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A 58-year-old man is brought by his adult daughter for psychiatric evaluation after being terminated from his job as a bank manager 6 months ago due to increasingly inappropriate social behavior. His daughter reports that over the past 2 years, he has exhibited progressive personality changes including loss of social decorum, making sexually inappropriate comments to strangers, shoplifting small items without apparent need, and eating excessive amounts of sweets despite a prior history of healthy eating habits. He shows no concern about his job loss or the impact of his behavior on others. On examination, he demonstrates a flat, apathetic affect with occasional inappropriate jocularity. He is oriented to person, place, and time. His memory for recent events is relatively preserved — he can recall three objects after five minutes and accurately describes what he had for breakfast. However, he struggles significantly with verbal fluency tasks and demonstrates concrete thinking on proverb interpretation. His MoCA score is 22/30 with primary deficits in executive function and language subtests. Brain MRI has been ordered.
Explanation
Behavioral variant frontotemporal dementia (bvFTD) is frequently misdiagnosed as a primary psychiatric disorder because it presents with progressive personality and behavioral changes rather than the memory loss typically associated with dementia. Key distinguishing features include: progressive loss of social decorum, behavioral disinhibition, apathy, loss of empathy, hyperorality/dietary changes, and executive dysfunction with relatively preserved episodic memory. Onset typically occurs in the 50s-60s, and MRI reveals frontal and/or anterior temporal atrophy.
Key Takeaway
Behavioral variant frontotemporal dementia presents with progressive personality deterioration, social disinhibition, apathy, loss of empathy, and hyperorality — often mimicking psychiatric illness. Preserved episodic memory with disproportionate executive dysfunction in a middle-aged patient with progressive behavioral changes should prompt neuroimaging to evaluate for bvFTD.