For many years the Ganser svndrome has been associated in the minds of clinicians with a somewhat exotic, if not bizarre, response to stress. Like a stepchild of psychiatry, it has been shuttled from one laxonomic locus to another, depending on the particular set of clinical facts that were observed in the isolated cases the authors had reported. In 1888. Moeli applied the term "vorbeireden," (pronounced foibigh-reyden: literally - talking past the point) to the symptom of approximate answers that would later become the hallmark of Ganser svndrome: "The answer is wrong it is true, but it bears nevertheless some relationship to the sense of the question and shows that the sphere of appropriate concepts has been touched upon."'1
In an 1897 lecture, Ganser described the clinical course of three prisoners awaiting trial who presented with approximate answers, confusion, amnesia for past events. sensory and motor conversion, and auditory and visual hallucinations. The symptoms cleared rapidly but the patients suffered amnesia for the period of time during which approximate answers were given2,3:
In all cases, the entire picture of the illness was suddenly transformed in an astonishing manner. The patients appealed completely dear and intact in their consciousness, were surprised at being hospitalized, asked how they had come to he there, and declared with a convincing expression of sincerity that they knew nothing of what happened to them for a rather extensive period of time preceding . . . Precisely when this clarity appeared, all hysterical disturbance completely disappeared.
Ganser also gave a lucid description of dissociative and sensory conversion symptoms in his patients-:
I the first case manifested] a vacant gaze as if lost in dreams, without taking part in any function of his environment . . . |t)ie second patient was observed] lying motionless in his bed. his wide open eyes with dilated pupils staring fixedly at the ceiling . . . for a time he was to a considerable degree cataleptic in so far as his arms and lingers could be placed and held in bizarre and difficult positions ... [in another instance] widely extending analgesia spread over the enlire body and over the longue so that the deepest pin prick nowhere evoked a sense of pain . . . [all of the cases] knew nothing about the foolish answers which they had given earlier and appeared astonished and unbelieving about the description which one gave of thenprevious behaviour.
Two of Ganser's cases had sustained a previous blast injury to the head with evidence of "severe shock.*' while the other had suffered "a severe episode of typhus with prolonged convalescence and psychic alterations." He classified the syndrome as a "hysterical twilight condition."
The syndrome that Ganser described was to generate a considerable amount of interest and hypothesizing lor the next 90 years. (Clinicians, experimenters, and forensic psychiatrists alike have been particularly fascinated with the core symptom of approximate answers, which immediately invokes the question of malingering. A transcript from Ganser's initial patient, who incorrectly identified himself as "Furst," provides a classic example of this puzzling symptom.
Causer: "Are you able to count to ten?"
Patient: "Yes." (Bul he does noi and is silent.)
Ganser: "Well then, count.'* (But he does not and only counts on being prompted.)
Patient: "188.8.131.52." (Then he is quiet again.)
Ganser: "What follows one?"
Patient: "12, 93 and
Ganser: "How much are 2 and 1?"
Ganser: "3 and 2?"
Ganser: "5 and 2?"
Ganser: "4 minus 1?"
Patient: "5, no 3."
Ganser: "How mam legs does a horse have?"
Ganser: "An elephant?"
Was the patient counting legs, or was he trying to pull Dr Ganser's? Ganser did not think this was malingering, although he certainly considered this as a serious possibility.
These answers, which are typical of my cases, naturally raise the question whether they are after all to be taken seriously, or whether an attempi has been made here at crude malingering ... A suspicion of malingering was all lhe more pertinent since in all the cases which I observed these people were criminals . . . At no point could my patients arouse the impression of the connived or the artificial except for lhe single, repeatedly demonstrated feature [approximate answers], and I come now to the question whether the peculiar manlier of response which they showed is to be regarded as malingering or as a genuine symptom. I musi say thai I never had the impression thai ihe.se patients soughl to deceive me. They never made any spontaneous absurd remarks; only when questioned did any such answers appear, and often they showed how troublesome to diem these repealed examinations were . . . these signs and symptoms belong io a true sickness, and in this 1 was confirmed bv the sudden alteration of the picture presented by the patients, by the appearance of a gap in the memory for a circumscribed episode, with the simultaneous rei urn of the memory for the earlier normal lime . . . The fluctuating level of consciousness with defects of memory is characteristic for acute hysterical mental illness ... it characterises the syndrome as a hysterical twilight state.2
In a second lecture published in 1992, Ganser added to his clinical findings after collecting more than 20 cases.4 He found that all of his patients suffered from bilateral temporal headaches, and that some manifested a relapse of the syndrome. He remarked that die hysteriform aspects of die syndrome could exist in a comorbid interaction with psychosis or central nervous system (GNS) disease. Ganser compared the symptom of approximate answers, "antuHnt vmim" to the response of "a ticket taker who gives out whatever ticket occurs to him regardless of which one von paid for." He noted that his patients did not appear disturbed by die stupid questions he asked of them, eg, "how many ears do you have?" When one of his patients answered "4" Io this question, Ganser tried to pursue the logical inconsistency by asking to see them. The patient pointed to two "outer" and two "inner" ears.
Wertham presented the case of a suspected murderer with antisocial personality who developed Ganser symptoms during the course of an examination for probation, having served prison time tor unrelated charges. In reaction lo the apparently successful evasion of punishment in this case, Wertham coined a remark that has been repeated often in modern psychiatric texts':
A "Ganser reaction" isa hysterical pseudostupidiiy which occurs almost exclusively in jails and in old-fashioned German psychiatric textbooks. It is now known Io be almost always due more to conscious malingering than to unconscious stupe-faction. Il is often elicited and always facilitated by such inept questions as "where is your left car?" '
In support of the theory that Ganser syndrome is a manifestation of malingering. Resnick'' cited the findings of Anderson et al,1 who found that normal controls, organic brain-damaged patients, patients with pseudo-dementia, and experimental subjects asked to simulate a mental illness all evidenced approximate answers. Interestingly, in the sttid\ cited, initial instructions to the first six simulating subjects requested them to imagine that they had just committed a murder and to feign insanity or mental abnormality Vo escape the consequences. They found that these instructions inhibited the subjects. They switched instructions with their subsequent group of 12 subjects, asking them to "feign abnormality for some reason best known to them." The highest number of approximate answers were found in the pseudo-dementia group, which included one patient with a Ganser stale. SikIi responses also were found frequently in simulants. Several of the simulants found il difficult to stav in role because of the "pull of reality." Others fell as if the role were "taking hold." Reporting about one of the simulants: "It also seemed as if she had some experience of a split for she seemed to have as she put it: 'two processes of thought, one thinking deeply io prevenl me from thinking deeply' " (suggestive of dissociative thinking).
Anderson el al1 assumed ? hai the mechanism of approximate answers was probably similar in both psetidodementia simulant groups, but warned thai "the clinical picture of experimental simulation in patients with pseudodementia and thai of volunteer simulants indicate that they are noi completely similar and that assumptions cannot safely be made on this topic based on information gained from the experimental investigation of simulation."
Since approximate answers appear to be the symptom that arouses such suspicion of deliberale deception, il is interesting to note thai approximate answers have beet) observed in normal persons (particularly when fatigued), in patients with delirium, in psveholic patients who are tired or being humorous, and in children. Anderson quoted the work of early theorists who hypothesized ? hai approximate answers were a result of a focusing of the field ol consciousness with a corresponding misapplication of perception.1
In a detailed review of the literature, Goldin and MacDonald questioned the validity of main of the case reports of Ganser syndrome, citing several anieles that failed to document well-defined examples of approximate answers.' They concluded that the Ganser state should be viewed as a condition intermediate between malingering and hysterical stales of ili ore unconscious motivation.
Whiilock reported six cases of Ganser syndrome, of whom five had suffered from significant GNS trauma or disease. s He concluded that the Ganser syndrome was a condition precipitated bv severe psychic stress in patients with cerebral insult or psychosis. This appeared to precipitate a transient superimposed illness that abruptly terminated with an amnesia for the conlusional interval. In his view. clouding of consciousness, with its attendant amnesia, was essential for the diagnosis of Ganser svnclroine.
Bleuler IeIt that the Ganserian twilight slate had an origin similar to that of the "faxen-psychosis," a hyperkinetic catatonia in which psveholic patients engage in buffooncry such as pouring water onto the floor instead of a cup. He thought this was based on an unconscious need to exaggerate their illness."
Although Mayer-Gross and colleagues equated Ganser's syndrome with hysterical pseudodementia, they added the caveat that many patients were later found to be suffering from epilepsy, unsuspected schizophrenia, or organic cerebral disease.'" They postulated that Ganser patients combined organicity with a hysterical overlay related to stress, in a fashion similar to the visual hallucinations seen in shipwreck victims who have been subjected to prolonged exposurr .nul dehydration.
Other authors have presented clinical data to support the concepì of Ganser syndrome as a guise for an incipient mental deterioration of an organic or psychotic nature. Stern and Whiles likened this to Shakespeare's Hamlet, who contrived to feign a mental illness as a way of defending himself against the true madness brewing within him.' '
Weiner and Braiman, reporting on six cases, believed that patients suffering from Ganser svndrome were psychotic. Of ihe three patients that they documented with ful! clinical detail, one suffered from a paranoid personality disorder, one had acute catatonic schizophrenia, and the other suffered from neurosyphilis. They proposed that the Ganser syndrome was "a reaction Io intolerable stress with a feeling of utter hopelessness." ' J
Lieberman reported a total of five well-documented cases of Ganser syndrome that are particularly instructive because of the presence of an underlying psychosis.1 iJ ' One patient, case 3, suffered a brief Ganser syndrome presenting with approximate answers, amnesia, flaccid paralysis, and a profound sensory loss that was impervious to pin prick or open flame." The patient's Ganser state cleared one day following an amobarbital interview. When asked why he had given approximate answers, he stated that he had "blown his top" and felt guilty that he was acting coiuran' to his mother's teachings. He decided that he needed to "reverse" his conduct in order to redeem himself, ie, to do things in an opposite way.
When I first came in here I was ignored and everyone pushed me away. I then figured I guess f am doing lfiings wrong so I had lo do them the opposite way and lhat's why 1 went into the deep sleep, only because nobody paid any attention to me. But that didn't seem to work either, so when I talked to you this afternoon, the reason I answered '2 + 2 = 5' is because l h is was die only way it seemed to me I could combine the truth and a lie at the same time.
Three days later, the patient developed a severe catatonic psychosis with excitement, requiring KGT and 5 months of hospitalization. On the basis of his cases. Lieberman concluded that Ganser syndrome is both a defense and an attempt at reconstruction, a last-ditch attempt to preserve reality testing. Patients with impending psvchosis may thus employ a Ganser defense to defend against the seriousness of a grave mental illness.
In a similar vein. Peszke and Levin argued that Ganser syndrome represented an atypical psvchosis, because it represents a breakdown of the synthetic, integrative, and coping functions of the ego.1 ' They emphasized that the clinical state with Ganser patients must be viewed on a clinically evolving continuum rather than at the instant that these dramatic symptoms are manifested. They hypothesized thai Ganser syndrome represented the attempt of a vulnerable person to mimic psychological disorder through semivohmtary symptoms thai are culturally predetermined and sensitized by preexisting injury such as head trauma: "It is the mad attempting to be seen as crazy.'1
GANSER SYNDROME AS A DISSOCIATIVE DISORDER
In 1984, Gocores et al reviewed a total of 43 cases of Ganser syndrome from lhe literature."' They found that 93% suffered from amnesia. 56% were disoriented, 51% had hailucinations. 33% experienced fugue, and 33% manifested conversion symptoms. Arguing that patients with multiple personality disorder, psychogenic amnesia, conversion symptoms, and individuals subjected io specific hypnotic suggestions may suffer from similar symptomatology, Cocores et al concluded that Ganser syndrome should be reclassified as an atypical form of dissociative disorder that could derive from an unrecognized self-hypnosis. Thev recommended that fuliire studies provide longer follow-up and a careful assessment of hvpnolizability.
Symptom Breakdown in 52 Cases of Ganser Syndrome
In 1987. Ganser syndrome was shifted fioni its status in DSM-Il] as a factitious disorder io an atypical dissociative disorder in DSM-IfI-R. In this reclassification, it has been returned to its original placement with the early concept of hysteria, which was viewed as a form of dissociation by some authors."1
SYMPTOM CONFIGURATION, DEMOGRAPHICS AND COMORBID DIAGNOSES
Ganser syndrome was found in approximately ().o% of consecutive cases in military prisoners, 0.6% of a civilian, noncriminal series.1- and 0.8% of workers referred for disability insurance.17 Older studies cited by Weiner and Braiman estimate that between 20%. and 33% were noncriminal cases.1"
To provide an updated estimate of the frequency and spectrum of symptoms found in Ganser syndrome, lhe author conducted a direct review of" 75 case reports from the literature.2,5,7,8,11-16,18-47 Of these, 23 cases were excluded for not presenting specific evidence of approximate answers clearly matching die pattern defined by Ganser, or for not providing enough clinical information to make a rudimentary estimate of symptom frequency.1,18,22,24-27,17 Additional specific reports cited also were excluded: cases 1 and 2 in Windoek,8 cases 2 and 3 in Weiner and B raiman,1'-' cases 1 and 4 in Nyiro and Iranyi,21 cases 2 and 6 through 9 in Tsoi23. Although I believe I have included the great majority of articles published in the English language, other articles were inaccessible or unavailable for translation.
Demographic Characteristics in Ganser Syndrome
Comorbidity and Intelligence in Ganser Syndrome
Table I summarizes the frequency of various symptoms. Amnesia, motor or sensory conversion symptoms, and disorientation appeared in the majority of cases. Fortv-eighl percent of patients experienced hallucinations or delusions. 44% manifested a disconnected demeanor described in various reports as perplexity, vacant stare, dreaminess, or "belle indifference," and 42% evidenced rapid clearing of Ganser symptoms within 21 days. The list of 10 core Ganser symptoms against which each case was rated included:
* approximate answers,
* amnesia for past events,
* rapid clearing of symptoms,
* amnesia for symptomatic state.
* loss of identity, and
* fugue stale.
Seventy-nine percent of the cases suffered from four or more Ganser symptoms. The average number of total Ganser svmptoms was 5.0 ±2.1.
Table 2 summarizes demographic characteristics: 80%. of the cases were male, 29% of cases had criminal charges, and 15% were involved in civil litigation. The average duration of Ganser svmptoms was 30 days. Table 3 reviews the clinical substrate from which Ganser syndrome arises. Psychosis, head trauma, oilier GNS disease, major depression, and alcoholism appeared frequently. It should be noted that only two cases were documented with a case of factitious disorder or malingering. Average IQ was 80 ±22.
Thirty-one case reports provided information about premorbid personality characteristics. Of these, 9 were described as normal, 6 with paranoid features, and IO with conduct disturbance or overt antisocial behavior. Another 18 patients were distributed with 2 or 3 patients each manifesting obsessional, histrionic:, avoidant, passive-aggressive, unstable, immature, aggressive, or schi/.otypical premorbid personality features.
Narcoanalysis with intravenous aniobarbital or other barbiturate was documented in 10 cases.184.108.40.206,29,31,37.3SM4 In six cases, this resulted in an unmasking or intensification of psychotic disorganization cii delusions. Approximate answers usually persisted under influence of" the drug. In three cases, the procedure appeared to be of value in helping a resolution of the syndrome. In one case, conversion symptoms were abolished, bul approximate answers continued during use of intravenous amobarbital.
TRANCE LOGIC AS A FACTOR IN GANSER SYNDROME
This review furnishes additional documentation supporting lhe classification of the Ganser syndrome as a dissociative condition. In a majority of cases reviewed, lhe Ganser slate was superimposed upon a more serious underlying nervous disorder. The symptoms of amnesia, disorientation, conversion symptoms, rapid clearing of symptoms, and perplexity are best explained by a dissociative state. While hallucinations could be a manifestation of coexisting psvchosis, they are also encountered in purely dissociative slates such as multiple personality disorder. In this regard, the author has observed a well-defined Ganser syndrome occurring in several persons suffering from multiple personality disorder. In one case, specific primitive or persecutor)' alters gave approximate answers to standardized questions during the same session in which the host personality was able lo respond normally. Higier's finding that subjects in the posthypnotic stale manifested some of the features of Ganser syndrome may relate to the spontaneous trance phenomenon that is part of multiple personality disorder.48
Orne's concept, of "trance logic" is particularly instructive in providing some explanations for the puzzling Ganser phenomena, including approximate answers.49-5" In a series of elegant experiments that have been recently replicated, ;i1 Orne found that hypnotized subjects could be reliably distinguished from simulators by the presence of trance logic, which is analogous to primary process thinking. ''' He defined it as "the apparently simultaneous perception and response to both hallucinations and reality without any apparent attempts to satisfy a need for logical consistency." For example, when highly hipnotizable subjects were told during trance that they would see a person in a different part of the lab than the person was actually sitting, they were surprised to see a "double" of the target individual. (One real and one hallucinated). Most hypnotized subjects also reported seeing features of the backdrop through the hallucinated individual as if he were transparent. Simulators failed to report "doubles" as frequently as hypnotized subjects, and never reported transparency.'1
These studies can provide us with a convincing explanation for some of the puzzling behavior of Ganser patients. Their approximate answers follow the pattern of trance logic. It is a form of knowing and not knowing .simultaneously. (Conscious perception is disconnected like a split-screen video into two segments of awareness. An ego that is overwhelmed by painful reality dissociates itself from that knowledge. Such a reality for Ganser patients usually includes the perception of an impending psychotic disintegration, the fading cognitive capacity of a damaged brain, depression, physical illness, or the psychic stress of an unbearable life situation. Perhaps this is why premature attempts to address the reality with narcoanalysis so often reveal an agitated, disorganized, or psychotic state, and why a rapid resolution frequently occurs with hospitalization and supportive therapy alone.
This line of reasoning also can explain some of the puzzling findings in lhe experimental studies comparing simulators with pseudodementia patients. As seen in the stud ? by An de iso ? et al,1 one of the problems associated with asking normal persons to simulate a mental disease is that approximately 20%i of any randomly selected experimental population will be highly hypnotizable individuals who mav be more likely to find themselves "taken hold" in a simulation role. The fact that such individuals exhibit approximate answers may in part be a function of a spontaneous trance, similar to that experienced by actors.
From a practical point of view, it should be remembered that Ganser patients also are likely to be highly hypnotizable individuals who will be very sensitive to suggestion in a way that mav not be entirely predictable. This can be used in a positive way to assist them in coping with the stress or underlying disorder that has precipitated their dissociative illness. A structured protective environment, coupled with supportive psychotherapy and treatment for comorbid conditions, is likely to facilitate a rapid resolution. Gonversely, overzcalous efforts to induce the patient to "tell the truth" or to "stop faking" are likely to propagate increasingly negative responses, or paradoxically, a pseudocompliance thai will further confound the clinical picture. In their study on sudden memory loss, Kennedy and Neville emphasized, "The patient, if pressed, may actually admit he is malingering when in fact there is strong evidence of an organic or psychogenic causation. A confession cannot therefore be accepted as certain evidence of malingering."32
According to Erickson and Rossi, "not knowing" is an essential component of the trance experience. :';i Since it is a form of trance that maylie lhe active process in dissociative disorders, could it be that in excessive haste to arrive at the "truth" with Ganser patients, we loo may sometimes miss the point?
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Symptom Breakdown in 52 Cases of Ganser Syndrome
Demographic Characteristics in Ganser Syndrome
Comorbidity and Intelligence in Ganser Syndrome