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Letters to Editor
Acknowledgments
Authors acknowledge the assistance of staffs of Tele
Medicine Centre, National Institute of Mental Health and
Neurosciences, Bengaluru, Karnataka, India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Shiva Shanker Reddy Mukku,
Narayana Manjunatha1,
Channaveerachari Naveen Kumar1,
Palanimuthu T. Sivakumar, Suresh Bada Math1
Geriatric Clinic and Service, 1Tele-Medicine Centre,
Department of Psychiatry, National Institute of Mental
Health and Neurosciences, Bengaluru, Karnataka, India.
E-mail: manjunatha.adc@gmail.com
Submitted: 23‑Nov‑2019, Revised: 11‑Jun‑2020,
Accepted: 01‑Jan‑2021, Published: 15-Feb-2021
REFERENCES
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mental health services among older adults with severe mental illness. Int
J Geriatr Psychiatry 2009;24:313‑8.
2. Das S, Manjunatha N, Kumar CN, Math SB, Thirthalli J. Tele‑psychiatric
after care clinic for the continuity of care: A pilot study from an
academic hospital. Asian J Psychiatr 2020;48:101886. doi: 10.1016/j.
ajp.2019.101886.
3. Hanson E, Magnusson L, Sennemark E. Blended learning networks
supported by information and communication technology: An intervention
for knowledge transformation within family care of older people.
Ganser syndrome: Intricacy in diagnosis and management
Sir,
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.[2‑5] 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
Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021
Gerontologist 2011;51:561‑70.
4. Cesta A, Cortellessa G, Rasconi R, Pecora F, Scopelliti M,
Tiberio L. Monitoring elderly people with the robocare domestic
environment: Interaction synthesis and user evaluation. Comput Intell
2011;27:60‑82.
5. Frennert SA, Forsberg A, Östlund B. Elderly people’s perceptions of a
telehealthcare system: Relative advantage, compatibility, complexity and
observability. J Technol Hum Serv 2013;31:218‑37.
6. Singh AP, Shanker Joshi H, Singh A, Agarwal M, Kaur P. Online medical
consultation: A review. Int J Community Med Public Health 2018;5:1230‑2.
7. Sivakumar PT, Mukku SS, Kar N, Manjunatha N, Phutane VH, Sinha P,
et al. Geriatric telepsychiatry: Promoting access to geriatric mental health
care beyond the physical barriers. Indian J Psychol Med 2020;42:41S‑46S.
8. Mostaghel R. Innovation and technology for the elderly: Systematic
literature review. J Bus Res 2016;69:4896-900.
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DOI:
10.4103/psychiatry.IndianJPsychiatry_719_19
How to cite this article: Mukku SS, Manjunatha N, Kumar CN,
Sivakumar PT, Math SB. Video consultations from tele
aftercare clinic: An early experience from an Indian geriatric
psychiatry service. Indian J Psychiatry 2021;63:102-3.
© 2021 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow
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
103
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Letters to Editor
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.
Craniopharyngioma mimicking bipolar disorder with rapidly progressive
functional decline
Sir,
Craniopharyngioma is a rare, benign, and slow‑growing
brain tumor. It is typically located over the sellar and
104
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Ajeet Sidana, Sumeesha Jaswal
Department of Psychiatry, GMCH, Chandigarh, India.
E‑mail: ajeetsidana@hotmail.com
Submitted: 23-Jan-2020, Revised: 10-Apr-2020,
Accepted: 03-May-2020, Published: 15-Feb-2021
REFERENCES
1. Dieguez S. Ganser syndrome. Front Neurol Neurosci 2018;42:1‑22.
2. Kumar V, Bagewadi V, Sagar D, Varambally S. Multimodal hallucinations in
schizophrenia and its management. Indian J Psychol Med 2017;39:86‑8.
3. Anupama M, Rao KN, Dhananjaya S. Ganser syndrome and lesion in the
temporoparietal region. Indian J Psychiatry 2006;48:123‑5.
4. Dabholkar PD. Ganser syndrome. A case report and discussion. Br J
Psychiatry 1987;151:256‑8.
5. Agarwal S, Dhami A, Dahuja M, Choudhary S. Ganser syndrome in
adolescent male: A rare case report. J Indian Assoc Child Adolesc Ment
Health 2018;14:93‑9.
This is an open access journal, and articles are distributed under the terms of
the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
the identical terms.
Access this article online
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Website:
www.indianjpsychiatry.org
DOI:
10.4103/psychiatry.IndianJPsychiatry_35_20
How to cite this article: Sidana A, Jaswal S. Ganser syndrome:
Intricacy in diagnosis and management. Indian J Psychiatry
2021;63:103-4.
© 2021 Indian Journal of Psychiatry | Published by Wolters Kluwer - Medknow
suprasellar region, constituting 1%–5% of primary brain
tumors with low incidence rate of one per million
person‑years approximately.[1] Headache, increased
intracranial pressure, and hydrocephalus are common
Indian Journal of Psychiatry Volume 63, Issue 1, January-February 2021