In 1898, Ganser 1 delivered a paper entitled "Concerning an unusual hysterical confusional state" in which he described prisoners who developed transitory symptoms of mental illness, characterized by disturbed consciousness, hallucinations, sensory changes of a hysterical kind, and characteristic answers to questions. Ganser termed these answers to questions vorbeigehen, i. e. passing by or beside the point, or giving approximate answers to questions within the patient's range of knowledge. Enoch and Trethowan 2 state that the four essential clinical features of the Ganser syndrome are: approximate answers, somatic conversion symptoms, clouding of consciousness, and visual or auditory pseudohallucinations.

Controversy has always surrounded the precise nosological status of the Ganser syndrome. Several authors such as Cocores et al. 3 have insisted on the relationship with malingering disorders, schizophreniform disorders, a hysterical dissociative state, or finally organic or toxic confusional states. Modern classifications subsume this syndrome under the general heading of unspecified dissociative disorders as in DSM-IV (300.15), and it is generally accepted in the literature that the Ganser syndrome is a dissociative disorder. However Sigal et al state 4 that the underlying mechanisms are still under discussion, and the organic and/or psychotic nature of this entity is still controversial. More recently, Fink and Taylor suggested that the Ganser syndrome could be one of the forms of catatonia 5.

In children and adolescents, the Ganser syndrome appears to be especially rare. Nine cases have been reported by Whitlock 6 in 1967, Nardi and Di Scipio 7 in 1977, Adler 8 in 1981, Burd and Kerbeshian 9 in 1985; Dabholkar 10 in 1987, Adler and Touyz 11 in 1989, Apter et al. 12 in 1993, Miller et al. 13 in 1997 and the last by Refaat et al. 14 in 2002). These cases met at least one of Ganser's original symptoms, the only feature being the approximate answers. Comorbid context was frequent: schizophrenia (Whitlock 6; Nardi and Di Scipio 7), major or minor head injury (Adler 8; Adler and Touyz 9; Miller et al. 13), bipolar disorder (Apter et al. 12), behavioral disorder (Apter et al. 12), Gilles de la Tourette syndrome (Burd and Kerbeshian 9; Refaat et al. 14), and atypical pervasive developmental disorder (Burd and Kerbeshian 14). The course of these cases also varied from rapid remission, which is the most frequent outcome, to chronic course with symptoms still present after many years follow-up (Adler and Touyz 11; Refaat et al. 14).

The lack of reports and information about its course made it worthwhile reporting the case of a 14-year-old girl who presented a Ganser syndrome, resolved in two weeks and followed seven months later by a relapse of the same syndrome, preceded by a major depressive episode. The possibility of the Ganser syndrome as a co-morbid condition or an expression of depressive disorder in adolescence will be discussed.

C is a 14-year-old girl who came to the emergency room in a bizarre state, with altered consciousness. It was just after spring break. Her parents came with her.

To our knowledge, this is the first case reported of recurrent Ganser syndrome in an adolescent. It is also the first report of a Ganser syndrome preceded by major depression symptoms in adolescence. In fact this case showed three of the four major features of the Ganser syndrome, i. e., the approximate answers, the clouding of consciousness and hallucinations. Following the rapid resolution of Ganser syndrome in two weeks, it reappeared seven months later, preceded by depressive symptoms, including depressed mood, decreased concentration, feelings of decreased self-worth, suicidal ideation, loss of appetite, and insomnia.

Some authors have reported affective disorders in the follow-up of patients with Ganser syndrome, but no one has presented recurrent Ganser symptoms and, in all instances, depressive or manic symptoms occurred after the resolution of the Ganser syndrome, except for one case described by Grieger and Clayton 15. In adolescents, Apter et al 12 have described two brothers (15 and 16) with conduct disorder who developed the Ganser syndrome while in jail and awaiting trial; both subsequently developed symptoms of bipolar disorder. The elder brother presented psychotic depression six months later, followed after several weeks by hypomania. The younger brother also presented a period of depressive symptoms followed by a manic-like psychosis. In adults, Grieger and Clayton 15 described the case of a 25-year-old woman had been reported with a history of recurrent depression who presented major depression a few weeks after resolution of a Ganser syndrome. Haddad 16 reported a similar case of a 31-year-old man with a mild mental handicap who presented a Ganser syndrome resolved after one week but immediately followed by major depression. There are different psychodynamic hypothesis to explain the association between affective disorders and the Ganser syndrome. Apter et al. 12 have postulated that for a large number of patients, the development of severe regression and dissociation of the Ganser syndrome is facilitated by the presence of serious comorbidity, such as affective disorders. Haddad 16 states that the Ganser syndrome and depression are also considered as separate manifestations of a common underlying conflict. When it is no longer possible to avoid the unpleasant situation and the burden of responsibility by the dissociative defense, guilt and symptoms of depression appear.

In the present case, our first interpretation was the appearance of the Ganser syndrome enabled our patient to escape from the guilt about lying to her parents, via a dissociative response and fast resolution of symptoms, as in the classic descriptions of the Ganser syndrome. The recent death of the aunt should be emphasized, as it probably rendered the patient more vulnerable. But the way the case evolved alters this first interpretation, with a second phase where depressive symptoms appear over a few weeks before the reappearance of the Ganser symptoms. On account of this chronology of disturbances, the following question appears relevant: wasn't the first episode a co-morbidity or also the manifestation of a depressive disorder?

In a recent article, Pietsch and colleagues emphasized how diagnosing a depressive episode in adolescence is complicated 17. A few other authors such as Moro 18 or Kirmayer and Groleau 19 state nosography has hard time in apprehending the depressive experience, and its multiple and varied expressions. Revah-Levy and colleagues have shown how the diagnostical instruments nowadays used to measure depression are not specific to adolescents, lack construct validity, and have limited or unknown reliability and validity in this age group 20. Kessler 21 states there is controversy around the designation and identification of the polymorphic symptoms that might be significant in adolescent depression. McClellan and Werry 22 state that even the efficiency of antidepressants leads us to reconsider the syndromic differences between depression in young people and that classically diagnosed in adults. The difficulties encountered in catering for depression in adolescents point to the need to consider, as Brooks and Kutcher 23 or McClellan and Werry 22 state, that the depressive experience in adolescence as being outside categorical approach.

It is by examining the way the depressive experience was expressed by our patient that it was possible a posteriori to consider the Ganser symptoms as probable signs of a depressive experience that was not recognized at the time of the first hospitalization. It was treated, although at a late stage, at the time of the second hospitalization. The evolution with complete and definitive recovery of dissociative symptoms suggests that the first episode wasn't schizophrenia or an other delusional disorder. The idea of comorbidity in a patient without any previous antecedents is more unlikely due to the closeness of the two psychiatric events. However we cannot exclude this possibility.

With respect to clinical implications, it should be emphasized that, even though the Ganser syndrome is uncommon in children and adolescents, its recognition is necessary to distinguish this disorder from psychotic disorders, especially in adolescence. There is also always a need for physical investigations to exclude any possible organic factors and to identify the underlying disorder. In our case, the use of an antidepressant was effective in improving the mood and it is possible that by treating the depression it also reduced Ganser symptoms, which can be seen as manifestation of depression. Our case reinforces the view that children and adolescents with Ganser syndrome should be admitted for assessment and suggests the need for follow-up after apparent recovery. The risk of recurrence of Ganser syndrome should also be better known. We believe our case helps to clarify the outcome and prognosis of Ganser syndrome in adolescence by helping clinicians to become aware of the fact that the Ganser syndrome might be present in addition to a depressive disorder as a co-morbid condition or as another form of manifestation of depressive experience in adolescence.

The authors declare that they have no competing interests.

MS, OT, MAS and OT drafted the manuscript. ARL participated in collecting and discussing clinical data. MRM carried out clinical assessment and discussion. All authors read and approved the final manuscript

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.