Insight in frontotemporal dementia: Conceptual analysis and empirical evaluation of the consensus criterion “loss of insight” in frontotemporal dementia

Living with a diagnosis of frontotemporal dementia: An interpretative phenomenological analysis

Frontotemporal dementia describes a spectrum of disorders which include behavioural changes, changes to affect, speech difficulties and physical issues. Although literature exists which identifies the need for the voices of people with dementia to be heard, there is a paucity of research which includes hearing the experiences of people diagnosed with FTD. The purpose of this research was to explore the lived experience of frontotemporal dementia from the persons' perspective using interpretative phenomenological analysis. The themes that emerged in the analysis were: the rocky road through assessment; the changing self; in touch with reality; and keeping going. Two overarching themes emerged which were: the need to hear the voice of people with frontotemporal dementia; and for people with frontotemporal dementia to exercise some control over the decision making process throughout their journey. Recommendations are presented for future practice and research.

Loss of "insight" into behavioral changes in ALS: Differences across cognitive profiles

OBJECTIVE

Behavioral impairment occurs in amyotrophic lateral sclerosis (ALS) and ALS-fronto-temporal dementia (ALS-FTD). It has been proposed that ALS patients without FTD retain an awareness of their behavioral impairment while ALS-FTD patients lose this awareness (referred to as retention vs. loss of "insight"). Loss of insight has not yet been studied across the entire ALS-FTD spectrum; our study addresses this gap by including patients with all the ALS cognitive-behavioral profiles.

METHODS

Eighty-three ALS patients (and their informants) took part in this bicentric study involving two German recruitment sites. Patients and informants completed the Frontal Systems Behavior Scale covering the domains of apathy, disinhibition, and executive dysfunctioning. Patients were classified into five groups according to the Strong and Rascovsky criteria: cognitively unimpaired (ALSni), cognitively impaired without dementia (ALSci), behaviorally impaired (ALSbi), a combination of behaviorally and cognitively impaired (ALScbi), and ALS-FTD. We applied Bayesian two-way ANOVA to test whether there were subgroup differences regarding insight into their behavioral decline.

RESULTS

All patient subgroups experienced behavioral decline (Bayes factor > 3). Only ALS-FTD patients lost insight into disinhibition and executive dysfunctioning. ALSbi patients exhibited worse insight than ALSni and ALSci patients (Bayes factor > 10). Evidence regarding the ALScbi patients was inconclusive. Higher IQ was associated with worse insight (Bayes factor > 3).

CONCLUSIONS

Our findings provide solid support for the notion that ALS patients without dementia experience behavioral decline regardless of their cognitive-behavioral profile and retain different levels of insight into this decline. The inverse association of premorbid verbal intelligence with insight was unexpected, leaving room for further investigation.

Insight in frontotemporal dementia and progressive supranuclear palsy

INTRODUCTION

Progressive supranuclear palsy (PSP) and behavioural variant frontotemporal dementia - (bv-FTD) share common neuropsychological features except for online monitoring awareness. Therefore, the aim of our study is to explore if this assessment could be used in standard clinical practice.

MATERIALS AND METHODS

We retrospectively analyse 93 subjects (27 FTD, 25 PSP, 42 healthy controls). Neuropsychological and instrumental examinations were performed for each patient.

RESULTS

FTD patients made fewer self-corrections than PSP patients despite a similar number of total errors. We also performed ROC curves: the area under the curve (AUC) is 0.79. A model for a logistic regression was also developed: the only significant predictor is the number of self-corrections (p = 0.004 β = 1244).

DISCUSSION AND CONCLUSIONS

In conclusion, our findings show online awareness is more compromised in FTD patients than in PSP patients. This difference could be useful for making a differential diagnosis between the two diseases: for each extra point in number of self-corrections the probability of suffering from PSP increases by about three and a half times (OR 3.47).

Frontotemporal asymmetry in socioemotional behavior: A pilot study in frontotemporal dementia

Clinical studies report abnormal socioemotional behavior in patients with right frontotemporal disease, but neuroimaging studies of socioemotional behavior usually show bilateral activations in normal subjects. This discrepancy suggests that impaired interhemispheric collaboration for socioemotional functions results from asymmetric frontotemporal disease. Behavioral variant frontotemporal dementia (bvFTD) can clarify the contribution of direction-independent frontotemporal asymmetry. In a two-part study, we evaluated bvFTD patients using socioemotional scales and magnetic and resonance imaging measures. Part A compared 18 patients on scales of social dysfunction and emotional intelligence with degree of asymmetry in frontal lobe volumes and analyzed differences between lower and higher asymmetry groups. Part B compared 24 patients on scales of social observation and emotional blunting with degree of asymmetry in frontotemporal cortical thickness using multiple linear regression. Both results showed that left or right hemispheric-specific contributions did not account for all socioemotional differences and that frontal lobe and frontotemporal differences in atrophy between the hemispheres accounted for significant variance in abnormalities in social and emotional behavior. These preliminary results indicate that the degree of frontal lobe and frontotemporal asymmetric involvement, regardless of direction or laterality, significantly contribute to socioemotional dysfunction and support the hypothesis that interhemispheric collaboration is important for complex socioemotional behavior.

Emotional quotient in frontotemporal dementia vs. Alzheimer's disease: the role of socioemotional agnosia

INTRODUCTION

Socioemotional dysfunction distinguishes behavioural variant frontotemporal dementia (bvFTD) from other dementias. Patients with bvFTD not only have early social impairment and emotional blunting, but they also have agnosia of their socioemotional dysfunction.

METHODS

To investigate the relationship between agnosia and dysfunction, we assessed self-knowledge of socioemotional dysfunction with an emotional quotient (EQ) scale administered to 12 patients with bvFTD and a comparison group of 12 age-matched patients with Alzheimer's disease (AD), and compared these self-ratings to caregiver ratings of social dysfunction and emotional blunting.

RESULTS

The bvFTD patients self-rated as having higher EQs than the AD patients, particularly higher self-ratings of their Social Skills, an EQ subscale which correlated with increased emotional blunting. On within-groups analysis, the bvFTD patients' high self-ratings of their EQ Appraisal of Emotions correlated with increased socioemotional dysfunction, whereas all of the AD patients' self-ratings correlated appropriately with their degree of dysfunction.

CONCLUSIONS

Large socioemotional agnosia scores (EQ minus function) distinguishes bvFTD from AD. Additionally, in bvFTD, agnosia specifically for their ability to appreciate others' emotions correlates with the degree of socioemotional dysfunction, suggesting a role for socioemotional agnosia in increasing socioemotional dysfunction.

Anosognosia and anosodiaphoria in mild cognitive impairment and Alzheimer's disease

Aims

To evaluate the occurrence of anosognosia (lack of awareness) and anosodiaphoria (insouciance) in mild cognitive impairment (MCI) and Alzheimer's disease (AD) and to evaluate the influence of a worsening of dementia on these phenomena.

Methods

A self-evaluation scale was used assessing degrees of anosognosia and anosodiaphoria; furthermore, a neuropsychological assessment and statistical analyses with nonparametric tests which could cope with data on an ordinal scale level and small samples were employed.

Results

Cognitive ability was lower in AD (n = 9) than in MCI patients (n = 12), but AD patients self-rated lower cognitive disabilities, which is interpreted as one relative sign of anosognosia in AD. Awareness of the reasons for cognitive problems was also lower in AD, which is considered as another sign of anosognosia. The main pattern in MCI found that the higher the awareness, the lower the cognitive ability. In AD low awareness paralleled low cognitive functioning. Anosodiaphoria was present in AD but not in MCI.

Conclusion

According to the literature anosognosia and anosodiaphoria seem to increase with progression of dementia from MCI as a result of right hemispheric alterations.

Possibilities and limits of mind-reading: a neurophilosophical perspective

Access to other minds once presupposed other individuals' expressions and narrations. Today, several methods have been developed which can measure brain states relevant for assessments of mental states without 1st person overt external behavior or speech. Functional magnetic resonance imaging and trace conditioning are used clinically to identify patterns of activity in the brain that suggest the presence of consciousness in people suffering from severe consciousness disorders and methods to communicate cerebrally with patients who are motorically unable to communicate. The techniques are also used non-clinically to access subjective awareness in adults and infants. In this article we inspect technical and theoretical limits on brain-machine interface access to other minds. We argue that these techniques hold promises of important medical breakthroughs, open up new vistas of communication, and of understanding the infant mind. Yet they also give rise to ethical concerns, notably misuse as a consequence of hypes and misinterpretations.

Impaired emotional processing in a patient with a left posterior insula-SII lesion

The present case-report investigated the influence of a lesion in the left posterior insula-SII cortices on the processing of emotions. MB and 16 normal controls explicitly rated the valence and the intensity of both facial expressions and emotional words. In addition, they had to perform a number comparison task and a lexical decision task without focusing their attention on emotional components of stimuli. MB identified the valence of emotional words as well as the control group. Nevertheless, she provided higher intensity scores for disgusted words and her responses in the lexical decision task were significantly delayed for these stimuli. In addition, MB's response times were not differently influenced by the presence of irrelevant emotional faces. However, she explicitly identified fewer facial expressions of disgust and she assessed them as significantly less intense. This pattern of results contributes to highlight the psychological and behavioral disorders observed after a left posterior insular stroke.

Ventromedial-frontopolar prefrontal cortex atrophy correlates with insight loss in frontotemporal dementia and Alzheimer's disease

Loss in insight is a major feature of frontotemporal dementia (FTD) but has been investigated relatively little. More importantly, the neural basis of insight loss is still poorly understood. The current study investigated insight deficit profiles across a large cohort of neurodegenerative patients (n = 81), including FTD and Alzheimer's disease (AD) patients. We employed a novel insight questionnaire, which tapped into changes across different domains: social interaction, emotion, diagnosis/treatment, language, and motivation. FTD subtypes varied considerably for insight loss, with the behavioral variant worst and the progressive non-fluent variant least affected. All other subtypes and AD showed milder but consistent insight loss. Voxel-based morphometry analysis revealed that overall insight loss correlated with ventromedial and frontopolar prefrontal atrophy, with exception of social interaction and emotion insight loss, which additionally correlated with lateral temporal and amygdala atrophy, respectively. Our results show that patients with neurodegenerative conditions show variable loss of insight, with ventromedial and frontopolar cortex regions appearing to be particularly important for insight.

Loss of emotional insight in behavioral variant frontotemporal dementia or "frontal anosodiaphoria"

Loss of insight is a prominent clinical manifestation of behavioral variant frontotemporal dementia (bvFTD), but its characteristics are poorly understood. Twelve bvFTD patients were compared with 12 Alzheimer's disease (AD) patients on a structured insight interview of cognitive insight (awareness of having a disorder) and emotional insight (concern over having a disorder). Compared to the AD patients, the bvFTD patients were less aware and less concerned about their disorder, and they had less appreciation of its effects on themselves and on others. After corrective feedback ("updating"), the bvFTD patients were just as aware of their disorder as the AD patients but remained unconcerned and unappreciative of its effects. These findings suggest that lack of insight in bvFTD is not due to "anosognosia," or impaired cognitive and executive awareness of disease, but to "frontal anosodiaphoria," or lack of emotional concern over having bvFTD and its impact on themselves and others.

Doctors' health and fitness to practise: performance problems in doctors and cognitive impairments

BACKGROUND

As a response to concerns over the safety of patient care and quality of care provided by doctors, there has been an increasing interest in identifying the reasons for medical errors.

METHODS

This paper reviews briefly the common neurocognitive causes for performance problems in doctors and provides an updated account of the current literature. Search on Medline and PsychINFO for English language articles between 1956 and September 2006 was performed, as well as a manual search by the authors for other relevant articles.

RESULTS

Neuropsychiatric and neuropsychological assessment is increasingly accepted as an accurate evaluation tool to clarify the performance problems in doctors. Furthermore, it seems that neurocognitive difficulties are commonly found to be the cause for such problems.

CONCLUSIONS

The performance problems in doctors need to be acknowledged 'better too soon than too late'. Neuropsychiatric and neuropsychological assessment helps to create an accurate treatment and rehabilitation plan for the specific functional tasks of the particular doctor's duties.

Generalized and symptom-specific insight in behavioral variant frontotemporal dementia and primary progressive aphasia

Behavioral variant frontotemporal dementia (FTD) and primary progressive aphasia (PPA) are related dementias with different presenting symptoms but with increasing symptom overlap as they progress. Loss of insight is associated with early behavioral variant FTD, but not PPA. This study used the Frontal Behavioral Inventory to compare patient and caregiver concepts of symptom presence and severity. Patients with behavioral variant FTD were found to have worse insight overall than PPA patients. However, the PPA group showed reduced insight into behavioral symptoms, and the behavioral variant FTD groups had intact insight into some language symptoms. Theoretical and clinical implications are discussed.

Diagnostic criteria for the behavioral variant of frontotemporal dementia (bvFTD): current limitations and future directions

The most widely established diagnostic criteria for the behavioral variant of frontotemporal dementia have now been in use for almost a decade. Although consensus criteria have provided a much needed standard for frontotemporal dementia research, a growing body of evidence suggests that revisions are needed to improve their applicability. In this article, we discuss the limitations of current diagnostic criteria and propose the establishment of an international consortium to revise diagnostic and research criteria for the behavioral variant of frontotemporal dementia.

Clinical presentation of prodromal frontotemporal dementia

BACKGROUND

Misrecognition of symptoms in the early stages of frontotemporal dementia (FTD) frequently contributes to diagnostic delay. Three frameworks have been proposed for the clinical identification of prodromal FTD: (1) cognitive profiling, (2) the presence of behavioral/psychiatric symptoms in the absence of memory complaints, and (3) a combined approach of cognitive, behavioral, and neuroimaging features.

OBJECTIVE

To evaluate current conceptual frameworks for the clinical recognition of prodromal FTD with current empirical evidence.

METHOD

We performed a comprehensive PsychINFO and MEDLINE database search to identify articles investigating the prodromal symptoms of FTD.

CONCLUSIONS

The 3 frameworks capture important aspects of the clinical picture of prodromal FTD but require further refinement. The prodromal stage of FTD is characterized by both cognitive and behavioral features. Diagnostic accuracy will likely be improved by considering a combination of cognitive and behavioral features, because some features overlap with prodromes for Alzheimer's disease and vascular dementia.