Brit. 3. Psychiat.

(i973), 123, 567—72

The Ganser Syndrome in Singapore: A Report on Ten Cases

By W. F. TSOI

INTRODUCTION sections and was adapted after Anderson et al.

The purpose of this paper is to report on ten
cases of this uncommon syndrome admitted to (i) Name, personal questions and orientation;
Woodbridge Hospital, Singapore, and studied (2) Questions to elicit symptoms of schizophrenia;
by the author in a systematic way. No attempt (@)Questions to elicit approximate answers;
will be made to review the literature, as this (4) Counting i, 2, 3. . . to 20 and backwards 20,
19, i8... i. Digit span and simple arithmetic;
has already been done recently by Goldin and
(@)Naming of objects like books, watch, pen
@ MacDonald Enoch and Irving (1962), knife, postage stamp, etc.;
Enoch et al. (1967) and Whitlock (1967). The (6) Name of Prime Minister and other simple
Ganser syndrome appears to be getting rarer in general knowledge questions pertaining to
the West, as reports in recent literature have Singapore;
usually covered a few cases only: May et al. (7) Copying five simple shapes—circle, triangle,
(1960) reported three cases and Whitlock (1967), square, rhombus (diamond) and five-cornered
six cases. star.
A brief description of Singapore and its Some cases were re-examined after they had
psychiatric services is relevant. Singapore is an recovered from the syndrome.
island city republic of slightly more than
2 million population in an area of 225 square RESULTS

miles. Its population is comprised of 76 per The main clinical findings are summarized
cent Chinese,15 per cent Malays, 7 per cent in Tables I and II. It was noticed that older
Indians and 2 per cent others, according to the patients were more prone to develop this
1970 Census report. Woodbridge Hospital is syndrome (Table III). The Indians were
the only psychiatric hospital and observation greatly over-represented (Table IV). There
centre for criminal offenders suspected to be of was also a bias towards the English-speaking
unsound mind. The official language of the class. Only three were criminal offenders
hospital is English, but the majority of the (charged with murder). There were no female
psychiatric patients spoke a variety of Chinese patients in this series.
dialects
and otherlanguages.For the pastten
years the hospital has admitted about 1,500 new Analysis of the ‘¿structured
interview'
patients
annually. Because all patients did not speak the same
language, or did not reach the same proficiency
METHOD OF Sruxw in English, it was not possible to adhere to
After a systematic examination, out of 21 a rigid scheme of questioning as was done by
cases suspected to present with the Ganser Anderson et al. (i@@@)in their studies on simula
syndrome, only lo cases were found to show tion. The author conducted all the interviews
sufficient symptoms for a diagnosis of the and kept the examination situation as uniform
syndrome to be made. These cases were inter as possible.
viewed by the author in a semi-structured On ‘¿Personal
Questions and Orientation', aJl
manner. Raven's Progressive Matrices test was patients except two (Cases 7 and 9) were able
carried out by the author in the last three cases. to give their names correctly. All patients either
A similar interview was also conducted on ten gave wrong or approximate answers for their
schizophrenic patients as ‘¿controls'. age, address, occupation, the place, the day
The ‘¿structuredinterview' consisted of seven and the date. Except for the date and sometimes
567
3D
 568 THE GANSER SYNDROME IN SINGAPORE: A REPORT ON TEN CASES

T@usu@ I
Summary of some data

Case Age Race Past personality Probable motivation

50 Indian Irresponsible Avoiding trial for murder

2 44 Malay Irresponsible Avoiding trial for murder

3 24 Chinese Immature Dissatisfied with army life

Inadequate
4 ‘¿9 Indian Normal Compensation forhead injury

5 20 Indian Irresponsible Avoiding trial for murder

6 @6 Indian Irresponsible Compensation for head injury

7 4' Indian Normal Escaping from domestic problem

8 37 Indian Irresponsible Desiring early retirement on medical ground

Muslim
9 20 Chinese Immature
lifeInadequate Dissatisfied with army

10 43 Malay Extrovert Desiring early retirement on medical ground

T4'usLEII was able to count from I to 20 forwards cor

Summaryof clinicalfiatures rectly and in the normal way. None were able
of to count from 20 to i backwards correctly.
Clinical
casesUnable featuresCasesNo.
TABLE HI
to answer simple
cases10Unable
questions .. ..All Age range 10—19 20—29 30—39 40—49 50—59

to add or count Singapore male

casesio..All
(approximate answers)..All population %° 27 i6 12 9 7

AmnesiaFugue/trance-like cases101,4,6,7,8,9,107 Ganser

syndrome
20* % 10 3010 30
statesComplaints
Worked out 1970,TenLE
from Census
of hearing Singapore.Population
voicesComplaints 1,3,5,7,9,1061,3,5,1046I
IVEthnic
visionsHysterical
of seeing
group
OthersSingaporeChinese Malay@Indians@
conversion

population %* 75 158 2
the day, the ‘¿control'group of schizophrenic
patients gave all correct answers. Ganser
On questions to elicit approximate answers, syndrome % 20 20 6o o
all patients were unable to tell how many
* Worked out from Census Population 1970,
weeks and how many months there were in a Singapore
year, and only three were able to reply that t Malay includes Indonesian.
@ there were seven days in a week. Only Case 7 Indian includes Pakistani and Ceylonese.
 BY W. F. TSOI 569
In the identification of simple objects, there illness, as the injuries in the two cases were
was a tendency for patients to give approximate relatively mild and the subsequent clinical
identifications, e.g. clock for watch, pencil for picture was more consistent with a functional
pen, photograph for postage stamp, etc. In the psychiatric disorder. Compensation in the two
copying of simple shapes there was no difference cases was a strong motivating factor.
from the control group. The author disagrees with Whitlock (1967)
Three patients in this group and several other that the Ganser syndrome is a psychotic illness,
‘¿borderline'cases were given the Progressive and was not able to differentiate clearly between
Matrices examination. The following observa this syndrome and pseudo-dementia from the
tions were noted. disturbance of consciousness which was too
(i) Some patients were very slow in giving subjective and ill-defined to be a good criterion.
responses; On the other band, approximate answers could
(2) The scores were very low—7, 6, 2, for the sometimes be elicited in schizophrenia or chronic
three patients; organic brain syndrome.
(@)Detailedobservations
showeda certain
pattern of ‘¿mistakes'—a
tendency to choose the P.@ychopathology
figure next to the black space, i.e. either the one The results of this study showed that these
above or the one to the left. patients were trying to simulate a psychotic
illness or exaggerate their psychotic experience,
DISCUSSION according to their idea of insanity acquired
It is difficult to place this group of patients at partly through mixing with psychotic patients in
any single point along the malingering, hysteria the wards. Of the four ‘¿essential'
clinical features,
@ and psychosis spectrum. Amongst the i cases Vorbeireden or more correctly Vorbeigehenwas the
who were observed to present with some of the one that made these patients stand out as a
features of the Ganser syndrome but were rejected separate clinical entity. What was more difficult
from this report, one patient had severe head to decide was whether the simulation was at
injuries, one was found to suffer from early the conscious or unconscious level. It was in
tertiary neurosyphilis (GPI), and another from teresting to note that approximate answers
severe schizophrenia. The last two cases pre were produced by Chinese, Indians and Malays
sented with sufficient features to almost warrant whose culture, belief@ and upbringing were
inclusion in this series. As in reports from other very different from the English-European
series, not all the cases reported here had all the pattern, and the approximation extended to
four essential clinical features of the Ganser other areas of behaviour—viz, naming of
syndrome, namely: (z) the approximate answer, objects, problem solving, etc.
(2) clouding of consciousness, (@) somatic The Ganser syndrome, like other psychiatric
conversion features, and (@) hallucinations diagnostic categories, is not an all-or-none
(Enoch et al., 1967). The syndrome appeared to phenomenon. The clinical picture in our cases
range from patients who gave an occasional covered a wide range of psychiatric abnormali
approximate answer to those who showed the ties, but they were most distinctive in the cogni
full-blown picture. It was difficult to decide tive area. Most of the cases reported by previous
where should be the cut-off point for a diagnosis authors do not give the impression of a fully
of the Ganser syndrome. developed Ganser syndrome. The questions
The author was more inclined to agree with covering areas listed in the proforma were able
Mayer-Gross et al. (1969), Henderson and to pick out some of the variations in this rare
Batchelor (1962), Curran and Partridge (1969), condition.
and Enoch and Irving (1962), and classify this Medico-legally, for criminal offenders, the
syndrome on the hysteria-malingering dimen Ganser syndrome by itself should not constitute
sion rather than as a psychosis. The fact that unsoundness of mind. For the purpose of civil
some patients had head injuries should not be compensation, as in the cases of head injuries,
sufficient argument to call this an organic the syndrome was best regarded as a functional
 57° THE GANSER SYNDROME IN SINGAPORE: A REPORT ON TEN CASES

neurotic disorder rather than a direct result of fellow servicemen's things and threw away some keys.
He complained that people wanted to kidnap him, and
brain injury.
he mistook his fellow servicemen as policemen who tried
to extort information from him. He said that the lance
CASE REPORTS corporal escorting him was from the C.I.D., and that he
Caui would get beaten up in this place (the hospital). He
Admitted on 25.1 1.65 was a so-year-old Tamil widower, complained of hearing voices and was disorientated.
born in India, educated in Tamil for five years and On i .3.67, during an examination, he expressed dislike
married at age 30—Wifedied in 1955. He came to Singa for army life, especially the uniform and the discipline.
pore in 5956 leaving behind two daughters and a son. Spontaneously he volunteered that during the day he
His last occupation was building sub-contractor. He took sometimes heard the voices of a girl scolding him and a
moderate amounts of alcohol for 20 years and smoked boy threatening him. On his way to the camp he saw two
@ marijuana for years. persons trying to strangle him and to kill him in order to
On 7.2.60 he was convicted for voluntarily causing hurt take away his money. When he reached the camp he
and wasjailed for two months. On i5.50.65after a quarrel asked the medical officer for a sub-machine gun to defend
over a woman he stabbed three persons with a knife and himself. For this he was referred to this hospital.
one of the victims died. He was admitted to this hospital During the structured interview on i .3.67 he gave his
because he had had depression, amnesia and outbursts of age as 19 and the date as 27.1 .67, the day as Friday (when
temper for one week. While in prison he was able to give it was Wednesday) and gave the name of the Defence
a brief account of the murder incident and his arrest by Minister for the Prime Minister. He was unable to count
the police three weeks before. He said that in the struggle I to 20 either forwards or backwards.
he fell into the drain and could not remember the details. On 4.3.67 he recovered spontaneously. He was rational
On I1.12.65he was broughtto theauthorforexamina and no longer gave incorrect answers. He said that his
tionbecausehe refusedto eathisrice,sayingthatitwas mind had been dull afew days ago. He was then discharged
dirty and contained worms. He heard voices scolding and from the hospital. He continued to serve in the Army, but
blaming him continuously. The voices followed him on 14.5.69 he was reported to have made an attempt to
wherever he went. He had amnesia of the murder incident.
hang hirnsell and on 10.7.69 he was medically boarded
He insisted
thathe had been admittedtwo months before, out from the Army.
even when he was told it was only one month, and also
said that he was given faecesto eat instead of rice. Case 4
These were some of the answers:4+3 = 5@ 2+4 = 7. Admitted on 15.3.67 was a 19-year-old single Indian
The place was Changi Prison. There were io months in storekeeper. His father was a telephone operator who had
a year and 8 days in a week. When asked to count i to 20 died two years before ofheart attack. His mother operated
he gave I, 3, 5, 7, 8, 10, 12 and stopped. On 30.12.65 he a food stall. He was the eldest in a family of 7 boys and 3
was found to be in coma. This was investigated and no girls, all living in a fiat. He was educated in English up to
cause was found. Retrospectively, it was believed that he the eighth year, and was a member of the Singapore
must have hoarded some chlorpromazineor amylobarbi Volunteer Armed Forces.
tone from otherpatientsand taken an overdosewithout On 3.1.67 he was knocked down in a traffic accident on
our knowledge.On another occasionhe showedflexibilitas his way to work and sustained mild head injury. Follow
cerea. On 26.! .66 he replied that he was 6o years old and ing this he had headache and pain in the right shoulder.
spontaneously complained of hearing voices scolding him He was treated by the author for ‘¿Depression'.
and seeing worms in his food. He sometimes saw a black On 15.3.67 he attempted suicide by jumping into the
man scolding him and threatening to kill him and cut sea from a busy pier, for which he was admitted to this
him up. He insistedthattherewas no milk inhisteawhen hospital. Two days later, when he was examined by the
this was not true. He continued to give approximate author, he complained he heard voices of people saying all
answers. sorts of things about him, and felt people wanting to
On 30.3.66 the day before he was due for mention in harm him. He gave incorrect or approximate answers to
court he was discovered to be in a stuporose state. He was simple questions. The following was a sample of his
hyperventilating, frothing at the mouth and groaning in responses. Question: ‘¿I
give you some numbers and you
pain. Physical examination was negative. He was found to repeatafterme, 74658.'Answer: ‘¿7465.'
Question:‘¿Can
be fit to stand trial on 31.3.66. you count 1,2, 3, up to 20.' Answer: ‘¿1,2,3,20.' Heidenti
fledobjectswrongly:tuning fork = iron;blood pressure
Case 3 set = balloon (pointing to the pump). He was given an
Admitted on 27.2.67 was a 24-year-old single Chinese identical examination on 2 1.3.67, when he answered all
serviceman. He was described as a difficult child who the questions correctly, but he was unable to remember
quarrelled frequently with his siblings and was demand the previous examination. He said he had been very well
ing. He did not complete his English secondary education previously but a little uncomfortable after the accident.
and was a labourer before joining the army. He was On 17.4.67he returnedtowork and was certified tobe fit
brought to the hospital by a lance-corporal with the for full duties. He wanted a medical certificate to show
historythatfortwo weeks he had been queer.He triedto that he had stayed in Woodbridge Hospital so that he
burn down the lavatory. One week ago, he burned his could claim compensation from the insurance.
 BY W. F. TSOI 57'
Case 5 described as restless. Once he absconded and was found in
Admitted on 7.8.67 was a 20-year-old unemployed a housing estate. He said he could not find his way home.
single Indian. His father was a plumbing contractor. His On 10.10.70 he was given a structured interview and
mother was mentally queer. He was educated in Tamil gave approximate answers. He scored only two correct
for four years and had a history of truancy. He stopped answers with coloured Progressive Matrices. During the
schooling for about two years and assisted his father examination he would turn the book round, stare at it,
intermittently. He was said to have connections with ponder over the figures and slap his forehead as if puzzled.
gangsters and was aggressive to his siblings. On 24.10.70 he went to his former police station and
On 1.8.67 he stabbed and killed another male Indian. broke some glasses.When returned to the hospital he was
He was arrested the next day and charged with murder. at first mute, and later said that the hospital was a hotel
He made a confession. At the request of his defence and he was suffering from a heart attack. He was taken
counsel he was observed in this hospital. On 7.8.67 when home periodically by his wife, and on one occasion wanted
he was given the structured interview by the author he to jump from a 12-storey building.
answered all questions correctly. He had amnesia for the On 8.2.7! he said he could not remember anything
murder incident. He could only remember that a detective except the two months when he went out with his wife,
came to arrest him. and expressed surprisewhen told ofthe situation he was in.
On i 7.8.67 he was reported to have had a fight with On 24.2.7! he underwent narco-analysis but this failed
other patients in the ward. After that he was very violent. to bring out much information. He regarded the narco
He was examined by the author the next day, when he analysis
as‘¿Gestapo'
treatment.
He was medicallyboarded
complained that someone was disturbing him and wanted out of service on 9.6.71. Soon after that he recovered
to kill him. He heard voices coming from the window and completely.
at 2.00 a.m. devils came to harm him. He gave approxi
mate or wrong answers.The followingwas a sample of his Su@@s@uw
responses. His age was 30. The place was his home and
he had come to this place by helicopter. There were 5 Twenty-one casessuspected tosuffer
from the
weeks in one year, and 15 days in one month. A monkey Ganser syndrome were studied. Of these 10
had 5 legs and a dog had 3 legs. He counted I to 20 thus: presented with sufficient symptoms to warrant
I, 2, 4, 5, 7, 8, g, 12, 19, i6, 17, 20. 2+3 = 6. He named
objects as follows: watch = clock, scissors = knife, a diagnosis of the Ganser syndrome. They were
$5 note = $io note, Diary = paper. For the Prime studied and are reported on in this paper.
Minister he gave the name of the President. The author concludes that the Ganser
On 26.8.67 he recovered from this syndrome and denied syndrome belongs to the hysteria-malingering
he had been given such an interview. He was rational in dimension rather than the psychosis. Five case
replies to simple questions. He remained in this rational
state until he was discharged on 1.9.67.
summariesareappended.

Case 10 Rrnit@czs
Admitted on 11.8.70 was a 43-year-Old Malay police ANDERSON, E. W., TR.Emow@i, W. H., and KENNA, J.
@ man, educated in Malay for a few years and married with ‘¿An experimental investigation of simulation

9 children, ages ranging from 7 to 20 years. He was a and pseudodementia.' Acta psych. ci neurol. Scarsd.
friendly and active person. He had worked in the Police Supp. 132 to Vol. @,pp. i—p.
Force since 1947 and was promoted to Sergeant in 1961, CEr@svs OP POPULATION (1970). Singapore Government
but was demoted to Lance-Corporal in 1969 because of Printing Office, Singapore.
breach of discipline. Since then he started to seek medical Cuitwi, D., and PARTRIDGE,M. (1969). Psychological
treatment for sore throat, flu, etc. He was brought to Medicine, 6th edition. London.
Woodbridge Hospital by his wife because for one month ENOCH, M. D., and IRvING, G. (i 962). ‘¿TheGamer
he had refusedto eat,had insomnia,did not go to work syndrome.' Ada psych. Scand., 38, 213—22.
and kept to himself at home. He sometimes wandered ENOCH, M. D., TRETHOwAN, W. H., and B@uuu@R, J. C.
aimlessly and cried a lot. He was mute on questioning, (ig67). In Some Uncommon Psychiatric Syndromes, p. 41.
and was diagnosed as suffering from ‘¿Reactive
Depression'. Bristol.
On 18.8.70 he showed signs of Gamer's syndrome. GoWIN, S., and MACDONALD, J. E. (i@@). ‘¿TheGamer
When asked what was 5 minus 2 he counted his fingers state.' J. ?nent.Sci., 101, 267—80.
and returnedtheanswer @.
A dog had 2 hands and 2 legs HENDERSON, D., and BATCHELOR, I. R. C. (1962). Text
(he then corrected this to ‘¿3
legs'). There were 6 days in a book of Psychiatry, 9th edition. London.
week; 3—I = I;2—I = 2. Duringhisstayin hospital he MCGRATH, S. D., and MCKENNA, J. (1961). ‘¿TheGamer
complained that his mind was blank and that his wife syndrome: a critical review.' Proc. 3rd World Congress
had absconded and his children were in the care of the of Psychiatry, Vol. I, pp. i@i-6i. Montreal: McGill
social welfare department. At midnight he saw his friend University Press.
come in to hospital to tell him that his wife had left him. MAY, R. H., VOEGELE, G. E., and PAOLMO, A. F. (1960).
He also heard his children crying. He had these nocturnal ‘¿TheGanser syndrome: a report of three cases.'
hallucinations from 24.9.70 to 7.10.70. In the ward, he was J. nerv.men!.Dis., ‘¿30,
331-9.
572 THE GANSER SYNDROME IN SINGAPORE: A REPORT ON TEN CASES

M@vast-GRoss,W., SLAmx, E., and Rom, M. (@69). W!irrI@ocK, F. A. (1967).‘¿The

Ganser syndrome.'Brit.
3.
Clinical Psychiatry. 3rd edition. Psychiat., 113, 19-29.

A synopsis of this paper was published in the May 1973 .Journal.

Wing Eoo Tsoi, M.B., B.S., M.R.C.P.(G.), M.R.C.PSyCh.,Medical Superintendent, Woodbridge Hospital
Singapore, 19, Republic of Singapore

(Received 21 JV'ovember 1972)

The Ganser Syndrome in Singapore: A Report on Ten Cases
W. F. TSOI
BJP 1973, 123:567-572.
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