Disinhibition in FTD
Partners in FTD Care, Summer 2021
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by Esther Kane, MSN, RN-CDP, AFTD Director of Support and Education
Disinhibition is a hallmark feature of behavioral variant FTD (bvFTD) (Raskovsky et al., 2011). The diagnostic criteria for probable bvFTD requires a decline in social cognition and/or executive function and at least three of the following symptoms: disinhibition, apathy, loss of empathy, compulsive/ritualistic behavior, and hyperorality, the tendency to insert edible or inedible objects into the mouth. Professionals not familiar with FTD, however, may fail to recognize the emergence of disinhibited behaviors as a symptom of dementia (Balasa et al., 2015).
People exhibiting disinhibition act impulsively, without considering the consequences or repercussions of their actions. Socially inappropriate behavior, loss of manners, and impulsive, rash, or careless actions are all examples of disinhibited behavior (Raskovsky et al., 2011). (In this issue’s case study, José exhibits socially inappropriate disinhibited behaviors when he begins publicly stripping on a cruise.) Disinhibition also poses a threat to the physical safety of the person diagnosed. The combination of impulsivity and poor judgment can lead to the person diagnosed misusing dangerous objects such as guns, vehicles, or power tools, and has also been associated with an increased suicide risk.
It is important to acknowledge that any of the behaviors described below can be part of an individual’s established personality. These behaviors become alarming when they reflect a notable change from the person’s usual personality, which can be caused by a disease process.
Socially inappropriate behavior
Examples of behaviors that violate social norms include inappropriately approaching, touching, or kissing strangers; verbal or physical aggression; public nudity or urination; inappropriate sexual behaviors; and criminal behaviors, such as shoplifting, traffic violations, financial mismanagement, or sexual advances. Studies have shown that new onset of criminal behavior in an adult should be considered an indicator of possible FTD.
Loss of manners or decorum
This category includes a range of behaviors that violate social graces. Examples include inappropriate laughter, cursing or loudness, offensive jokes and opinions, or crude and/or sexually explicit remarks. People may also display a general lack of etiquette, loss of respect for other’s personal space, and a lack of response to social cues. Some people with FTD exhibit poor hygiene or grooming or impolite physical behaviors.
Impulsive, rash, or careless actions
The revised diagnostic criteria for FTD acknowledge that not all behavioral disinhibition leads to obvious breaches in social or interpersonal conduct; in fact, it can manifest as impulsive behaviors that may or may not be performed in a social context. These include reckless driving, new-onset gambling (as evidenced by José), buying or selling objects without regard for consequences, trying to consume items or poisonous liquids, irresponsibly using dangerous objects, and indiscriminate sharing of personal information.
Failing to recognize the link between an undiagnosed person’s newly disinhibited behaviors and FTD could lead them to being incorrectly treated for psychiatric illness, or potentially caught in the criminal justice system (Rankin et al., 2008). Clinicians need to be aware that new onset disinhibited behavior may be an early symptom of a progressive neurodegenerative disease.
Balasa M., et al.; Catalan Collaborative Study Group for FTLD (2015). Diagnostic accuracy of behavioral variant frontotemporal dementia consortium criteria (FTDC) in a clinicopathological cohort. Neuropathology and Applied Neurobiology, 41(7), 882-92. https://doi.org/10.1111/nan.12194.
Lanata, S. C., and Miller, B. L. (2016). The behavioural variant frontotemporal dementia (bvFTD) syndrome in psychiatry. Journal of Neurology, Neurosurgery, and Psychiatry, 87(5), 501–511. https://doi.org/10.1136/jnnp-2015-310697.
Rankin, K. P., et al. (2008). Spontaneous social behaviors discriminate behavioral dementias from psychiatric disorders and other dementias. The Journal of Clinical Psychiatry, 69(1), 60–73. https://doi.org/10.4088/jcp.v69n0109.
Rascovsky, K., et al. (2011). Sensitivity of revised diagnostic criteria for the behavioral variant of frontotemporal dementia. Brain: A Journal of Neurology, 134(Pt 9), 2456–2477. https://doi.org/10.1093/brain/awr179.
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