Vicarious Embarrassment or "Fremdscham": Overendorsement in Frontotemporal Dementia

Impairments in knowledge of social norms in presymptomatic, prodromal, and symptomatic frontotemporal dementia

INTRODUCTION

We aimed to assess the knowledge of social norms in patients with behavioral variant frontotemporal dementia (bvFTD) with the Dutch version of the Social Norms Questionnaire (SNQ-NL).

METHODS

The SNQ-NL was administered in 34 patients with bvFTD, 20 prodromal mutation carriers, 76 presymptomatic mutation carriers, and 56 controls. Group differences and correlations with other neuropsychological tests and gray matter volume were examined.

RESULTS

Patients with bvFTD had lower total SNQ-NL scores and more over-adherence errors than presymptomatic mutation carriers and controls (P < 0.001). SNQ-NL performance correlated with tests for executive functioning and social cognition, and with gray matter volume in bilateral frontal and unilateral temporal regions.

DISCUSSION

The SNQ-NL can identify impairments in knowledge of social norms in bvFTD, highlighting its significance in clinical diagnosis and upcoming clinical trials. The SNQ-NL currently fails to differentiate presymptomatic mutation carriers from controls; to this end, larger sample sizes from larger cohorts and longitudinal follow-up are warranted.

Highlights

The Dutch version of the Social Norms Questionnaire (SNQ-NL) is able to detect impairment in social cognition in symptomatic bvFTD patients.A trend towards a lower performance in prodromal mutation carriers was found.Performance on the SNQ-NL is related to other measures of social cognition, executive functioning, and language.Lower SNQ-NL performance is related to gray matter volume loss in bilateral frontal and temporal regions.The SNQ-NL provides insight into the underlying cause of deficits in social cognition in bvFTD.

Empathy and Impaired Socioemotional Self-Perception in Frontotemporal Dementia

OBJECTIVE

Impaired empathy is a core feature of behavioral variant frontotemporal dementia (bvFTD). Patients with bvFTD are also prominently impaired in experiencing self-conscious emotions. The investigators explored whether impaired empathy in bvFTD, such as self-conscious emotions, may result from impaired self-consciousness in social situations (socioemotional self-perception).

METHODS

This pilot study evaluated 25 patients with bvFTD and compared them with 25 patients with Alzheimer's disease who had comparable dementia severity. Their caregivers completed the Social Dysfunction Scale (SDS), which quantifies empathy, and an extensive intake interview that included questions regarding self-consciousness and insight. The patients completed two measures of self-perception in social situations, the Schutte Self-Report Emotional Intelligence Test (SSEIT) scale and the Embarrassability Scale (EMB).

RESULTS

Caregivers of patients with bvFTD, but not of patients with Alzheimer's disease, reported a high correlation between significantly decreased empathy (SDS) and decreased self-consciousness (intake interview questions). Consistent with lack of insight, the patients with bvFTD, unlike the patients with Alzheimer's disease, did not report decreases on the SSEIT and EMB measures.

CONCLUSIONS

These preliminary findings suggest that impaired socioemotional self-perception plays a role in the loss of empathy among patients with bvFTD. A lack of self-consciousness in social situations may contribute to a loss of empathy resulting from an inability to co-represent another's emotion in relation to oneself.

Measuring Behavior and Social Cognition in FTLD

Because changes to socioemotional cognition and behavior are an early and central symptom in many of the FTLD syndromes, an objective and standardized approach to patient identification and staging relies on availability of validated socioemotional measures. Such tests should reflect functioning in key selectively vulnerable brain networks central to socioemotional behavior, specifically the intrinsically connected networks underpinning salience (SN) and semantic appraisal (SAN). There have been many challenges to the development of appropriate tests for patients with the FTLD syndromes, including the difficulty of creating standardized evaluations for the highly idiosyncratic deficits caused by salience-driven attention impairments, the trade-off between behaviorally or psychophysiologically precise measures versus the need for easily administered measures that can scale to broader clinical contexts, and the complexities of measuring socioemotional behavior across linguistically and culturally diverse samples. A subset of available socioemotional tests are reviewed with respect to evidence for their ability to reflect structural and functional changes to the FTLD-specific SN and SAN networks, and their differential diagnostic utility in the neurodegenerative disease syndromes is discussed.