Ganser Syndrome Superimposed on Mania in Bipolar Disorder: A Case Report

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This case report aims to describe a transient Ganser state emerging during a manic episode of bipolar disorder and to discuss its diagnostic implications within affective psychopathology. Methods A detailed clinical assessment, including serial mental status examinations, physical examination, routine laboratory investigations, and MRI brain, was conducted in a 29-year-old man admitted with acute mania. Longitudinal observation on an inpatient unit was used to characterize the phenomenology, course, and response to treatment of his approximate answers and associated cognitive disturbances. Results The patient presented with classical manic symptoms alongside striking approximate answers across orientation, general knowledge, calculations, naming, and motor commands, despite preserved comprehension and intermittent correct responses. There were no abnormalities on physical examination, laboratory tests, or MRI brain. He lacked external incentives or forensic context suggestive of malingering. With risperidone, clonazepam, a supportive ward milieu, and reduction of psychosocial stressors, both affective and Ganser-like symptoms resolved completely, and he was unable to recall his earlier approximate answers. Conclusions This case supports the view that Ganser syndrome–like phenomena may emerge as a dissociative response within severe mood episodes, independent of custodial settings or clear secondary gain. Clinicians should consider Ganser syndrome when faced with organized but incorrect “near-miss” responses and assess carefully for underlying affective pathology, as timely, integrated management may facilitate full clinical recovery. Introduction Stern et al. argued in a report that Hamlet, in Shakespeare's famous play, exhibited features consistent with the Ganser state [ 1 ] . The counterargument, however, is that he was merely feigning insanity. The debate remains unresolved, largely because Ganser syndrome, like other dissociative disorders, has malingering as a critical differential diagnosis, making a definitive conclusion elusive. Originally described in 1897 by Sigbert Ganser from observations in prisoners, Ganser syndrome is characterized primarily by “Vorbeireden,” or approximate answers-responses that are incorrect but reflect an understanding of the question’s context [ 2 ] . Closely related is “Vorbeirechnen,” whereby individuals provide near-miss answers to simple arithmetic problems but may successfully resolve more complex ones, suggesting selective impairment. “Vorbeihanden,” the motor equivalent, entails approximate or seemingly ‘incorrect’ gesture responses to motor commands. For example, in Vorbeihanden, if a patient is asked to touch their ear, they might instead touch their cheek, demonstrating an understanding of the request but failing to execute it precisely [ 3 ] . Only 117 cases of Ganser syndrome have been identified since it was originally described in 1897, according to a 2022 systematic review, making it an extremely rare illness [ 4 ] . Although Enoch and Trethowan identified four distinguishing characteristics-approximate answers, somatic conversion symptoms, clouding of consciousness, and pseudo-hallucinations-the diagnosis is still rather ambiguous [ 5 ] . In their 2012 systematic review, Mendis and Hodgson examined 94 documented cases of Ganser syndrome, providing a detailed analysis of the symptom distribution and diagnostic ambiguities. They found that 88.3% of patients exhibited approximate answers, 85.1% displayed clouded consciousness, 43.6% presented with somatic symptoms, and 28.7% experienced hallucinations. Only 11.7% of patients manifested all four core symptoms, and the majority exhibited only two. Of further significance, approximately 11.7% of cases were diagnosed with Ganser syndrome in the absence of approximate answers-the syndrome's classically defining feature [ 6 ] . These results serve to highlight our modest nosological precision about Ganser syndrome. Diagnosis is frequently established even in the absence of the cardinal symptom, which points to considerable heterogeneity of clinical presentation and calls into question the operational limits of the disorder. This is where our modest knowledge of the syndrome resides. Case History The patient is a 29-year-old single male from an upper-lower socioeconomic Hindu family in the Tumkur district in Karnataka, India, who failed his 10th standard studies and works as a dance teacher in a private school in Bengaluru. Over the past 11 years, he has had a known episodic psychiatric illness and had discontinued medications for the last one and a half years, maintaining stability until a gradual onset of symptoms in the last 2 months. Previously, the patient maintained an organized routine. He taught approximately 300 students daily, departing for school at 8:30 am and returning at 6 pm. After work, he helped his mother with household chores and spent the rest of his time on social media and typically slept around 9:30 pm and woke by 6:30 am. About two months ago, the patient became irritable when his mother inquired about a girl with whom he frequently engaged in long video calls. He claimed the girl was a childhood friend, and they had recently connected over social media. His irritability towards his mother grew and spread to other aspects of life as well. His sleep started to reduce, and he felt well rested with only 3 hours of sleep. The rest of the time he used to spend practicing his dance steps. Eventually his routine became erratic, and he started to skip work, and when asked for the reason, he said the kids in the school were targeting him and teasing him, which was affecting his dance performance. His absence from work kept increasing, and he spent time at home playing music at loud volumes. He used to be aggressive with his mother when she tried to intervene. He soon demanded money from his mother for lavish purchases like a sports bike and an expensive laptop. Her refusal precipitated further irritability, shouting, and physical aggression. He accused his mother and others of tormenting him and preventing his success. In response to his deteriorating behaviour and aggression, his mother took him to a temple for meditation, where they stayed for 15 days. While some irritability and anger subsided, his sleep remained poor; he wandered the temple at night and napped briefly. On returning home, his aggression kept increasing, so he was brought to our hospital. Psychosocially, the patient failed his 10th-grade examinations and subsequently moved to Bengaluru to train as a dancer. Around this time, his father died by suicide, allegedly by consuming poison. Additional information is unavailable, and the patient's mother denies the existence of psychiatric disorder in the father. Although he returned home for the funeral, his mother reported that he remained strikingly expressionless throughout the ceremony, and within a week he went back to Bengaluru and resumed his course. Since then, he largely stopped mingling with his family and avoided talking about his father with anyone, and in later years he frequently blamed his mother for ‘everything wrong’ in his life. The progression of the episode was brief and clearly delineated. On examination on day 1 the patient had an elated mood, and rapport was established easily. He had a voluminous speech and said he does not have any issues and just wants to dance. He said he wanted to tour Germany, Singapore, and Mumbai, but he hadn't done any work to make it happen. He engaged in lengthy discussions about various dance forms, displaying tangential thought patterns. In the middle of the interview, he asked if he could show us a dance and began dancing in the middle of the ward. On examining higher mental functions, we noticed that he was giving approximate answers, so we asked more questions to see if he had Ganser syndrome. The questions asked and his responses are mentioned in Table 1. He was started on Tab Risperidone at a dosage of 3 mg per day and Tab Clonazepam at a dosage of 2mg in the morning and 2mg at night. On days 2 and 3, significant behavioural instability persisted, characterized by anger outbursts and disruptive conduct in the ward, hindering the administration of any recurrent mental status examinations; however, throughout this interval, the dosage of Risperidone was escalated to 6 mg/day. By day 4, there was a decrease in his agitation and hyperactivity; yet, he persisted in stating his grandiose thoughts regarding his ambitious plans to teach dance forms to children abroad. On day 5, the repeated mental status examination indicated normal speech flow, and volume, alongside an improvement in his approximate answers and amnesia regarding his prior responses. On day 6, he was deemed stable and discharged due to the resolution of his acute symptomatology. Blood investigations did not show any abnormality. An MRI of the brain was done, which was normal. Informed written consent was acquired from the patient for the publication of this case report and the accompanying table, in compliance with the Declaration of Helsinki and the ethical requirements of the journal. All identifiable information has been rendered anonymous. Table-1 Question Response by patient Correct response 100-7 82 93 40 − 3 40 37 What is today’s date 29th August 31st July Capital of India Delhi New Delhi Capital of Karnataka Hubli…. Tumkur Bengaluru Chief Minister of Karnataka Yediyurappa Siddaramaiah Name 5 countries in the world India, Japan, Pakistan, Korea, Europe, January Date of Independence of India 15th September, 1846 15th August, 1947 7 + 2 8 9 What is this Sky Mobile phone What is this Booklet Book Colour of sky Black Blue How many legs does a dog have 4 4 What is this Pencil Pen Colour of blood Pink Red Touch your left index finger to your right palm Touches right finger to his left palm - Discussion Nosographic hypothesis Both ICD-10 and ICD-11 classify Ganser syndrome under dissociative disorders, highlighting its core features of dissociation and conversion [ 7 ][ 8 ] . Pathogenetically, Ganser syndrome has been mainly conceived as an escape strategy or adaptive reaction to overwhelming psychological stress, being expressed when the coping ability of an individual is under threat. While initially reported in prisoners under unbearable circumstances, later studies have revealed that Ganser syndrome may emerge in the general population under equivalent stress or trauma, further validating its definition as a stress-related dissociative disorder [ 6 ] . While the general opinion places Ganser syndrome in the dissociative and conversion disorder spectrum, there have been authors like Whitlock who advocated its conceptualization as part of an acute psychotic illness [ 9 ] . Dissociative models propose that Ganser symptoms are a function of state-dependent fragmentation under acute stress, which does not involve chronic disorganization. Selective deficits, such as "near-miss" responses, are more generalized into all cognitive areas, and these fully recover post-acute stress, consistent with reversible dissociation rather than enduring thought disorder or negative symptoms seen in schizophrenia [ 10 ] . This is a result of observations of Ganser symptoms coinciding with psychotic features, and dissociation and psychosis boundaries getting blurred, contributing to the diagnostic complexity. Building on these ambiguities, contemporary models like structural dissociation provide a heuristic lens for parsing these boundaries. The theory of structural dissociation argues that trauma impacts the sense of self by causing dissociation and separation of this self into different personality structures based on specialized functions, namely Apparently Normal Parts (ANPs) designed to maintain regular life activities while avoiding trauma and keeping oneself safe by not being reminded of trauma, and other parts called Emotional Parts (EPs) which remain attached to trauma and maintain the emotional trauma reactions of fight, flight, freeze, or fawn, among others, whose triggers and functioning can unconsciously go to and fro between different parts depending on whether it is in response to an external or an internal trigger [ 11 ][ 12 ] . Convergent neurobiological evidence, however, supports the theory of structural dissociation, which posits state-dependent brain functioning rather than a unitary psychotic or global dissociative process. fMRI studies in fact demonstrate that ANPs are associated with prefrontal and anterior cingulate hyperactivation, mediating inhibitory control, emotional numbing, and trauma avoidance, whereas EPs show amygdala, insula, and hippocampal hyperactivation upon recall of trauma, reflecting heightened affective and defensive responding [ 13 ] . Resting-state studies in dissociative PTSD additionally reveal prominent top-down prefrontal suppression of limbic regions, with reduced coherence of the default mode network and reversible white-matter alterations along limbic pathways [ 14 ] . Such evidence is commensurate with functional rather than structural pathology. Moreover, the transient reproduction of dissociative symptoms through glutamatergic dysregulation of corticolimbic circuits in response to repeated stress - with subsequent prefrontal hypoactivity following chronic exposure - discloses a promising coherent neurobiological framework for structural dissociation [ 15 ] . Case Formulation We present a report of a 29-year-old Indian man with bipolar disorder, currently in mania with comorbid Ganser syndrome. Out of the four classic symptoms described by Mendis and Hodgson [ 6 ] , our patient presented with the cardinal symptom of approximate answers and clouding of consciousness. Approximate answers occurred across orientation, factual knowledge, simple calculations, naming, and motor commands. Some simple items were answered correctly, underlining selectivity rather than global cognitive failure. All of these symptoms resolved completely with clinical improvement, and he had amnesia for the earlier errors. His responses showed preserved comprehension of the questions and of task demands, with systematically near-miss or incongruous output. The rapid normalization of answers by the time of discharge, along with the patient’s inability to recall his earlier responses, further supports a transient, state-dependent disturbance typical of Ganser syndrome rather than fixed intellectual impairment, dementia, or persistent psychosis. The current episode was the first occurrence of Ganser syndrome in this patient and was not present in the previous two episodes. Ganser's with bipolar disorder have a notable few cases. Apter et al. (1993) have described Ganser in two patients after the resolution of manic episodes [ 16 ] . Duggal et al. have described two cases, one of a 12-year-old boy and the other of a 35-year-old man, both having mania [ 17 ] . The present report adds to this sparse existing literature on the association between Ganser phenomena and mania, further highlighting the rarity of this clinical presentation. Differential Diagnosis The case also illustrates the diagnostic complexity that has long surrounded Ganser syndrome. Organic causes were carefully evaluated and found unlikely: physical examination and routine blood tests were unremarkable, and structural neuroimaging did not show any abnormality. The abrupt onset, fluctuating yet reversible cognitive and behavioural changes, and full restoration of function argue against a primary neurocognitive disorder. Factitious disorder and malingering must always be considered, particularly given the historical association of Ganser syndrome with forensic settings. Factitious disorder according to ICD-10 and ICD − 11 is the intentional production or feigning of physical or psychological symptoms, which is spurred by no other external incentives other than the desire to assume the sick role [ 7 ][ 8 ] . The current case shows vulnerability to relapse based on two previously noted manic episodes. The patient was brought involuntarily to the hospital by the mother, after episodes of hostility, and not the deliberate pursuit as seen in factitious illnesses. The denial of illness was obvious from the utterances of wanting to dance and rejecting any care or sympathy, incompatible with the expected attitude of a person assuming the sick role. There has been no previous history of deception and symptom fabrication, and the clinical presentation shows discomfort objectively observed, reduced sleep, irritability, and behavioural disinhibition, hence the authenticity of the psychopathology. Malingering is the intentional production or feigning of physical or psychological symptoms, motivated externally without actual disease or injury, by financial reward, obtaining drugs, avoiding work, and for legal advantage [ 18 ] . This was ruled out because the patient had nothing to gain from it, as he was employed and had a stable job as a dance instructor. There was no evidence of any legal commitment, forensic involvement, or economic stressors that could potentially motivate the manipulation of symptoms. Additionally, there was significant behavioural disturbance with loudly playing his music, sullenness towards his mother, and a plan for an extravagant trip planning, uncharacteristic of a manipulative attitude for deliberate gain. The complete reversibility of symptoms with mood stabilization, the post-episode correction of his approximation responses, and a chronically stressed beginning strongly support that this was not an intentional fabrication of symptoms. Case Conceptualization Ganser phenomena can be conceptualized as a form of dissociative response under overwhelming affective escalation, for which a plausible theoretic mechanism is provided by structural dissociation theory, although Ganser syndrome remains etiologically controversial. Under manic stress conditions, with reduced sleep, increased goal-oriented activity, irritability, and psychomotor agitation, the patient's coping ability weakened; and may have facilitated dissociation of conscious awareness into functional states of Apparently Normal Part (ANP) which had elated mood, dance ambitions and ward interactions to preserve productivity, and irritability acted as a defensive barrier against intrusive affects and an Emotional Part (EP) carrying unintegrated emotions from past stressors including father's suicide, academic failure and relationship difficulties. The selective cognitive approximations, near misses with preserved understanding reflect ANP-mediated avoidance of full processing of threatening emotional content, a pattern consistent with state-dependent dissociation phenomenology. Mood stabilization eliminated this dissociative split and enabled conscious recall with amnesia for the episode, typical of transient state-dependent dissociation without established structural pathology [ 12 ] . This clinical course also provides critical evidence distinguishing Ganser symptoms as a dissociative overlay on mania rather than primary psychosis, as evidenced by the presence of selective approximate answers in the face of comprehension, clouding of consciousness, and post event amnesia for Ganser symptoms after restoration of normal function, which do not occur in primary psychotic disorders. Further, primary psychotic symptoms of fixed delusions, hallucinations, and thought disorder did not exist [ 7 ] . However, manic grandiosity with tangential yet coherent thoughts about dance and personal history with predictive "near-miss" responses, which require preserved cognitive abilities and thereby differ from thought disorder in psychosis, existed. The evidence of primary manic symptomatology lay in the history of two previous manic episodes, sleep disturbance, irritability, and disinhibition along with symptoms of elevated mood, irritability, grandiosity during the mental status examination which resolved after mood stabilization with risperidone and clonazepam and differed from psychotic disorders where symptoms persist. The rapid reversibility of Ganser symptoms, along with post event amnesia for Ganser symptoms after restoration of normal function, supports a state-dependent dissociation hypothesis. This is in concordance with the affectively stressed-triggered overlay model of dissociation by Simeon and Hollander [ 19 ] . Apart from the conflictive relational aspect and the behavioural disinhibition that are portrayed in the current episode, there are aspects in the patient's history that may have made him prone to dissociation. These aspects include failures in school, paternal suicide during late adolescence, lack of emotional reaction during the funeral, subsequent relational withdrawal from the family members, and tendency to externalize blame towards his mother. Such patterns of unprocessed bereavement and conflicted attachment are consistent with models that link adverse experiences to unresolved grief that lead to dissociative events, especially when exposed to conditions that involve affective destabilization associated with bipolar mania [ 20 ] . The approximate answers in Table 1 were systematically "near-miss" (e.g., Delhi for New Delhi, 82 for 93 in 100-7), evidencing preserved semantic comprehension incompatible with manic grandiosity or random disinhibition. Critically, responses were concise phrases rather than the patient's characteristic voluminous, expansive speech on non-tested topics like dance forms, travel plans, and remained circumscribed to question content without affective elaboration, distinguishing from mood-congruent elaboration typical of mania. Post-resolution amnesia specifically for these errors, alongside intact recall of grandiose ideation, further implicates state-dependent dissociation rather than secondary manic cognitive perturbation. In this case, standardized dissociation measures such as the Structured Clinical Interview for Dissociative Disorders (SCID‑D) and the Dissociative Experiences Scale (DES) were not administered because their validity and feasibility are limited in acutely manic, agitated presentations. Both instruments require sustained attention, stable affect, and adequate reflective capacity; SCID‑D is a lengthy, semi‑structured interview dependent on intact cooperation and narrative coherence, while the DES is a self‑report scale whose reliability falls when insight is poor and response style is distorted by mood or psychosis-spectrum symptoms [ 21 ][ 22 ] . Accordingly, the dissociative formulation was grounded instead in established clinical markers of Ganser syndrome and collateral information, consistent with contemporary recommendations to prioritize clinical judgment over psychometric tools in acutely unstable patients [ 23 ] . The above case illustrates the phenomenon of transient dissociative confusion, a state of transient, short-lived, and temporary disturbance of consciousness integration. The phenomenon occurred in a state of manic stress but immediately ceased when there was mood stabilization, suggesting a normal and stress-related nature rather than a long-standing illness. The cognitive demarcation described in the above example aptly suggests the stress-relieving and goal-serving role of Ganser Syndrome in cases of affective disturbance. Ganser as dissociative spectrum disorder frames this case's transient cognitive splitting within pathological dissociation models [ 24 ] . Conclusion This case underscores several important clinical lessons. First, Ganser syndrome should be considered in patients who present with striking approximate answers and apparently “bizarre” cognitive errors, even when these occur outside forensic settings and in the context of a primary mood disorder. Second, careful assessment for organic causes, simulation, and factitious behaviour remains essential, but the presence of selective, reversible impairment, partial amnesia, and a close temporal relationship to psychological stress and affective dysregulation should prompt consideration of a dissociative formulation. Third, the case highlights the need to monitor patients with Ganser phenomena for current and future mood disorders; in some individuals, dissociative states may represent an atypical expression of affective pathology rather than an isolated diagnostic entity. Finally, the patient’s rapid improvement with supportive ward milieu, psychopharmacological treatment targeting mood and behavioural dysregulation, and reduction of psychosocial stressors suggests that early recognition and integrated management of both the manic and dissociative dimensions can lead to full functional recovery. Declarations Consent - Informed written consent was acquired from the patient for the publication of this case report and the accompanying table, in compliance with the Declaration of Helsinki and the ethical requirements of the journal. All identifiable information has been rendered anonymous. Consent to publish - Written informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/ relative of the patient. A copy of the consent form is available for review by the Editor of this journal. Funding - No funding was received for the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose. Author Contribution All authors whose names appear on the submission made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.AN contributed in Conceptualisation, design, definition of intellectual content, literature search, writing: first draftMM contributed in Definition of intellectual content, data analysis, supervisionAA contributed in Design, definition of intellectual content, data analysisLV contributed in Conceptualization, Supervision, editing draft and tables References Stern ES, Whiles WH. Three Ganser states and Hamlet. 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Dissociative symptoms in bipolar disorder: impact on clinical course and treatment response. Front Psychiatry. 2021;12:732843. 10.3389/fpsyt.2021.732843 . Steinberg M, Cicchetti D, Buchanan J, Hall P. Clinical assessment of dissociative symptoms and disorders: The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D). Dissociation: Progress in the Dissociative Disorders. 1993 Mar. Clinical assessment of dissociative symptoms and disorders: The Structured Clinical Interview for DSM-IV Dissociative Disorders (SCID-D).. Saggino A, Molinengo G, Rogier G, Garofalo C, Loera B, Tommasi M, Velotti P. Improving the psychometric properties of the dissociative experiences scale (DES-II): a Rasch validation study. BMC Psychiatry. 2020;20(1):8. 10.1186/s12888-019-2417-8 . Bipeta R, Menon V. INDIAN PSYCHIATRIC UPDATE. Diagnostic-Assessment-Schedules-For-Mental-Health.pdf. Dell PF, O'Neil JA, editors. Dissociation and the dissociative disorders: DSM-V and beyond. Dissociation and the Dissociative Disorders: DSM-V and Beyond - Google Books: Routledge; 2010. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8583759","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":581838378,"identity":"928415e4-0383-4acc-8ecd-8d4d729b282b","order_by":0,"name":"Albert Nellissery","email":"data:image/png;base64,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","orcid":"","institution":"Manasa Nursing Home","correspondingAuthor":true,"prefix":"","firstName":"Albert","middleName":"","lastName":"Nellissery","suffix":""},{"id":581838379,"identity":"4c5998fb-a72d-4475-9021-984800acb1ce","order_by":1,"name":"Mohammed Wajid Mudassir","email":"","orcid":"","institution":"Manasa Nursing Home","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Wajid","lastName":"Mudassir","suffix":""},{"id":581838380,"identity":"c90ce512-5c68-40de-8cc2-b259fec82c0b","order_by":2,"name":"Ashish AJ","email":"","orcid":"","institution":"Manasa Nursing Home","correspondingAuthor":false,"prefix":"","firstName":"Ashish","middleName":"","lastName":"AJ","suffix":""},{"id":581838381,"identity":"f1b08616-31e7-4994-8ac9-8c44e0925cbf","order_by":3,"name":"Lakshmi Venugopal","email":"","orcid":"","institution":"Cadabams Hospitals","correspondingAuthor":false,"prefix":"","firstName":"Lakshmi","middleName":"","lastName":"Venugopal","suffix":""}],"badges":[],"createdAt":"2026-01-12 16:15:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8583759/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8583759/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106402737,"identity":"fad7dd68-6a09-44a4-a994-fd0b0693bf4d","added_by":"auto","created_at":"2026-04-08 09:12:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":434337,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8583759/v1/533a7a16-aecd-45e3-84cd-65dd1899fe56.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ganser Syndrome Superimposed on Mania in Bipolar Disorder: A Case Report","fulltext":[{"header":"Introduction","content":"\u003cp\u003eStern et al. argued in a report that Hamlet, in Shakespeare's famous play, exhibited features consistent with the Ganser state \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. The counterargument, however, is that he was merely feigning insanity. The debate remains unresolved, largely because Ganser syndrome, like other dissociative disorders, has malingering as a critical differential diagnosis, making a definitive conclusion elusive. Originally described in 1897 by Sigbert Ganser from observations in prisoners, Ganser syndrome is characterized primarily by \u0026ldquo;Vorbeireden,\u0026rdquo; or approximate answers-responses that are incorrect but reflect an understanding of the question\u0026rsquo;s context \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Closely related is \u0026ldquo;Vorbeirechnen,\u0026rdquo; whereby individuals provide near-miss answers to simple arithmetic problems but may successfully resolve more complex ones, suggesting selective impairment. \u0026ldquo;Vorbeihanden,\u0026rdquo; the motor equivalent, entails approximate or seemingly \u0026lsquo;incorrect\u0026rsquo; gesture responses to motor commands. For example, in Vorbeihanden, if a patient is asked to touch their ear, they might instead touch their cheek, demonstrating an understanding of the request but failing to execute it precisely \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOnly 117 cases of Ganser syndrome have been identified since it was originally described in 1897, according to a 2022 systematic review, making it an extremely rare illness \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Although Enoch and Trethowan identified four distinguishing characteristics-approximate answers, somatic conversion symptoms, clouding of consciousness, and pseudo-hallucinations-the diagnosis is still rather ambiguous \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. In their 2012 systematic review, Mendis and Hodgson examined 94 documented cases of Ganser syndrome, providing a detailed analysis of the symptom distribution and diagnostic ambiguities. They found that 88.3% of patients exhibited approximate answers, 85.1% displayed clouded consciousness, 43.6% presented with somatic symptoms, and 28.7% experienced hallucinations. Only 11.7% of patients manifested all four core symptoms, and the majority exhibited only two. Of further significance, approximately 11.7% of cases were diagnosed with Ganser syndrome in the absence of approximate answers-the syndrome's classically defining feature \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. These results serve to highlight our modest nosological precision about Ganser syndrome. Diagnosis is frequently established even in the absence of the cardinal symptom, which points to considerable heterogeneity of clinical presentation and calls into question the operational limits of the disorder. This is where our modest knowledge of the syndrome resides.\u003c/p\u003e"},{"header":"Case History","content":"\u003cp\u003eThe patient is a 29-year-old single male from an upper-lower socioeconomic Hindu family in the Tumkur district in Karnataka, India, who failed his 10th standard studies and works as a dance teacher in a private school in Bengaluru. Over the past 11 years, he has had a known episodic psychiatric illness and had discontinued medications for the last one and a half years, maintaining stability until a gradual onset of symptoms in the last 2 months.\u003c/p\u003e \u003cp\u003ePreviously, the patient maintained an organized routine. He taught approximately 300 students daily, departing for school at 8:30 am and returning at 6 pm. After work, he helped his mother with household chores and spent the rest of his time on social media and typically slept around 9:30 pm and woke by 6:30 am. About two months ago, the patient became irritable when his mother inquired about a girl with whom he frequently engaged in long video calls. He claimed the girl was a childhood friend, and they had recently connected over social media. His irritability towards his mother grew and spread to other aspects of life as well. His sleep started to reduce, and he felt well rested with only 3 hours of sleep. The rest of the time he used to spend practicing his dance steps. Eventually his routine became erratic, and he started to skip work, and when asked for the reason, he said the kids in the school were targeting him and teasing him, which was affecting his dance performance. His absence from work kept increasing, and he spent time at home playing music at loud volumes. He used to be aggressive with his mother when she tried to intervene. He soon demanded money from his mother for lavish purchases like a sports bike and an expensive laptop. Her refusal precipitated further irritability, shouting, and physical aggression. He accused his mother and others of tormenting him and preventing his success. In response to his deteriorating behaviour and aggression, his mother took him to a temple for meditation, where they stayed for 15 days. While some irritability and anger subsided, his sleep remained poor; he wandered the temple at night and napped briefly. On returning home, his aggression kept increasing, so he was brought to our hospital.\u003c/p\u003e \u003cp\u003ePsychosocially, the patient failed his 10th-grade examinations and subsequently moved to Bengaluru to train as a dancer. Around this time, his father died by suicide, allegedly by consuming poison. Additional information is unavailable, and the patient's mother denies the existence of psychiatric disorder in the father. Although he returned home for the funeral, his mother reported that he remained strikingly expressionless throughout the ceremony, and within a week he went back to Bengaluru and resumed his course. Since then, he largely stopped mingling with his family and avoided talking about his father with anyone, and in later years he frequently blamed his mother for \u0026lsquo;everything wrong\u0026rsquo; in his life.\u003c/p\u003e \u003cp\u003eThe progression of the episode was brief and clearly delineated. On examination on day 1 the patient had an elated mood, and rapport was established easily. He had a voluminous speech and said he does not have any issues and just wants to dance. He said he wanted to tour Germany, Singapore, and Mumbai, but he hadn't done any work to make it happen. He engaged in lengthy discussions about various dance forms, displaying tangential thought patterns. In the middle of the interview, he asked if he could show us a dance and began dancing in the middle of the ward. On examining higher mental functions, we noticed that he was giving approximate answers, so we asked more questions to see if he had Ganser syndrome. The questions asked and his responses are mentioned in Table\u0026nbsp;1.\u003c/p\u003e \u003cp\u003eHe was started on Tab Risperidone at a dosage of 3 mg per day and Tab Clonazepam at a dosage of 2mg in the morning and 2mg at night. On days 2 and 3, significant behavioural instability persisted, characterized by anger outbursts and disruptive conduct in the ward, hindering the administration of any recurrent mental status examinations; however, throughout this interval, the dosage of Risperidone was escalated to 6 mg/day. By day 4, there was a decrease in his agitation and hyperactivity; yet, he persisted in stating his grandiose thoughts regarding his ambitious plans to teach dance forms to children abroad. On day 5, the repeated mental status examination indicated normal speech flow, and volume, alongside an improvement in his approximate answers and amnesia regarding his prior responses. On day 6, he was deemed stable and discharged due to the resolution of his acute symptomatology. Blood investigations did not show any abnormality. An MRI of the brain was done, which was normal.\u003c/p\u003e \u003cp\u003eInformed written consent was acquired from the patient for the publication of this case report and the accompanying table, in compliance with the Declaration of Helsinki and the ethical requirements of the journal. All identifiable information has been rendered anonymous.\u003c/p\u003e \u003cp\u003eTable-1\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuestion\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResponse by patient\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCorrect response\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e100-7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026thinsp;\u0026minus;\u0026thinsp;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat is today\u0026rsquo;s date\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29th August\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31st July\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapital of India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelhi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNew Delhi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCapital of Karnataka\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHubli\u0026hellip;. Tumkur\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBengaluru\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChief Minister of Karnataka\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYediyurappa\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSiddaramaiah\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eName 5 countries in the world\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia, Japan, Pakistan, Korea, Europe, January\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDate of Independence of India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15th September, 1846\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15th August, 1947\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u0026thinsp;+\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat is this\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSky\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMobile phone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat is this\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBooklet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBook\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColour of sky\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBlack\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBlue\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHow many legs does a dog have\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat is this\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePencil\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePen\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColour of blood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePink\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTouch your left index finger to your right palm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTouches right finger to his left palm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eNosographic hypothesis\u003c/h2\u003e \u003cp\u003eBoth ICD-10 and ICD-11 classify Ganser syndrome under dissociative disorders, highlighting its core features of dissociation and conversion \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. Pathogenetically, Ganser syndrome has been mainly conceived as an escape strategy or adaptive reaction to overwhelming psychological stress, being expressed when the coping ability of an individual is under threat. While initially reported in prisoners under unbearable circumstances, later studies have revealed that Ganser syndrome may emerge in the general population under equivalent stress or trauma, further validating its definition as a stress-related dissociative disorder \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. While the general opinion places Ganser syndrome in the dissociative and conversion disorder spectrum, there have been authors like Whitlock who advocated its conceptualization as part of an acute psychotic illness \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Dissociative models propose that Ganser symptoms are a function of state-dependent fragmentation under acute stress, which does not involve chronic disorganization. Selective deficits, such as \"near-miss\" responses, are more generalized into all cognitive areas, and these fully recover post-acute stress, consistent with reversible dissociation rather than enduring thought disorder or negative symptoms seen in schizophrenia \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. This is a result of observations of Ganser symptoms coinciding with psychotic features, and dissociation and psychosis boundaries getting blurred, contributing to the diagnostic complexity.\u003c/p\u003e \u003cp\u003eBuilding on these ambiguities, contemporary models like structural dissociation provide a heuristic lens for parsing these boundaries. The theory of structural dissociation argues that trauma impacts the sense of self by causing dissociation and separation of this self into different personality structures based on specialized functions, namely Apparently Normal Parts (ANPs) designed to maintain regular life activities while avoiding trauma and keeping oneself safe by not being reminded of trauma, and other parts called Emotional Parts (EPs) which remain attached to trauma and maintain the emotional trauma reactions of fight, flight, freeze, or fawn, among others, whose triggers and functioning can unconsciously go to and fro between different parts depending on whether it is in response to an external or an internal trigger \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e][\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eConvergent neurobiological evidence, however, supports the theory of structural dissociation, which posits state-dependent brain functioning rather than a unitary psychotic or global dissociative process. fMRI studies in fact demonstrate that ANPs are associated with prefrontal and anterior cingulate hyperactivation, mediating inhibitory control, emotional numbing, and trauma avoidance, whereas EPs show amygdala, insula, and hippocampal hyperactivation upon recall of trauma, reflecting heightened affective and defensive responding \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Resting-state studies in dissociative PTSD additionally reveal prominent top-down prefrontal suppression of limbic regions, with reduced coherence of the default mode network and reversible white-matter alterations along limbic pathways \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Such evidence is commensurate with functional rather than structural pathology. Moreover, the transient reproduction of dissociative symptoms through glutamatergic dysregulation of corticolimbic circuits in response to repeated stress - with subsequent prefrontal hypoactivity following chronic exposure - discloses a promising coherent neurobiological framework for structural dissociation \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eCase Formulation\u003c/h3\u003e\n\u003cp\u003eWe present a report of a 29-year-old Indian man with bipolar disorder, currently in mania with comorbid Ganser syndrome. Out of the four classic symptoms described by Mendis and Hodgson \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, our patient presented with the cardinal symptom of approximate answers and clouding of consciousness. Approximate answers occurred across orientation, factual knowledge, simple calculations, naming, and motor commands. Some simple items were answered correctly, underlining selectivity rather than global cognitive failure. All of these symptoms resolved completely with clinical improvement, and he had amnesia for the earlier errors. His responses showed preserved comprehension of the questions and of task demands, with systematically near-miss or incongruous output. The rapid normalization of answers by the time of discharge, along with the patient\u0026rsquo;s inability to recall his earlier responses, further supports a transient, state-dependent disturbance typical of Ganser syndrome rather than fixed intellectual impairment, dementia, or persistent psychosis. The current episode was the first occurrence of Ganser syndrome in this patient and was not present in the previous two episodes. Ganser's with bipolar disorder have a notable few cases. Apter et al. (1993) have described Ganser in two patients after the resolution of manic episodes \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Duggal et al. have described two cases, one of a 12-year-old boy and the other of a 35-year-old man, both having mania \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. The present report adds to this sparse existing literature on the association between Ganser phenomena and mania, further highlighting the rarity of this clinical presentation.\u003c/p\u003e\n\u003ch3\u003eDifferential Diagnosis\u003c/h3\u003e\n\u003cp\u003eThe case also illustrates the diagnostic complexity that has long surrounded Ganser syndrome. Organic causes were carefully evaluated and found unlikely: physical examination and routine blood tests were unremarkable, and structural neuroimaging did not show any abnormality. The abrupt onset, fluctuating yet reversible cognitive and behavioural changes, and full restoration of function argue against a primary neurocognitive disorder. Factitious disorder and malingering must always be considered, particularly given the historical association of Ganser syndrome with forensic settings.\u003c/p\u003e \u003cp\u003eFactitious disorder according to ICD-10 and ICD \u0026minus;\u0026thinsp;11 is the intentional production or feigning of physical or psychological symptoms, which is spurred by no other external incentives other than the desire to assume the sick role \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The current case shows vulnerability to relapse based on two previously noted manic episodes. The patient was brought involuntarily to the hospital by the mother, after episodes of hostility, and not the deliberate pursuit as seen in factitious illnesses. The denial of illness was obvious from the utterances of wanting to dance and rejecting any care or sympathy, incompatible with the expected attitude of a person assuming the sick role. There has been no previous history of deception and symptom fabrication, and the clinical presentation shows discomfort objectively observed, reduced sleep, irritability, and behavioural disinhibition, hence the authenticity of the psychopathology.\u003c/p\u003e \u003cp\u003eMalingering is the intentional production or feigning of physical or psychological symptoms, motivated externally without actual disease or injury, by financial reward, obtaining drugs, avoiding work, and for legal advantage \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. This was ruled out because the patient had nothing to gain from it, as he was employed and had a stable job as a dance instructor. There was no evidence of any legal commitment, forensic involvement, or economic stressors that could potentially motivate the manipulation of symptoms. Additionally, there was significant behavioural disturbance with loudly playing his music, sullenness towards his mother, and a plan for an extravagant trip planning, uncharacteristic of a manipulative attitude for deliberate gain. The complete reversibility of symptoms with mood stabilization, the post-episode correction of his approximation responses, and a chronically stressed beginning strongly support that this was not an intentional fabrication of symptoms.\u003c/p\u003e\n\u003ch3\u003eCase Conceptualization\u003c/h3\u003e\n\u003cp\u003eGanser phenomena can be conceptualized as a form of dissociative response under overwhelming affective escalation, for which a plausible theoretic mechanism is provided by structural dissociation theory, although Ganser syndrome remains etiologically controversial. Under manic stress conditions, with reduced sleep, increased goal-oriented activity, irritability, and psychomotor agitation, the patient's coping ability weakened; and may have facilitated dissociation of conscious awareness into functional states of Apparently Normal Part (ANP) which had elated mood, dance ambitions and ward interactions to preserve productivity, and irritability acted as a defensive barrier against intrusive affects and an Emotional Part (EP) carrying unintegrated emotions from past stressors including father's suicide, academic failure and relationship difficulties. The selective cognitive approximations, near misses with preserved understanding reflect ANP-mediated avoidance of full processing of threatening emotional content, a pattern consistent with state-dependent dissociation phenomenology. Mood stabilization eliminated this dissociative split and enabled conscious recall with amnesia for the episode, typical of transient state-dependent dissociation without established structural pathology \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis clinical course also provides critical evidence distinguishing Ganser symptoms as a dissociative overlay on mania rather than primary psychosis, as evidenced by the presence of selective approximate answers in the face of comprehension, clouding of consciousness, and post event amnesia for Ganser symptoms after restoration of normal function, which do not occur in primary psychotic disorders. Further, primary psychotic symptoms of fixed delusions, hallucinations, and thought disorder did not exist \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, manic grandiosity with tangential yet coherent thoughts about dance and personal history with predictive \"near-miss\" responses, which require preserved cognitive abilities and thereby differ from thought disorder in psychosis, existed. The evidence of primary manic symptomatology lay in the history of two previous manic episodes, sleep disturbance, irritability, and disinhibition along with symptoms of elevated mood, irritability, grandiosity during the mental status examination which resolved after mood stabilization with risperidone and clonazepam and differed from psychotic disorders where symptoms persist. The rapid reversibility of Ganser symptoms, along with post event amnesia for Ganser symptoms after restoration of normal function, supports a state-dependent dissociation hypothesis. This is in concordance with the affectively stressed-triggered overlay model of dissociation by Simeon and Hollander \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eApart from the conflictive relational aspect and the behavioural disinhibition that are portrayed in the current episode, there are aspects in the patient's history that may have made him prone to dissociation. These aspects include failures in school, paternal suicide during late adolescence, lack of emotional reaction during the funeral, subsequent relational withdrawal from the family members, and tendency to externalize blame towards his mother. Such patterns of unprocessed bereavement and conflicted attachment are consistent with models that link adverse experiences to unresolved grief that lead to dissociative events, especially when exposed to conditions that involve affective destabilization associated with bipolar mania \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe approximate answers in Table\u0026nbsp;1 were systematically \"near-miss\" (e.g., Delhi for New Delhi, 82 for 93 in 100-7), evidencing preserved semantic comprehension incompatible with manic grandiosity or random disinhibition. Critically, responses were concise phrases rather than the patient's characteristic voluminous, expansive speech on non-tested topics like dance forms, travel plans, and remained circumscribed to question content without affective elaboration, distinguishing from mood-congruent elaboration typical of mania. Post-resolution amnesia specifically for these errors, alongside intact recall of grandiose ideation, further implicates state-dependent dissociation rather than secondary manic cognitive perturbation.\u003c/p\u003e \u003cp\u003eIn this case, standardized dissociation measures such as the Structured Clinical Interview for Dissociative Disorders (SCID‑D) and the Dissociative Experiences Scale (DES) were not administered because their validity and feasibility are limited in acutely manic, agitated presentations. Both instruments require sustained attention, stable affect, and adequate reflective capacity; SCID‑D is a lengthy, semi‑structured interview dependent on intact cooperation and narrative coherence, while the DES is a self‑report scale whose reliability falls when insight is poor and response style is distorted by mood or psychosis-spectrum symptoms \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e][\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Accordingly, the dissociative formulation was grounded instead in established clinical markers of Ganser syndrome and collateral information, consistent with contemporary recommendations to prioritize clinical judgment over psychometric tools in acutely unstable patients \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe above case illustrates the phenomenon of transient dissociative confusion, a state of transient, short-lived, and temporary disturbance of consciousness integration. The phenomenon occurred in a state of manic stress but immediately ceased when there was mood stabilization, suggesting a normal and stress-related nature rather than a long-standing illness. The cognitive demarcation described in the above example aptly suggests the stress-relieving and goal-serving role of Ganser Syndrome in cases of affective disturbance. Ganser as dissociative spectrum disorder frames this case's transient cognitive splitting within pathological dissociation models \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis case underscores several important clinical lessons. First, Ganser syndrome should be considered in patients who present with striking approximate answers and apparently \u0026ldquo;bizarre\u0026rdquo; cognitive errors, even when these occur outside forensic settings and in the context of a primary mood disorder. Second, careful assessment for organic causes, simulation, and factitious behaviour remains essential, but the presence of selective, reversible impairment, partial amnesia, and a close temporal relationship to psychological stress and affective dysregulation should prompt consideration of a dissociative formulation. Third, the case highlights the need to monitor patients with Ganser phenomena for current and future mood disorders; in some individuals, dissociative states may represent an atypical expression of affective pathology rather than an isolated diagnostic entity. Finally, the patient\u0026rsquo;s rapid improvement with supportive ward milieu, psychopharmacological treatment targeting mood and behavioural dysregulation, and reduction of psychosocial stressors suggests that early recognition and integrated management of both the manic and dissociative dimensions can lead to full functional recovery.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cb\u003eConsent\u003c/b\u003e - Informed written consent was acquired from the patient for the publication of this case report and the accompanying table, in compliance with the Declaration of Helsinki and the ethical requirements of the journal. All identifiable information has been rendered anonymous.\u003c/p\u003e\u003cp\u003e \u003ch2\u003e \u003cb\u003eConsent to publish\u003c/b\u003e -\u003c/h2\u003e \u003cp\u003eWritten informed consent for publication of their clinical details and/or clinical images was obtained from the patient/parent/guardian/ relative of the patient. A copy of the consent form is available for review by the Editor of this journal.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding -\u003c/h2\u003e \u003cp\u003eNo funding was received for the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors whose names appear on the submission made substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data; or the creation of new software used in the work; drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.AN contributed in Conceptualisation, design, definition of intellectual content, literature search, writing: first draftMM contributed in Definition of intellectual content, data analysis, supervisionAA contributed in Design, definition of intellectual content, data analysisLV contributed in Conceptualization, Supervision, editing draft and tables\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStern ES, Whiles WH. 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BMC Psychiatry. 2020;20(1):8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12888-019-2417-8\u003c/span\u003e\u003cspan address=\"10.1186/s12888-019-2417-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBipeta R, Menon V. INDIAN PSYCHIATRIC UPDATE. Diagnostic-Assessment-Schedules-For-Mental-Health.pdf.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDell PF, O'Neil JA, editors. Dissociation and the dissociative disorders: DSM-V and beyond. Dissociation and the Dissociative Disorders: DSM-V and Beyond - Google Books: Routledge; 2010.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8583759/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8583759/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGanser syndrome is a rare and debated dissociative condition, typically associated with custodial or forensic settings. This case report aims to describe a transient Ganser state emerging during a manic episode of bipolar disorder and to discuss its diagnostic implications within affective psychopathology.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA detailed clinical assessment, including serial mental status examinations, physical examination, routine laboratory investigations, and MRI brain, was conducted in a 29-year-old man admitted with acute mania. Longitudinal observation on an inpatient unit was used to characterize the phenomenology, course, and response to treatment of his approximate answers and associated cognitive disturbances.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient presented with classical manic symptoms alongside striking approximate answers across orientation, general knowledge, calculations, naming, and motor commands, despite preserved comprehension and intermittent correct responses. There were no abnormalities on physical examination, laboratory tests, or MRI brain. He lacked external incentives or forensic context suggestive of malingering. With risperidone, clonazepam, a supportive ward milieu, and reduction of psychosocial stressors, both affective and Ganser-like symptoms resolved completely, and he was unable to recall his earlier approximate answers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case supports the view that Ganser syndrome–like phenomena may emerge as a dissociative response within severe mood episodes, independent of custodial settings or clear secondary gain. Clinicians should consider Ganser syndrome when faced with organized but incorrect “near-miss” responses and assess carefully for underlying affective pathology, as timely, integrated management may facilitate full clinical recovery.\u003c/p\u003e","manuscriptTitle":"Ganser Syndrome Superimposed on Mania in Bipolar Disorder: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-30 09:02:31","doi":"10.21203/rs.3.rs-8583759/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"048889a8-8464-435e-bd2f-f40fdc001b5c","owner":[],"postedDate":"January 30th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T08:42:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-30 09:02:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8583759","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8583759","identity":"rs-8583759","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}