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Ganser’s Syndrome in a Man With AIDS
Ganser’s Syndrome in a Man With AIDS MARLA WAX DEIBLER, M.A., CANDICE HACKER, B.S. JAMES ROUGH, B.S., JANINE DARBY, B.S. RUTH M. LAMDAN, M.D., F.A.P.M.
I
n 1898, German psychiatrist Siegbert Ganser first recognized the syndrome that would bear his name as a presentation of Vorbeireden, or “approximate answers.” Central features of Ganser’s syndrome include 1) approximate answers, 2) somatic conversion symptoms, 3) clouding of consciousness, and 4) hallucinations.1 Although it has been regarded as a psychotic disorder,2 it is currently classified among disorders of dissociation.3 The syndrome is uncommon, and rates of incidence and prevalence remain unclear. There appears to be a higher incidence of the condition in male subjects who belong to an ethnic minority.4–6 According to a review of 41 cases of Ganser’s syndrome,4 symptoms may span a wide range and include conversion features such as paralysis, anesthesias, paresthesias, and hysterical seizures (seen in 33% of the cases); psychogenic fugue (seen in 33%); disorientation to time and place (seen in 56%); perceptual disturbances such as auditory hallucinations, visual hallucinations, and olfactory hallucinations (seen in 51%); and amnesia, including localized, selective, and continuous types (seen in 93% of the cases). Approximate answers and amnesia were highly correlated at 93%, suggesting a dissociative mechanism.4 Onset of the syndrome is frequently associated with a stressful life event,7 which is most often of a domestic, sexual, or financial nature.2 Most cases are transient and resolve suddenly with an inability to recall the event.1 Ganser’s syndrome has been reported in a variety of patients, including those who have suffered trauma (per Ganser), organic brain disease,8 alcoholism with Korsakov’s psychosis,2 schizophrenia,6 depression,1,7 and neurosyphillis,6 although it has been most commonly reported in forensic settings.5,9,10 The condition is thought to unconsciously ocReceived Nov. 18, 2002; accepted Dec. 13, 2002. From the Temple University School of Medicine, Philadelphia. Address reprint requests to Dr. Lamdan, Temple University Health Sciences Center and Department of Psychiatry, 1316 West Ontario St., Jones Hall, 7th Floor, Philadelphia, PA 19140. Copyright 䉷 2003 The Academy of Psychosomatic Medicine.
342
cur in response to a psychologically intolerable event.10 Further, it has been suggested that individuals presenting with Ganser’s syndrome frequently have underlying axis II psychopathology.4,5 Presented here is a description of an HIV-positive male patient who came into an outpatient psychiatry clinic exhibiting Ganser’s syndrome.
Case Report
Mr. A was a 38-year-old Puerto Rican male who came to the outpatient clinic with a chief complaint of depression, which began 2 years earlier when he received a diagnosis of HIV/AIDS. Symptoms included depressed mood, anhedonia, feelings of guilt and worthlessness, disturbed sleep, nightmares, decreased appetite, aches and pains, suicidal ideation, and intermittent double vision. He also reported seeing ghosts in the corners at night and hearing voices telling him to kill himself. He reported two recent suicide attempts: one by medication overdose and another by self-inflicted knife wound to the abdomen. He denied any personal or family psychiatric history, treatment, or alcohol/drug abuse. However, reports by his ex-wife indicated a history of emotional difficulties and alcohol abuse since childhood. Mr. A immigrated to the United States at the age of 5 with his grandmother. He completed 11 years of formal education. He was homeless, although permitted to sleep in the garage of his former sister-in-law. He was currently unemployed, having been fired from factory work because of altercations with coworkers. Mr. A described a lack of supportive relationships in his life with the exception of his ex-wife and her sister. Moreover, he described his relationships with other family members as conflicted. He felt certain that if they learned about his HIV status or, more importantly, his transmission of the virus to his exPsychosomatics 44:4, July-August 2003
Case Reports wife, they would “kill him.” Mr. A contracted HIV through unprotected sex with a prostitute. On initial examination, Mr. A was pleasant and cooperative. He responded to questions in a logical manner. However, there were many inconsistencies in his story with vague content. Mood was sad; affect was congruent and at times tearful. He presented his predicament as pathetic and bereft, at times appearing dazed and childlike. Thought processes were linear. There was a slight latency of responses. He acknowledged suicidal ideation but denied current plan or intent. He reported auditory and visual hallucinations, although inconsistently. During the MiniMental State Examination (MMSE),11 Mr. A answered each question incorrectly, giving answers that were each slightly different from the correct response. For example, when asked what year it was, he gave the previous year. When asked in which city he was located, he responded by naming a nearby city in an adjacent state. When asked to repeat three spoken items, he stated that he was unable to do so. He failed to answer even one question correctly on the entire exam. There was no evidence of inattention or other signs of delirium. When asked about his incorrect responses, Mr. A conveyed no insight and denied an ability to provide correct responses. Despite his confused presentation, it was noted that Mr. A walked to the clinic location without assistance from over 1 mile away. The MMSE data appeared to be inconsistent with his initial presentation, and we considered a diagnosis of Ganser’s syndrome. He was referred for a magnetic resonance imaging (MRI) scan and neuropsychological testing to rule out a cognitive disorder. His family was contacted for clarification of his history. Medical records indicated a diagnosis of HIV confirmed by Western blot and AIDS, with an absolute CD4 count of 50. He was being treated with a combination regimen of lamivudine/zidovudine, efavirenz, and trimethoprim/sulfamethoxazole, with no problems of adherence despite homelessness. Upon evaluation, his CD4 count was greater than 200 and his viral load was undetectable at less than 50. His primary care doctor had prescribed paroxetine, 20 mg/day, 3 weeks before our evaluation. Results of the MRI scan with gadolinium were unremarkable with the exception of an area of gliosis and volume loss resulting from an old brain insult to the left anterior temporal lobe and a mucous retention cyst within the right maxillary sinus. A neuropsychological battery, which consisted of a second MMSE,11 as well as the Test of Memory and Malingering (TOMM),12 WAIS-III,13 Wide-Range Achievement Test, 3rd ed.,14 and the MMPI, 2nd ed.,15 was Psychosomatics 44:4, July-August 2003
scheduled. He achieved a total score of 25 out of 30 on the second MMSE, suggesting that his overall cognitive ability was not nearly as impaired as first presented. He performed very well on the Test of Memory and Malingering, scoring a 41 on trial 1, followed by scores of 50 and 50 in subsequent trials, indicating that Mr. A was not malingering and was putting forth his best effort. Overall, Mr. A’s intellectual ability was below average. Although he did not complete all 14 subtests of the WAIS-III because of a failure to attend further testing appointments, he performed consistently below average on all seven subtests that he did complete. Full-scale, verbal, and performance IQs were not able to be obtained. He completed only 130 of 567 items on the MMPI-II, an insufficient number of items to be scored.
Discussion
This patient demonstrated all essential features of Ganser’s syndrome on his initial presentation. Upon mental status examination, he responded with approximate answers throughout. “Clouding,” as described in the Ganser literature,11 was evident in his disorientation to time and place as well as deficits in long-term, short-term, and working memory, not delirium. The patient also reported perceptual disturbances including visual hallucinations (seeing ghosts), auditory hallucinations (hearing voices), and intermittent double vision. His dazed presentation and a number of other symptoms spontaneously resolved within 1 week, when he presented as fully oriented with superior performance on the TOMM during the second visit. Further, a number of problems presented during the second visit were inconsistent with those reported upon initial visit. It is important to differentiate such a presentation as being either intentionally produced, as seen with malingering (overt secondary gain) and factitious disorder (psychological gain as being in the sick role), or not under one’s conscious control, as seen with hysteria or dissociative disorders. However, this can be a difficult task. In Ganser’s syndrome, symptoms are unconsciously produced, although they may appear to have secondary gain. In this case, the patient was confronted regarding his knowledge of giving approximate answers, and he responded with indifference, demonstrating no awareness of the occurrence. Moreover, he showed no anxiety or fear of being discovered. He did not appear to be particularly guarded or both343
Case Reports ered by the inconsistencies in his reporting of symptoms. Further, when the clinician exited the room and the patient was left without supervision, his presentation did not appear to change significantly as observed from another room through a one-way mirror. Neuropsychiatric factors were ruled out as the etiology of the Ganser’s syndrome presentation. At initial presentation, the patient had an undetectable viral load. Although this patient had been HIV positive for 2 years, HIV/AIDSrelated dementia is not likely. MRI results did not identify any significant abnormality, including the global cerebral atrophy or white matter abnormalities that have been commonly associated with HIV/AIDS dementia.16 However, it has been suggested that some HIV-infected patients do exhibit mild neuropsychological deficits—including effects on attention, speed of information processing, and learning (dysfunction of frontal-subcortical systems)—that worsen as the disease progresses and that can be observed at any stage of infection, although most often seen in later stages of the disease.16 This, again, is very unlikely, would not produce such global confusion and disorientation that would remit within 1 week, and was not due to delirium. Therefore, this Ganser’s syndrome presentation did not appear to be due to the direct effects of HIV infection, and there were no acute metabolic abnormalities. Psychological factors appeared to be of primary importance in the conceptualization of this patient’s condition. The chief complaint of depression is likely to have some relevance in the presentation and has been previously associated with Ganser’s syndrome.1,7 The patient reported depressed mood and difficulty adjusting to life changes that occurred following his HIV diagnosis. Circumstances surrounding his infection as well as the transmission of the disease to his wife may have significantly contributed to his level of stress and further limited his ability to cope effectively. Once his wife was informed of the patient’s HIV status and learned that she too was HIV positive, she ended their relationship, which served as another insult to the patient’s potential for resilience, his support system,
and his psychological well-being. Moreover, it had been stressed to the patient that if her family learned that he had transmitted the infection to her, his physical safety would be at risk. These changes began to affect all aspects of his life, including his work and his relationships with others. He therefore found himself, 2 years later, resources taxed, immune system compromised, living with HIV/AIDS, unemployed, single, having to rely on his ex-wife’s family, and living in fear for his own physical safety. Depression and other emotional difficulties are likely to be experienced by such a disabled individual, and it may be predicted that he may be of potential danger to himself. Finding himself unable to cope, having failed twice at suicide, the patient attempted to seek treatment in the hopes of changing his life circumstances. It is quite possible that he came to the clinic exhibiting Ganser’s syndrome with an unconscious motivation and desperation to appear sick enough to acquire immediate help in escaping from his chaotic lifestyle. Perhaps a lack of mature, abstract thinking ability and well-developed language skills, coupled with difficulties with emotional insight and a tremendous amount of life and death stressors, may have influenced him to unconsciously resort to appearing severely cognitively impaired. Further, his Ganser’s presentation may be viewed as a flight from reality into dissociation and mental illness, serving to allow the patient temporary escape from his intolerable life circumstances. Moreover, taking on the sick role of mental illness may serve him and his survival by decreasing the likelihood of harm by his wife’s family, since they may feel sorry for him or may fear his “mental illness.” This case is a peculiar one in that no case of Ganser’s syndrome in an individual with HIV/AIDS, to our knowledge, has been previously reported. The neurological deficits that may arise in individuals with HIV/AIDS complicate the differential diagnosis of Ganser’s syndrome. Fortunately, one can take from this case a further understanding of the severity of illness involved in the development and presentation of Ganser’s syndrome as in other dissociative disorders.
References
1. Enoch MD, Trethowan WH: The Ganser syndrome, in Uncommon Psychiatric Syndromes. Bristol, UK, John Wright, 1979, pp 50–62 2. Whitlock FA: The Ganser syndrome. Br J Psychiatry 1967; 113:19–29 3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994, p 491 4. Cocores JA, Santa WG, Patel MD: The Ganser syndrome: evi-
344
dence suggesting its classification as a dissociative disorder. Int J Psychiatry Med 1984; 14:47–56 5. Sigal M, Altmark D, Alfici S, Gelkopf M: Ganser syndrome: a review of 15 cases. Compr Psychiatry 1992; 33:134–138 6. Tsoi WF: The Ganser syndrome in Singapore: a report of ten cases. Br J Psychiatry 1973; 123:567–572 7. Haddad PM: Ganser syndrome followed by major depressive episode. Br J Psychiatry 1993; 162:251–253
Psychosomatics 44:4, July-August 2003
Case Reports 8. Sim M: Guide to Psychiatry. Edinburgh, Churchill Livingstone, 1974 9. Carney MW, Chary TK, Robotis P, Childs A: Ganser syndrome and its management. Br J Psychiatry 1987; 151:697–700 10. Anderson HS, Sestoft D, Lillebaek T: Ganser syndrome after solitary confinement in prison: a short review and a case report. Nord J Psychiatry 2001; 55:199–201 11. Folstein MF, Folstein SE, McHugh PR: “Mini-Mental State”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198 12. Tombaugh T: Test of Memory Malingering. North Tonawanda, NY, Multi-Health Systems, 1996
Psychosomatics 44:4, July-August 2003
13. Wechsler D: Wechsler Adult Intelligence Scale, 3rd ed. San Antonio, Tex, Psychological Corp (Harcourt), 1997 14. Wilkinson GS: Wide-Range Achievement Test 3: Administration Manual. Wilmington, Del, Wide Range, 1993 15. Hathaway SR, McKinley JC: Minnesota Multiphasic Personality Inventory 2. Minneapolis, University of Minnesota Press, 1989 16. Lopez OL, Becker JT: HIV infection and associated conditions, in Clinical Neuropsychology: A Pocket Handbook for Assessment. Edited by Snyder PJ, Nussbaum PD. Washington, DC, American Psychological Association, 1998, pp 341–364
345
I
n 1898, German psychiatrist Siegbert Ganser first recognized the syndrome that would bear his name as a presentation of Vorbeireden, or “approximate answers.” Central features of Ganser’s syndrome include 1) approximate answers, 2) somatic conversion symptoms, 3) clouding of consciousness, and 4) hallucinations.1 Although it has been regarded as a psychotic disorder,2 it is currently classified among disorders of dissociation.3 The syndrome is uncommon, and rates of incidence and prevalence remain unclear. There appears to be a higher incidence of the condition in male subjects who belong to an ethnic minority.4–6 According to a review of 41 cases of Ganser’s syndrome,4 symptoms may span a wide range and include conversion features such as paralysis, anesthesias, paresthesias, and hysterical seizures (seen in 33% of the cases); psychogenic fugue (seen in 33%); disorientation to time and place (seen in 56%); perceptual disturbances such as auditory hallucinations, visual hallucinations, and olfactory hallucinations (seen in 51%); and amnesia, including localized, selective, and continuous types (seen in 93% of the cases). Approximate answers and amnesia were highly correlated at 93%, suggesting a dissociative mechanism.4 Onset of the syndrome is frequently associated with a stressful life event,7 which is most often of a domestic, sexual, or financial nature.2 Most cases are transient and resolve suddenly with an inability to recall the event.1 Ganser’s syndrome has been reported in a variety of patients, including those who have suffered trauma (per Ganser), organic brain disease,8 alcoholism with Korsakov’s psychosis,2 schizophrenia,6 depression,1,7 and neurosyphillis,6 although it has been most commonly reported in forensic settings.5,9,10 The condition is thought to unconsciously ocReceived Nov. 18, 2002; accepted Dec. 13, 2002. From the Temple University School of Medicine, Philadelphia. Address reprint requests to Dr. Lamdan, Temple University Health Sciences Center and Department of Psychiatry, 1316 West Ontario St., Jones Hall, 7th Floor, Philadelphia, PA 19140. Copyright 䉷 2003 The Academy of Psychosomatic Medicine.
342
cur in response to a psychologically intolerable event.10 Further, it has been suggested that individuals presenting with Ganser’s syndrome frequently have underlying axis II psychopathology.4,5 Presented here is a description of an HIV-positive male patient who came into an outpatient psychiatry clinic exhibiting Ganser’s syndrome.
Case Report
Mr. A was a 38-year-old Puerto Rican male who came to the outpatient clinic with a chief complaint of depression, which began 2 years earlier when he received a diagnosis of HIV/AIDS. Symptoms included depressed mood, anhedonia, feelings of guilt and worthlessness, disturbed sleep, nightmares, decreased appetite, aches and pains, suicidal ideation, and intermittent double vision. He also reported seeing ghosts in the corners at night and hearing voices telling him to kill himself. He reported two recent suicide attempts: one by medication overdose and another by self-inflicted knife wound to the abdomen. He denied any personal or family psychiatric history, treatment, or alcohol/drug abuse. However, reports by his ex-wife indicated a history of emotional difficulties and alcohol abuse since childhood. Mr. A immigrated to the United States at the age of 5 with his grandmother. He completed 11 years of formal education. He was homeless, although permitted to sleep in the garage of his former sister-in-law. He was currently unemployed, having been fired from factory work because of altercations with coworkers. Mr. A described a lack of supportive relationships in his life with the exception of his ex-wife and her sister. Moreover, he described his relationships with other family members as conflicted. He felt certain that if they learned about his HIV status or, more importantly, his transmission of the virus to his exPsychosomatics 44:4, July-August 2003
Case Reports wife, they would “kill him.” Mr. A contracted HIV through unprotected sex with a prostitute. On initial examination, Mr. A was pleasant and cooperative. He responded to questions in a logical manner. However, there were many inconsistencies in his story with vague content. Mood was sad; affect was congruent and at times tearful. He presented his predicament as pathetic and bereft, at times appearing dazed and childlike. Thought processes were linear. There was a slight latency of responses. He acknowledged suicidal ideation but denied current plan or intent. He reported auditory and visual hallucinations, although inconsistently. During the MiniMental State Examination (MMSE),11 Mr. A answered each question incorrectly, giving answers that were each slightly different from the correct response. For example, when asked what year it was, he gave the previous year. When asked in which city he was located, he responded by naming a nearby city in an adjacent state. When asked to repeat three spoken items, he stated that he was unable to do so. He failed to answer even one question correctly on the entire exam. There was no evidence of inattention or other signs of delirium. When asked about his incorrect responses, Mr. A conveyed no insight and denied an ability to provide correct responses. Despite his confused presentation, it was noted that Mr. A walked to the clinic location without assistance from over 1 mile away. The MMSE data appeared to be inconsistent with his initial presentation, and we considered a diagnosis of Ganser’s syndrome. He was referred for a magnetic resonance imaging (MRI) scan and neuropsychological testing to rule out a cognitive disorder. His family was contacted for clarification of his history. Medical records indicated a diagnosis of HIV confirmed by Western blot and AIDS, with an absolute CD4 count of 50. He was being treated with a combination regimen of lamivudine/zidovudine, efavirenz, and trimethoprim/sulfamethoxazole, with no problems of adherence despite homelessness. Upon evaluation, his CD4 count was greater than 200 and his viral load was undetectable at less than 50. His primary care doctor had prescribed paroxetine, 20 mg/day, 3 weeks before our evaluation. Results of the MRI scan with gadolinium were unremarkable with the exception of an area of gliosis and volume loss resulting from an old brain insult to the left anterior temporal lobe and a mucous retention cyst within the right maxillary sinus. A neuropsychological battery, which consisted of a second MMSE,11 as well as the Test of Memory and Malingering (TOMM),12 WAIS-III,13 Wide-Range Achievement Test, 3rd ed.,14 and the MMPI, 2nd ed.,15 was Psychosomatics 44:4, July-August 2003
scheduled. He achieved a total score of 25 out of 30 on the second MMSE, suggesting that his overall cognitive ability was not nearly as impaired as first presented. He performed very well on the Test of Memory and Malingering, scoring a 41 on trial 1, followed by scores of 50 and 50 in subsequent trials, indicating that Mr. A was not malingering and was putting forth his best effort. Overall, Mr. A’s intellectual ability was below average. Although he did not complete all 14 subtests of the WAIS-III because of a failure to attend further testing appointments, he performed consistently below average on all seven subtests that he did complete. Full-scale, verbal, and performance IQs were not able to be obtained. He completed only 130 of 567 items on the MMPI-II, an insufficient number of items to be scored.
Discussion
This patient demonstrated all essential features of Ganser’s syndrome on his initial presentation. Upon mental status examination, he responded with approximate answers throughout. “Clouding,” as described in the Ganser literature,11 was evident in his disorientation to time and place as well as deficits in long-term, short-term, and working memory, not delirium. The patient also reported perceptual disturbances including visual hallucinations (seeing ghosts), auditory hallucinations (hearing voices), and intermittent double vision. His dazed presentation and a number of other symptoms spontaneously resolved within 1 week, when he presented as fully oriented with superior performance on the TOMM during the second visit. Further, a number of problems presented during the second visit were inconsistent with those reported upon initial visit. It is important to differentiate such a presentation as being either intentionally produced, as seen with malingering (overt secondary gain) and factitious disorder (psychological gain as being in the sick role), or not under one’s conscious control, as seen with hysteria or dissociative disorders. However, this can be a difficult task. In Ganser’s syndrome, symptoms are unconsciously produced, although they may appear to have secondary gain. In this case, the patient was confronted regarding his knowledge of giving approximate answers, and he responded with indifference, demonstrating no awareness of the occurrence. Moreover, he showed no anxiety or fear of being discovered. He did not appear to be particularly guarded or both343
Case Reports ered by the inconsistencies in his reporting of symptoms. Further, when the clinician exited the room and the patient was left without supervision, his presentation did not appear to change significantly as observed from another room through a one-way mirror. Neuropsychiatric factors were ruled out as the etiology of the Ganser’s syndrome presentation. At initial presentation, the patient had an undetectable viral load. Although this patient had been HIV positive for 2 years, HIV/AIDSrelated dementia is not likely. MRI results did not identify any significant abnormality, including the global cerebral atrophy or white matter abnormalities that have been commonly associated with HIV/AIDS dementia.16 However, it has been suggested that some HIV-infected patients do exhibit mild neuropsychological deficits—including effects on attention, speed of information processing, and learning (dysfunction of frontal-subcortical systems)—that worsen as the disease progresses and that can be observed at any stage of infection, although most often seen in later stages of the disease.16 This, again, is very unlikely, would not produce such global confusion and disorientation that would remit within 1 week, and was not due to delirium. Therefore, this Ganser’s syndrome presentation did not appear to be due to the direct effects of HIV infection, and there were no acute metabolic abnormalities. Psychological factors appeared to be of primary importance in the conceptualization of this patient’s condition. The chief complaint of depression is likely to have some relevance in the presentation and has been previously associated with Ganser’s syndrome.1,7 The patient reported depressed mood and difficulty adjusting to life changes that occurred following his HIV diagnosis. Circumstances surrounding his infection as well as the transmission of the disease to his wife may have significantly contributed to his level of stress and further limited his ability to cope effectively. Once his wife was informed of the patient’s HIV status and learned that she too was HIV positive, she ended their relationship, which served as another insult to the patient’s potential for resilience, his support system,
and his psychological well-being. Moreover, it had been stressed to the patient that if her family learned that he had transmitted the infection to her, his physical safety would be at risk. These changes began to affect all aspects of his life, including his work and his relationships with others. He therefore found himself, 2 years later, resources taxed, immune system compromised, living with HIV/AIDS, unemployed, single, having to rely on his ex-wife’s family, and living in fear for his own physical safety. Depression and other emotional difficulties are likely to be experienced by such a disabled individual, and it may be predicted that he may be of potential danger to himself. Finding himself unable to cope, having failed twice at suicide, the patient attempted to seek treatment in the hopes of changing his life circumstances. It is quite possible that he came to the clinic exhibiting Ganser’s syndrome with an unconscious motivation and desperation to appear sick enough to acquire immediate help in escaping from his chaotic lifestyle. Perhaps a lack of mature, abstract thinking ability and well-developed language skills, coupled with difficulties with emotional insight and a tremendous amount of life and death stressors, may have influenced him to unconsciously resort to appearing severely cognitively impaired. Further, his Ganser’s presentation may be viewed as a flight from reality into dissociation and mental illness, serving to allow the patient temporary escape from his intolerable life circumstances. Moreover, taking on the sick role of mental illness may serve him and his survival by decreasing the likelihood of harm by his wife’s family, since they may feel sorry for him or may fear his “mental illness.” This case is a peculiar one in that no case of Ganser’s syndrome in an individual with HIV/AIDS, to our knowledge, has been previously reported. The neurological deficits that may arise in individuals with HIV/AIDS complicate the differential diagnosis of Ganser’s syndrome. Fortunately, one can take from this case a further understanding of the severity of illness involved in the development and presentation of Ganser’s syndrome as in other dissociative disorders.
References
1. Enoch MD, Trethowan WH: The Ganser syndrome, in Uncommon Psychiatric Syndromes. Bristol, UK, John Wright, 1979, pp 50–62 2. Whitlock FA: The Ganser syndrome. Br J Psychiatry 1967; 113:19–29 3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, APA, 1994, p 491 4. Cocores JA, Santa WG, Patel MD: The Ganser syndrome: evi-
344
dence suggesting its classification as a dissociative disorder. Int J Psychiatry Med 1984; 14:47–56 5. Sigal M, Altmark D, Alfici S, Gelkopf M: Ganser syndrome: a review of 15 cases. Compr Psychiatry 1992; 33:134–138 6. Tsoi WF: The Ganser syndrome in Singapore: a report of ten cases. Br J Psychiatry 1973; 123:567–572 7. Haddad PM: Ganser syndrome followed by major depressive episode. Br J Psychiatry 1993; 162:251–253
Psychosomatics 44:4, July-August 2003
Case Reports 8. Sim M: Guide to Psychiatry. Edinburgh, Churchill Livingstone, 1974 9. Carney MW, Chary TK, Robotis P, Childs A: Ganser syndrome and its management. Br J Psychiatry 1987; 151:697–700 10. Anderson HS, Sestoft D, Lillebaek T: Ganser syndrome after solitary confinement in prison: a short review and a case report. Nord J Psychiatry 2001; 55:199–201 11. Folstein MF, Folstein SE, McHugh PR: “Mini-Mental State”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12:189–198 12. Tombaugh T: Test of Memory Malingering. North Tonawanda, NY, Multi-Health Systems, 1996
Psychosomatics 44:4, July-August 2003
13. Wechsler D: Wechsler Adult Intelligence Scale, 3rd ed. San Antonio, Tex, Psychological Corp (Harcourt), 1997 14. Wilkinson GS: Wide-Range Achievement Test 3: Administration Manual. Wilmington, Del, Wide Range, 1993 15. Hathaway SR, McKinley JC: Minnesota Multiphasic Personality Inventory 2. Minneapolis, University of Minnesota Press, 1989 16. Lopez OL, Becker JT: HIV infection and associated conditions, in Clinical Neuropsychology: A Pocket Handbook for Assessment. Edited by Snyder PJ, Nussbaum PD. Washington, DC, American Psychological Association, 1998, pp 341–364
345