CPCP: Frontotemporal Dementia vs Bipolar Disorder by Dr. Ann Van De Walle Jones, MD

Ann Van de Walle-Jones, MD
Ann Van de Walle-Jones, MD

Today’s excellent Clinical Problems in Consultation Psychiatry (CPCP) presentation was by Neurology resident, Dr. Ann Van De Walle Jones, MD and it’s about distinguishing Frontotemporal Dementia from bipolar and other psychiatric disorders. Technically, according to the Diagnostic and Statistical Manual vers. 5 (DSM5), I should call it Major or Mild Frontotemporal Neurocognitive Disorder.  The diagnostic criteria include (either 1 or 2):

1.Behavioral variant:

Three or more of the following behavioral symptoms:

Behavioral disinhibtion

Apathy or inertia

Loss of sympathy or empathy

Perseverative, stereotyped or compulsive/ritualistic behavior

Hyperorality and dietary changes

Prominent decline in social cognition and/or executive abilities

2.Language variant:

Prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension.

Relative sparing of learning and memory and percptual-motor function

Frontotemporal dementia can mimic other psychiatric disorders clinically. It can be challenging to distinguish from bipolar disorder because patients can appear to be hypomanic or manic. Dr. Van De Walle Jones includes a published case report illustrating the difficulty. She also included a fascinating account of composer Maurice Ravel’s song “Bolero” and how it might have illustrated his early own early symptoms of the disease. A 2008 New York Times article by Sandra Blakeslee tells the same story.

I was not familiar with the Frontal Behavioral Inventory (FBI) although apparently it has been around for a while:

Kertesz, A., et al. (1997). “Frontal behavioral inventory: diagnostic criteria for frontal lobe dementia.” Can J Neurol Sci 24(1): 29-36.
OBJECTIVE: To utilize the diagnostic criteria of frontal lobe dementia (FLD). METHODS: We studied 12 patients with FLD diagnosed clinically, with radiological confirmation in 10 and autopsy confirmation in 2; sixteen patients with Alzheimer’s disease matched for stage and severity to FLD and 11 patients with depressive dementia were used as control groups. A 24-item Frontal Behavioral Inventory (FBI) using the most relevant behavioral manifestations of FLD was administered in these populations. RESULTS: FLD patient scores on the FBI were much higher compared with control groups (AD and DD). Item analysis showed loss of insight, indifference, distractibility, personal neglect and apathy as the most frequent negative symptoms. Perseveration, disinhibition, inappropriateness, impulsivity, and irresponsibility were the most significant positive symptoms. An operational definition of FLD included a minimum FBI score of 27. Only one false positive was shown in the depressive group and none among the AD group, indicating little overlap between patient groups, and a high discriminating value of the FBI. CONCLUSIONS: The FBI appears to be a useful diagnostic instrument and a method to operate the behavioral criteria of FLD. Further prospective studies are warranted to establish validity.

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