Year : 2021  |  Volume : 63  |  Issue : 1  |  Page : 103--104

Ganser syndrome: Intricacy in diagnosis and management

Ajeet Sidana, Sumeesha Jaswal 
 Department of Psychiatry, GMCH, Chandigarh, India

Correspondence Address:
Ajeet Sidana
Department of Psychiatry, GMCH, Chandigarh

How to cite this article:
Sidana A, Jaswal S. Ganser syndrome: Intricacy in diagnosis and management.Indian J Psychiatry 2021;63:103-104

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Sidana A, Jaswal S. Ganser syndrome: Intricacy in diagnosis and management. Indian J Psychiatry [serial online] 2021 [cited 2021 Apr 13 ];63:103-104
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A rare and controversial diagnostic entity, Ganser syndrome is characterized by “Approximate answers, dulling of consciousness, hysterical neurological changes, and hallucinations.”[1]

There are few case reports from India showing the finding of approximate answers.[2],[3],[4],[5] Controversy is centered around the diagnosis and malingering is a very close differential for it. Here, the authors report a case in a nonprison setting which also illustrates the diagnostic difficulty in between the two, especially in view of constraints in terms of changing clinical pictures, noncooperation of patient for detailed psychological assessments and informants.

Mr. M 40-year-old married male, employed as teacher in government school, admitted with the complaints of odd behavior, fearfulness, hearing of voices, people are talking about him and alcohol use from the past 4 years. Family history showed that his mother, maternal grandmother and maternal uncle had committed suicide. On examination, thought broadcasting and auditory hallucinations-second person, commanding type were noted. The patient was started on tablet lorazepam 8 mg and thiamine 200 mg in divided doses for the management of alcohol withdrawal which was gradually tapered down and Clinical Institute Withdrawal Assessment of Alcohol Scale, revised (CIWA-Ar) score decreased from 14 to 4 at the end of the 1st week. Once patient's complaints resolved his behavior started to change. He would keep looking around and would answer each question after thinking. His affect was inappropriate and he would laugh during the interview. On further exploration about history, it came to notice that he would also post pictures on social media, claiming he was working abroad, would buy any book that was titled by author named the same as him and claim that he wrote it. P.G.I. Battery of brain dysfunction and magnetic resonance imaging brain was normal. There was no history of seizure disorder and there were no signs of ophthalmoplegia and ataxia. In view of history, mental status examination (MSE), normal neurocognitive profile, and recent change in behavior, a provisional impression of psychotic illness was considered and tablet olanzapine 5 mg was started and titrated up to 10 mg for next 10 days but no improvement was seen in behavior. During this time, approximate answers were noted, for example, when asked which place he was he would answer - Canada, BJP office, extortion camp, theater, FOX studio, on different occasions, would not recognize his wife (calling her with different names), would at times call himself as an actor, director, farmer, and surveyor. He was not able to do simple calculations (2 + 2 = 5, 5 + 4 = 7) and would give wrong answers after thinking. He would name objects differently and would say a dog has 2 legs, grass was blue. His answers were at times correct also. Considering the difficulty in diagnosis and no improvement with treatment over a period of 2–3 weeks, all medications were stopped and his symptoms resolved. In view of the clinical picture of approximate answers, the diagnosis was revised to Ganser syndrome. It was noticed in the ward that one day he was talking to bank employees and during that time he answered all queries correctly. The recent behavior aroused the suspicion of malingering. To settle down confusion between Ganser syndrome and malingering, psychometry and lorazepam interview were planned but he refused for both. MMPI profile showed over reporting. Keeping in view of history, behavioral observation, repeat mental status examinations, lack of any apparent benefit of malingering, collateral information provided, the final diagnosis of mental and behavioral disorder due to use of alcohol-psychotic disorder schizophrenia with Ganser syndrome was kept and the same was conveyed to patient and his wife. Supportive therapy was tried but patient was not receptive.

The index case highlights the need of detailed behavioral observation, repeat mental status examinations, psychological, and neurological assessments to reach at the diagnosis of Ganser syndrome.

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