You are in: eMedicine Specialties > Psychiatry > Emergency Ganser SyndromeArticle Last Updated: Aug 30, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Daniel Schneider, MD, Staff Physician, Department of Psychiatry and Neurology, University of Massachusetts Coauthor(s): Brian R Szetela, MD, Assistant Professor, Department of Psychiatry, University of Massachusetts Medical School; Consulting Psychiatrist, Psychiatric Consultation - Liaison Service, University of Massachusetts Memorial Medical Center; Robert C Daly, MB, ChB, MPH, BCh, Senior Fellow, Department of Behavioral Endocrinology, National Institute of Mental Health, National Institutes of Health Editors: Alan D Schmetzer, MD, Professor and Vice-Chair for Education, Department of Psychiatry, Director of Residency Training, Indiana University School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories; Harold H Harsch, MD, Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin; Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA Author and Editor Disclosure Synonyms and related keywords: psychotic episodes, psychotic illness, psychosis, clouding of consciousness, inattentiveness, drowsiness, hysterical paralysis, hallucinations, hysteria, malingering, alcoholism, head injury, epilepsy, stroke, cerebral infection, dissociative disorder, factitious disorder, amnesia, psychosocial stress, vorbeireden, echolalia, echopraxia, confusion, Ganser syndrome, Ganser's syndrome INTRODUCTIONSection 2 of 11
  BackgroundIn 1898, German psychiatrist Sigbert Ganser first published a lecture, delivered the previous year, describing 3 patients who exhibited a set of symptoms, which he felt described a new hysterical syndrome. Ganser syndrome, as it is now known, has been the subject of much debate since this original paper. Questions about its etiology, its definition, its classification, as well as its status as a true mental illness versus a specific form of malingering has been the subject of multiple journal articles and book chapters. The most well-recognized symptom of this disorder is the so-called symptom of approximate answers (alternately designated by the German terms vorbeireden, "talking past"; vorbeigehen, "to pass by"; or danebenreden, "talking next to" in the literature). Here, the patient responds to questions with an incorrect answer, but by the nature of the answer reveals an understanding of the question posed. This can be illustrated by the patient answering "3" when asked, "How many legs has a horse?" or "black" when asked "What color is snow?" or "Tuesday" when asked "What is the day after Sunday?" Frequently, the patient will answer a number of questions with these bizarre approximate answers. This is in direct contrast to answers that are simply nonsensical, perseverative, or otherwise inappropriate. Ganser was clear that, although approximate answers may be the "most obvious" of the symptoms he described, the syndrome included other important components as well. Although early investigators did not always agree with Ganser on this point, there has been a consensus over the last many decades that the true Ganser syndrome (as opposed to the "Ganser symptom" or "Ganser sign") includes a number of related symptoms. Enoch and Trethowan (1979) proposed an influential set of 4 essential criteria: approximate answers, clouding of consciousness, hallucinations (visual and auditory), and somatic conversion symptoms. Others have emphasized Ganser's description of a limited time-course, sudden remission, and amnesia for events during the illness state as important constituent symptoms as well. The exact number of these symptoms needed to make a diagnosis has been a matter of dispute though having the symptom of approximate answers and at least one other relevant symptom appears to be a reasonable minimum. PathophysiologyThe basic underlying etiology is unknown. From the time of the earliest case reports, debates over the hysterical versus psychotic origin of the symptomatology were common in the literature. Organic etiologies have also been proposed due to the obvious comparisons with acute delirium, noted as early as Ganser's original article, as well as the frequent history of head injury or recent illness in these patients. The limited time-course of the syndrome as well as the subsequent amnesia has lead to the popularity in recent years for dissociation as an explanation, and malingering and factitious disorder have also proposed as possible etiologies. These causative explanations are not mutually exclusive, and it is possible that not all patients develop this set of symptoms for the same reasons. In most, if not all, cases described in the literature, psychological or physical stressors have been identified occurring prior to the initiation of symptoms. The classic example was when one was placed in jail and then he gives some very bizarre answers to questions. A commonly suggested psychodynamic mechanism for the syndrome is the urge to avoid an unpleasant situation and its burden of responsibility. Organic etiologies, such as head injury, dementia, alcoholism, epilepsy, stroke, and cerebral infection, have also been identified as causes of the syndrome. In one positron emission tomography (PET) study, hypometabolism in the bilateral occipital and posterior temporal and parietal lobes was found in a patient exhibiting the syndrome after severe asthma-induced hypoxia. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) currently classifies Ganser syndrome as a dissociative disorder. FrequencyInternationalThe full syndrome is considered very rare. Fewer than 100 cases have been described and documented in the literature. Mortality/Morbidity
RaceInformation on race has not always been available in the case reports, but patients of all racial origins have been reported. Some have noted that it may be more frequent in those of a racial minority status. SexIn one review of 43 case reports, 74% were noted to be male. In another review of 15 case reports, all were male. The vast majority of case reports are male, but whether this difference is real or due to selection bias is uncertain. AgeIn one review of 43 case reports, the average age was 32 years, with a range from 15-62 years. Cases from across the age range have been reported. CLINICALSection 3 of 11
HistoryGanser 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.
Physical
CausesRule out major underlying organic or psychiatric etiologies. DIFFERENTIALSSection 4 of 11
Alcoholism Bipolar Affective Disorder Delirium Dementia Due to Head Trauma Dementia Due to HIV Disease Depression Dissociative Disorders Encephalopathy, Hepatic Factitious Disorder Head Trauma Malingering Meningitis Schizophrenia
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