Enhancing theory of mind in behavioural variant frontotemporal dementia with transcranial direct current stimulation

The neural structures of theory of mind are valence-sensitive: evidence from three tDCS studies

Several cortical structures are involved in theory of mind (ToM), including the dorsolateral prefrontal cortex (dlPFC), the ventromedial prefrontal cortex (vmPFC), and the right temporo- parietal junction (rTPJ). We investigated the role of these regions in mind reading with respect to the valence of mental states. Sixty-five healthy adult participants were recruited and received transcranial direct current stimulation (tDCS) (1.5 mA, 20 min) with one week interval in three separate studies. The stimulation conditions were anodal tDCS over the dlPFC coupled with cathodal tDCS over the vmPFC, reversed stimulation conditions, and sham in the first study, and anodal tDCS over the vmPFC, or dlPFC, and sham stimulation, with an extracranial return electrode in the second and third study. During stimulation, participants underwent the reading mind from eyes/voice tests (RMET or RMVT) in each stimulation condition. Anodal left dlPFC/cathodal right vmPFC stimulation increased the accuracy of negative mental state attributions, anodal rTPJ decreased the accuracy of negative and neutral mental state attributions, and decreased the reaction time of positive mental state attributions. Our results imply that the neural correlates of ToM are valence-sensitive.

Long-term, home-based transcranial direct current stimulation coupled with computerized cognitive training in frontotemporal dementia: A case report

We present the case of a 62-year-old woman with probable behavioral variant of frontotemporal dementia (bvFTD) with cognitive/language deficits who demonstrated improved performance on cognitive/language testing and in functional tasks following long-term, home-based transcranial direct current stimulation (tDCS) coupled with computerized cognitive training (CCT). The patient underwent home-based tDCS (anode on the left prefrontal cortex and cathode on the right homologue) for 46 sessions over 10 weeks along with CCT. On post-treatment testing, the patient improved by 3 points on the Mini-Mental State Exam (MMSE) (23 to 26). She also showed improvement on several cognitive/language tasks, such as immediate recall of single words and word pairs, total accurate words in sentence repetition, delayed recall, semantic processing, and sentence level comprehension. There was no decline in several other cognitive and language tasks. Family members reported subjective improvements in expressiveness, communication, and interaction with others as well as increased attention to grooming and style which contrasted with her pre-treatment condition. This report suggests that home-based tDCS combined with CCT for an extended period may slow decline, and improve cognitive/language performance and everyday function in FTD.

Quantitative Electroencephalography Markers for an Accurate Diagnosis of Frontotemporal Dementia: A Spectral Power Ratio Approach

Background and Objectives: Frontotemporal dementia (FTD) is the second most common form of presenile dementia; however, its diagnosis has been poorly investigated. Previous attempts to diagnose FTD using quantitative electroencephalography (qEEG) have yielded inconsistent results in both spectral and functional connectivity analyses. This study aimed to introduce an accurate qEEG marker that could be used to diagnose FTD and other neurological abnormalities. Materials and Methods: We used open-access electroencephalography data from OpenNeuro to investigate the power ratio between the frontal and temporal lobes in the resting state of 23 patients with FTD and 29 healthy controls. Spectral data were extracted using a fast Fourier transform in the delta (0.5 ≤ 4 Hz), theta (4 ≤ 8 Hz), alpha (8-13 Hz), beta (>13-30 Hz), and gamma (>30-45 Hz) bands. Results: We found that the spectral power ratio between the frontal and temporal lobes is a promising qEEG marker of FTD. Frontal (F)-theta/temporal (T)-alpha, F-alpha/T-theta, F-theta/F-alpha, and T-beta/T-gamma showed a consistently high discrimination score for the diagnosis of FTD for different parameters and referencing methods. Conclusions: The study findings can serve as reference for future research focused on diagnosing FTD and other neurological anomalies.

The Effects of Transcranial Direct Current Stimulation (tDCS) on the Cognitive Functions: A Systematic Review and Meta-analysis

Previous studies have investigated the effect of transcranial direct current stimulation (tDCS) on cognitive functions. However, these studies reported inconsistent results due to differences in experiment design, measurements, and stimulation parameters. Nonetheless, there is a lack of meta-analyses and review studies on tDCS and its impact on cognitive functions, including working memory, inhibition, flexibility, and theory of mind. We performed a systematic review and meta-analysis of tDCS studies published from the earliest available data up to October 2021, including studies reporting the effects of tDCS on cognitive functions in human populations. Therefore, these systematic review and meta-analysis aim to comprehensively analyze the effects of anodal and cathodal tDCS on cognitive functions by investigating 69 articles with a total of 5545 participants. Our study reveals significant anodal tDCS effects on various cognitive functions. Specifically, we observed improvements in working memory reaction time (RT), inhibition RT, flexibility RT, theory of mind RT, working memory accuracy, theory of mind accuracy and flexibility accuracy. Furthermore, our findings demonstrate noteworthy cathodal tDCS effects, enhancing working memory accuracy, inhibition accuracy, flexibility RT, flexibility accuracy, theory of mind RT, and theory of mind accuracy. Notably, regarding the influence of stimulation parameters of tDCS on cognitive functions, the results indicated significant differences across various aspects, including the timing of stimulation (online vs. offline studies), population type (clinical vs. healthy studies), stimulation duration (< 15 min vs. > 15 min), electrical current intensities (1-1.5 m.A vs. > 1.5 m.A), stimulation sites (right frontal vs. left frontal studies), age groups (young vs. older studies), and different cognitive tasks in each cognitive functioning aspect. In conclusion, our results demonstrate that tDCS can effectively enhance cognitive task performance, offering valuable insights into the potential benefits of this method for cognitive improvement.

Advances in the treatment and management of frontotemporal dementia

INTRODUCTION

Frontotemporal dementia (FTD) is a complex neurodegenerative disorder, characterized by a wide range of pathological conditions associated with the buildup of proteins such as tau and TDP-43. With a strong hereditary component, FTD often results from genetic variants in three genes - MAPT, GRN, and C9orf72.

AREAS COVERED

In this review, the authors explore abnormal protein accumulation in FTD and forthcoming treatments, providing a detailed analysis of new diagnostic advancements, including innovative markers. They analyze how these discoveries have influenced therapeutic strategies, particularly disease-modifying treatments, which could potentially transform FTD management. This comprehensive exploration of FTD from its molecular underpinnings to its therapeutic prospects offers a compelling overview of the current state of FTD research.

EXPERT OPINION

Notable challenges in FTD management involve identifying reliable biomarkers for early diagnosis and response monitoring. Genetic forms of FTD, particularly those linked to C9orf72 and GRN, show promise, with targeted therapies resulting in substantial progress in disease-modifying strategies. The potential of neuromodulation techniques, like tDCS and rTMS, is being explored, requiring further study. Ongoing trials and multi-disciplinary care highlight the continued push toward effective FTD treatments. With increasing understanding of FTD's molecular and clinical intricacies, the hope for developing effective interventions grows.

Try to see it my way - Examining the relationship between visual perspective taking and theory of mind in frontotemporal dementia

The behavioural variant of frontotemporal dementia (bvFTD) is characterised by pronounced alterations in social functioning, including the understanding of others' thoughts and feelings via theory of mind. The emergence of such impairments in other social disorders such as autism and schizophrenia is suggested to reflect an inability to imagine the other person's visual perspective of the world. To our knowledge, relationships between visual perspective taking and theory of mind have not previously been explored in bvFTD. Here, we sought to examine the capacity for visual perspective taking and theory of mind in bvFTD, and to establish their inter-relationships and underlying neural correlates. Fifteen bvFTD patients and 15 healthy Controls completed a comprehensive battery of perspective taking measures, comprising Level 1 ('what') and Level 2 ('how') visual perspective taking tasks, a cartoon task capturing theory of mind, and a questionnaire assessing subjective perspective taking in daily life. Compared with Controls, bvFTD patients displayed significant impairments across all perspective taking measures. These perspective taking impairments, however, were not correlated with one another in bvFTD. Region-of-interest voxel-based morphometry analyses suggested distinct neural correlates for visual perspective taking (inferior frontal gyrus) versus theory of mind (medial prefrontal cortex, precuneus), which appeared to partially overlap with those implicated in subjective perspective taking (inferior frontal gyrus, precuneus, temporoparietal junction). Despite pervasive impairments in all aspects of perspective taking in bvFTD, these did not appear to relate to one another at the behavioural or neural level in our study. Future large-scale studies manipulating discrete aspects of the tasks will help to clarify the neurocognitive mechanisms of, and relationships between, visual perspective taking and theory of mind in bvFTD, along with their real-world implications.

The Transdiagnostic Relevance of Self-Other Distinction to Psychiatry Spans Emotional, Cognitive and Motor Domains

Self-other distinction refers to the ability to distinguish between our own and other people's physical and mental states (actions, perceptions, emotions etc.). Both the right temporo-parietal junction and brain areas associated with the human mirror neuron system are likely to critically influence self-other distinction, given their respective contributions to theory of mind and embodied empathy. The degree of appropriate self-other distinction will vary according to the exact social situation, and how helpful it is to feel into, or remain detached from, another person's mental state. Indeed, the emotional resonance that we can share with others affords the gift of empathy, but over-sharing may pose a downside, leading to a range of difficulties from personal distress to paranoia, and perhaps even motor tics and compulsions. The aim of this perspective paper is to consider how evidence from behavioral and neurophysiological studies supports a role for problems with self-other distinction in a range of psychiatric symptoms spanning the emotional, cognitive and motor domains. The various signs and symptoms associated with problematic self-other distinction comprise both maladaptive and adaptive (compensatory) responses to dysfunction within a common underlying neuropsychological mechanism, compelling the adoption of more holistic transdiagnostic therapeutic approaches within Psychiatry.

Neuronavigated Magnetic Stimulation combined with cognitive training for Alzheimer's patients: an EEG graph study

Alzheimer's disease (AD) is the most common neurodegenerative disorder in elderly subjects. Recent studies verified the effects of cognitive training combined with repetitive transcranial magnetic stimulation (rTMS-COG) in AD patients. Here, we analyzed neuropsychological and neurophysiological data, derived from electroencephalography (EEG), to evaluate the effects of a 6-week protocol of rTMS-COG in 72 AD. We designed a randomized, double-blind, sham-controlled trial to evaluate efficacy of rTMS on 6 brain regions obtained by an individual MRI combined with COG related to brain areas to stimulate (i.e., syntax and grammar tasks, comprehension of lexical meaning and categorization tasks, action naming, object naming, spatial memory, spatial attention). Patients underwent neuropsychological and EEG examination before (T₀), after treatment (T₁), and after 40 weeks (T₂), to evaluate the effects of rehabilitation therapy. "Small World" (SW) graph approach was introduced allowing us to model the architecture of brain connectivity in order to correlate it with cognitive improvements. We found that following 6 weeks of intensive daily treatment the immediate results showed an improvement in cognitive scales among AD patients. SW present no differences before and after the treatment, whereas a crucial SW modulation emerges at 40-week follow-up, emphasizing the importance of rTMS-COG rehabilitation treatment for AD. Additional results demonstrated that the delta and alpha1 SW seem to be diagnostic biomarkers of AD, whereas alpha2 SW might represent a prognostic biomarker of cognitive recovery. Derived EEG parameters can be awarded the role of diagnostic and predictive biomarkers of AD progression, and rTMS-COG can be regarded as a potentially useful treatment for AD.

Transcranial direct current stimulation for empathy: A systematic review and meta-analysis

Transcranial Direct Current Stimulation (tDCS) has been used to modulate empathy, but no studies have meta-analyzed the evidence base for its efficacy. This study aimed to determine the efficacy of tDCS at modulating empathy. We conducted a systematic review and meta-analysis of randomized controlled trials involving anodal or cathodal versus sham tDCS to modulate empathy in healthy adults and clinical populations. Random-effects modelling was applied to pooling overall efficacy estimates using standardized mean differences (Hedge's g) and 95% confidence intervals. Outcome measures for tasks designed to measure empathy were reaction time and accuracy. Anodal tDCS appears to improve lab-based computerized measures of cognitive empathy in healthy adult volunteers. While the evidence provided by this review may be of relevance to individuals with impaired empathic capabilities, the generalizability of our findings is geared towards nonclinical populations given the preponderance of healthy volunteers in our review. Hence, it is not clear if moderate improvements in speed and accuracy on lab-based computerized empathy measures would lead to meaningful clinical improvements. Future studies should consider the use of tDCS to modulate empathy in clinical populations.

Experimental Disease-Modifying Agents for Frontotemporal Lobar Degeneration

Frontotemporal dementia is a clinically, genetically and pathologically heterogeneous neurodegenerative disorder, enclosing a wide range of different pathological entities, associated with the accumulation of proteins such as tau and TPD-43. Characterized by a high hereditability, mutations in three main genes, MAPT, GRN and C9orf72, can drive the neurodegenerative process. The connection between different genes and proteinopathies through specific mechanisms has shed light on the pathophysiology of the disease, leading to the identification of potential pharmacological targets. New experimental strategies are emerging, in both preclinical and clinical settings, which focus on small molecules rather than gene therapy. In this review, we provide an insight into the aberrant mechanisms leading to FTLD-related proteinopathies and discuss recent therapies with the potential to ameliorate neurodegeneration and disease progression.

A Scoping Review of Neuromodulation Techniques in Neurodegenerative Diseases: A Useful Tool for Clinical Practice?

Background and Objectives: Neurodegenerative diseases that typically affect the elderly such as Alzheimer’s disease, Parkinson’s disease and frontotemporal dementia are typically characterised by significant cognitive impairment that worsens significantly over time. To date, viable pharmacological options for the cognitive symptoms in these clinical conditions are lacking. In recent years, various studies have employed neuromodulation techniques to try and contrast patients’ decay. Materials and Methods: We conducted an in-depth literature review of the state-of-the-art of the contribution of these techniques across these neurodegenerative diseases. Results: The present review reports that neuromodulation techniques targeting cognitive impairment do not allow to draw yet any definitive conclusion about their clinical efficacy although preliminary evidence is very encouraging. Conclusions: Further and more robust studies should evaluate the potentialities and limitations of the application of these promising therapeutic tools to neurodegenerative diseases.

Effects of Transcranial Direct Current Stimulation on Information Processing Speed, Working Memory, Attention, and Social Cognition in Multiple Sclerosis

Multiple Sclerosis (MS) is a chronic inflammatory disease of the central nervous system. Cognitive impairment occurs in 40-65% of patients and could drastically affect their quality of life. Deficits could involve general cognition (e.g., attention and working memory) as well as social cognition. Transcranial direct current stimulation (tDCS), is a novel brain stimulation technique that has been assessed in the context of several neuropsychiatric symptoms, including those described in the context of MS. However, very rare trials have assessed tDCS effects on general cognition in MS, and none has tackled social cognition. The aim of this work was to assess tDCS effects on general and social cognition in MS. Eleven right-handed patients with MS received two blocks (bifrontal tDCS and sham, 2 mA, 20 min, anode/cathode over left/right prefrontal cortex) of 5 daily stimulations separated by a 3-week washout interval. Working memory and attention were, respectively, measured using N-Back Test (0-Back, 1-Back, and 2-Back) and Symbol Digit Modalities Test (SDMT) at the first and fifth day of each block and 1 week later. Social cognition was evaluated using Faux Pas Test and Eyes Test at baseline and 1 week after each block. Interestingly, accuracy of 1-Back test improved following sham but not active bifrontal tDCS. Therefore, active bifrontal tDCS could have impaired working memory via cathodal stimulation of the right prefrontal cortex. No significant tDCS effects were observed on social cognitive measures and SDMT. Admitting the small sample size and the learning (practice) effect that might arise from the repetitive administration of each task, the current results should be considered as preliminary and further investigations in larger patient samples are needed to gain a closer understanding of tDCS effects on cognition in MS.

Theory of Mind Performance Predicts tDCS-Mediated Effects on the Medial Prefrontal Cortex: A Pilot Study to Investigate the Role of Sex and Age

Transcranial Direct Current Stimulation (tDCS) has become an increasingly promising tool for understanding the relationship between brain and behavior. The purpose of this study was to investigate whether the magnitude of sex- and age-related tDCS effects previously found in the medial prefrontal cortex (mPFC) during a Theory of Mind (ToM) task correlates with social cognition performance; in particular, we explored whether different patterns of activity would be detected in high- and low-performing participants. For this, young and elderly, male and female participants were categorized as a low- or high-performer according to their score on the Reading the Mind in the Eyes task. Furthermore, we explored whether sex- and age-related effects associated with active tDCS on the mPFC were related to cognitive functioning. We observed the following results: (i) elderly participants experience a significant decline in ToM performance compared to young participants; (ii) low-performing elderly females report slowing of reaction time when anodal tDCS is applied over the mPFC during a ToM task; and (iii) low-performing elderly females are characterized by lower scores in executive control functions, verbal fluency and verbal short-term memory. The relationship between tDCS results and cognitive functioning is discussed in light of the neuroscientific literature on sex- and age-related differences.

Aging, sex and cognitive Theory of Mind: a transcranial direct current stimulation study

Aging is accompanied by changes in cognitive abilities and a great interest is spreading among researchers about aging impact on social cognition skills, such as the Theory of Mind (ToM). Transcranial direct current stimulation (tDCS) has been used in social cognition studies founding evidence of sex-related different effects on cognitive ToM task in a young people sample. In this randomized, double-blind, sham-controlled study, we applied one active and one sham tDCS session on the medial prefrontal cortex (mPFC) during a cognitive ToM task, including both social (i.e., communicative) and nonsocial (i.e., private) intention attribution conditions, in sixty healthy aging individuals (30 males and 30 females). In half of the participants the anode was positioned over the mPFC, whereas in the other half the cathode was positioned over the mPFC. The results showed that: (i) anodal tDCS over the mPFC led to significant slower reaction times (vs. sham) for social intention attribution task only in female participants; (ii) No effects were found in both females and males during cathodal stimulation. We show for the first time sex-related differences in cognitive ToM abilities in healthy aging, extending previous findings concerning young participants.

Neurocognitive mechanisms of theory of mind impairment in neurodegeneration: a transdiagnostic approach

Much of human interaction is predicated upon our innate capacity to infer the thoughts, beliefs, emotions, and perspectives of others, in short, to possess a "theory of mind" (ToM). While the term has evolved considerably since its inception, ToM encompasses our unique ability to apprehend the mental states of others, enabling us to anticipate and predict subsequent behavior. From a developmental perspective, ToM has been a topic of keen research interest, with numerous studies seeking to explicate the origins of this fundamental capacity and its disruption in developmental disorders such as autism. The study of ToM at the opposite end of the lifespan, however, is paradoxically new born, emerging as a topic of interest in its own right comparatively recently. Here, we consider the unique insights afforded by studying ToM capacity in neurodegenerative disorders. Arguing from a novel, transdiagnostic perspective, we consider how ToM vulnerability reflects the progressive degradation of neural circuits specialized for an array of higher-order cognitive processes. This mechanistic approach enables us to consider the common and unique neurocognitive mechanisms that underpin ToM dysfunction across neurodegenerative disorders and for the first time examine its relation to behavioral disturbances across social, intimate, legal, and criminal settings. As such, we aim to provide a comprehensive overview of ToM research in neurodegeneration, the resultant challenges for family members, clinicians, and the legal profession, and future directions worthy of exploration.

Non-Invasive Brain Stimulation in Dementia: A Complex Network Story

Non-invasive brain stimulation (NIBS) is emerging as a promising rehabilitation tool for a number of neurodegenerative diseases. However, the therapeutic mechanisms of NIBS are not completely understood. In this review, we will summarize NIBS results in the context of brain imaging studies of functional connectivity and metabolites to gain insight into the possible mechanisms underlying recovery. We will briefly discuss how the clinical manifestations of common neurodegenerative disorders may be related with aberrant connectivity within large-scale neural networks. We will then focus on recent studies combining resting-state functional magnetic resonance imaging with NIBS to delineate how stimulation of different brain regions induce complex network modifications, both at the local and distal level. Moreover, we will review studies combining magnetic resonance spectroscopy and NIBS to investigate how microscale changes are related to modifications of large-scale networks. Finally, we will re-examine previous NIBS studies in dementia in light of this network perspective. A better understanding of NIBS impact on the functionality of large-scale brain networks may be useful to design beneficial treatments for neurodegenerative disorders.