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.
C was living with her parents and her 16-year-old sister. C comes from an upper middle class Catholic family. Both parents are teachers in an elementary school. The only psychiatric background in the family concerned one aunt (one of her mother's sisters) who had been undergoing treatment for depression for two years with a complete remission. C was a premature child (33 weeks) at birth but her psychomotor development was normal. No psychological or medical problems have been reported in the early childhood. C had her menarche when she was 13 years old. Neither C nor her sister had medical or psychiatric previous record. No evidence of recent traumatic events have been found in the family. Her learning skills have always been average. She was described by her parents as too serious and highly concerned by her school results while not experiencing any academic difficulties. She was also described as being shy and dependent.
Before Easter vacation, one of C's aunts (the wife of one of her father's brothers) died of lung cancer three weeks after she was diagnosed but the parents didn't inform C right away because she was taking her school exams. At the burial, C was very sad but there were no pathological manifestation. Her behavior and reactions were considered normal.
The Easter vacation started a few days later. The first week of vacation C went to Prague with her school. Every pupil stayed in a Czech host family. No problem occurred during this week. Soon after she came back, her parents discovered that she lied to them. They had asked her to bring back crystal glasses for which they had given her some money. C came back with the glasses, but she did not tell her parents they had been a present from the family she visited, and she used the money for other purposes. C was very upset when her parents discovered the truth, even if they didn't consider this event relevant.
The day after a discussion concerning her untruthfulness, C suddenly presented the first symptoms, in the form of insomnia, logorrhea, anxiety with incoherent discourse and amnesia of recent events, such as her aunt's death and the recent holiday in Prague. She said that she was her dead aunt, she wondered about her origins: "I am the daughter of my aunt", she said to her father: "You are not my father". While watching a film on television, she said she recognized places where she spent her childhood. Her parents took turns to stay with her night and day. She would sleep only four hours a night. There was neither agitation nor aggressiveness but several fluctuations a day from mutism to logorrhea with incoherent ideas about her origins.
The following days, no change occurred but her parents still hoped she would recover spontaneously. She was unable to return to school. Then the parents referred her to a physician who sent her to our emergency room.
Initial medical and psychiatric assessment
In the emergency room, C was quiet. She only complained about sleep disturbance. She also answered questions with approximate answers. When asked who she was, she said: "Anne". When asked where she was, she replied: "At my place". When asked who were the people who came with her, she replied: "My uncle and my aunt". She also gave wrong answers to questions involving simple arithmetic, for example "three plus three equals seven". C wondered about her filiation: "What if my father was not my father? I may be Jacques Chirac's (former president of France) daughter or your daughter." There was no other delusion. Her discourse was diffluent, going from questioning her origins to her aunt's death and finally to the holiday in Prague. She also presented visual hallucinations. She was scared, pointing to snakes on the walls of the emergency room. Her behavior varied from one interviewer to another: with one, she could be confused giving approximate answers, with another, she could be mute and opposing. The clinician reported no other signs of disintegration of thought processes and of emotional responsiveness.
In view of the atypical presentation, an organic etiology was looked for. Physical and neurological examination results were normal. A computed tomographic (CT) head scan and a EEG showed no abnormalities. Blood test results were also normal and the drug screen was negative. There was no history of head injury or trauma, or other illness.
The first hospitalization
C was therefore admitted to our child and adolescent psychiatric unit. The two first days of the hospitalization, C received 25 mg a day of cyamepromazine. She started sleeping normally again within 48 hours. She did not seem to suffer from hospital life. No behavioral disorder was reported. The first week, we observed fluctuations in the symptoms during the day, alternating phases of coherence with a good adaptation and phases of confusion with approximate answers. By the second week of hospitalization, stable recovery was complete. Delusions and hallucinations didn't last; she presented amnesia of the episode.
The psychological tests produced results within the normal range.
After staying 15 days in hospital, she came back home without treatment and was able to return to school.
Until the end of the summer vacation C did not present any disturbances. In September, C went back to school for the beginning of the school year without any trouble. But in the beginning of November, after a school holiday, she started to cry a lot, with irritability, decreased concentration, loss of appetite, negative self perceptions, suicidal ideation, telling her parents she wanted to die, and never go back to school. She refused to consult her psychiatrist during this period and the general practitionner of the family advised to wait.
At the beginning of December, she presented insomnia, expressed intensive negative self-perception, refused to go to school and isolated herself at home. Her parents reported that at the end of December for a few days she seemed to be "in a numbed state, talking nonsense". On New Year's Eve, she suddenly started dancing on her own in the middle of the family meal, talking about another dancer dressed in black. Her parents, alarmed by this behavior and by the visual hallucinations, decided to bring her back to our emergency room.
The second hospitalization
At the emergency room she arrived with a very sad look on her face, she only spoke when called upon to do so. She presented a delirious discourse on her filiations, and approximate answers; there were moments of disturbed consciousness and visual hallucinations. She though she was in "something like a cemetery". She cried a lot, and between periods of confusion she said she wanted to die. No other symptom of a psychotic disorder has been reported. No stress, drug consumption or any other precipitating factor have been found linked with this episode.
The next day, on the ward, the psychiatrist made the decision to treat her with fluoxetine at 20 mg/day, on account of the chronology that had been noted: appearance of a depressive state, in November, which was not treated, and deterioration of the depressive state, followed by appearance of Ganser symptoms (clouding of consciousness, approximate answers, and visual hallucinations). She also received 25 mg/day cyamepromazine at bedtime for the first three days. The Ganser symptoms improved from the start of the third week of fluoxetine administration; there was no further clouding of consciousness, no visual hallucinations, and depressive symptoms (insomnia, irritability, suicidal ideation and depressed mood) disappeared at the same time. She was hospitalized one month total and then returned to school.
Fluoxetine treatment was prescribed at 20 mg/day, but after two months C started to refuse to take any medication and stopped taking it. The school year ended uneventfully; there were no further disturbance. C continued with a combination of psychiatric follow-up and interpersonal psychotherapy for another year. No further episode occurred. Then C decided to end up to the follow-up.