Ganser Syndrome Clinical Presentation

Ganser syndrome has been observed frequently in conjunction with a marked psychosocial or physical stressor (ie, head injury, serious illness). Typically, the duration of symptoms is brief.

• DSM-IV-TR criteria: The giving of approximate answers to questions (eg, "2 plus 2 equals 5") when not associated with dissociative amnesia or dissociative fugue.
• Enoch and Trethowan's 4 identified symptoms for the syndrome are as follows:

  • Approximate answers
  • Clouding of consciousness
  • Somatic conversion symptoms
  • Hallucinations
• Other commonly observed features include the following:

  • A dreamy or perplexed appearance
  • Memory or personal identity loss
  • No recollection of the syndromal state upon recovery
  • Perseveration
  • No response to painful stimuli
  • Catatonic posturing
  • Echolalia
  • Echopraxia

• Perform a complete mental status examination, including a full history.

  • According to the DSM-IV-TR, the mental status exam can be completely normal except for the symptom of approximate answers. However, more traditional accounts argue that the presence of an alteration of consciousness, hallucinations, and possible conversion symptoms like sensory changes or paralysis may also occur.
  • Given that this syndrome has been reported in schizophrenia, depression, and mania, it would be prudent to be vigilant for suicidal or homicidal behavior.
• Perform a complete physical examination, including a full neurologic examination.

  • Be sure to assess vital signs and check airway, breathing, and circulation.
  • Reports of catatonic posturing and sensory and motor abnormalities have been noted.
• Sample mental status and physical examination

  • Appearance: The patient is well developed, well nourished, and appears his stated age. He is mildly malodorous with unkempt hair and is wearing a hospital gown.
  • Behavior: He is pleasant but only minimally cooperative. His eye contact is poor, with long episodes of staring. He answers questions but only after long pauses.
  • Speech: His speech is notable for his latency of response and his short, succinct answers.
  • Mood/affect: He states that his mood is "good," and no evidence indicates that he is not euthymic other then a notably blunted affect.
  • Thought form/content: His thought form and content are difficult to assess due to his limited verbal output. There is no obvious evidence of delusional or obsessive thoughts.
  • Perceptual abnormalities: The possibility of response to auditory or visual hallucinations is raised by his prolonged episodes of staring, but this remains uncertain at the moment.
  • Cognitive functioning: The ability to assess his cognitive abilities is limited by his paucity of verbal output. He is clearly alert; however, when asked questions he frequently gives an incorrect answer that shows some understanding of the subject and possible knowledge of the correct answer. For instance, when asked how many legs a dog has, he answers "3" or when asked for the color of snow, he answers "black."
  • Neurologic examination: His pupils are equal, round, and reactive to light. His eye movements are intact with no evidence of nystagmus. His fundoscopic examination is normal. His face is symmetric but with diminished response to pinprick. His tongue and palate are midline and his hearing appears grossly intact. Strength is MRC 5/5 throughout with good bulk. His tone is difficult to assess due to the presence of a facilitory paratonia and he had some occasional catatonic posturing, most obvious in the upper extremities. His coordination and gait are all within normal limits. Deep tendon reflexes are 2+ throughout with down-going toes. Sensation is notable for significantly diminished response to pinprick throughout.
  • General examination: His vitals are stable. His neck is supple with no evidence of bruits. His heart is in a regular rate and rhythm with normal heart sounds. His chest is clear to auscultation. His abdomen is nontender and nondistended with normal bowel sounds and no obvious masses.

Rule out major underlying organic or psychiatric etiologies.