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C A S E R E P O R T

Ganser syndrome: a case report from Thailand

Kanida Tassniyom1 MD, Suchat Paholpak1 MD, Sompon Tassniyom2 MD, Thawatchai Krisanaprakornkit1 MD &

Peerada Unprai1 BSc

1 Department of Psychiatry, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand2 Department of Pediatrics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Keywords

Ganser syndrome, case report, Thailand

Correspondence

Kanida Tassniyom MD, Department of

Psychiatry, Faculty of Medicine, Khon Kaen

University, Khon Kaen, Thailand.

Email: kanida@hotmail.com

Received: 12 March 2009

Accepted: 5 May 2009

DOI:10.1111/j.1758-5872.2009.00007.x

Abstract

Ganser syndrome or syndrome of approximates is characterized by the

patient giving incorrect answers to questions, despite showing an under-

standing of the questions, clouding of consciousness, perceptual abnorm-

alities and symptoms of somatic conversion. The syndrome has a sudden

onset, resolves abruptly, and is followed by subsequent amnesia. It was first

described by Sigbert Ganser in 1897. It was earlier described as a hysterical

disorder, and debate about its classification continues today. Currently, it is

categorized under the rubric of dissociative disorder. Overall, fewer than 50cases have been reported. The etiology of Ganser syndrome remains

unknown. Some precipitating stressors have been reported and in other

cases patients have had organic brain syndrome. Hospital admission has

been recommended, but treatment with antipsychotic medication is not

necessarily advised because the syndrome can resolve without treatment.

The prognosis is uncertain. The present report is of a 40-year-old Thai male

with symptoms of clouding of consciousness, approximate answers to

simple questions, reported auditory hallucinations and somatic delusions.

All symptoms resolved within 5 days and the patient had no recollection of

the event. Ganser syndrome is still considered a rare psychiatric syndrome

requiring further exploration.

Introduction

Ganser syndrome or syndrome of approximates is

characterized by four main clinical features: approx-

imate answers to simple questions, clouding of con-

sciousness, perceptual abnormalities and symptoms of

somatic conversion (Dwyer & Reid, 2004; Sadock &

Sadock, 2007). The outstanding feature of Ganser

syndrome is approximate answers, although incorrect,

indicating that the question has been understood. For

example if asked How much is two plus three? the

patient may give an answer of Four or Six. Cloud-

ing of consciousness can fluctuate during the course of

the illness. Perceptual disturbances include auditory or

visual hallucinations, which may be vivid, accompa-

nied by abnormal behavior responding to the halluci-

nations. Various somatic conversion symptoms can be

found, including gait abnormalities, hemiplegia or

hyperalgesia.

Ganser syndrome was first described in 1897 by a

neurologist Sigbert J.M. Ganser while working at a

penal institution in Germany. He wrote Concerning

an unusual hysterical confusional state describing the

syndrome in three prisoners. In the 1960s, Ganser

syndrome was described in English textbooks under

the description Hysterical disorders, while American

textbooks listed it under Rare, unclassified, collective

and exotic psychotic syndromes (Whitlock, 1967).

The syndrome has had many reclassifications, such as

adjustment reaction, somatization disorder, factitious

disorder, psychotic disorder, and malingering. Cur-

rently in the International Statistical Classification of

Diseases and Related Health Problems 10th Revision

(ICD-10), Ganser syndrome is categorized under dis-

sociative disorder and in Diagnostic and Statistical

Manual (DSM)-IV-TR under dissociative disorder not

otherwise specified (NOS; Cocores et al., 1984; Brom-

berg, 1986; Knobloch, 1986).

Ganser syndrome is a rare disorder; overall fewer

than 50 cases have been reported. The condition is

poorly understood and has been neglected (Carney

et al., 1987). Men with the syndrome outnumber

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Asia-Pacific Psychiatry ISSN 1758-5864

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women by approximately two to one. The male pre-

ponderance may relate to the reported occurrence of

the syndrome in military personnel and prisoners

(Tsoi, 1973). The etiology of Ganser syndrome remains

unknown. Some case reports describe precipitating

stressors and others organic brain syndromes, head

injuries, seizures or psychiatric illness.The differential diagnoses of this syndrome include

other forms of dissociative disorders, malingering, or-

ganic dementia, depressive disorder (pseudodemen-

tia), epilepsy, catatonia, post concussional syndrome,

compensation neurosis and schizophrenia.

Hospital admission is often recommended. A brief

hospital admission may clarify the diagnosis and fre-

quently includes remission (Carney et al., 1987). In-

itiation of antipsychotic medication is unclear. Ganser

syndrome can resolve abruptly in the absence of

specific treatment, with the patient having no memory

of the episode. The prognosis of the syndrome is

uncertain, although a review of published case studies

suggests that some patients experience further epi-

sodes (Dwyer & Reid, 2004).

Because the syndrome is uncommon and often

underdiagnosed, the present report from Thailand

will add to the collection of previous published case

reports.

Case report

A 40-year-old, single, Thai male, working as a govern-

ment officer in the northeastern province of Thailandpresented to the internal medicine clinic at Srinagarind

Hospital, Khon Kaen University with the chief com-

plaint of diplopia and pain in both thighs lasting 7 days.

The physician found that the patient had clouding of

consciousness, strange responses and an unusual per-

sonality. Work-up of the man as an inpatient revealed

no organic causes. A psychiatric consultation was

requested.

Table 1 lists some of the questions that were asked

during the psychiatric interview, together with the

patients answers. The patient believed that black

magic was placed on him, during which something

was inserted into his thigh causing progressive pain.

(In Thai folk culture some people still believe in black

magic, sorcerers and ghosts that can place screws or

buffalo skin into the body.) The patient heard voices

which forced him to obey their commands. Sometimes

he heard the voices of people talking. When in

crowded places people would talk behind his back and

try to humiliate him. He was mildly anxious and

depressed. No specific stressor was found.

The patients aunt confirmed that he had no

previous psychiatric history. He had a motorcycle

accident 15 years ago and craniotomy was performed

to remove an intracranial blood clot. There were no

neurological complications. He was also diagnosed

with aplastic anemia in 2003, but the disease was now

inactive. He had no history of seizure or substance

abuse. One of his grandparents and two of his aunts

had psychiatric disorders with unknown diagnosis.

Physical examination revealed clouding of con-

sciousness, but no other abnormalities. Neurological

examination and laboratory investigations were nor-

mal. Brain CT scan revealed an old cerebral infarction

Table 1. Questions and answers from a psychiatric interview with a

40-year-old male Thai patient with Ganser syndrome (correct answers

are given in brackets)

Question What is your name?

Response The patient gives a name that is not his.

Question What do you do for a living?

Answer A government officer at the office of elementary

education.(The patient is a government officer at a court

administrative office.)

Question What is todays date?

Answer Today is Monday, 30 February 2007, in the summer,

3 p.m.

(It is actually Saturday, 30 June 2007, rainy season,

4.30 p.m.)

Question What is this place?

Answer At the moment, Im on the plane, these are all

airhostesses.

Question How much is 111?

Answer Three.

Question How much is 212?

Answer Five.Questi on Serial 7 (Patient is asked to subtract 7 from 100 and

then 7 from the result four more times.)

Answer 92, 84, 75, 67, 59.

Question What is this?

(A pen is shown to the patient.)

Answer Penci l.

Question What is this?

(Eyeglasses are shown to the patient.)

Answer Binocular on ears.

Question Please use your left hand to touch your right ear.

Response The patient lifts his right hand and touches his left ear.

Question The patient is asked to let go of his ear.

Response The patient does not do so.

Question 3 stage command (Patient is asked to take a piece ofblank paper in their right hand, fold it in half, and put it

on the floor.)

Response The patient picks up the paper with his left hand and

places it on the table.

Question Please copy this figure.

(The patient is shown intersecting pentagon.)

Response The patient draws two overlapping circles.

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in the right occipital lobe and a skull defect at the

temporoparietal region from the previous craniotomy.

Five days after diagnosis, all of the symptoms

subsided suddenly without psychotropic medication.

The patient couldnt remember the odd answers he

gave during the interview and could not recall the

events of the past few days.

Discussion and conclusion

We present here a report of Ganser syndrome in a Thai

male. The patient presented with all four classic symp-

toms of the syndrome: approximate answers and ap-

parent understanding of questions; sudden clouding of

consciousness; occasional symptoms of auditory hallu-

cination; and somatic symptoms with pain in both legs

without any evident pathology. A history of intracra-

nial hemorrhage in the right temporoparietal region,

an underlying disease of aplastic anemia, and history

of psychiatric disorder in family members were predis-

posing factors. He had no history of substance misuse.

No precipitating factor was identified; the patient did

not describe stress or life struggles before the symp-

toms appeared. His relatives said he that he was work-

ing as usual until the symptoms occurred. All four

symptoms persisted for only a short period of time. No

organic cause was found to explain the symptoms, and

without any psychotropic treatment the symptoms

subsided dramatically in 1 week.

Only a few cases of Ganser syndrome have been

reported during the last decade. Understanding of thissyndrome is minimal and its classification is uncertain.

The syndrome has been classified as malingering,

factitious disorder, psychotic disorder or dissociative

disorder (in two major diagnostic classifications) (Dab-

holkar, 1987). No specific diagnosis criteria are given in

either the DSM or ICD systems. The development of

diagnostic criteria is missing because of the small

number of Ganser syndrome cases. Clinicians are

advised to use their clinical judgment after ruling out

other psychiatric diagnoses. Therefore, it is difficult to

diagnose this disorder with certainty. Furthermore, the

lack of objective markers makes the diagnosis process

difficult (Lee & Koenig, 2001).

From the Ganser syndrome in the Lancet (2004)

(Dwyer & Reid, 2004) suggested four clinical symptoms:

approximate answers; clouding of consciousness;

perceptual abnormalities; and somatic conversions. In

the present case the patient fulfilled all of these

criteria. Whitlock (1967) suggested that the diagnosis

of Ganser syndrome should be restricted to the patient

who develops clouding of consciousness with charac-

teristic verbal responses to questions and abrupt termi-

nation of the illness. Subsequent amnesia, and

hallucination or conversion may be detected or not.

In most cases, Ganser syndrome has been diagnosed by

experts.

In the present case, differential diagnosis was

made to separate the syndrome from brief psychoticdisorder, delirium, mood disorder, substance-induced

disorder, anxiety disorder, malingering and epilepsy.

The syndrome in the present patient was differentiated

from acute and transient psychotic disorder because

the symptoms of auditory hallucination were present

without delusions, and no disorganized speech or

behaviour were seen. This patient was not delirious

because most aspects of cognitions were normal, ex-

cept clouding of consciousness. The patient had no

abnormal sleep/wake pattern or abnormal behaviour,

and did not report abnormal mood. Electroencephalo-

gram showed no signs of epileptic discharge. The

patient did not have impaired memory or other de-

mentia symptoms. Psychological testing was per-

formed and did not reveal any signs of faking. Blood

tests and comprehensive workup did not identify an

organic explanation or cause of the symptoms. No

trace of substance use was found in the blood or urine

of the patient.

In Thailand, psychiatric diseases are still misunder-

stood as being caused by black magic. People believe in

supernatural powers and take patients, such as the

man described herein, to monks or sorcerers for treat-

ment. Extraordinary methods of removing the black

magic may be performed.Recognition is important in this underdiagnosed

and little known condition. Additional case series are

required to monitor the development of psychopathol-

ogy in this condition in response to changes in lifestyle

and social environment in the 21st century.

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