Neurologic-Psychiatric Syndromes in Focus - Part II

J. Bogousslavsky

• Verlag: S. Karger
• Jahr: 2017
• ISBN:
  9783318060898
• Thema: Medicina
• Thema: Neurología

Bogousslavsky J (ed): Neurologic-Psychiatric Syndromes in Focus. Part II – From Psychiatry to Neurology.
Front Neurol Neurosci. Basel, Karger, 2018, vol 42, pp 1–22 (DOI: 10.1159/000475676)

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Ganser Syndrome

Sebastian Dieguez

Laboratory for Cognitive and Neurological Sciences, Département de Médecine, Université de Fribourg, Fribourg, Switzerland

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Abstract

Ganser’s syndrome is a rare and controversial condition, whose main and most striking feature is the production of approximate answers (or near misses) to very simple questions. For instance, asked how many legs a horse has, Ganser patients will reply “5”, and answers to plain arithmetic questions will likewise be wrong, but only slightly off the mark (e.g., 2 + 2 = 3). This symptom was originally described by Sigbert Ganser in 1897 in prisoners on remand and labeled Vorbeigehen (“to pass by”), although the term Vorbeireden (“to talk beside the point”) is also frequently used. A number of associated symptoms were also reported: “clouding of consciousness,” somatoform conversion disorder, hallucinations, sudden and spontaneous recovery, subsequent amnesia for the episode, premorbid traumatic psychosocial experience and/or (usually mild) head trauma. Etiological, epidemiological and diagnostic issues have never been resolved for Ganser’s syndrome. Ganser saw it as a form of “twilight hysteria,” whereas others suggested that malingering, psychosis or dissociation were more appropriate labels, oftentimes combined with organic impairment and a subjectively intolerable psychosocial context. A central conundrum of Ganser’s syndrome is whether it could simultaneously be a cultural and pathological representation of insanity, whereas cognitive, organic, affective, motivational and social factors would converge towards a naïve idea of what mental illness should look like, especially through the provision of approximate answers.

© 2018 S. Karger AG, Basel

“Why a four-year-old child could understand this report!

Run out and find me a four-year-old child!”

(Groucho Marx in Duck Soup, 1933).

Introduction

An old saying holds that a stupid question deserves a stupid answer. Patients with Ganser’s syndrome seem to obey this principle in the most determined way: their central diagnostic feature is indeed a tendency to reliably provide wrong and approximate responses, especially to the most trivial and innocent questions. On the surface, this looks simple enough, yet, 120 years after it was first described by the German psychiatrist Sigbert Josef Maria Ganser (1853–1931?), this rare and controversial condition still raises profound and unresolved issues ([1], see [2] for (scarce) biographical details). Indeed, neurological and psychiatric patients make all sorts of “errors” upon being interrogated and tested: why should there be a specific syndrome for underperforming in a clinical setting? Is not this simply a consequence of other disorders, such as confused thinking, dementia, lack of attention, or a manifestation of poor collaboration, perhaps bordering on intentional deception (i.e., malingering)? As it turns out, to understand the puzzling nature of Ganser’s syndrome and its specificity among other neuropsychiatric disorders, it is important to realize how deeply connected are its clinical presentation and phenomenology, on the one hand, and its controversial history and nosological status, on the other hand. It is as though the concomitant perplexity of both patients and clinicians – the former upon trying to answer plain questions, the latter upon trying to categorize and understand such (false) responses – was the very specificity of Ganser’s syndrome.

A historical sketch and fuller description of the syndrome will help in clarifying this notion. Ganser first reported his observations on prisoners in 1897 at a conference and published them a year later [1]. Much of the early literature on Ganser’s syndrome focused on convicted individuals awaiting trial, raising the notion that it was a “prison psychosis” related to the psychological consequences of confinement, guilt and stressful uncertainty about one’s predicament. The beginning of Ganser’s report offers a classical illustration of the syndrome that will ultimately bear his name:

“These patients have a number of common features which justify grouping them together as a distinct entity. I will select, from the four cases which I have seen, the outstanding features and sketch them for you. The most obvious sign which they present consists of their inability to answer correctly the simplest questions which are asked of them, even though by many of their answers they indicate that they have grasped, in a large part, the sense of the question, and in their answers they betray at once a baffling ignorance and a surprising lack of knowledge which they most assuredly once possessed, or still possess.

As a demonstration I would like to report a conversation with one of these patients: Are you able to count to ten? Yes. (But he does not, and is silent.) Well, then, count. (But he does not, and only counts on being prompted.) 1, 2, 3, 4. (Then he is quiet again.) What follows one? Two. Then? Twelve, 93 and … and after 93? (He continues in that fashion.) On another occasion: 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 14, 18, 19, 20, 21, 24, 27. How much are two and one? Three. Three and two? Seven. Five and two? Four. What is four minus one? Five (Then he corrected the answer to three.) In what city are we? In Berlin, in Russia. What are we doing here? We wanted to go hunting, and we unhitched our horses. How many noses do you have? I do not know. Have you any nose at all? I do not know if I have a nose. Have you eyes? I have no eyes. How many fingers do you have? Eleven. How many ears? (He first touches his ears, and then says: Two.) How many legs does a horse have? Three. An elephant? Five. After being shown a coin and asked, What is that? the answer is: A map which a person hangs on his watch chain. Glancing at the eagle stamped upon a coin: I do not know that person. Is it Kaiser Wilhelm? He was shown a Thaler coin and was asked: Do you know the Thaler? He said, I do not know a Thaler. That is a toy which one gives to children. What is your name? My name is Fürst (incorrect)” (translation in [3], pp 120–121).

This extract highlights Ganser’s crucial insight that the pattern of false responses provided by his patients indicated that the errors were not completely random, but that the correct answer was being avoided. Indeed, the very answers showed that the question had been properly understood, that it successfully activated the appropriate semantic domain relevant to the question, and that the response had been seemingly selected in the range of possibilities closely surrounding the correct solution (hence, the term approximate answers).

Now, on the face of it, such behavior was strongly suggestive of intentional deception: the patients seemed to make mistakes on purpose. Ganser indeed readily admitted that “we cannot fail to recognize how in the choice of answers the patient appears to pass over deliberately the indicated correct answer and to select a false one, which any child could easily recognize as such” ([3], p 121). Yet, he was adamant that his patients were not malingering: “I come now to the question whether the peculiar manner of response which they showed is to be regarded in itself as malingering or as a genuine symptom. I must say that I never had the impression that these patients sought 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 them these repeated examinations were. They appeared unwilling to have anyone think of their answers as false and simple-minded, and of themselves as ignorant and foolish, whereas they appeared convinced that whatever they said was correct” ([3], p 125). Because he classified right away the condition as hysterical, Ganser also duly reminded his audience that hysterical symptoms by themselves had always been (and still are) related to suspicions of malingering, yet equally frequently distinguished from intentional and conscious deceptions.

Furthermore, he felt that his patients presented with “a combination of manifestations of illness, which are well-known and whose simulation by people unfamiliar with psychiatry is improbable to the highest degree” ([3], p 126). This “combination” was what made, in Ganser’s mind, the disorder so specific and unlikely to be merely the product of fabrication or role-playing, calling it eventually a “peculiar hysterical twilight state.” In addition to giving approximate answers – a behavior dubbed “Vorbeigehen” (“to pass over,” “to pass by”) by Ganser, which appears in the text only once in the passive form “vorbeigegangen,” but oftentimes referred to as “Vorbeireden” (“to talk at cross-purposes”) in the literature –, other features were considered highly significant. These were: the presence of hallucinations (mostly visual and auditory, sometimes labelled pseudo-hallucinations when their authentic perceptual nature is in doubt); somatoform disorders in the form of hysterical stigmata (somatic complaints and movement and sensory disturbances not explained by organic factors); clouding of consciousness (a state of perplexity and bewilderment with attention deficits and seeming dissociation from the self and surroundings); sudden and “astonishing” recovery for all symptoms (although with occasional signs of partial relapse); subsequent amnesia for the episode; and the presence of a triggering factor aside from the crimino-legal context, including psychosocial difficulties such as financial worries or bitter distress, and organic elements such as typhus or head trauma.

This full picture must be kept in mind when considering the approximate answers these patients provide. To get a fuller sense of this behavior, it is worth quoting again Ganser on another of his patients:

“Reviewing the crime of which he was guilty or mentioning his family brought forth not the slightest response from him. These appeared to him completely foreign. He was disoriented for place, for the date, and for the length of his hospitalization, which he always stated to be one to 2 days. Persons of his immediate environment, whom he had previously not known at all, he now addressed with questions, using the commonest names for them, such as Müller, Schulze, or Lehmann. A key which was shown him he identified as a revolver, and made of silver. He was able to name a watch and a watch-chain correctly, but incorrectly read the time. Instead of 9.30, he said 5.30 in the morning. He incorrectly read letters which were written out; for example, e, u, a, and n he identified alike as e; s and r he identified as i; and t was identified as f. When asked to read the paper, he read out in a senseless fashion, Bismarck, King Albert, Rothschild, money, beams, Bismarck, Majesty, Privy Cabinet, always the same words in a different sequence. One hour later, however, during the examination of the sense of taste, he correctly read the names of the different flavors labeled on the bottles. He designated a Thaler, a Mark piece, and a fifty-Pfenning piece alike as one Mark. A five-Mark bill he described as printed paper, whose value he was not able to recognize. At least, however, he read the number 5 printed on the bill, and then also recognized the correct value of the fifty-Pfennig piece and the Thaler” ([3], p 123).

As can be seen, a striking feature of the clinical picture is its seeming unpredictability: approximate responses are intermingled with correct ones, and they span a broad range of behaviors. Moreover, the patient shows no sign of realizing the absurdity of the whole situation. Such a poetic creativity in being wrong has been duly noticed by André Breton, who briefly mentions Ganser’s syndrome (“symptôme de Ganser ou des réponses à côté”) in his Surrealist Manifesto (1924). It has even been suggested that Hamlet’s strange behavior, answers, and irresolution could be explained by Ganser’s syndrome [4].

On the clinical and scientific front, however, much debate and confusion has surrounded this “peculiar hysterical twilight state” and its characteristically approximate responses. Allen and Postel [2,5] go as far as to talk of a “repressed” chapter of the “history of hysteria” and, somewhat hyperbolically, deplore the “feast” of “successive layers of silence and falsification” that followed Ganser’s initial observations and the slipshod or mindlessly anhistoric nature of most research on the topic. On a side note, there is a curious and ironic uncertainty in Ganser’s 1898 original report. Al...