Moral Emotions in Frontotemporal Dementia

A systematic review of cognitive and behavioral tools to differentiate behavioral variant frontotemporal dementia from other conditions

The behavioral variant of frontotemporal dementia (bvFTD) is thought to be the commonest clinical presentation of frontotemporal lobar degeneration and is predominantly characterized by changes in behavior. In patients lacking unequivocal biomarker evidence of frontotemporal neurodegeneration, the clinical diagnosis of bvFTD is often unstable. In response, we conducted a systematic review and critical appraisal of cognitive and behavioral tools that have sought to differentiate bvFTD from other conditions. A systematic literature review of PubMed, Scopus, and Web of Science was conducted on December 31, 2023 for cognitive and behavioral tools that differentiated bvFTD from other cohorts. Ninety-six studies were included. The quality appraisal of almost all studies was low and introduced a high risk of bias. The few studies that were of high quality had a prospective study design and recruited patients suspected (but not yet confirmed) to have bvFTD. These studies reported that behavioral tools (e.g., the Frontal Behavioral Inventory) and social cognition tests (e.g., the Ekman's Faces Test) had good test performance in differentiating bvFTD from a broad range of psychiatric and neurological conditions. Importantly, the review highlighted the extreme paucity of studies that have evaluated methods where, in Bayesian terms, there is genuine clinical uncertainty regarding a diagnosis of bvFTD. Most studies used healthy controls of typical Alzheimer's disease as comparators-groups that often have negligible pretest probability of bvFTD. In response, we propose a study design checklist for studies seeking to develop diagnostic algorithms in bvFTD research.

The Implications of Moral Neuroscience for Brain Disease: Review and Update

The last 2 decades have seen an explosion of neuroscience research on morality, with significant implications for brain disease. Many studies have proposed a neuromorality based on intuitive sentiments or emotions aimed at maintaining collaborative social groups. These moral emotions are normative, deontological, and action based, with a rapid evaluation of intentionality. The neuromoral circuitry interacts with the basic mechanisms of socioemotional cognition, including social perception, behavioral control, theory of mind, and social emotions such as empathy. Moral transgressions may result from primary disorders of moral intuitions, or they may be secondary moral impairments from disturbances in these other socioemotional cognitive mechanisms. The proposed neuromoral system for moral intuitions has its major hub in the ventromedial prefrontal cortex and engages other frontal regions as well as the anterior insulae, anterior temporal lobe structures, and right temporoparietal junction and adjacent posterior superior temporal sulcus. Brain diseases that affect these regions, such as behavioral variant frontotemporal dementia, may result in primary disturbances of moral behavior, including criminal behavior. Individuals with focal brain tumors and other lesions in the right temporal and medial frontal regions have committed moral violations. These transgressions can have social and legal consequences for the individuals and require increased awareness of neuromoral disturbances among such individuals with brain diseases.

Moral reasoning through the eyes of persons with behavioral variant frontotemporal dementia

Introduction

Persons with behavioral variant frontotemporal dementia (bvFTD) can exhibit apparently antisocial behaviors. An example is their tendency to adopt utilitarian choices in sacrificial moral dilemmas, i.e. harmful actions to promote overall welfare. Moral cognition models interpret such tendencies as deriving from a lack of emotional engagement and selective impairment in prosocial sentiments.

Methods

We applied a qualitative approach to test those theoretical assumptions and to further explore the emotional experiences and values of people with bvFTD while they contemplate moral scenarios. We conducted semistructured interviews with 14 participants: 7 persons with bvFTD and 7 older healthy controls. Transcripts were coded using ATLAS.ti 5.0.

Results

During the moral reasoning task, persons with bvFTD reported more positive emotions than negative and showed significantly less cognitive precision in their moral reasoning compared to controls. Persons with bvFTD also organized their choices predominantly around kindness and altruism, and their responses reflected higher rule compliance. Our study showed that bvFTD persons' utilitarian responses to moral dilemmas did not arise from an emotionally disengaged or antisocial perspective. Instead, they were underpinned by positive emotionality and prosocial values.

Discussion

These findings enrich current understandings of moral cognition and highlight the importance of incorporating mixed methods approaches in dementia research that take into consideration the viewpoint of cognitively impaired individuals.

Culpability for offenses in frontotemporal dementia and other brain disorders

The responsibility of persons with brain disorders who commit offenses may depend on how their disorders alter brain mechanisms for culpability. Criminal behavior can result from brain disorders that alter social cognition including a neuromoral system of intuitive moral emotions that are absolute (deontological) normative codes and that includes an emotion-mediated evaluation of intentionality. This neuromoral system has its hub in the ventromedial prefrontal cortex (VMPFC) with other frontal, anterior temporal-amygdalar, insular, and right temporoparietal connections. Among brain disorders, investigators report offenses in persons with brain tumors, epilepsy, and traumatic brain injury, but it is those with a form of dementia with VMPFC pathology, behavioral variant frontotemporal dementia (bvFTD), who are most prone to criminal behavior. This review presents four new patients with bvFTD who were interviewed after committing offenses. These patients knew the nature of their acts and the wrongness of the type of action but lacked substantial capacity to experience the criminality of their conduct at the intuitive, deontological, moral emotional level. Disease in VMPFC and its amygdalar connections may impair moral emotions in these patients. These findings recommend evaluation for the experience of moral emotions and VMPFC-amygdala dysfunction among persons with antisocial behavior, with or without brain disease.

Moral Emotions and Their Brain Structural Correlates Across Neurodegenerative Disorders

BACKGROUND

Although social cognition is compromised in patients with neurodegenerative disorders such as behavioral variant frontotemporal dementia (bvFTD) and Alzheimer's disease (AD), research on moral emotions and their neural correlates in these populations is scarce. No previous study has explored the utility of moral emotions, compared to and in combination with classical general cognitive state tools, to discriminate bvFTD from AD patients.

OBJECTIVE

To examine self-conscious (guilt and embarrassment) and other-oriented (pity and indignation) moral emotions, their subjective experience, and their structural brain underpinnings in bvFTD (n = 31) and AD (n = 30) patients, compared to healthy controls (n = 37). We also explored the potential utility of moral emotions measures to discriminate bvFTD from AD.

METHODS

We used a modified version of the Moral Sentiment Task measuring the participants' accuracy scores and their emotional subjective experiences.

RESULTS

bvFTD patients exhibited greater impairments in self-conscious and other-oriented moral emotions as compared with AD patients and healthy controls. Moral emotions combined with general cognitive state tools emerged as useful measures to discriminate bvFTD from AD patients. In bvFTD patients, lower moral emotions scores were associated with lower gray matter volumes in caudate nucleus and inferior and middle temporal gyri. In AD, these scores were associated with lower gray matter volumes in superior and middle frontal gyri, middle temporal gyrus, inferior parietal lobule and supramarginal gyrus.

CONCLUSION

These findings contribute to a better understanding of moral emotion deficits across neurodegenerative disorders, highlighting the potential benefits of integrating this domain into the clinical assessment.

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.

THE IMPLICATIONS OF FRONTOTEMPORAL DEMENTIA FOR BRAIN DYSFUNCTION IN PSYCHOPATHY

Understanding how psychopathy compares with brain disease can help clarify its underlying mechanisms. This literature review is a broad overview of the neurobiology of psychopathic traits in comparison to behavioral variant frontotemporal dementia (bvFTD), a disorder uniquely associated with criminal behavior. In addition to violation of social norms, both psychopathy and bvFTD result in impaired socioemotional perception and empathy, impulsivity, and altered moral judgment. Despite wide areas of decreased function in psychopathy, structural changes are primarily evident in amygdala and, to a lesser extent, anterior insula, whereas in bvFTD neuropathology involves a wider paralimbic region. In psychopathy, relatively intact medial prefrontal and anterior cingulate cortices facilitate theory of mind and psychopathic traits such as deceitfulness and manipulation, bold fearlessness, and risk-taking behavior. In conclusion, many frontotemporal areas are hypoactive in psychopathy and bvFTD, but differences in dysfunctional connectivity in psychopathy vs. direct involvement in bvFTD potentially explain similarities and differences between these two conditions.

The long‐term impact of loneliness and social isolation on depression and anxiety in memory clinic attendees and their care partners: A longitudinal actor–partner interdependence model

Introduction

Methods

Results

Discussion

Emotion regulation and decision-making in persons with dementia: A scoping review

BACKGROUND AND OBJECTIVES

Emotion is integral to decision-making, and emotion regulation is associated with improved well-being in older age. Persons with dementia are likely to experience impairments in emotion regulation processes that can potentially contribute to differential decision-making and well-being outcomes. To promote the development of theoretical models of well-being in dementia, we review the quantitative evidence concerning the associations between emotion regulation and decision-making in dementia.

METHODS

Scoping review.

RESULTS

Seven studies of persons with dementia met our criteria. In persons with frontotemporal lobar degeneration, emotion regulation processes that precede the emotional experience were associated with decision-making in a moral (but not uncertainty) context. Independent of type of dementia, evidence concerning the associations between emotion regulation processes that occur after emotion is experienced and decision-making was mixed and drew on different methodologies. No studies relating to the associations between decision-making in dementia and several emotion regulation processes and strategies were found.

CONCLUSIONS

In this review, we sought to clarify the concept of everyday decision-making in dementia and map the current state of evidence concerning its associations with emotion regulation. Our findings show that emotion regulation processes are associated with decision-making in dementia, depending on type of decision-making assessment and emotional experience. We outline the gaps in the literature to set a research agenda for promoting our understanding of how emotion regulation processes can shape the various decisions that are made by persons with dementia on a daily basis.

Artificial Intelligence in Service of Human Needs: Pragmatic First Steps Toward an Ethics for Semi-Autonomous Agents

The ethics of robots and artificial intelligence (AI) typically centers on "giving ethics" to as-yet imaginary AI with human-levels of autonomy in order to protect us from their potentially destructive power. It is often assumed that to do that, we should program AI with the true moral theory (whatever that might be), much as we teach morality to our children. This paper argues that the focus on AI with human-level autonomy is misguided. The robots and AI that we have now and in the near future are "semi-autonomous" in that their ability to make choices and to act is limited across a number of dimensions. Further, it may be morally problematic to create AI with human-level autonomy, even if it becomes possible. As such, any useful approach to AI ethics should begin with a theory of giving ethics to semi-autonomous agents (SAAs). In this paper, we work toward such a theory by evaluating our obligations to and for "natural" SAAs, including nonhuman animals and humans with developing and diminished capacities. Drawing on research in neuroscience, bioethics, and philosophy, we identify the ways in which AI semi-autonomy differs from semi-autonomy in humans and nonhuman animals. We conclude on the basis of these comparisons that when giving ethics to SAAs, we should focus on principles and restrictions that protect human interests, but that we can only permissibly maintain this approach so long as we do not aim at developing technology with human-level autonomy.