The spectrum of recurrent thoughts and behaviors in frontotemporal dementia

"Unvoluntary" Movement Disorders: Distinguishing between Tics, Akathisia, Restless Legs, and Stereotypies

Tics, stereotypies, akathisia, and restless legs fall at different places on the spectrum of discrete, unwanted and potentially disabling motor routines. Unlike tremor, chorea, myoclonus, or dystonia, this subgroup of abnormal movements is characterized by the subject's variable ability to inhibit or release undesired motor patterns on demand. Though it may be sometimes clinically challenging, it is crucial to distinguish these "unvoluntary" motor behaviors because secondary causes and management approaches differ substantially. To this end, physicians must consider the degree of repetitiveness of the movements, the existence of volitional control, and the association with sensory symptoms, or cognitive-ideational antecedent. This review aims to summarize the current existing knowledge on phenomenology, diagnosis, and treatment of tics, stereotypies, akathisia, and restless leg syndrome.

Trichotillomania as a Manifestation of Dementia

Pathological hair-pulling or trichotillomania, which is commonly associated with anxiety and depression, obsessive-compulsive disorder, and neurodevelopmental disorders, has been rarely associated with dementing illnesses. Investigators have not clarified the neural correlates and treatment of trichotillomania in dementia. We report a patient who developed an early-onset cognitive decline with genetic, cerebrospinal fluid biomarker and structural and functional neuroimaging studies consistent with Alzheimer's disease. Eight years into her disease, she developed severe, repetitive hair-pulling behavior leading to marked hair loss, along with other repetitive and “frontal” behaviors. Selective serotonin reuptake inhibitors (SSRIs) were ineffective in controlling her hair-pulling behavior, which subsequently responded to quetiapine 150 mg/day. This patient and a review of the literature suggest that trichotillomania may be a compulsive-related symptom in dementias of different etiologies as they involve frontal areas and release primitive grooming behavior from frontostriatal dysfunction. Dopamine blockade, rather than SSRIs, may be effective in managing trichotillomania in dementia.

Parkinsonism, movement disorders and genetics in frontotemporal dementia

Frontotemporal dementia (FTD) refers to a group of clinically and genetically heterogeneous neurodegenerative disorders that are a common cause of adult-onset behavioural and cognitive impairment. FTD often presents in combination with various hyperkinetic or hypokinetic movement disorders, and evidence suggests that various genetic mutations underlie these different presentations. Here, we review the known syndromatic-genetic correlations in FTD. Although no direct genotype-phenotype correlations have been identified, mutations in multiple genes have been associated with various presentations. Mutations in the genes that encode microtubule-associated protein tau (MAPT) and progranulin (PGRN) can manifest as symmetrical parkinsonism, including the phenotypes of Richardson syndrome and corticobasal syndrome (CBS). Expansions in the C9orf72 gene are most frequently associated with familial FTD, typically combined with motor neuron disease, but other manifestations, such as symmetrical parkinsonism, CBS and multiple system atrophy-like presentations, have been described in patients with these mutations. Less common gene mutations, such as those in TARDBP, CHMP2B, VCP, FUS and TREM2, can also present as atypical parkinsonism. The most common hyperkinetic movement disorders in FTD are motor and vocal stereotypies, which have been observed in up to 78% of patients with autopsy-proven FTD. Other hyperkinetic movements, such as chorea, orofacial dyskinesias, myoclonus and dystonia, are also observed in some patients with FTD.

Tau-mediated NMDA receptor impairment underlies dysfunction of a selectively vulnerable network in a mouse model of frontotemporal dementia

Frontotemporal dementia (FTD) is a neurodegenerative behavioral disorder that selectively affects the salience network, including the ventral striatum and insula. Tau mutations cause FTD, but how mutant tau impairs the salience network is unknown. Here, we address this question using a mouse model expressing the entire human tau gene with an FTD-associated mutation (V337M). Mutant, but not wild-type, human tau transgenic mice had aging-dependent repetitive and disinhibited behaviors, with synaptic deficits selectively in the ventral striatum and insula. There, mutant tau depleted PSD-95, resulting in smaller postsynaptic densities and impaired synaptic localization of NMDA receptors (NMDARs). In the ventral striatum, decreased NMDAR-mediated transmission reduced striatal neuron firing. Pharmacologically enhancing NMDAR function with the NMDAR co-agonist cycloserine reversed electrophysiological and behavioral deficits. These results indicate that NMDAR hypofunction critically contributes to FTD-associated behavioral and electrophysiological alterations and that this process can be therapeutically targeted by a Food and Drug Administration-approved drug.

The synergistic effect of growing older with hoarding behaviors

Clinically significant hoarding behaviors (HB) have been defined as acquisition of, and failure to discard, large numbers of items, which limits the use of one's home and causes functional impairment or distress. HB disproportionally affect adults aged 55 and older, and although research on HB has accelerated in the past decade, few studies focus on older adults. This qualitative study, based on grounded theory methodology, utilized interview data from 22 older adults with HB to understand the dynamic interaction between HB and the aging process. Participants described the specific ways that their chronic HB were complicated by changes in their health status, social context, and home setting, resulting in greater functional impairment and distress. By identifying these changes that commonly occur with age and their synergistic relationship with HB, nurses and other health professionals can develop targeted interventions to improve home safety and support the independence of these older adults.

Compulsive carnival song whistling following cardiac arrest: a case study

BACKGROUND

Compulsivity is the repetitive, irresistible urge to perform a behavior, the experience of loss of voluntary control over this intense urge and the tendency to perform repetitive acts in a habitual or stereotyped manner. Compulsivity is part of obsessive-compulsive disorder (OCD), but may occasionally occur as stand-alone symptom following brain damage induced by cardiac arrest. In this case report, we describe a patient who developed compulsivity following cardiac arrest. We review diagnostic options, underlying mechanisms and possible treatments.

CASE PRESENTATION

A 65-year-old man presented at our clinic with continuous compulsive whistling following cardiac arrest. Neither obsessive-compulsive symptoms, nor other psychiatric complaints were present prior to the hypoxic incident. An EEG showed diffuse hypofunction, mainly in baso-temporal areas. Treatment with clomipramine resulted in a decrease of whistling.

DISCUSSION

This case report illustrates de novo manifestation of compulsivity following cardiac arrest and subsequent brain damage and gives additional information on diagnostic options, mechanisms and treatment options. Differential diagnosis between stereotypies, punding, or OCD is difficult. Compulsivity following brain damage may benefit from treatment with serotonin reuptake inhibitors. This finding enhances our knowledge of treatments in similar cases.

Management of frontotemporal dementia: targeting symptom management in such a heterogeneous disease requires a wide range of therapeutic options

There are no US FDA-approved therapies for the management of frontotemporal dementia (FTD). Evidence-based medicine that would support a FDA indication for the treatment of FTD requires large-scale, randomized, double-blind, placebo-controlled trials that do not currently exist. Progress in obtaining approval and therapeutic indications for FTD has been severely hampered by the heterogeneity of clinical and pathological phenotypes seen in various FTD disease states. These issues are often misinterpreted by clinicians, caregivers and patients suggesting that potential treatment options are nonexistent for this devastating disease. This article discusses these issues in the context of recent studies and publications investigating therapeutic options in FTD, and further suggests a rationale for individualized therapy in FTD. Targeting the myriad of symptoms seen in FTD requires recognition of such symptoms that may play primary or secondary roles in the spectrum of deficits that lead to functional disability in FTD, and the availability of a wide range of therapeutic options that may be helpful in alleviating such symptomatology. Fortunately, agents targeting the many cognitive, behavioral, psychiatric and motor symptoms that can be seen in FTD are readily available, having been previously developed and approved for symptomatic benefit in other disease states. In contrast to the widespread belief that beneficial treatments are not available for FTD today, our therapeutic armament is stocked with pharmacological tools that may improve quality of life for those suffering from this devastating and incurable class of degenerative diseases.

Cognitive functioning in individuals with severe compulsive hoarding behaviors and late life depression

OBJECTIVES

The cognitive characteristics of individuals with severe compulsive hoarding behaviors (SCH) are not well understood and existing studies have largely focused on individuals with SCH and concurrent anxiety disorders. The present study was conducted to evaluate the frequency with which SCH co-occurs with LLD and to compare the cognitive characteristics of individuals with late life depression and concurrent SCH (LLD+SCH) to that of LLD individuals without SCH (LLD).

METHODS

Participants included 52 LLD individuals who received psychiatric and neuropsychological evaluations as part of a larger study. Cognitive performance on measures of memory, attention, language, information processing speed, and categorization/problem solving ability was evaluated for each participant using standard neuropsychological measures. Measures of depression and anxiety symptom severity were also obtained.

RESULTS

Seven (13%) of the 52 LLD participants reported significant SCH behaviors. The two groups (LLD+SCH; LLD) did not differ with respect to demographic characteristics or severity of depression or anxiety. Individuals with LLD+SCH demonstrated significantly poorer performance on two measures of categorization/problem solving ability relative to individuals with isolated LLD. Clinically significant impairments on measures of categorization ability, information processing speed, and verbal memory were more common for SCH+LLD than LLD participants.

CONCLUSIONS

Our preliminary results suggest that SCH behaviors in LLD are associated with specific aspects of executive dysfunction characterized by categorization deficits and to a lesser extent information processing speed and verbal memory deficits. Further study of cognitive functioning in older adults with LLD and SCH may clarify the underlying cognitive characteristics of the SCH syndrome.

The plight of caring for young patients with frontotemporal dementia

We present the case of a 39-year-old patient with frontotemporal dementia. This case depicts the complexities in the process leading to the diagnosis, treatment, and placement of young patients presenting with severe psychiatric symptoms as the first signs of an underlying neurological disease. Obstacles in the health care system and residential placement process that hinder the optimal and timely care of such difficult cases are discussed. Practical solutions are offered that center upon better awareness and education and the provision of additional resources. These interventions are likely to provide a positive return on investment for the medical system and could be used as strong levers for new health policies relevant to younger patients with neurological illness.

The use of selective serotonin reuptake inhibitors in elderly patients

Depression is common among the elderly, and several factors need to be taken into account in selecting the appropriate antidepressant in this age group. Various physiologic changes occur in individuals as they age, potentially leading to changes in the pharmacodynamic and pharmacokinetic properties of drugs in elderly individuals. The efficacy of various medications, their side-effect profiles, and the potential for drug-drug interactions may differ in older patients compared to younger ones. The selective serotonin reuptake inhibitors (SSRIs), which are seen as being among the first-line agents for treatment of depression in elderly patients, have been shown to be effective but carry with them side effects and drug-drug interactions that warrant special attention when these medications are prescribed to older individuals. This review focuses on the pharmacology of SSRIs in elderly patients and on practical issues related to using these medications.

Neurobiology and treatment of compulsive hoarding

Compulsive hoarding is a common and often disabling neuropsychiatric disorder. This article reviews the phenomenology, etiology, neurobiology, and treatment of compulsive hoarding. Compulsive hoarding is part of a discrete clinical syndrome that includes difficulty discarding, urges to save, clutter, excessive acquisition, indecisiveness, perfectionism, procrastination, disorganization, and avoidance. Epidemiological and taxometric studies indicate that compulsive hoarding is a separate but related obsessive-compulsive spectrum disorder that is frequently comorbid with obsessive-compulsive disorder (OCD). Compulsive hoarding is a genetically discrete, strongly heritable phenotype. Neuroimaging and neuropsychological studies indicate that compulsive hoarding is neurobiologically distinct from OCD and implicate dysfunction of the anterior cingulate cortex and other ventral and medial prefrontal cortical areas that mediate decision-making, attention, and emotional regulation. Effective treatments for compulsive hoarding include pharmacotherapy and cognitive-behavioral therapy. More research will be required to determine the etiology and pathophysiology of compulsive hoarding, and to develop better treatments for this disorder.