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Why do some people fake illness?

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By Koushani Das, Farooq Ali Khan, Abhishek Kumar, Raamesh Gowri Raghavan, and Sukant Khurana

INTRODUCTION

Ganser syndrome termed as” factitious” or “dissociative disorder” is a type of mental or psychotic disorder where a person acts or portrays as if he /she is sick but in reality he is not. Ganser syndrome was first described in 1897 by Sigbert Ganser in 4 prisoners. Initially, it was believed to be rare or unusual, occurring mainly in forensic settings. Hence, it was referred to as prison psychosis. (Ganser, 1965; cf. Cocores et al., 1984; Miller, 1997). This disorder was initially classified as a factitious disorder; currently, it is classified under ‘dissociative disorder not otherwise specified’. Based on the clinical features it has been named variously as ‘nonsense syndrome’, ‘approximate answer syndrome’, pseudo dementia and ‘balderdash syndrome’.

Ganser’s syndrome is frequent in men, with a probable male-to-female ratio of 3 or 4:1. It is most often described in individuals between the ages of 15 and 40. The very idea of this male dominance is likely to be influenced by the fact that the probable ratio of males to females in prison system is countably high. [1]

CAUSES

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Evidences in Ganser syndrome has proved the fact that the condition is a psychotic one which basically occurs after an acute cerebral trauma, emotional disturbances or due to a head injury.

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Oyung et al had postulated that emotional stresses cause corticolimbic release of glutamate. Hyper Glutaminergic release in frontal lobe of brain cause symptoms such as in Ganser syndrome and stroke.[2]

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Affected people do tend to mimic behavior which is quite similar to a schizophrenic patient.

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SYMPTOMS

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Affected people with Ganser syndrome generally have short term effects.

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They tend to make statements that do not make sense/illogical statements

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Ganser affected patients report memory loss for not only a certain period of their life, but also for their Ganser-like symptoms, such as “approximate answers” given in past interviews (Nardi et al., 1977).

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They have nonsensical arguments and tend to report to hallucinations or encounter things that do not exist in real.

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One of the most common symptoms of Ganser Syndrome is ‘vorbeireden’. It is a condition where people tend to give absurd /illogical answers to simple questions or statements

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visual and auditory hallucinations

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child-like behavior and somatic symptoms including pseudo seizures and neurological symptoms

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Loss of recollection of the condition upon recovery

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Precipitating stress.

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Physical symptoms:

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Physical symptoms including hysterical paralysis and amnesia are quite common among affected patients.

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Other symptoms include antisocial personality disorder and have an extreme desire to get attention.

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The examinee/patient resort to provide absurd or ridiculous answers to questions that are well within his or her competency.[3]

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For example: when a patient is asked “what is 2+2?” , Ganser syndrome affected patients tend to answer “5” instead of “4”.

DIAGNOSIS/ TREATMENT

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Supportive psychotherapy (Epstein (1991)) and observing/monitoring for safety are the major components of treatment of Ganser syndrome.

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Medicines or antidepressants are generally not used for Ganser syndrome until and unless the person also suffers from anxiety or depression. The major complication during Ganser syndrome is Amnesia (loss of memory) during the syndrome.

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The DES (Dissociative Experiences Scale) provides a list of obviously dissociative symptoms; the participant is asked to rate what percentage of the time he/she experiences them. Hence it is possible for this reason, that individuals with true dissociative disorders tend to produce MMPI (Minnesota multiple personality inventory) profiles that appear malingered (Bliss, 1984; Coons & Sterne, 1986; Solomon, 1983).

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Heron, et al. (1991) reported severe MMPI-2 elevations in a patient with Ganser syndrome. MMPI test is carried out on patients suffering from mental illness that assess personality traits and psychopathology.

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The original MMPI was developed and invented at the University of Minnesota Hospitals and first published in 1942. The original authors of the MMPI were Starke R. Hathaway, PhD, and J. C. McKinley, MD. The MMPI is copyrighted and is a trademark of the University of Minnesota.

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Certain evidences of benefit from benzodiazepines like Xanax (alprazolam), which is an inexpensive drug used to cure anxiety and panic attacks are available at $8( 0.5 mg ,60 tablets), antipsychotic medication or other various treatments, such as electroconvulsive therapy or hypnosis, is quite limited.[4]

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Antipsychotic Drugs like Clozaril ($ 84.93) or Saphris ($569.28) can be used to treat Schizophrenia or Bipolar Disorder after proper consultation.

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BENZODIAZEPINES ARE PRESCRIBED FOR THE FOLLOWING:

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Anxiety (36%)

Panic Disorder (30%)

Epilepsy (8%)

Lennox-Gastaut Syndrome (8%)

Alcohol Addiction (6%)

Spasticity (5%)

Musculoskeletal Conditions (5%)

Insomnia (3%)

Other (1%)

Differential diagnosis [5]

The differential diagnosis associated to Ganser syndrome is as follows:

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Acute psychotic illness such as schizophrenia

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Bipolar affective disorder or manic-depressive illness (MDI), is a common, severe, and persistent mental illness.

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Depression

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Wernicke’s encephalopathy and HIV encephalopathy

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Temporal lobe epilepsy

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Head injury

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Encephalitis, acute inflammation of brain

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Meningitis, acute inflammation that cover brain spinal cord

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Drug intoxication.

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Malingering or pretending/acting to be ill.

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Investigation

No such investigation is diagnostic but a number of them may be performed to exclude other pathologies. It is thus necessary to exclude an underlying organic cause.

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Mental state examination( MSE ) should be performed.

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Liver function test.

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Urea and electrolyte test

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Vitamin B12 levels should be measured

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FBC Or full blood count test

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Thyroid function test

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Urine drug screen

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CT scan or MRI scans to exclude structural pathology.

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Lumbar puncture may be carried out to exclude meningitis or encephalitis.

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Electroencephalograph (EEG), does not always show any specific disorder [6] However, it should be carried out to exclude out any underlying causes such as delirium or seizure disorder.

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Contacts:

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Dallas counseling and treatment center is involved in psychological testing (http://www.dallasctc.com/testing/) and for the patients undergoing MMPI, the cost incurred is $250. This basically includes a meeting with a testing clinician and the administration of the test. Appointments can be taken at Appointment@DallasCTC.com

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Treatments used for Ganser Syndrome includes psychotherapy, electroconvulsive therapy and antipsychotic medication. Fortis Healthcare in India provides with Electroconvulsive therapy or ECT. (http://www.fortishealthcare.com/india/key-medical-procedures/electroconvulsive-therapy-ect-117)

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More information about various anxiety disorders, schizophrenia and depression can be studied at National Institute Of Mental Health , USA which throws light on prevention and cure of mental illness (https://www.nimh.nih.gov/index.shtml)

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CASE STUDIES

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A 12 yr old boy has been reported with around 2–3 symptoms of Ganser syndrome after having a mild head injury. The patient suffered from abnormal mental behavior (7)

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A 34 yr old farmer was taken to a general physician with symptoms of vomiting, dizziness, headache and irrelevant talking. He was referred to a psychiatrist when no obvious abnormalities were detected on general examination.

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The farmer had some personal family and monetary issues. He had incurred a loan of Rs 300,000 on marriage expenses of his sisters. His past history revealed that he was diagnosed with depression after failing in XII standard examination.

On a Mental State Examination (MSE), he gave absurd answers like a chair has 2 legs and identified a pen as a pencil. He identified his younger brother as older brother and forgot his mother’s name. The patient was treated with faradic stimulation and showed positive results towards recovery. Finally a CT scan was done which showed intracerebral hemorrhage in the left temporoparietal area. [8]

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A recently published case of dissociative disorders have a history of immigration (Fujiwara et al., 2008). A patient with background of immigration who encountered a series of stressful experiences in the process, after a minor head injury suffered from Ganser like symptoms[9]

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PREVENTION

There are no full proof or certain ways to prevent Ganser syndrome.

Ganser syndrome can be cured within certain period if the underlying cause of stress is identified and rectified. Traditionally, the syndrome has been identified as drastic and self limiting, with Ganser patients recovering quickly and completely from the syndrome (Enoch et al., 1991).

REFERENCES:

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1.( Dwyer J Reid S Ganser syndrome. Lancet. 2004 Jul 31-Aug 6 364(9432):471–3.)

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2. Oyung D, Harpreet SD, Jacob NJ. Neurobiological basis of Ganser Syndrome. Indian J Psychiatry. 2003; 45:255–6. PMC free article] [Pubmed]

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3. http://emedicine.medscape.com/article/287390-overview- absurd answers given by Ganser affected patients

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4. Ganser Syndrome Medication (http://emedicine.medscape.com/article/287390-medication?src=refgate src1

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5. [Differential diagnosis of the Ganser syndrome a case study] https://www.ncbi.nlm.nih.gov/pubmed/17492585

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6. Electrophysiological assessment of neuropsychiatric disorders

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https://www.ncbi.nlm.nih.gov/pubmed/11782889?dopt=Abstract

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7.https://www.ncbi.nlm.nih.gov/pubmed/9000788 -Case study: Ganser syndrome in children and adolescents

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8. Ganser syndrome and lesion in the temporoparietal region-https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2913563/#CIT10

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9. Ganser syndrome with work-related onset in a patient with a background of immigration (http://www.tandfonline.com/doi/abs/10.1080/1354680090293103)

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