Could It Be Ganser's Syndrome?

Robert E. Cosgray and Ronald W. Fawley

The terrn, "Ganser's syndrome," was identified by Sigbert J. Ganser, a German

psychiatrist, near the turn of the century. Ganser's syndrome, defined as an
hysterical reacton, was often used to describe prisoners who appeared to be
trying to escape prosecution. Today, Ganser's syndrome is debated by both
psychiatric and judicial systems. This paper addresses these issues by identify-
ing guidelines for assessment and recognition of common malingering behav-
iors displayed by Ganser's syndrome patients. Psychiatric nurses who practice in
both psychiatric and legal systems need an understanding of Ganser's syndrome
to adequately assess the patient, plan effective treatment, and complete an
evaluation of care. This understanding will enable the nurse to answer the m-
portant question, "Could it be Ganser's syndrome?" With the increase of crime
and the prison population, the use of "Insufficient Comprehension to Stand
Trial" may be a legal option for defendants. If they are exhibiting inappropriate
behavior and are a danger to themselves or others, a psychiatric evaluation may
be ordered by the court. It is then the responsibility of a psychiatric facility to
assess, treat, and evaluate Ganser's syndrome patients in an attempt to return
them to competency. The patients may return to court following the psychiatric
evaluation if they are found competent to stand trial,
1989 W.B. Saunders Company.

T HE MALINGERING behavior of Ganser's

syndrome cannot be easily isolated from hys-
teria in many cases (Cramer, Gershberg, & Stem,
1971). A review of the literature addresses only
males as displaying symptoms of Ganser's syn-
drome. The patient generally displays a mimicry of
true dementia, answering questions not only
wrongly, but too neatly so, for example, answer-
ing the classic question, "How many legs has a
cow?" with a crisp "Three." A patient with Gan-
ser's syndrome, however, gives the unmistakable
sense of selecting purposely, although uncon-
sciously, the approximate wrong answer. The pa-
tient's exaggeration of his difficulties and his ex-
hibition of vorbeireden or "passing by the point"
in responses to specific questions are consistent
with the syndrome (Burd & Kerbeshian, 1985).
The most remarkable features of this syndrome are
the incorrect and often ridiculous replies of the
patient, although it is quite clear that he has un-
derstood the sense of the questions. Furthermore,
although these patients often appear to be disori-
ented in time and place, their genera] behavior
gives the distinct impression of alertness. The
schizophrenic patient taJks past the point of de-
fault; the patient in a Ganser's syndrome state taJks
past the point of design, although this design is not
necessarily conscious (Kaplan & Sadock, 1985).
TYPES OF GANSER SYNDROME
There are a variety of types of Ganser's syn-
drome in terms of etiology and symptoms. Socio-
pathic, hysterical, and schizophrenic psychiatric
illnesses have been related to producing Ganser's
syndrome behaviors (Spiro, 1986). In fact, there is
no agreement as to the cause for this syndrome's
relation to psychoneurosis, psychosis, and malin-
gering illness. Davidson (1965) reports that evi-
dence can be found for any of these theses. It is
agreed that Ganser's syndrome may reveal itself in
two forms: conscious and unconscious. There is
From the Logansport State Hospital, Logansport, IN.
Address reptint requests to Robert E. Cosgray, R.N.C.,
B.S.N., MA, Evening Nursing Supervisor, Logansport
State Hospital, Logansport, IN 47947.
e 1989 W.B. Saunders Company.
0883-9417/89/0304-0010$3.00/0

Archives of Psychiatric Nursinq, Vol. 11I,No. 4 (August), 1989: pp. 241-245 241

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242
also agreement that the conscious form of Ganser's
syndrome may be a sociopathic or hysterical reac-
tion (Spiro, 1986). The conscious and unconscious
symptoms of Ganser's syndrome will each be di s-
cussed.
Conscious
The person exhibiting conscious behaviors of
Ganser's syndrome may be deliberately pretending
to escape a threatening or frustrating reality by
conveying the impression of amnesia or mental
illness. The premorbid personality of the Ganser's
syndrome patient is often typified by certain hys-
terical features. By simulating a mental illness, the
person hopes to avoid incarceration or punishment.
The following is an example of a conscious form
of Ganser's syndrome:
Mr. Smith, incarcerated because of multiple murder
charges, was ordered by the court to a psychiatric facility
where he was observed displaying bizarre, inappropriate
behavior. Mr. Srnith appeared to be extremely psychotic
with facial grimaces, tics, paranoid ideations, flight of
ideas, and auditory hallucinations. His appearance and
dress were appropriate. In the weeks that followed, Mr.
Smith continued to display the psychotic behavior, but it
was obvious the behavior was inconsistent according to
documentation in the chart from various treatment disci-
plines.
Documentation by the psychiatric nurse during group
and individual therapy revealed that Mr. Smith was eva-
sive by displaying flight of ideas, paranoia, and psychotic
behavior. The rehabilitation department documented that
Mr. Srnith participated actively in sports, crafts, and mi-
lieu therapy, although he continued to exhibit flight of
ideas verbally. It was also documented that, when he par-
ticipated in sports, the facial grimaces, tics, and psychotic
behavior were not present. He al so presented himself as
relaxed with thought processes intact. When confronted by
staff conceming this, Mr. Srnith would irnrnediately revert
to his former inappropriate behavior.
A review of the documentation provided by nurses in
the chart revealed that Mr. Smith was only cornfortable
talking to certain nonprofessional staff. The conversation
and behavior with these staff, as time went on, became
more appropriate. When approached by professionals,
such as registered nurses or psychiatrists, his behavior was
inappropriate. As a result, by reviewing documentation of
all disciplines, inconsistencies were noted.
Unconscious
The unconscious form of Ganser's syndrome
may be considered an unusual dissociative state in
which the patient unconsciously attempts to imitate
the disorganized behavior and thinking of a psy-
chotic patient according to his naive and personal
mental image of madness. The patient may exhibit
COSGRAY ANO FAWLEY
feelings of intense fear about being caught in an
inescapable situation. The following is an example
of an unconscious form of Ganser's syndrome:
Mr. Adams was brought to a psychiatric facility for the
fourth time in 5 years. After a previous placement in an
extended living situation, Mr. Adams began displaying
inappropriate behavior, sucb as walking in front of moving
traffic and laughing for no apparent reason. He also had
not concem for his personal appearance and hygiene.
During the initial assessment by the psychiatric nurse, it
was elicited that Mr. Adams' thought processes were in-
tact. When confronted about bis inappropriate behavior in
cornrnunity living, Mr. Adams stated, "Everybody thinks
I'm crazy, and that's the way crazy people act." Mr.
Adams explained during the therapy sessions that followed
that he felt extremely uncornfortable in cornrnunity living.
Through low self-esteem, Mr. Adams presumed that peo-
pie did not like him due to previous psychiatric hospital-
izations.
ASSESSMENT
The psychiatric nursing assessment usually is
completed during the admission phase in the psy-
chiatric hospital or in jail or prison. This assess-
ment provides valuable baseline information. The
psychiatric nursing assessment of Ganser's syn-
drome behaviors or symptoms should inc1ude: past
psychiatric hospitalizations, criminal and incarcer-
ation background, farnily history, drug history,
and physiological factors. Each area should be re-
viewed for symptomatology to adequately collect
necessary information about the patient.
Past Psychiatric Hospitalizations
The number and extent of past psychiatric hos-
pitalizations is important information to the psy-
chiatric nurse. The extent of psychiatric hospital-
izations may correlate with the patient's
knowledge of mental illness and perceptions of
psychotic behavior. If the patient has been exposed
to mental illness or psychotic behavior over an
extended period of time, he may be better
equipped to mimic schizophrenic behavior. Fre-
quent hospitalizations tend to be a complication of
Ganser's syndrome (APA, [DSM III-R], 1988).
The nurse must elicit information conceming legal
issues during past psychiatric hospitalizations. if
the patient has been hospitalized previously with-
out charges, he may be better equipped to feign
mental illness. Another important issue to consider
is whether the patient decompensates when a court
date is set. In this respect, the patient who has been
hospitalized several times is more likely to be re-
GANSER SYNDROME
hospitalized if he displays inappropriate behavior.
This phenomenon, however, is not specific for this
disorder; it is also found in individuals with schizo-
phrenia. Auditory and visual hallucinations, hys-
teria, true disorientation, circumscribed amnesia,
and lack of insight are often symptoms associated
with the Ganser's syndrome state. These symp-
toms of confusion cause the syndrome to appear
often as an organic psychosis (Kaplan & Sadock
1985).
Criminal and Incarceration Background
Past history of criminal offenses and incarcera-
tions can be helpful in assessing the nursing care
required. It has been found that prisoners facing
criminal charges may demonstrate some Ganser's
syndrome symptomatology or may appear stupe-
fied. Professional nurses caring for these patients
.rnust familiarize themselves with legal issues per-
taining to the patient's reason for admission. If the
patient is facing felony charges, it may be benefi-
cial for him to act "crazy" as opposed to facing
long-term incarceration. Finally, it is significant to
note if the patient has previously used symptoms of
mental illness to escape prosecution.
Family History
The information pertaining to family history is
significant as an assessment instrument. In a re-
view of the literature, there is little applicable in-
formation on this topic. The literature does reveal,
however, that the syndrome is more widespread in
males and usually begins in early adult life, but it
can start during adolescence or childhood. This is
primarily thought to emerge as the beginning of a
borderline personality (Gruber, 1987). It is impor-
tant to elicit information about family members to
determine if they have used psychiatric symptom-
atology to escape punishment. It has been pointed
out that Ganser's syndrome has never been ob-
served in persons of superior intelligence. Every
attempt should be made to interview family mem-
bers to elicit family history information, since the
psychiatric history by the patient cannot be con-
sidered valid when psychiatric abnormalities are
questioned.
Drug History
Virtually without exception, patients presenting
Ganser's syndrome find themselves in confining
situations, such as psychiatric or substance abuse
243
treatment facilities. This situation may be due to
chemical abuse. Ganser's syndrome is almost al-
ways superimposed on asevere personality disor-
der. The individual may secretly use substances for
the purpose of producing symptoms that suggest an
organic mental disorder. Stimulants such as am-
phetamines, cocaine, or caffeine may be used to
produce restlessness or insomnia; hallucinogens
such as Iysergic acid diethylamide (LSD), mesca-
line, or tetrahydrocannabinol (THC) may be used
to induce altered leveis of consciousness and per-
ception; analgesics such as heroin or morphine
may be used to induce euphoria; and hypnotics
such as barbiturates or alcohol may be used to
induce lethargy. Combinations of these substances
can produce very bizarre presentations (DSM l/I-
R, 1988).
Physiological Factors
Whitlock suggests that head injuries preceding
the symptoms of Ganser's syndrome behavior
must be ruled out (Cited in Peszke & Levin 1987).
For example, in three cases described by Ganser,
two had suffered serious head injuries. When head
injuries occur, alterations in behavior such as con-
fusion, temporary amnesia, and personality
changes may result. The results of these personal-
ity changes may be manifested by violent out-
bursts. Another possible physiological cause is se-
vere illness, which may manifest identical
symptoms. For example, a third case described by
Ganser was recovering from severe typhus with
prolonged convalescence and psychic alterations.
TREATMENT
Differentiation of Ganser' s syndrome from other
mental disorders is extremely difficult. Assisting
the diagnostician with data for a diagnosis is the
responsibility of all team members. The psychiat-
ric nurse must notice that the total clinical picture
is not characteristic of any recognized mental dis-
order. Psychological tests may be helpful when the
responses elicited suggest a mixture of perceptual,
cognitive, and intellectual impairment that is not
indicative of any mental disorder but suggests,
rather, the individual's concept of mental disorder.
There is the danger, however, that simulated bi-
zarre responses will be taken at face value.
The treatment modalities of the Ganser's syn-
drome symptoms in the conscious form differ from
those for the unconscious formo It would not seem
244
logical to treat the conscious forrn of Ganser' s syn-
drome as one would the unconscious forrn (i.e., by
using electroconvulsive therapy or drugs) since
there is no clinical basis for such an approach.
Treatment o/ the Conscious Form
The treatment of the conscious forrns of Gan-
ser's syndrome symptoms may include the tech-
nique of confrontation and the consistent docu-
mentation of behaviors displayed throughout
hospitalization.
Confrontation. Individuals who display a con-
scious forrn of Ganser's syndrome tend to avoid
anxiety-producing situations such as incarceration.
When the professional calls attention to the pa-
tient's anxiety or significant discrepancies in the
individual's reactions, there is often a defensive
response. The intention of confrontation is to en-
able the individual to adrnit reality with precision
and clarity. Confrontation is anxiety-producing,
but clear and direct cornrnunication of behavioral
discrepancies is appropriate as a forrn of therapy.
Calling the individual's attention to selected facets
of behavior is the initial step in the process re-
quired to enable the individual to face himself and
his legal difficulties in a straightforward manner
(Haber, Leach, Schudy, & Sideleau, 1978).
Documentation. Documentation is also a valu-
able tool when treating the conscious forrn of Gan-
ser's syndrome. Thorough documentation on ad-
mission establishes a baseline of behavior. Precise
and consistent documentation by the psychiatric
nurse will assist in establishing a pattem of incon-
sistent behaviors as they occur. Accurate docu-
mentation will also assist the interdisciplinary
treatment team in forrnalizing a plan of active
treatment.
Treatment o/ the Unconscious Form
In the unconscious forrn of Ganser's syndrome,
electroconvulsive therapy has been effectively uti-
lized but such a drastic physical approach hardly
seems advisable. Psychotherapy, tranquilizers,
and possibly intravenous injections of amobarbital
(Amytol, Eli Lilly, Indianapolis, IN) or diazepam
(Valium, Roche Laboratories, Nutley, NJ) are usu-
ally effective in speeding the patient's recovery.
Individual psychotherapy utilized in a patient-
centered approach places emphasis on the process
of the relationship and not the cure of particular
symptoms. The role of the nurse is to assist the
COSGRAY ANO FAWlEY
patient in identifying his own ability to develop.
The nurse's attitude creates an atmosphere that fa-
cilitates the growth of the patient. It is important
for the nurse to establish a trusting relationship
with the Ganser's syndrome patient in order for
psychotherapy to be an effective mode of treat-
mento Psychotherapy is then utilized in an effort to
reduce stress. By reducing stress, the Ganser's
syndrome patient will be able to identify precipi-
tating problems. After the patient has identified the
precipitating problems, a nursing diagnosis and
plan of action can be implemented.
Major tranquilizers may be useful in the treat-
ment of agitated behaviors. Minor tranquilizers are
used in the treatment of anxiety. Both of these
types of tranquilizers may be helpful in reducing
stress associated with Ganser's syndrome. They
may be given orally, intramuscularly, or intrave-
nously. Intravenous therapy is the quickest route to
reduce acute aggressive behavior in the Ganser pa-
tient. Follow-up therapy of the patient must be
considered, as in any patient who, under stress,
has developed a dissociative state.
EVALUATION
A true dementia frequently has a demonstrable
organic etiology or pathophysiological process. In
pseudodementia, there are often near-miss, ap-
proximate answers rather than the gross inability to
answer questions correctly, as is usually the case in
Ganser's syndrome. Ganser's syndrome is usually
short lived, and the patient recovers within a few
days or weeks.
In a true psychosis, the individual's behavior on
the ward generally will not differ markedly from
his/her behavior in the clinician's office. In con-
trast, an individual with Ganser's syndrome may
appear to respond to auditory hallucinations only
when under the impression that he is being
watched.
SUMMARY
Through careful observation and assessment,
the nurse can elicit valuable inforrnation to assist in
the diagnosis of Ganser's syndrome. As a result,
the psychiatric nurse can then plan and implement
effective nursing careo As a member of the treat-
ment team, the contribution of the nurse is impor-
tant in forrnulating a treatment plan. An in-depth
assessment and evaluation by the nurse will facil-
GANSER SYNDROME
itate appropriate treatment and will expedite the
return of the patient to the judicial system.
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Burd, L., & Kerbeshian, J. (1985). Tourette syndrome: Atyp-
ical pervasive developmental disorder and Ganser syn-
drome in a 15-year-old. Canadian Journal o/ Psychia-
try, 30, 74-76.
Cramer, B., Gershberg, M.R., & Stem, M. (1971). Mun-
chausen syndrome. Archives of General Psychiatry, 24,
573-578.
245
Davidson, H.A. (1965). Forensic psychiatry (2nd ed.). New
York, NY: Ronald Press.
Gruber, M. (1987). Trying to care for a Great Pretender. Nurs-
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Haber, J., Leach, G., Schudy, S., & Sideleau, B. (1978).
Issues in mental health nursing. New York, NY:Mc-
Graw-Hill.
Kaplan, H.S., & Sadock, B.J. (1985). Comprehensive Text-
book o/ Psychiatry, Baltirnore: Williams & Wilkins.
Peszke, M.A., & Levin, G.A. (1987). The Ganser syndrome:
A diagnostic and etiological enigma. Connecticut Med-
icine, 51(2), 79-83.
Spiro, H.R. (1986). Chronic factitious illness. Archives of Gen-
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