Ganser syndrome - a dissociative disorder or a factitious disorder? A case report. / Zespól Gansera ­ zaburzenie dysocjacyjne czy zaburzenie pozorowane? Opis przypadku.

Ganser syndrome (GS) is one of afew eponyms that have survived in psychiatry until the present day. GS is a little-known and rare disorder. It is most often described as a response to a stressor (e.g. incarceration), that is why it is an important issue in forensic psychiatry. Organic causes are taken into consideration. The basic symptoms of the syndrome are: approximate answers, visual and auditory hallucinations, clouding of consciousness and conversion symptoms. Additionally, patients may perform activities in an awry manner and suffer from insensitivity to painful stimuli.GS is usually acute and subsides spontaneously. Usually patients do not remember they had an episode of the disease. Diagnostic criteria of GS are imprecise and its classification has been changed over the years. GS was not listed in the DSM-5 classification, although in the DSM-IV it was classified as a dissociative disorder. Currently some authors tend to classify it rather as a factitious disorder. WHO (ICD-10 and ICD-11) classifies GS as a dissociative and conversion disorder, which seems to be appropriate in the light of current knowledge. The presented case report describes apatient with a nearly identical pattern of full-blown GS, which occurred twice. The symptoms appeared shortly after the patient was incarcerated. The course of the disorder was chronic and recurrent. The patient was insensitive to pain stimuli. Somatic causes were excluded in the diagnostic process.

Gaslighting in alleged assault ascertained as Munchausen syndrome transcending to malingering in highly counterintuitive self inflicted acid burns.

A factitious disorder leading to the self-infliction of highly counter-intuitive burns was diagnosed in a middle-aged female. The injuries were otherwise alleged to have been sustained by assault inflicted upon her by an unknown person. The case was diagnosed by medico-legal interpretation of injuries, in spite of a highly deceptive and concocted history by the patient and her husband. The entity was unique in being associated with magnificent primary, secondary and tertiary gains. The exploitation of the morbid sequel to malinger by the patient, and the involvement of the husband for the prolongation of the illness of his wife for financial gains as gaslighting was highly unusual. The self-infliction of injuries over hands is seen in factitious disorder. However, a combination of a guarded self-immersion of the hands and feet in a corrosive by an illiterate female, followed by malingering to earn livelihood is unprecedented in factitious disorders. The delayed presentation which required amputation of all the limbs to save the life of the patient is a glaring highlight of this case.

Therapeutic Potential of Curcumin in Reversing the Depression and Associated Pseudodementia via Modulating Stress Hormone, Hippocampal Neurotransmitters, and BDNF Levels in Rats.

Depressive state adversely affects the memory functions, especially in the geriatric population. The initial stage of memory deficits associated with depression is particularly called as pseudodementia. It is the starting point of memory disturbance before dementia. The purpose of this research was to study depression and its consequent pseudodementia. For this purpose 24 male albino Wistar rats were divided into four groups. Depression was induced by 14 days of chronic restraint stress (CRS) daily for 4 h. After developing a depression model, pattern separation test was conducted to monitor pseudodementia in rats. Morris water maze test (MWM) was also performed to observe spatial memory. It was observed that model animals displayed impaired pattern separation and spatial memory. Treatment was started after the development of pseudodementia in rats. Curcumin at a dose of 200 mg/kg was given to model rats for one week along with the stress procedure. Following the treatment with curcumin, rats were again subjected to the aforementioned behavioral tests before decapitation. Corticosterone levels, brain derived neurotrophic factor (BDNF) and neurochemical analysis were conducted. Model rats showed depressogenic behavior and impaired memory performance. In addition to this, high corticosterone levels and decreased hippocampal BDNF, 5-HT, dopamine (DA), and acetylcholine (ACh) levels were also observed in depressed animals. These behavioral biochemical and neurochemical changes were effectively restored following treatment with curcumin. Hence, it is suggested from this study that pseudodementia can be reversed unlike true dementia by controlling the factors such as depression which induce memory impairment.

Exfoliative cheilitis related to psychologic factors uncovered during primary immunodeficiency evaluation.

A 40-year-old previously healthy, non-atopic woman was referred for evaluation of a possible immunodeficiency disorder in the setting of an unusual erosive cheilitis and history of recurrent methicillin-resistant Staphylococcus aureus (MRSA) infection. Extensive work-up was non-diagnostic, including screening for immunologic disorders. She had failed multiple therapeutic modalities, including corticosteroid and immunosuppressive therapy. Tissue biopsy from the lip proved pivotal in demonstrating changes suggestive of factitial disease. This led to further detailed history-taking, yielding evidence of considerable psychologic distress. The patient was diagnosed with exfoliative cheilitis related to factitial disease in association with underlying untreated anxiety and psychologic trauma.

The Mayo Clinic Experience With Psychogenic Purpura (Gardner-Diamond Syndrome).

BACKGROUND: The objective of this study was to describe presentation, natural history, management and long-term outcomes of patients with psychogenic purpura (PP), also known as Gardner-Diamond Syndrome. METHODS: In this retrospective study, records of patients with a diagnosis of PP seen at Mayo Clinic, Rochester from 1976 to 2016 were reviewed. Available literature regarding PP was also comparatively reviewed. RESULTS: Seventy-six patients with a diagnosis of PP were identified and 54/76 (71%) experienced a prodromal sensation. The Condensed MCMDM-1 bleeding score, excluding cutaneous manifestations, was <3 in 91% of patients. Laboratory tests of primary and secondary hemostasis were normal. Fifty-four percent of patients had an underlying psychiatric diagnosis. Management approaches included psychological counseling and psychiatry evaluation in 44 patients. Pharmacologic treatment for 30 patients included psychotropic agents, antihistamines, hormonal medications and anti-inflammatory agents. At a median follow-up of 5years (range 1-34),13/28 (46.4%) experienced recurrent ecchymoses and 6 continued to seek hematology follow-up at Mayo Clinic, Rochester. Our data was similar to the aggregate data from case reports in the literature. CONCLUSIONS: For patients with unexplained recurrent ecchymosis a diagnosis of PP should be considered. Diagnosis is one of exclusion and initial evaluation should include documenting a bleeding score and obtaining laboratory tests assessing primary and secondary hemostasis. The relatively low bleeding scores together with laboratory assessments support that PP is primarily a dermal rather than a systemic bleeding diathesis. In our cohort, addressing psychological stressors was the most effective treatment; however pharmacologic therapy can be used for refractory disease.

Administration of 5-HT-1B agonist ameliorates pseudodementia induced by depression in rats.

Major depressive disorder (MDD) is the leading cause of memory impairment in general population. The serotonin hypothesis provides a target model for the treatment of depression and depression-associated memory loss. 5-HT-1B receptor is suggested as a potential candidate in the pathophysiology of depressive illness. Dysfunction of 5-HT-1B receptors has been observed previously in depressive patients. Zolmitriptan, 5-HT-1B agonist is clinically recommended for the treatment of migraine. However, in present study this drug was tested as a potential treatment for depression and associated memory loss by altering the serotonergic function at receptor level. Rats (n=24) were equally divided into unstressed and stressed groups. Depression was induced by 19 days of restraint stress for 4 h which was followed by forced swim test and pattern separation test to assess depressive symptoms and memory impairment, respectively. The initial sign of depression-associated memory loss involves impaired pattern separation which is regarded as pseudodementia. In this study stressed rats showed depression- and pseudodementia-like symptoms. After the induction of depression, rats were treated with zolmitriptan at a dose of 0.3 mg/kg which resulted in a significant attenuation of depression and depression-associated memory impairment. Results are discussed with reference to the modulation of function of 5-HT-1B receptor following the administration of exogenous agonist.

Ganser Syndrome.

Ganser's syndrome is a rare and controversial condition, whose main and most striking feature is the production of approximate answers (or near misses) to very simple questions. For instance, asked how many legs a horse has, Ganser patients will reply "5", and answers to plain arithmetic questions will likewise be wrong, but only slightly off the mark (e.g., 2 + 2 = 3). This symptom was originally described by Sigbert Ganser in 1897 in prisoners on remand and labeled Vorbeigehen ("to pass by"), although the term Vorbeireden ("to talk beside the point") is also frequently used. A number of associated symptoms were also reported: "clouding of consciousness," somatoform conversion disorder, hallucinations, sudden and spontaneous recovery, subsequent amnesia for the episode, premorbid traumatic psychosocial experience and/or (usually mild) head trauma. Etiological, epidemiological and diagnostic issues have never been resolved for Ganser's syndrome. Ganser saw it as a form of "twilight hysteria," whereas others suggested that malingering, psychosis or dissociation were more appropriate labels, oftentimes combined with organic impairment and a subjectively intolerable psychosocial context. A central conundrum of Ganser's syndrome is whether it could simultaneously be a cultural and pathological representation of insanity, whereas cognitive, organic, affective, motivational and social factors would converge towards a naïve idea of what mental illness should look like, especially through the provision of approximate answers.

Hyperreligiosity in malignant brain tumors: a case report and accompanying bibliographic review.

Religion is a complex cognitive process with biopsychosocial and cultural dimensions, product of the activation of different circuits of the neocortex. In some cases, religiosity can appear as a pathological correlate in patients with brain lesions in the areas involved. We present the clinical case of a patient with an astrocytoma in the right prefrontal region, with apparent inflammatory involvement of the right temporal lobe. This tumor debuted almost exclusively as an alteration of personality consisting of hyperreligiosity, logorrhea, and mystical experiences. A review of the literature has been conducted and possible pathophysiological mechanisms are proposed.

Frontotemporal Dementia-Like Syndrome Following Recall of Childhood Sexual Abuse.

Numerous psychopathological syndromes have been attributed to posttraumatic stress, both at the time of the trauma and many years later. To date, however, there is little literature on pseudodementia as a delayed traumatic stress response. The authors present a case history of a 50-year-old woman who developed severe cognitive impairment following retrieval of previously forgotten memories of childhood sexual abuse. Her cognitive condition deteriorated rapidly and dramatically. Neuropsychological assessment and clinical presentation led to a diagnosis of frontotemporal dementia (vs. corticobasal degeneration). Detailed neurologic and medical evaluations could not identify any underlying physical cause. Her condition progressively worsened over 9 months, at which point memantine, an N-methyl-D-aspartate receptor antagonist, was begun. The patient regained full functioning over the next year. Although an organic cause could not be ruled out, it was likely that recovery of traumatic memories was contributory to the patient's condition, as ongoing psychotherapy had begun 1 year into the course. If additional cases with similar presentations are reported, such cases would corroborate the notion that persistent, severe, and reversible cognitive impairment constitutes a previously unrecognized and atypical posttraumatic response.

Artefactual skin lesions in children and adolescents: review of the literature and two cases of factitious purpura.

BACKGROUND: Self harm is a great diagnostic and treatment challenge. In addition, psychocutaneous conditions are rare in the pediatric population and may therefore be misdiagnosed. Dermatitis artefacta is a psychocutaneous syndrome, which is a subgroup of the general spectrum of self-inflicted skin lesions. Dermatitis artefacta encompasses an array of different clinical manifestations, including purpura. Factitious purpura has rarely been reported in children. METHODS: Case report and review of the literature. RESULTS: We describe two Caucasian patients (9-year-old boy and 10-year-old girl) with striking purpuric lesions diagnosed as factitious purpura. The clinical lesions were similar, but the underlying psychological problems differed significantly (depression and stress). The current state of knowledge of dermatitis artefacta in children and adolescents was reviewed. CONCLUSION: The presence of purpura in children and adolescents typically causes extensive intervention programs due to the possible serious pathological consequences. The two cases demonstrate a need for a high degree of attention to psychological disturbances, lesional evolution, and distribution once the suspicion is established.

Uncommon and/or bizarre features of dementia.

This study aimed at describing uncommon or bizarre symptoms observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published since 1967. Search terms used included uncommon presentation, behavioural and psychological symptoms, dementia, Alzheimer's disease, and fronto-temporal dementia. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms are described as case-reports and there are no systematic investigations. Bizarre behaviours arising late in life should be thoroughly investigated as symptoms of dementia.

Ganser-like syndrome after loss of psychic self-activation syndrome: psychogenic or organic?

Very few data are available on the long-term changes in the cognitive abilities of patients with loss of psychic self-activation syndrome (LPSAS). Here, we present a 25-year follow-up study on a case of LPSAS resulting from bilateral pallidal lesions caused by carbon monoxide intoxication. Typical signs of LPSAS were observed, showing no changes in severity, but Ganser syndrome (GS) gradually developed and worsened during the follow-up period. GS is generally assumed to be a psychogenic syndrome, but an organic etiology has been suspected by the authors of several case reports. Here, atypical features of GS plead against the independence of GS and LPSAS. DaTSCAN and brain 18FDG-PET were performed. Since left hippocampal hypometabolism has been previously described in patients with functional amnesia, it is possible that long periods of mental inactivity may have psychological consequences, but the atypical features of GS also suggest that an organic mechanism may be involved.

Dermatitis artefacta in a vulnerable adult with a dissociative state.

Dermatitis artefacta (DA), a factitious skin disorder, often occurs as a response to traumatic life events or as a factitious behaviour, which may result in secondary gain. It can be difficult to get patients to engage with health services, and they seldom admit to causing the lesions themselves. The possibility of DA lesions occurring in dissociative states is less well known. We present a case of DA diagnosed in a vulnerable adult, who we believe caused the lesions during periods of dissociation. We discuss the way in which the concept of dissociation can provide an acceptable way of discussing the behaviour with patients and initiating psychological therapy.

Pseudodementia caused by severe depression.

The diagnosis of pseudodementia may be difficult in a patient with a history of major depressive disorder. Clinical case history. A 70-year-old man with a history of major depressive disorder, in remission for 3 years, presented with confusion, agitation and cognitive disorder. The differential diagnosis included depression with pseudodementia, drug-induced dementia or Alzheimer disease. Mild cognitive improvement was noted after discontinuation of simvastatin. After 9 months of treatment for depression, the patient had remission that was sustained for >1 year, with mild residual difficulty remembering words of songs. The differential diagnosis of dementia includes major depressive disorder and adverse events from simvastatin.