Analyzing theory of mind impairment in patients with behavioral variant frontotemporal dementia

The Role of Empathy in ADHD Children: Neuropsychological Assessment and Possible Rehabilitation Suggestions-A Narrative Review

Background and Objectives: Theory of mind (ToM) deficits in children with ADHD are closely related to social difficulties and problems in interpersonal interactions. Evidence suggests that these cognitive deficits negatively affect the ability to understand and respond to others' emotions and intentions, thus contributing to social isolation and a lower quality of life. However, the findings across studies vary, indicating that ADHD subtype and comorbidities, such as anxiety and mood disorders, can significantly influence sociocognitive deficits, modulating the extent of social problems. Materials and Methods: This review examines the relationship among ADHD, ToM, and empathy, analyzing studies comparing children with ADHD with peers with typical development or other neurodevelopmental conditions. A search in PubMed, Scopus, and the Cochrane Library prior to January 10, without time restrictions, using "ADHD", "Cognitive Empathy", and "Theory of Mind" identified relevant studies assessing these abilities through neuropsychological tests or questionnaires. Results: Of the initial 243 studies, 23 studies met the inclusion criteria. Children with ADHD exhibited significant impairments in ToM and empathy, affecting social cognition and interpersonal understanding. Various assessment tools revealed difficulties in understanding beliefs, emotions, and intentions, with executive function deficits playing a crucial role in shaping these social challenges. Conclusions: This review highlights the need for targeted therapeutic interventions that not only address cognitive deficits but consider emotional and metacognitive aspects, such as emotion regulation and self-awareness. Future research should focus on integrating executive function training with approaches that develop metacognitive and emotional skills, thus providing more comprehensive support.

Awareness impairment in Alzheimer's disease and frontotemporal dementia: a systematic MRI review

This review aims to define awareness impairment and related disturbances in neurodegenerative diseases, including Alzheimer's disease (AD) and frontotemporal lobar degeneration (FTLD) spectrum of disorders. An update of the available scientific literature on the use of magnetic resonance imaging (MRI) in the study of awareness in these disorders is also offered. MRI plays an important role in the characterization of neurodegenerative signatures and can increase our knowledge on brain structural and functional correlates of awareness. In the reviewing process, we established a-priori criteria and we searched the scientific literature for relevant articles on this topic. In summary, we selected 36 articles out of 1340 publications retrieved from PubMed. Based on this selection, this review discusses the multiple terms used to define different or overlapping aspects of awareness impairment, and specifically summarizes recent application of MRI for investigating anosognosia, social cognition, including theory of mind and emotional processing, free will, and autonoetic awareness alterations in different neurodegenerative disorders, with most of these studies focused on AD and FTLD. This systematic review highlights the importance of awareness impairment and related domains in neurodegenerative disorders, especially in AD and FTLD, and it outlines MRI structural and functional correlates in these populations.

Combining Neuropsychological Assessment with Neuroimaging to Distinguish Early-Stage Alzheimer's Disease from Frontotemporal Lobar Degeneration in Non-Western Tonal Native Language-Speaking Individuals Living in Taiwan: A Case Series

Neuropsychological tests (NPTs), which are routinely used in clinical practice for assessment of dementia, are also considered to be essential for differential diagnosis of Alzheimer's disease (AD) and frontotemporal lobar degeneration (FTLD), especially the behavioral variants of frontotemporal dementia (bvFTD) and primary progressive aphasia (PPA) at their initial clinical presentations. However, the heterogeneous features of these diseases, which have many overlapping signs, make differentiation between AD and FTLD highly challenging. Moreover, NPTs were primarily developed in Western countries and for native speakers of non-tonal languages. Hence, there is an ongoing dispute over the validity and reliability of these tests in culturally different and typologically diverse language populations. The purpose of this case series was to examine which of the NPTs adjusted for Taiwanese society may be used to distinguish these two diseases. Since AD and FTLD have different effects on individuals' brain, we combined NPTs with neuroimaging. We found that participants diagnosed with FTLD had lower scores in NPTs assessing language or social cognition than AD participants. PPA participants also had lower measures in the Free and Cued Selective Reminding Test than those diagnosed with bvFTD, while bvFTD participants showed poorer performances in the behavioral measures than PPA participants. In addition, the initial diagnosis was supported by the standard one-year clinical follow-up.

Social Cognition in Behavioral Variant Frontotemporal Dementia and Pathological Subtypes: A Narrative Review

Behavioral variant frontotemporal dementia (bvFTD) belongs to the spectrum of frontotemporal lobar degeneration (FTLD) and is characterized by frontal dysfunction with executive deficits and prominent socioemotional impairments. Social cognition, such as emotion processing, theory of mind, and empathy may significantly impact daily behavior in bvFTD. Abnormal protein accumulation of tau or TDP-43 are the main causes of neurodegeneration and cognitive decline. Differential diagnosis is difficult due to the heterogeneous pathology in bvFTD and the high clinicopathological overlap with other FTLD syndromes, especially in late disease stages. Despite recent advances, social cognition in bvFTD has not yet received sufficient attention, nor has its association with underlying pathology. This narrative review evaluates social behavior and social cognition in bvFTD, by relating these symptoms to neural correlates and underlying molecular pathology or genetic subtypes. Negative and positive behavioral symptoms, such as apathy and disinhibition, share similar brain atrophy and reflect social cognition. More complex social cognitive impairments are probably caused by the interference of executive impairments due to increasing neurodegeneration. Evidence suggests that underlying TDP-43 is associated with neuropsychiatric and early social cognitive dysfunction, while patients with underlying tau pathology are marked by strong cognitive dysfunction with increasing social impairments in later stages. Despite many current research gaps and controversies, finding distinct social cognitive markers in association to underlying pathology in bvFTD is essential for validating biomarkers, for clinical trials of novel therapies, and for clinical practice.

Behavioral Variant Frontotemporal Dementia and Social and Criminal Transgressions

OBJECTIVE

Behavioral variant frontotemporal dementia (bvFTD) is associated with social and criminal transgressions; studies from countries around the world have documented such behavior in persons with this condition. An overview and analysis of social and criminal transgressions in bvFTD and their potential neurobiological mechanisms can provide a window for understanding the relationship of antisocial behavior and the brain.

METHODS

This review evaluated the literature on the frequency of social and criminal transgressions in bvFTD and the neurobiological disturbances that underlie them.

RESULTS

There is a high frequency of transgressions among patients with bvFTD due to impairments in neurocognition, such as social perception, behavioral regulation, and theory of mind, and impairments in social emotions, such as self-conscious emotions and empathy. Additionally, there is significant evidence for a specific impairment in an innate sense of morality. Alterations in these neurobiological processes result from predominantly right-hemisphere pathology in frontal (ventromedial, orbitofrontal, inferolateral frontal), anterior temporal (amygdala, temporal pole), limbic (anterior cingulate, amygdala), and insular regions.

CONCLUSIONS

Overlapping disturbances in neurocognition, social emotions, and moral reasoning result from disease in the mostly mesial and right-sided frontotemporal network necessary for responding emotionally to others and for behavioral control. With increased sophistication in neurobiological interventions, future goals may be the routine evaluation of these processes among individuals with bvFTD who engage in social and criminal transgressions and the targeting of these neurobiological mechanisms with behavioral, pharmacological, and other interventions.

Exploring the Relationship Between Deficits in Social Cognition and Neurodegenerative Dementia: A Systematic Review

Background

Neurodegenerative diseases might affect social cognition in various ways depending on their components (theory of mind, emotional processing, attribution bias, and social perception) and the subtype of dementia they cause. This review aims to explore this difference in cognitive function among individuals with different aetiologies of dementia.

Methods

The following databases were explored: MEDLINE via PubMed, Cochrane Library, Lilacs, Web of Science, and PsycINFO. We selected studies examining social cognition in individuals with neurodegenerative diseases in which dementia was the primary symptom that was studied. The neurodegenerative diseases included Alzheimer's disease, Lewy body disease and frontotemporal lobar degeneration. The search yielded 2,803 articles.

Results

One hundred twenty-two articles were included in the present review. The summarised results indicate that people with neurodegenerative diseases indeed have deficits in social cognitive performance. Both in populations with Alzheimer's disease and in populations with frontotemporal dementia, we found that emotional processing was strongly affected. However, although theory of mind impairment could also be observed in the initial stages of frontotemporal dementia, in Alzheimer's disease it was only appreciated when performing highly complex task or in advanced stages of the disease.

Conclusions

Each type of dementia has a differential profile of social cognition deterioration. This review could provide a useful reference for clinicians to improve detection and diagnosis, which would undoubtedly guarantee better interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020152562, PROSPERO, identifier: CRD42020152562.

Speech and language impairments in behavioral variant frontotemporal dementia: A systematic review

Although behavioral variant frontotemporal dementia (bvFTD) is classically defined by behavioral and socio-emotional changes, impairments often extend to other cognitive functions. These include early speech and language deficits related to the disease's core neural disruptions. Yet, their scope and clinical relevance remains poorly understood. This systematic review characterizes such disturbances in bvFTD, considering clinically, neuroanatomically, genetically, and neuropathologically defined subgroups. We included 181 experimental studies, with at least 5 bvFTD patients diagnosed using accepted criteria, comparing speech and language outcomes between bvFTD patients and healthy controls or between bvFTD subgroups. Results reveal extensive and heterogeneous deficits across cohorts, with (a) consistent lexico-semantic, reading & writing, and prosodic impairments; (b) inconsistent deficits in motor speech and grammar; and (c) relative preservation of phonological skills. Also, preliminary findings suggest that the severity of speech and language deficits might be associated with global cognitive impairment, predominantly temporal or fronto-temporal atrophy and MAPT mutations (vs C9orf72). Although under-recognized, these impairments contribute to patient characterization and phenotyping, while potentially informing diagnosis and management.

Neuropsychological and socio-cognitive deficits in patients with obstructive sleep apnea

Introduction: Patients with obstructive sleep apnea (OSA) suffer from several neurocognitive deficits. We investigated the cognitive and socio-cognitive profiles of patients with severe OSA, controlling for potentially relevant mediating variables (i.e. age, body-mass index, cognitive reserve and depression). Moreover, we studied the neuropsychological profile of a high-risk OSA phenotype characterized by severe OSA and severe nocturnal hypoxemia.Method: We assessed 29 previously untreated severe OSA patients with a mean age of 55.6 (± 9.9 years) and a mean apnea-hypopnea index (AHI) of 53.1 (± 17.4). A control group of 34 healthy participants was also enrolled. Participants completed an extensive neuropsychological battery that included social cognition, a relatively new investigation area among OSA patients.Data analysis: Data were analyzed with a Bayesian approach. Specifically, Bayesian ANCOVA was used to investigate whether the grouping variable could predict test performance. Age, body-mass index, cognitive reserve and state of depression were added as covariates to the null model to weight the effects of these potential confounding factors. Three groups were analyzed: healthy controls (H), OSA with severe apnea and severe nocturnal oxygen desaturation (D⁺), and OSA with severe apnea non-desaturators (D^-). Performances on the various neuropsychological tests were treated as the dependent variables.Results: The results indicate that non-verbal reasoning, the theory of mind skills, and mental shifting ability were impaired in OSA patients. Patients with severe nocturnal hypoxemia underperformed compared to patients with the same severity of apnea but non-desaturators. Additionally, we observed a trend toward a worse performance among OSA desaturator patients in the following abilities: constructional ability, short term verbal memory, phonological fluency, and the ability to inhibit automatic and dominant responses.Conclusion: The data suggest a key role of hypoxemia in affecting cognitive functioning in OSA patients. Executive functions and the concomitant involvement of social cognition are particularly affected.

Diversified social cognition in temporal lobe epilepsy

OBJECTIVES

In an integrated model of social cognition (SC), the theory of mind (ToM), the recognition of behavior in social situations (RBSS), empathy, and sensitivity to moral and conventional rules (SMCR) cooperate in generating mental representations of the interpersonal relationships. The aim of this study was to extend our knowledge of the SC of temporal lobe epilepsy (TLE) patients by characterizing its various aspects and predictors.

MATERIALS AND METHODS

Fifty adult patients with TLE and 50 healthy controls were assessed using ToM, RBSS and SMCR neuropsychological tests, the Empathy Questionnaire, and the psychopathology Symptoms Check List 90R (SCL90-R).

RESULTS

Patients and controls were similar in terms of occupation, income level, age, sex, marital status and the number of family members. Multivariate analysis of variance with demographic variables as the covariates showed that they were similar in SMCR and empathy. The patients, conversely, had lower ToM and RBSS scores, and higher scores on the SCL90-R psychoticism, depression, paranoid ideation, obsessive-compulsive, somatization and anxiety scales. Impaired RBSS was predicted by psychopathological symptoms, income level, schooling and the duration of epilepsy; ToM related to TLE laterality, seizure frequency and epilepsy duration.

CONCLUSIONS

In adult patients with TLE, SC is simultaneously partially impaired and partially preserved, and the fact this is associated with clinical, demographic and psychological variables suggests that SC depends on the integrity of the temporal lobe and the interconnected brain regions, as well as psychosocial stimuli. This approach may contribute to clarify the neurobehavioural phenotype of TLE.

Frontotemporal dementias: main syndromes and underlying brain changes

PURPOSE OF REVIEW

Frontotemporal dementia (FTD) is a rare dementia, that accounts for about 15% of all dementia cases. Despite consensus diagnostic criteria, FTD remains difficult to diagnose in life because of its complex and variable clinical phenomenology and heterogeneous disorders. This review provides an update on the current knowledge of the main FTD syndromes -- the behavioural variant, semantic variant, and nonfluent/agrammatic variant-- their brain abnormalities and genetic profiles.

RECENT FINDINGS

The complexity of the clinical features in FTD has become increasingly apparent, particularly in the domain of behaviour. Such behaviour changes are now also being recognized in the language variants of FTD. Initial interest on emotion processing and social cognition is now complemented by studies on other behavioural disturbance, that spans gambling, antisocial behaviours, repetitive behaviours, and apathy. At a biological level, novel pathological subcategories continue to be identified. From a genetic viewpoint, abnormalities in three genes explain nearly three quarters of familial cases of FTD.

SUMMARY

In the absence of effective drug treatments, novel approaches are needed to target some of the most disabling features of FTD, such as language loss or behaviour disturbance. Recent interventions appear promising but will require confirmation.

Evaluation of Discriminative Detection Abilities of Social Cognition Measures for the Diagnosis of the Behavioral Variant of Frontotemporal Dementia: a Systematic Review

The use of social tasks in the neuropsychological assessment of the behavioral variant of frontotemporal dementia (bvFTD) is at present not required by diagnostic guidelines, despite extensive literature shows relevant social cognitive dysfunctions in such patients. In this systematic review, we explored the clinical maturity of social cognition measures in the diagnosis of bvFTD. Papers were selected according to the PRISMA guidelines by searching the PubMed and Medline databases. Only papers reporting indices of diagnostic accuracy and/or sensitivity/specificity in classifying bvFTD from controls or from other relevant diseases were considered. Quality of evidence was assessed through QUADAS-2. Among the 663 articles entered in the paper selection only 14 papers were eligible for the scope of the present review and showed an overall moderate-to-low quality. The major risk of bias was the lack of pathological confirmation. The evaluation of the accuracy of social cognition tasks in bvFTD detection compared to normal controls, as well as in the discrimination with Alzheimer's disease and psychiatric patients, is mainly focused on emotion recognition and theory of mind. However, the use of different cognitive measures, variable task formats and the limited normative data hamper study comparability. Although literature seems to suggest that emotion recognition and ToM tasks could be the best choice to ensure a high diagnostic accuracy in clinical settings, further comparative studies are required and no recommendation concerning the use of a specific social task in bvFTD diagnosis can be currently provided.

The understanding of mental states and the cognitive phenotype of frontal lobe epilepsy

OBJECTIVE

Previous studies of frontal lobe epilepsy (FLE) have documented different impairments of theory of mind (ToM), while the study of frontal lobe (FL) lesion without seizures has produced inconsistent results. Given the role played by the FLs in ToM, we evaluated this and other functions in patients with FLE with and without FL lesions. The main objective was to clarify the salience of ToM impairment in the cognitive pattern of FLE and its capacity to discriminate these patients from healthy subjects. The effects of FL lesions on ToM were also explored.

METHODS

Seventy-five adult patients with FLE (40 cases with FL lesions) were compared with 42 healthy controls. The Faux Pas Task (FPT) and other neuropsychological tests were utilized to assess ToM, reasoning, language, memory, praxis, attention, and executive abilities.

RESULTS

The patients obtained lower z scores for the FPT than for other tests. The ToM, Executive, and Verbal factors discriminated patients from healthy subjects. The patients with or without FL lesion showed significant impairments in recognizing and understanding others' epistemic and affective mental states, but adequate capacity to exclude inexistent mental states was retained. In comparison with controls, the patients with FL lesions obtained lower scores for lexical, memory, praxis, attention, and executive functions, whereas those without lesion only showed attention and initiative deficits. Schooling was the major predictor of ToM, whereas the capacity to exclude inexistent mental states was related to seizure onset age and epilepsy duration. Other cognitive functions were related to schooling, age, or FLE laterality.

SIGNIFICANCE

Impaired understanding of real mental states is a specific, salient, and discriminating cognitive aspect of FLE. Poor education is a risk factor for ToM deficit, whereas the clinical variables and FL lesions have no impact. These results suggest that impaired ToM may be a marker of FLE neurobehavioral phenotype.