Ganser syndrome is a rare dissociative disorder characterized by a set of distinctive psychological symptoms. It typically manifests as giving nonsensical or incorrect answers to simple questions, a behavior known as “nonsense syndrome” or the “syndrome of approximate answers.”
Patients with Ganser syndrome often display confusion, memory loss, and impaired consciousness. They may appear to have difficulty performing basic tasks or recalling common knowledge.
The condition is more prevalent in individuals under stress, particularly those in forensic or custodial institution settings. It can be acute or chronic, with symptoms potentially lasting from hours to months.
Ganser syndrome was first identified by German physician Sigbert Ganser (1853-1931). In 1898, he documented the disorder among criminals awaiting trial at a correctional institute in Halle, Germany.
He identified the syndrome’s characteristic symptoms as impaired consciousness and distorted communication, namely approximation answers (also known as Vorbeireden in the literature). Vorbeireden refers to the difficulty of precisely answering questions, even if the content of the questions is comprehended.
Symptom Presentation
Ganser syndrome manifests through a unique combination of symptoms affecting cognition, behavior, and perception. Patients exhibit characteristic signs that distinguish this condition from other psychiatric disorders.
The hallmark feature of Ganser syndrome is approximate answers to simple questions. Patients provide responses that are close but incorrect. For example, when asked how many legs a dog has, they might say “five” instead of four.
Other common symptoms include:
- Confusion and disorientation
- Hallucination
- Memory loss or amnesia
- Somatic complaints without clear physical cause
- Altered consciousness or trance-like states
- Clouding of consciousness
Gait abnormalities, rigidity, and temporary blindness may also occur in some cases. Patients often appear perplexed and struggle with basic tasks.
Psychological symptoms of Ganser syndrome often correspond to the patient’s sense of mental illness rather than any recognized categorization. The syndrome may occur in persons with other mental disorders such as schizophrenia, depressive disorders, toxic states, paresis, alcohol use disorders and factitious disorders.
Etiology and Risk Factors
To date, no conclusive cause or reason for the condition has been identified. The publications that categorize the syndrome as a dissociative disorder or a factitious disorder disagree on their postulated etiologies. As a result, there are various views about why the syndrome occurs.
Extreme stress is a key trigger for Ganser syndrome. Traumatic experiences, especially in childhood, can predispose individuals to dissociative symptoms. Acute stressors like imprisonment, severe accidents, or combat exposure may precipitate onset.
Work-related stress can also contribute. A 2009 study from Hans Markowitsch and colleagues found Ganser syndrome emerged in an immigrant following occupational difficulties. This highlights how cultural adjustment and job pressures can act as risk factors.
Ganser syndrome is often known as “prison psychosis” due to its prevalence among convicts, sparking debate about whether the condition solely affects this community.
Estes and New concluded in a study of prisoners that fleeing an uncomfortable environment, such as incarceration, triggered the syndrome’s primary symptoms. The study addressed the malingering dispute surrounding the illness, as well as the stress factor that frequently precedes the disorder.
Traumatic brain injuries, particularly to frontal regions, have been implicated in some cases. This suggests a potential interplay between psychological trauma and neurological insult in Ganser syndrome development.
Neurotransmitter imbalances may play a role. Alterations in dopamine and serotonin systems could influence the manifestation of dissociative symptoms.
Co-occurring Disorders
Ganser syndrome often appears alongside other mental health conditions. Depression and anxiety frequently co-occur, potentially exacerbating dissociative symptoms.
Schizophrenia has been linked to Ganser-like presentations. The cognitive deficits in schizophrenia may predispose some patients to approximate answers and confusion characteristic of Ganser syndrome.
Other dissociative disorders can overlap with Ganser syndrome. This suggests shared underlying mechanisms related to disrupted integration of consciousness, memory, and identity.
Factitious disorders have also been associated with Ganser syndrome. Some experts debate whether certain cases represent genuine dissociation or conscious production of symptoms.
Diagnosis
Diagnosing Ganser syndrome requires careful evaluation of specific symptoms and ruling out other conditions. The process involves assessing the patient’s behavior, responses, and medical history.
The DSM-IV-TR classified Ganser syndrome as a dissociative disorder defined by the giving of approximate answers to questions. DSM-IV does not specify any diagnostic criteria—apart from approximate answers—as a requirement for a Ganser syndrome diagnosis.
The DSM-5 classifies Ganser syndrome under Other Specified Dissociative Disorder. The ICD-10 lists it as a dissociative disorder. Diagnosis often requires observation over time to establish a pattern of symptoms.
Although there is no universally accepted method for diagnosing the illness, a comprehensive neurological and mental state examination, as well as tests to identify malingering, have been advised. In addition to the mental assessment, other examinations should be conducted to rule out any other underlying causes.
These include computer tomography (CT) or magnetic resonance imaging (MRI) scans to rule out structural pathology, a lumbar puncture to rule out meningitis or encephalitis, and electroencephalography (EEG) to rule out delirium or seizures.
Debates
There is debate over whether Ganser syndrome is a legitimate clinical condition. Bromberg, for example, has claimed that the syndrome is not caused by or related to mental illness, but rather serves as a shield against legal punishment. Some interpret it as conscious lying, denial, and repression, and describe Ganser syndrome symptoms as malingering rather than a dissociative or factitious disease.
One 2007 case study of Ganser syndrome presented a middle-aged man who had been in a car crash and wanted disability insurance benefits. Because he had a big incentive, psychologists took careful measures and implemented testing with malingering instruments, which showed that the man performed below chance on simple memory tests and claimed to experience non-existent symptoms.
Upon further inspection of the collateral information, they found that the patient took part in high-level sports and other activities that were inconsistent with the cognitive dysfunctions he reported, and they determined it to be a case of malingering.
Estes and New (1948) argued that the syndrome’s symptoms were motivated by the desire to escape an “intolerable situation”. Stern and Whiles provided an alternate explanation, citing Ganser syndrome, which manifests itself in individuals who, while not psychologically well, are unaware of it and seek to look so.
Others have ascribed the syndrome to inattention, willful avoidance, suppression, alcoholic excess, head trauma, and unconscious attempts to deceive people in order to avoid accepting responsibility for their acts. This denial of behaviour can be interpreted as a means of overcoming fear and helplessness caused by the traumatic experience that frequently precedes the condition.
These controversies focus on the main symptom of Ganser syndrome and its importance in its diagnosis. Approximate answers are prominent in the Ganser syndrome literature, causing concern in those who believe that this is a relatively simple symptom to feign.
References:
- Bromberg, W. (1986). The neglect of Ganser Syndrome. The American Journal of Psychiatry, 143(7), 937-938
- Dieguez, S. edited by J. Bogousslavsky, J. (2017) Neurologic-Psychiatric Syndromes in Focus – Part II: From Psychiatry to Neurology.. S.Karger AG ISBN 978-3-318-06088-1
- Dwyer, Justin et al. Ganser’s syndrome (2004) The Lancet, Volume 364, Issue 9432, 471 – 473
- Epstein, R.S. (1991). Ganser Syndrome, Trance Logic, and the Question of Malingering. Psychiatric Annals, 21(4), 238-244. doi:10.3928/0048-5713-19910401-11
- Mendis, S.; Hodgson, R.E. (2012). Ganser Syndrome: examining the aetiological debate through a systematic case report review. European Journal of Psychiatry, 26(2). doi:10.4321/S0213-61632012000200003
- Merckelbach, H.; Peters, M.; Jelicic, M.; Brands, I. and Smeets, T. (2006). Detecting malingering of Ganser‐like symptoms with tests: A case study. Psychiatry and Clinical Neurosciences, 60: 636-638. doi:10.1111/j.1440-1819.2006.01571.x
- Staniloiu, A., Bender, A., Smolewska, K., Ellis, J., Abramowitz, C., & Markowitsch, H. J. (2009). Ganser syndrome with work-related onset in a patient with a background of immigration. Cognitive Neuropsychiatry, 14(3), 180–198.
- Trifu, Simona & Ion, Daniela & Enache, Iulia Ioana & Vasile, Antonia Ioana. (2019). Ganser Syndrome As A Particularity of the Cognitive Deficit In Schizophrenia. International Journal of Research GRANTHAALAYAH 7. 222-230. 10.5281/zenodo.3566736.
- Whitlock, F.A. (1967) The Ganser Syndrome. British Journal of Psychiatry, 113(494), 19 29. doi: 10.1192/bjp.113.494.19