10.1192/bjp.113.494.19Access the most recent version at DOI: 1967, 113:19-29.BJP

F. A. WHITLOCKThe Ganser Syndrome

Referenceshttp://bjp.rcpsych.org/content/113/494/19#BIBLThis article cites 0 articles, 0 of which you can access for free at:

permissionsReprints/

permissions@rcpsych.ac.ukto To obtain reprints or permission to reproduce material from this paper, please write

to this article atYou can respond http://bjp.rcpsych.org/cgi/eletter-submit/113/494/19

from Downloaded

The Royal College of PsychiatristsPublished by on December 17, 2012http://bjp.rcpsych.org/

http://bjp.rcpsych.org/site/subscriptions/ go to: The British Journal of PsychiatryTo subscribe to

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

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

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

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

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

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.

REFERENCES

ANDERSON, E. W. (1964). Psychiahy. London., and MALLINSON, W. P. (1941). Psychogenic

episodes in the course of major psychoses. J. ment.Sd., 87, 383396.

, TRETHOWAN, W. H., and KENNA, J. C. (ig@g). Anexperimental investigation of simulation and pseudodementia. Ada psych. ci neurol. Scan. Supp. 132 to Vol.34, pp. 142.

AIUEn, S., and METH, J. M. (ig@g). American Handbook ofPsychiatry. Vol. I. 547-548.

BAUMANN, W. (igo6). Emseltener Fall vom hysterischemDmmerzustande. Neurol. Ceniralb. Leipz., 25,849854.

BENDER, L. (1934). Psychiatric mechanisms in childmurderers.3. nerv.ment.Dzs., 8o, 3247.

Bunci, 0. (1936). Lehrbuch der Geisteskrankheiten. 4th Ed.:Munich.

CitrrcHi.zY, M. (1964). Psychiatric symptoms andparietal disease.Proc. Roy. Soc. Med., 57, 422428.

Cuiu@.AN, D., and PARTRIDGE, M. (1963). PsychologicalMedicine. 5th Ed. London.

ENOCH, M. D., and IRvING, G. (1962). TheGansersyndrome.Ada. psych.Scan., 38, 213222.

FISH, F. (1962). Schizophrenia: Bristol.GANSER, S. J. (i8g8). Uber einen eigenartigen hysteri

schen Dmmerzustand.Arch.f. Psychiat., Ben., 30,633640.

GoLrnN, S., and MACDONALD, J. E. (ig@@). The Ganserstate.3. ment.Sci., 101, 267280.

GREGORY, I. (1961). Psychiatry. Philadelphia.

HENDERSON, D., and BATCHELOR, I. R. C. (1962). Textbookof Psychiatry. 9th Ed. O.U.P.

KILOH, L. G. (96'). Pseudo-dementia. Ada psych.Scan., 37, 336351.

LIEBERMANN, A. A. (1945). TheGanser syndrome.illinois med. 3., 88, 302-306.

McGa@m, S. D., and MCKENNA, J. (,@6i). TheGamersyndrome; a critical review. Proc. @d WorldCongress of Psychiatry. Vol. I. p. 156. Montreal.

MAY, R. H., VOEGELE, G. E., and PAouLo, A. F. (I)6o).TheGanser syndrome; a report of three cases.3. nerv.ment.Dis., 130, 331339.

MAYER-GROSS, W., S1@mR, E., and Rom, M. (i g6o).Clinical Psychiatry. 2nd Ed. London.

NoYEs, A. P., and KOLB, L. C. (1963). Modern ClinicalPsychiatry.6th Ed. Philadelphia.

PICK, A. (i917). Monatschr.f. Psychiat., Bert., 42, 197.Scorr, P. D. (1965). TheGamer syndrome.Bnit. 3.

Criminol., 5, 127134.SIM, M. (1963). Guide to Psychiatry. Edinburgh.SKo'rrowE, I. (1964). Clinical Psychiatry for Practitioners and

Students. 2nd Ed. London.SLA1'ER, E. (p965). Diagnosisof hysteria. Brit. med. 3.,

2, 13951399.Smius@, E. E., and WmLEs, W. H. (1942). ThreeGanser

states and Hamlet. 3. ment. Sd., 88, 134141.SzAsz, T. (1961). The Myth of Mental illness. New York.TYNDAL, M. (1956). Someaspects of the Gamer state.

3. ment.Sd., 102, 324329.Voss, G. (@9o8). Zuraetiologie der Dammerzustnde.

Zentralbl. f. Xervenh. u. Psychiat., Leipz., 31, 678-682.WEINER, H., and BRAIMAN, A. (1955). TheGamer

syndrome. Am. 3. Psych., iii, 767773.WERNICKE, C. (igo6). Grundniss den Psychiatnie. Leipzig.WERTHAM, F. (i@@). The Show of Violence. New York.Wmm, C. W. M., and LEwIN, W. (ig6o). AKorsakoff

syndrome in the post-cingulectomy confusionalstate.Brain, 83, 648-653.

F. A. Whitlock, Professor of Psychological Medicine, University of Queensland, Brisbane Royal Hospital,Herston, Brisbane

(Received 25 October, 1965)