Angelica Staniloiu4, Ash Bender1, 2, Kathy Smolewska3, Janet Elis2, Carolyn Abramowitz1, 2, &
Hans J. Markowitsch4
1Centre for Addiction and Mental Health, Toronto, ON, Canada, 2University of Toronto,
3University of Waterloo, Waterloo, ON, Canada and 4University of Bielefeld, Bielefeld, Germany
Short title: Ganser syndrome and immigration
University of Bielefeld
Tel.: +49 5211064487
The current report describes the case of a patient with a background of immigration, who, after a minor
work‐related head injury, developed severe and persistent psychiatric symptoms accompanied by
features of Ganser syndrome. The similarity between this case and other case‐reports in the literature
(Fujiwara et al., 2008) suggests that psychosocial stresses accompanying immigration may have a
catalytic effect in triggering and maintaining the dissociative symptomatology.
Key words: dissociation, head injury, psychosocial stress, vorbeireden
Dissociative disorders can be classified into three subcategories: those with sensory and perceptual
disturbances, those with disorders of the motor system and those with memory and identity
disturbances (e.g., Markowitsch, 2003). Numerous variants of dissociative reactions have been
described since the 19th century and are listed in DSM‐IV‐TR and other sources. Among the old
descriptions were those of Wanderlust (Burgl, 1900) (a euphemistic expression for the psychogenic
fugue condition) and the Ganser syndrome (Ganser, 1898). Most recently, dissociative reactions have
been postulated to occur at a greater frequency in individuals who experienced stressful events during
childhood or youth and who failed to develop appropriate coping strategies (cf. Table 23.2 in
Markowitsch, 2000; Del Piccolo, Saltini, & Zimmermann, 1998; Michal et al., 2007; Sotiropoulos et al.,
In this article we wish to draw attention to dissociative syndromes that can occur concomitantly
with other psychiatric symptoms, in individuals with a background of immigration, limited intellectual
flexibility and inadequate adaptation to their new socio‐economic status and conditions. The co‐
occurring psychiatric symptoms may include mood (depressive) symptoms, somatic symptoms,
confabulatory tendencies, memory disturbances (dementia‐like symptoms) and schizophrenia‐like
features. Among the dissociative syndromes, Ganser syndrome was historically frequently diagnosed (cf.
Markowitsch, 1992), but is currently a rare diagnosis. This may be partly due to a changed focus in its
definition. In the DSM‐IV‐TR, Ganser syndrome is included in the category of Dissociative Disorders Not
Otherwise Specified (as opposed to a factitious disorder as in DSM manuals prior to DSM IV), and is
simply defined by giving approximate answers to questions (vorbeireden). In contrast, Ganser‘s (1898,
1904) original description of the syndrome was much broader and included a hysterical semi‐trance or
twilight state, characterized by a tendency to give approximate answers. In addition, Ganser identified
impairments of consciousness, amnesia, and hallucinations as prominent features of the condition.
In 2000, Steinberg wrote that most features (e.g., severity, duration, number, type of symptoms)
of Ganser’s syndrome are still “vague”. In terms of diagnosis, “[p]art of the difficulty is the very common
overlap with major organic or psychiatric disorders, most commonly psychosis, organic brain syndromes,
major depressive disorder… A careful review of all convincing cases of Ganser syndrome in the literature
revealed that the majority of patients suffer such comorbidity.” (p. 1775). Steinberg furthermore stated
that amnesia, disorientation, hallucinations, and conversion symptoms are very common and Ganser
syndrome “might be a type of brief reactive psychosis to stress” (p. 1775).
The comorbid occurrence of Ganser syndrome and other psychiatric conditions may raise the
question of a common pathophysiological denominator. Memory disturbances, confabulatory
tendencies, and depressive conditions all are associated with frontal lobe dysfunctions. Data on patients
with dissociative amnesias or a condition coined ‘mnestic block syndrome’ (Markowitsch et al., 1999)
indicate hypometabolic zones in the right inferolateral prefrontal and, to a lesser degree, in anterior
temporal cortex (Brand et al., in rev.). Damage or dysfunction of prefrontal cortical regions also accounts
for the appearance of confabulatory tendencies and depressive conditions and autobiographical
amnesia (Kroll, Markowitsch, Knight, & von Cramon, 1996). Furthermore, brain imaging research in
healthy subjects indicates that autobiographical memory retrieval engages prefrontal cortical areas (Fink
et al., 1996; Piefke, Weiss, Zilles, Markowitsch, & Fink, 2003).
Apart from possible neuroanatomical substrates, psychosocial factors and personality traits may
play significant roles in psychopathology. Relations between unfortunate life experiences and the
subsequent development of dissociative states have been emphasized repeatedly, as well as
associations between dissociative states and anxious‐depressive and/or narcissistic personality traits
(e.g., Hennig‐Fast et al., 2008; Markowitsch, Fink, Thöne, Kessler, & Heiss, 1997; Markowitsch et al.,
1999). A link between dissociative disorders and alexithymia (Modestin, Lotscher, & Erni, 2002) as well
as between alexithymia and language and speech problems has been also suggested (Kokkonen et al.,
2003). Among the cases with dissociative identity disorder and autobiographical amnesia recently
published, a substantial proportion of them had a background of immigration. In one of the recent
papers on this subject, two out of five patients reported therein developed symptomatology after
migrating to Germany from the United Kingdom and Kazakhstan (Fujiwara et al., 2008). Although no
robust epidemiological data on Ganser syndrome is available yet (Assion, 2001), a number of patients
with Ganser syndrome described in single case reports are male subjects with a background of
immigration (Assion & Schmidt, 2004; Butzke, Hoffmann, Offinger, & Stanga, 2005; Weller, 1988) and
several case reports point out a higher frequency of Ganser syndrome among ethnic minorities (Sigal,
Altmark, Alfici, & Gelkopf, 1992; Tsoi, 1973), respectively. Studies of immigrant populations suggest that
while certain factors related to foreign nativity may offer protection against certain psychiatric disorders
in some ethnic groups (Breslau et al., 2007), other features might place the person at risk (Zolkowska,
Cantor‐Graae, & McNeil, 2001). In several immigrant populations somatization was found to be a
prevalent condition and was associated with psychological distress (Kohn, Flaherty, & Levav, 1989;
Ritsner, Ponizovsky, Kurs, & Modai, 2000), while in immigrants with an ethnic background more prone
to experience dissociative symptoms in response to stressful situations (Lewis‐Fernandez et al., 2002,
Seligman & Kirmayer, 2008), acculturation was identified as a negative predictor of dissociation
(Marshall & Orlando, 2002).
Mr. P is a 37‐year‐old Albanian right‐handed male who incurred a mild head injury while working as a
carpenter in Canada. Since the accident, Mr. P has developed numerous somatic and psychological
symptoms that have resulted in significant global functional impairment and inability to work. At the
time of Mr. P’s referral for a neuropsychological assessment, he had several provisional diagnoses
(Major Depressive Disorder, Single Episode, with Psychotic Features; Psychotic Disorder Not Otherwise
Specified; Panic Disorder without a history of agoraphobia; Dissociative Disorder NOS ‐Ganser
syndrome; Factitious Disorder) and was receiving treatment with antidepressant and antipsychotic
medication. For the purpose of the assessment, a clinical interview was conducted with Mr. P (who had
adequate command of English) and his wife. Mr. P’s medical records were also reviewed.
Mr. P reported feeling light‐headed at the time of the accident. He could not recall certain
aspects of the accident, including whether or not he lost consciousness. He did not seek treatment
immediately after it, but continued to work. Two weeks after the accident, Mr. P was hospitalized for
the first time for symptoms of intermittent confusion, headache, back pain and weakness. Routine blood
work, neurology exams, EEG and a plain CT scan of brain were within normal limits. Mr. P. was
discharged after a few days with a diagnosis of concussion and was fully oriented at the time of the
discharge. Several weeks later, Mr. P reported experiencing anxiety attacks, fears of crowds, fatigue,
insomnia, memory loss, weakness and increased back and neck pain. His family doctor suspected an
anxiety disorder and prescribed him an anxiolytic antidepressant.
In the months that followed, Mr. P developed agitation and depressive and psychotic symptoms.
He complained of anhedonia, disturbed sleep, guilt with respect to being a burden to his family, fatigue,
difficulties concentrating, passive suicidal ideation, paranoid ideation and auditory and visual
hallucinations (with religious content). He was diagnosed with major depressive disorder with mood‐
incongruent psychotic features and was prescribed anti‐depressant and anti‐psychotic medication.
Given new onset problems with balance and gait, Mr. P. underwent another neurological exam, which
again was unremarkable. As he tended to provide approximate answers, he was opined to suffer from
“a psychogenic movement disorder with Ganser syndrome”. Approximately two months later his
symptoms worsened and subsequently he was admitted involuntarily to a psychiatric clinic. At the time
of the admission, he endorsed clouded consciousness, memory impairment, and agitation, irritability
alternating with tearfulness, poor sleep, conversion symptoms, and auditory and visual hallucinations.
He scored 3/30 on Mini Mental Status Exam (MMSE). He said that he was age 28 and had 8 children
(instead of 2). He misjudged the year by one and stated that it was winter instead of summer. He
reported that he was living with his parents in a town in Albania. Some of his statements at the time
were likened to the “approximate answers”, suggestive of Ganser syndrome. Other responses seemed
more consistent with overt denial or confusion stemming from delusions.
During his inpatient stay, Mr. P received treatment with antidepressant and antipsychotic
medication. His blood work, structural MRI and serology for syphilis and HIV were negative. His mood
improved slowly and the psychotic symptoms gradually subsided. His level of insight and orientation
varied. He continued to report several somatic and neurological symptoms, but did not appear to be
particularly concerned about them (“la belle indifference”). He ambulated with a cane and exhibited a
stiff circular motion with his right leg. Although his MMSE score improved, it remained
disproportionately low (17/30). He continued to display a tendency to respond with approximate
answers. For example, he stated that he had “12 fingers” and that a week had “six” days. When asked
how many legs an elephant has, he reported: “I don’t know, I never see an elephant”. When asked to
count down from 10, he counted: “10, 8, 7, 9, 5, 4, 3, 1, 0.”
According to Mr. P and his wife, Mr. P had no history of alcohol or illicit substance use and no
psychiatric or medical illness prior to the work‐related accident (information that was consistent with
previous documentation on file). Mr. P denied any history of psychological trauma or legal or claim
history. He reported completing 12 years of schooling, with grades in the average level. Prior to his
accident he had been the sole provider for his family and he reportedly worked successfully for the
same company for a few years, without any conflict or significant absence.
The following tests were administered (or intended to be administered):
‐ Test of Memory Malingering (TOMM; Tombaugh, 1996)
Wide Range Achievement Test ‐ 3rd Edition( WRAT ‐III); Reading & Math Subtests
‐ Wechsler Memory Scales ‐ 3rd Edition (WMS‐III); Information and Orientation Subtest
‐ Peabody Picture Vocabulary Test ‐ 3rd Edition, Form B (PPVT – IIIB)
‐ Test of Non‐Verbal Intelligence (TONI)
‐ Delis Kaplan Executive Function System (DKEFS) Trail Making Test
As the patient was very difficult to test, additional information was obtained in interviews with
him. Prior to starting the testing process, Mr. P. was asked a series of general interview questions, to
assess for problems with awareness and orientation. He was unable to correctly identify his age
(misjudged it by 6 years), date of birth, date at the time of the assessment (i.e., he misjudged the year
by one and the day of the month by 6 days), location of assessment, or home address. When queried
about his current mood, he described it as flat. Mr. P’s wife confirmed his current limitations in
functioning and stated that she has had to take over many of the tasks that he assumed responsibility
for previously (e.g., organizing finances). He reported that he has neither “wishes” nor the “desire” for
Testing Results and Interpretation
General Behavioral Observations. In contrast to his relatively calm presentation during the
interview, Mr. P became increasingly agitated during testing; he seemed to understand all instructions,
but was difficult to engage and impatient. Overall, observations of Mr. P’s approach to tasks suggested
that he might not have put forth a concerted effort. This was consistent with his exceptionally poor
performance on all tasks, including a measure of memory malingering. Consequently, the test results
were considered to be an invalid indicator of his cognitive abilities. However, a qualitative account of his
responses and behavior during the testing process is presented below.
Test of Memory Malingering. Mr. P was given the TOMM in order to help determine whether he
has bona fide memory impairments. While the TOMM is sensitive to malingering and/or lack of effort, it
is insensitive to neurological impairments. Mr. P scored extremely low (i.e., below the 95% confidence
interval for chance performance) on both recall and retention trials of this forced‐choice test. To confirm
that Mr. P understood the instructions, the examiner had asked Mr. P to reiterate the instructions for
the task prior to beginning Trial 2. His response confirmed that he had indeed understood the
When an examinee achieves a score below 18/50 (i.e., the lowest score that one can achieve
within the 95% confidence interval for chance performance), it implies that the person knew some of
the pictures were correct but intentionally picked the incorrect picture (consistently giving only one
answer, i.e., always saying “I have seen the top picture”, would already result in 25/50 correct!). In
particular, performance on Trial 2 has been found to be very high for non‐malingers regardless of age,
neurological dysfunction, or psychological symptoms. Specifically, more than 95% of adults obtained a
score of 49 or 50 (out of 50) on the second trial. Mr. P’s score on both Trials 1 and 2 was below 18.
Furthermore, his score on Trial 2 was lower (or worse) than his score on Trial 1.
Mr. P’s low score on the TOMM suggests that either his memory impairment on the test is false
or exaggerated or that his low score was due to lack of effort. A score falling in this range is rarely, if
ever, obtained by persons suffering from a traumatic brain injury (TBI) or moderate‐to‐severe dementia.
In fact, according to TOMM validation studies, among individuals with a known TBI, 0% of the sample
scored as low as Mr. P on the second trial of the test.
WMS‐III Information and Orientation Subtest. The Information and Orientation subtest is an
optional component of the WMS‐III that consists of 18 questions related to basic personal and current
information. It can be used to assess whether the examinee is oriented to a person, place, time or
situation. Mr. P provided numerous incorrect responses, answering less than 25% of the questions
correctly. He was able to correctly identify his first and last name, place of birth, the approximate time
of day and differentiate his right hand from his left. Several of the other questions asked were repetitive
with those posed during the interview conducted approximately one hour earlier. Mr. P’s responses
were not only incorrect but some were actually inconsistent with answers he provided previously e.g.,
his age and current date). When asked to provide his date of birth, Mr. P responded “I don’t know....I
have to see my license;” he was able to find his wallet and license without difficulty and read his date of
birth correctly off the license.
An interesting observation was made when Mr. P was asked to name the current and previous
president of the U.S.A. He stated that the current president is Bill Clinton (incorrect). When the
examiner asked him to identify who was president before Bill Clinton, Mr. P responded “George Bush”
(correct). However, immediately after providing the correct response, he stated, “actually ... George
Bush is the premier of Canada.”
WRAT‐3 Reading and Math Subtests. Mr. P’s scores on the WRAT‐3 reading and math subtests
placed him at a level below the 1st percentile in both reading and arithmetic ability. On the letter reading
component, Mr. P identified less than half of the letters correctly. For example, he read the “O” as a
“Q”, the “P” as “B” and the “J” as “H”. His word reading mistakes were of a similar nature. For example,
he read “cat” as “car” and “felt” as “fill.”
During the interview, Mr. P reported that math had been his strongest subject in school.
However, on the math subtest, he was unable to consistently compute basic, single‐digit operations. For
example, he correctly wrote in the answer for “1 + 1” as “2” but provided incorrect answers for nine of
the ten computations that followed (e.g., “5 – 1 = 3”, “2 + 7 = 5”). Furthermore, he made several errors
on an earlier set of questions that consisted of even simpler items (e.g., number of squares on a page:
“4” instead of “5”; when asked, “Which is more, 9 or 6?” he responded “6”).
Peabody Picture Vocabulary Test. The PPVT is a norm‐referenced achievement test of receptive
vocabulary. It was administered to ascertain Mr. P’s comprehension of spoken words. Similar to his
results on the WRAT‐3, Mr. P scored extremely low on this achievement test (< 0.1 percentile; age
equivalent < 1 year 9 months). Within each 12‐item set, regardless of difficulty, Mr. P made 7 to 9 errors
with the greatest number of errors (e.g., 11 incorrect out of 12) on the second least difficult set. It
should be noted that Mr. P’s poor performance on the PPVT‐III was inconsistent with observations of his
communicative abilities during clinical interviewing. Specifically, he had little difficulty comprehending
questions asked of him during the interview.
Test of Non‐Verbal Intelligence (TONI‐3). Given Mr. P’s questionable performance on the above‐
mentioned tests, a measure of intelligence was selected that was completely free of the use of
language. The TONI‐3 is a measure of aptitude and abstract reasoning that does not involve reading,
writing, speaking, or listening on the part of the test subject. To indicate his response, Mr. P could point,
nod or use any other symbolic gesture of his choice. Unfortunately, Mr. P responded correctly to only
one item on the first set of puzzles on this test. He did not indicate that he was having any difficulty
selecting a response and he was observed to be examining the options before providing an answer. As a
result, administration of the test was discontinued when he reached the maximum number of errors
Delis Kaplan Executive Function System (DKEFS) Trail Making Test. The DKEFS Trail Making Test
was the final task administered. At this point, Mr. P was becoming very agitated, both physically and
emotionally. The Trail Making Test is broken down into five components that gradually increase in
complexity (i.e., visual scanning, letter sequencing, number sequencing, inhibition/switching, motor
speed). During the completion of this group of tasks, Mr. P appeared to be selecting incorrect responses
intentionally. For example, on the visual scanning test which simply required him to draw a line through
all circles with the number “3”, Mr. P drew a line through other numbers (e.g., 10, 1) and letters (e.g.,
“B”). Furthermore, despite spending almost four minutes on the task, he failed to mark several circles
that contained the target number. There was no evident pattern to his errors (e.g., suggestive of
neglect) and he reiterated the instructions correctly when requested to do so upon completing the first
condition. Next, Mr. P was asked to complete condition 2 (i.e., number sequencing). This task required
him to connect 16 numbered circles, in numeric order. Although Mr. P acknowledged that he
understood the instructions, it took him over 5 minutes to connect the 16 circles. While working on the
task, he requested step‐by‐step instruction at almost every circle numbered 3 to 15. He stated that he
was “confused” about which number “came next” and made several sequencing errors (i.e., drew a line
from “3” to “5” rather than “3” to “4” to “5”). In addition, he demonstrated “set‐loss” errors;
specifically, he would draw a line from a numbered circle to a circle with a letter in it. With constant
correction and redirection, he finally managed to complete the task. Similar difficulties were noted in his
performance on condition 3 (i.e., letter sequencing). It took him over 5 minutes to complete the task and
stated that he could not recall the order of the letters in the alphabet after A, B, C.
Since Mr. P’s performance was already deemed severely impaired on the first three conditions,
the fourth condition was not administered. However, Condition 5 was administered because it provided
an index of motor speed independent of visual scanning and sequencing. It took Mr. P over one minute
to connect the series of empty circles on the page, despite having to only trace over the pre‐defined line
that was already present on the page.
Unfortunately, a complete profile of Mr. P’s cognitive strengths and weaknesses could not be
ascertained. He scored extremely low on all tests of cognitive functioning, with little or no discrimination
between tasks. In other words, his performance was dismal regardless of the functional domain, nature
of the stimuli, task difficulty, or response mode. These results suggested that Mr. P was not putting forth
his best effort. This was also suggested by his performance on the TOMM, where scores on both recall
and retention trials were significantly below chance.
Although Mr. P’s neuropsychological profile might raise the suspicion of a deliberate effort to
feign cognitive impairment, no clear external incentives (such as disputed or pending financial benefits)
motivating his behavior could be identified. Consequently, a diagnosis of malingering could not be
established (Vrij, 2000; Boone, 2007).
With respect to other diagnostic considerations, the intentionality of the production of
psychological symptoms is characteristic of Factitious Disorder, but still debated in Ganser syndrome. A
key difference between the two conditions is the role of motivation. According to the diagnostic criteria
for Factitious Disorder, the individual is motivated to assume the role of a sick person. However, we did
not find sufficient evidence to suggest that Mr. P is deliberately trying to assume the sick role. Overall,
Mr. P’s history of presenting complaints and the results of the current assessment are most consistent
with a diagnosis of Ganser syndrome. Schorer (1965) characterized the Ganser syndrome not only by the
presence of approximate answers to simple questions, but also by perceptual abnormalities (e.g., visual
and auditory hallucinations), clouding of consciousness, and symptoms of somatic conversion. Although
Ganser originally described the condition as being hysterical in origin, the classification of the syndrome
has been repeatedly debated over the last century (Enoch & Trethowan, 1979; Grieger & Clayton, 1990).
In the current versions of the DSM‐IV and the ICD‐10, Ganser syndrome is categorized as a dissociative
disorder and the symptoms are considered to be psychogenic. The DSM‐IV‐TR criteria for Ganser
syndrome nowadays include only approximate answers in the absence of dissociative amnesia or
Within the classical research literature, Ganser syndrome however, is typically diagnosed on the
basis of four clinical features: giving of approximate answers to simple and familiar questions, presence
of disturbed consciousness, somatic conversion symptoms, and hallucinations (Sigal et al., 1992; Enoch
& Trethowan, 1979). Mr. P exhibited all four features.
While Ganser syndrome is assumed to be associated with a stress‐related reaction, malingering
must be ruled out. As with all psychiatric conditions, an underlying medical condition must be also
excluded. Although a number of patients with Ganser syndrome described in the literature had the
onset of their psychiatric symptoms after a traumatic brain injury (Dalfen & Feinstein, 2000), similar to
Mr. P, several cases of the traumatic brain injuries of mild severity (Miller, Bramble, & Buxton, 1997)
and therefore they could not solely account for the onset of the Ganser symptoms.
While most authors agree that the onset of Ganser syndrome is acute in nature, its duration has
long been debated. Some have observed rapid spontaneous remission (Cocores, Santa, & Patel, 1984),
while others report abrupt cessation of symptoms with psychotherapeutic intervention (Dabholkar,
1987). However, in other instances, the symptoms have been observed to persist for months despite
therapeutic interventions (Miller, Bramble, & Buxton, 1997) or the absence of obvious gain (Dalfen &
Feinstein, 2000). Subsequent amnesia for the episode upon remission has also been reported (Whitlock,
1967). The onset of Mr. P’s symptoms was sudden and the symptoms have persisted for more than a
year. Although Mr. P’s symptoms appear to have decreased in severity, he has not achieved remission
despite several psychopharmacological trials.
In addition to a diagnosis of Ganser syndrome, Mr. P meets criteria for Major Depressive
Disorder, Single Episode, Moderate. The onset of his depressive symptoms was concurrent with that of
the Ganser syndrome, occurring shortly after the work‐related mild head injury. Mr. P has reported
symptoms of depressed mood, anhedonia, physical agitation, insomnia, problems with concentration,
low energy, feelings of worthlessness and suicidal ideation. At the time of the present assessment, Mr. P
endorsed all of these symptoms with the exception of suicidal ideation.
With regard to other potential diagnoses, Mr. P’s initial presentation (i.e., perceptual
disturbances, delusions, approximate answers, disorientation) was suggestive of a possible primary
psychotic illness. However, these symptoms have not been present independent of his mood and
dissociative symptoms and appear be better accounted for by a dual diagnosis of Dissociative Disorder
NOS (Ganser syndrome) and Major Depressive Disorder – a common psychiatric co‐occurrence
(Markowitsch, 2002; Markowitsch et al., 1999).
At the time of the neuropsychological assessment, Mr. P had undergone structural, but not
functional imaging of the brain. Although results from both the CT scan and MRI were not indicative of
organic impairment, the possibility of a neurological etiology cannot be fully ruled out. In fact, several
authors have suggested a possible organic basis to the psychiatric presentation of the Ganser syndrome
that becomes apparent over time. For example, Ladowsky‐Brooks and Fischer (2003) describe a patient,
who presented with features of Ganser syndrome and frontal‐temporal lobe dysfunction (e.g.
approximate answers and the seemingly deliberate selection of incorrect responses on tests of
neuropsychological function). However, the individual’s cognitive decline over a period of a year, in
combination with findings from functional imaging, resulted in a diagnosis of frontotemporal dementia.
Therefore, it is suggested that Mr. P’s symptoms be monitored and that signs of further cognitive
decline be investigated via functional imaging. This is of special importance for two reasons: First of all,
temporal‐frontal dysfunction was noted in several cases of dissociative amnesia, which were studied
neuropsychologically and with glucose positron emission tomography (Brand et al., in rev.; Markowitsch,
2003; Reinhold, Kühnel, Brand, & Markowitsch, 2006). Secondly, the connection between stress‐related
cognitive decline, fronto‐temporal dysfunction, and the later development of dementia was already
pointed out by Porter and Landfield in 1998 and has been repeatedly emphasized since (e.g.,
Sotiropoulos et al., 2008).
In conclusion, Mr. P ‘s case illustrates another example of patients who, following a seemingly
minor stressful life event develop severe and persistent psychiatric symptoms, particularly in the
domain of dissociative disorders, accompanied by an apparent lack of effort to deal with everyday life
demands. The lack of drive and initiative and the apparent resignation to the new life situation have
already been identified as characteristics of patients with dissociative disorders (independent of the
presence of depression). Over a decade ago Kessler et al. (1997) described a 29‐year‐old former
university student with severe anterograde amnesia, which was associated with lack of drive and poor
concentration and emotional flattening, in the absence of brain damage. The authors conjectured that
this condition provided him with a mechanism that “enabled him to escape from the inability to cope
with the stresses of his life” (p. 611), a mechanism that in our opinion, may also apply to Mr. P.
Although no firm conclusion can be drawn, the fact that, similar to other cases of Ganser
syndrome, Mr. P‘s symptoms occurred on a background of immigration, suggests a new avenue for
exploring and understanding the social dimensions of Ganser syndrome. While some aspects of foreign
nativity might confer protective effects, other factors related to immigration might increase the risk for
certain psychiatric disorders. Studies examining the relationship between the time of immigration and
the onset of psychiatric disorders reveal that the risk for certain psychiatric disorders might be directly
related to the duration of the residence in the new country (Breslau et al., 2007; Mavreas & Bebbington,
1989) and subsequently suggest periodical psychiatric screening of immigrants. Among others, a
possible explanation for the delayed onset of certain psychiatric illnesses could be that chronic stress
resulting from the interaction between factors related to immigration and individual characteristics may
lead to severe psychic changes later in life, when additional minor, but subjectively intolerable stress
situations take place. The occurrence of Ganser syndrome in immigrants might be subsequently viewed
as a stress reaction, which results from the interplay between psycho‐socio‐economic and acculturative
factors related to immigration, ethnic features – such as a higher predisposition among certain ethnic
groups to respond to stress with dissociative symptoms (Guarnaccia, Rivera, Franco, & Neighbors, 1996;
Kirmayer, 1994) – and individual characteristics (such as personality profile, cognitive flexibility,
language competence, conceptual model of illness. )
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