a
conversion kind are by no meanscommon accompaniments, and the
so-calledhystericalpersonality cannot be regarded asan essential
predisposing factor. Hysteria, withits implications of secondary
gain and malingering, is a term so loaded with value judgmentsthat
it has become useless as a clinical description. In any case,
although Ganser used theterm hystericaltwilight statehimself, he
wasquite positive that none of his patients wasmalingering, a
consideration which applies withequal force to those described in
this paper. It isconcluded that hysteria and hysterical
areloadedwords implying a particular medianism of doubtful
validity.
A good many clinical descriptions subsequentto Ganser's original
communication have tendedto emphasize the psychotic nature of the
illnessrather than the hysterical one. If this is accepted,it might
be best to regard the Ganser syndromeand symptoms as peculiar
mental states precipitated by severe emotional stress, leading
totransient psychotic illnesses usually of briefduration. Clouding
of consciousness, of eitheran organic or a psychogenic kind, is an
essentialfeature of the syndrome. Partial or total amnesiais an
inevitable consequence of the initialdisturbance of consciousness.
The occurrence ofGanser-like symptoms in the absence of cloudingof
consciousness should lead to a considerationof malingering or
near-malingering of thepseudo-dementia kind, or of the
buffoonerysyndrome arising on a basis of schizophrenia.No useful
purpose is served by continuing toplace the Ganser state in the
category of hysteria,a term so imprecise as to defy
definition.However, at this stage it would be too much to
hope that hysteria will disappear from currentpsychiatric
nomenclature. But if it has to beretained, it should certainly not
include theGanser syndrome as one of its manifestations.
Su@n&@u@@AND CoNcI@usIoNsI. The recent literature in English
and American
journals and psychiatric text-books dealing witha variety of
aspects of the Ganser syndrome isreviewed. Consideration of
Ganser's threeoriginal cases and a number of cases examinedby the
present writer has led to the followingconclusions:
(a) Although the Ganser syndrome is traditionally regarded as an
hysterical disorder, theevidence is strongly in support of the
opinionthat the condition is a psychotic one, occurringeither after
acute cerebral trauma or in thecourse of an acute psychotic
illness, commonlyof a schizophreniform or psychogenic kind.
(b) The basic essential of the condition is adisturbance of
consciousness. It is maintainedthat this symptom separates the
Ganser syndrome from hysterical pseudo-dementia, acondition
occurring without clouding of consciousness in intellectually dull
persons in socialdifficulties.
(c) Certain similarities between the verbalresponses of the
Ganser patient, the schizophrenic and the aphasic are discussed.
Examplesof these similarities are provided by some of thecases
described.
(d) The belief that the Ganser syndromeoccurs mainly in
prisoners and male patients isnot supported by the evidence
provided by thepresent and other authors.
(e) It is suggested that a diagnosis of Gansersyndrome should be
restricted to patients who,following cerebral trauma or in the
course of anacute psychosis, develop clouding of consciousness,
with characteristic verbal responses toquestions, and whose illness
terminates abruptlywith subsequent amnesia. In a number of
caseshallucinations and conversion symptoms mightbe detected.
However, more commonly only aproportion of the features described
by Ganserwill be observed. In such cases, a diagnosis ofGanser-like
symptoms in the course of apsychotic illness might be more
appropriate.
-
BY F. A. WHITLOCK 29Ac1u@iowI2no@rrs
I should like to thank my colleagues, Dr. K. Davison andDr.
Howard Tait for making available to me the caserecords of the
second and fourth patients in this series.
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F. A. Whitlock, Professor of Psychological Medicine, University
of Queensland, Brisbane Royal Hospital,Herston, Brisbane
(Received 25 October, 1965)