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Neurobiological Basis of Ganser Syndrome He Correctly Answered That He Had Ten Fingers

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Neurobiological Basis of Ganser Syndrome He Correctly Answered That He Had Ten Fingers INDIAN JOURNAL OF PSYCHIATRY, 2003,45 (IV), 255-256 that Christmas fell on November 27 , that CASE REPORT there were 6 days in a week and 10 mondis in a year. After slowly counting each finger, Neurobiological Basis of Ganser Syndrome he correctly answered that he had ten fingers. He was able to say that he had ten toes, two arms, and two legs. To many DANIEL OUYANG, HARPREET S. DUGGAL, NJ. JACOB simple questions of mundane knowledge, he would just answer don't know'. He ABSTRACT became more tired and uncooperative as the questioning continued, widi more and more 'don't know' answers. His answers were Ganser syndrome continues to be a rare and widely misunderstood condition. inconsistent and would vary day to day. He While DSM-IV classifies Ganser syndrome as a dissociative disorder, its etiology initially was able to say that a horse has four continues to be debated. There are episodic reports in the literature of Ganser legs. A few to two days later, he changed syndrome in patients with head trauma or strokes. However, the mechanisms by his answer. which these cerebral insults lead to Ganser syndrome or other dissociative states are largely unknown.A case of a patient with Ganser syndrome with a prior history On initial examination, Mr. B endorsed of stroke and bifrontal infarcts is described. This case demonstrates how organic difficulty seeing. He gave consistendy incor­ pathology may predispose a patient to dissociative states, such as Ganser syndrome. rect answers to counting die number of We review the relationship between hyperglutamatergic states, caused by stroke fingers and claimed he could not see tilings and stress, and dissociative symptoms. during exam. However, Mr. B was able to easily maneuver himself diroughout die Key wards: Ganser syndrome, stroke, glutamate, dissociative symptoms hospital floor without problems and was even seen "reading" die newspaper at times. Upon questioning, Mr. B admitted to au­ ditory hallucinations in the evenings, in the The Ganser syndrome (GS) is a very admitted with depressive symptoms and form of screaming voices and voices talking rare and unusual condition first described suicidal ideation. He had been doing well to him. He also gave a questionable history in 1897 by the German psychiatrist Sigbert up to 3 months prior when he obtained a of visual halucinations, which he noted Ganser in his studies of prisoners. The credit card and accumulated a large debt. might have just been dreams. syndrome is defined by four essential clini­ He received a few threatening calls from cal features 1) the approxinsare answer, 2) creditors and began believing that the police Mr. B's laboratory investigations were clouding of consciousness, 3) somatic con­ would come and arrest him because of his unremarkable. His EEG was normal while version features, and 4) hallucinations (Enoch debt. He then became depressed, afraid, and a head CT scan revealed a few scattered & Hall, 2001). The approximate answer to socially withdrawn. Mr. B's medical history punctate foci of decreased attenuation in simple questions (the Ganser symptom) is was significant for a stroke 2 years ago. bom freantal lobes, right greater than left, the most striking symptom, but not alone which left him with residual left sided most consistent with old lacunar infarcts, diagnostic for GS (Scott, 1965). The etollogy weakness. His medical conditions included On frontal assessment battery (Dubois et of the syndrome is still polemical. While diabetes and migraine headaches. He had al, 2000). Mr. B displayed significant psychological mechanism have been fonda- high school education and was currendy improvement in 5 out of 6 categories, mental to the development of GS, there are unemployed. including conceptualization, lexical fluency; anecdotal reports associating this syndrome programming, sensitivity to interference, and with organic brain conditions. However, During hospitalization, Mr. B displayed go-no-go testing. Overall, Mt. B scored 7/ most of these cases are of patients with apathetic indifference and psychomotor 18 on diis test, indicating severe frontal lobe head injury, We report a case of a patient retardations. His Mini Meistal Status Exami­ dysfunction. who had a history of stroke and developed nation (MMSE) was 16/27 (excluding items Mr. B was treated widi risperidone (0.5 GS after he faced a psychologically stressful related to reading, writing, and design copy­ mg/d) and citalopram (30 mg/d). He Often situation. The organic etiology of GS is ing). His main deficits were in temporal voiced his feelings that he needed housing further discussed and glutamatergic mecha­ orientation, serial 7's, and recall. On more widi a higher level of care, after placement nisms in the development of dissociative detailed questioning, he gave approximate issues were settled, Mr. B was discharged symptoms are explored. answers, interspersed with correct ones. When asked 2 + 2, he answered, after much one week after admission to a personal care ^liberation 5. When asked the color of die home where he felt he would be safe. He was pleased widi his new housing and CASE REPORT pky, he said yellow. He answered mat the l month between Feb and April was June, die appeared cheerful and energetic. However, day after Sunday was Tuesday, and the day before discharge, Mr. B continued to have Mr. B, a 54 year old single man, was after Wednesday was Friday. He answered cognitive deficits and to give approximate (255) NEUROBIOLOGICAL BASIS Of GANSER SYNDROME answers. While he no longer had suicidal in the dissociative symptoms in PTSD Dissociative flashbacks after right frontal iniury ideation, the persistence of approximate (Chambers et al, 1999). As Ganser syndrome in a Vietnam veteran with combat-related answers indicated that his Ganser syndrome is seen in prisoners and those in stressful postaumatic Stress Disorder. J Neuropsychiatry had not yet resolved. situations, there may be a significant role of Clin Neurosti, 13, 101-105. stress, and possibly glutamate, in its etiology. Chambers, RA, et al (1999) Glutamate and post­ Glutamate surge is also seen after a brain traumatic stress disorder: toward a psychobiology DISCUSSION infact and dissociative symptoms have been of dissociation. Semin Clin Neuropsychiatry. 4. reported to occur following stroke (Chambers 274-281. This patient clearly met the four essential et al, 1999; Duggal, 2003). Further evidence Dubois, B., Slachevsky, A., Litvan, I. & Pillon, B. criteria for diagnosing GS. Interestingly, this supporting the role of glutamate in (2000) The FAB: A frontal assessment battery patient had bifrontal of lacunar infacts and dissociative symptoms is provided by at bedside. Neurology, 55, 162 1-1626. impairment on neuropsychological testing, Moghaddam et al (1997) who showed that Duggal, H. (2003) A Lesion Approach to which indicated an organic etiology. Such an in rats, low doses of ketamine increased Neurobiology of Dissociative Sympromi. I Neu­ etiology is supported by anaedotal reports. both glutamate and depamine outflow in ropsychiatry Clin Neurosci, IS, 245-246. In a review of 15 patients with GS, Sigal the prefrontal cortex. Ketamine, which Enoch, M.D. & Hall, H.N. (2001) Ganser's et al (1992) reported that 7 out of their 15 activates gluramatergic neurotransmsssion syndrome. In: Uncommon Psychiatric Syndromes,, patients had evidence for organicity; with by acting as a noncompetitive NMDA 4th Ed. London: Arnold Publishers, 75-94. six patients having history of head trauma antagonist, has been shown in humans to Ganser, S.J.M.(I965)A peculiar hysterical scale. with loss of consciousness and one who produce symptoms similar to those seen in Translated by Schorer CE. British Journal of had a right cerebrovascular event with heft schizophrenia and dissociative states. Criminology, 5, 120-126. hemiparesis. Closed head injury with or Ketamine has also been and shown to Latcham, R., White, A. & Sims,A. (1978) Ganser without loss of consciousness has been impair performance in frontal Lobe sensitive syndrome: the aesiological argument.Neurol associated with GS (Miller, 1997; Lee & tests (Moghaddam et al, 1997). Finally; Neurosurg Psychiatry, 41, 851-854. Koenig. 2001). However, there are only rare frontal lobe involvement has been cited to Lee, B.H. & Koenig.T. (2001) A case of Ganser reports of GS following a cerebrovascular result in dissociative symptoms has syndrome: organic or hysterical! Gen Hosp event. In one such case, a Patient with evidenced in the case of a man who Psychiatry, 23, 230-23 I. micro-embolic shower to the brain, including developed recurrent dissociative flashbacks Miller, P., Bramble,0.& Buxton,N.(1997) Case the frontal region, developed GS after the after suffering a traumatic brain injury to study: Canser Syndrome in children and event Latcham et al. 1978. The increasing the right dorsolateral prefrontal cortex adolescents. J Am Acad Child Adoleac Psychiatry, number of reports of brain insult-associased (Berthier et al, 2001). Thus drawing from 36, 112-115. GS is not surprising cosisidering the fact these observations, it can be speculated that Moghaddam, B., Adams, B.,Verma. A. & Daly that two of Ganser's three original patients hyperglutamatergic transmission especially O. (1997) Activation of Glutamatergic had history of head injury (Ganser, 1965). in the frontal lobes may predispose indi­ Neurosransmission by Ketamine: A Novel Step The mechanism by which a brain insult viduals to dissociative states such as GS. in the Pathway from NMDA Receptor Blockade may predispose one to GS and other More research is headed so further address to Dopaminergic and Cognitive Disruptions dissociative states is unknown but recent this hypothesh hypergiutamatergic Associated with the Prefrontal Correx.JNeurosci, 17, 2921-2927. literature supports the role of Glutamate in transmission. dissociative symptoms. The current consen­ Scott, PD. (1965)The Ganser Syndrome. British sus is that GS is a dissociative syndrome. Journal of Criminology, 5, 127-134. Stress induces a cortico-limbic release of REFERENCES Sigal, M., Altmark, D., Ahlci, S.
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