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CATEGORY 1 CME
Premiere Date: April 20, 2023
Expiration Date: October 20, 2024
This exercise provides CE credit for:
1. Physicians (CME)
2. Different
All different clinicians both will obtain a CME Attendance Certificates or could select any of the forms of CE credit score being supplied.
ACTIVITY GOAL
The purpose of this exercise is to study frontotemporal lobar degeneration and the a number of overlapping syndromes that it encompasses, in addition to distinguish behavioral variant frontotemporal lobar degeneration from different psychiatric problems.
LEARNING OBJECTIVES
1. Perceive the differential analysis of sufferers with progressive behavioral and cognitive impairment.
2. Perceive the analysis and administration of cognitive and behavioral signs in sufferers with behavioral variant frontotemporal dementia.
TARGET AUDIENCE
This accredited persevering with training (CE) exercise is meant for psychiatrists, psychologists, main care physicians, doctor assistants, nurse practitioners, and different well being care professionals searching for to enhance the care of sufferers with psychological well being problems.
ACCREDITATION/CREDIT DESIGNATION/FINANCIAL SUPPORT
This exercise has been deliberate and applied in accordance with the accreditation necessities and insurance policies of the Accreditation Council for Persevering with Medical Training (ACCME) by way of the joint providership of Physicians’ Training Useful resource®, LLC, and Psychiatric Instances®. Physicians’ Training Useful resource®, LLC, is accredited by the ACCME to supply persevering with medical training for physicians.
Physicians’ Training Useful resource, LLC, designates this enduring materials for a most of 1.5 AMA PRA Class 1 Credit™. Physicians ought to declare solely the credit score commensurate with the extent of their participation within the exercise.
This exercise is funded completely by Physicians’ Training Useful resource, LLC. No industrial assist was acquired.
OFF-LABEL DISCLOSURE/DISCLAIMER
This accredited CE exercise could or could not focus on investigational, unapproved, or off-label use of medicine. Contributors are suggested to seek the advice of prescribing info for any merchandise mentioned. The data supplied on this accredited CE exercise is for persevering with medical training functions solely and isn’t meant to substitute for the unbiased scientific judgment of a doctor relative to diagnostic or remedy choices for a selected affected person’s medical situation. The opinions expressed within the content material are solely these of the person college members and don’t mirror these of Physicians’ Training Useful resource®, LLC.
FACULTY, STAFF, AND PLANNERS’ DISCLOSURES AND CONFLICT OF INTEREST (COI) MITIGATION
Not one of the employees of Physicians’ Training Useful resource, LLC, or Psychiatric Instances or the planners of this academic exercise have related monetary relationship(s) to reveal with ineligible firms whose main enterprise is producing, advertising and marketing, promoting, reselling, or distributing well being care merchandise utilized by or on sufferers. Drs Abu Raya, Illanes-Manrique, and Miller notice nothing to reveal concerning this text.
For content-related questions, e-mail us at PTEditor@mmhgroup.com. For questions in regards to the accreditation of this CE exercise or declare credit score, please contact information@gotoper.com and embody “The Border Zone Between bvFTD and Major Psychiatric Issues” within the topic line.
HOW TO CLAIM CREDIT
After you have learn the article, please use the next URL to guage and request credit score: https://training.gotoper.com/exercise/ptcme23april. If you don’t have already got an account with Physicians’ Training Useful resource®, LLC, you may be prompted to create one. You have to have an account to guage and request credit score for this exercise.
Frontotemporal lobar degeneration (FTLD) is a clinicopathological time period that encompasses a spectrum of a number of overlapping syndromes related to a selected set of non–Alzheimer illness (AD) neurodegenerative histopathologies that features the tau, TDP-43, and FET proteins. These pathological processes in another way have an effect on the frontotemporal neural networks and their subcortical connections within the thalamus, basal ganglia, and brainstem, which could clarify the heterogenous scientific traits of FTLD spectrum problems.1 The scientific syndromes related to these neuropathologies contain habits, language, and motion. Nevertheless, prediction of the exact underlying pathology related to these scientific syndromes is imperfect, and higher biomarkers are wanted.1,2
Frontotemporal dementia (FTD), a separate entity from FTLD, is an early-onset dementia that normally impacts individuals youthful than 65 years.2 The three most important scientific entities subsumed underneath the time period FTD are behavioral variant FTD (bvFTD), nonfluent variant main progressive aphasia (nfvPPA), and semantic variant main progressive aphasia (svPPA) (Desk 1). FTD could overlap with different scientific syndromes akin to amyotrophic lateral sclerosis (ALS)/motor neuron illness (MND),progressive supranuclear palsy (PSP), or corticobasal syndrome (CBS).1
Desk 1. Entities Subsumed Underneath Frontotemporal Dementia
For psychiatrists, bvFTD is of explicit curiosity as a result of it overlaps clinically with obsessive-compulsive dysfunction (OCD); affective, psychotic, and character problems; and different psychiatric problems. bvFTD accounts for roughly 60% of FTD circumstances, whereas the opposite 40% are language variants (nfvPPA and svPPA).2 bvFTD is the second-most frequent reason behind dementia in adults aged lower than 65 years and might be the commonest dementia for these aged youthful than 60 years. The common age of onset is between 45 and 65 years, however circumstances have been documented in sufferers aged youthful than 30 years and in very previous sufferers as effectively.1,2
A global consortium established diagnostic standards for bvFTD in 2011, and the analysis was divided into potential, possible, and particular, as outlined in Desk 2.3,4 These standards have elevated the flexibility of clinicians to tell apart between bvFTD and different neurocognitive problems, akin to AD, however it’s nonetheless troublesome to tell apart bvFTD from a main psychiatric dysfunction.
Desk 2. Division of bvFTD Diagnosis3,4
Diagnostic Challenges
Distinguishing bvFTD from a main psychiatric dysfunction may be difficult for a number of causes, together with the shortage of definitive biomarkers, the sometimes-slow evolution of bvFTD from a primarily psychiatric situation to a dementia, and the lack of expertise within the medical neighborhood concerning the anatomic substrates of habits. It’s estimated that about 50% of sufferers with FTD obtain an preliminary misdiagnosis of despair or one other psychiatric dysfunction.1
The sometimes-early age of signs onset could also be a problem for clinicians. Though bvFTD typically presents in sufferers older than 40 years, and lots of main psychiatric problems begin earlier in life, there are exceptions. Warning on this regard is important when a affected person is recognized with any late-onset psychiatric dysfunction akin to late-life despair, schizophrenia, and bipolar dysfunction, or OCD. In these circumstances, bvFTD needs to be thought of within the differential analysis.
Diagnostic confusion is frequent when a affected person meets diagnostic standards for bvFTD however has a really gradual illness course—over many years—with gradual development of cognitive impairment and infrequently regular MRI and PET research. This syndrome is assessed as FTD phenocopy. Some sufferers have a main psychiatric disturbance akin to bipolar dysfunction, character dysfunction, or autism spectrum dysfunction,5,6 whereas others have a gradual sporadic or genetic type of bvFTD. The latter has been reported in carriers of C9orf72 pathological expansions, and these sufferers have had long-standing early psychiatric signs and late-onset psychosis that may evolve to comorbid bvFTD.7
Overlapping behavioral signs are a serious problem in distinguishing bvFTD from a main psychiatric dysfunction. For example, bvFTD could also be misdiagnosed as late-onset despair, when apathy and lack of empathy are current; as bipolar dysfunction, when the presentation is disinhibition; as schizophrenia or schizoaffective dysfunction, when psychosis is the presenting characteristic; and as OCD, when repetitive motor syndromes are distinguished (Desk 3).
Desk 3. Scientific Options of Major Psychiatric Dysfunction, FTD, and AD
Typically, disinhibition is a presenting and core characteristic of bvFTD, and it’s characterised by socially inappropriate behaviors and an extreme searching for of pleasurable actions that may result in dangerous social, monetary, and authorized penalties. Sufferers could current with inappropriate sexual behaviors like public masturbation or sexual harassment, touching strangers, and verbal dysdecorum with inappropriate familiarity and extreme jocularity. Theft and unhealthy monetary choices are additionally frequent.8 When disinhibition is distinguished, bvFTD is usually misdiagnosed as bipolar dysfunction, though sufferers with bvFTD normally lack the expansive temper and sense of grandiosity that’s seen in sufferers with a main psychiatric dysfunction.
Apathy can be a core symptom of bvFTD and should current in quite a lot of methods, akin to a decreased involvement in hobbies and duties, lack of spontaneous actions, decline in self-care, lack of self-awareness, and emotional flatness with impairment in private, social, and occupational operate. These modifications may be misdiagnosed as manifestations of temper problems, akin to depressive dysfunction. When apathy is seen in bvFTD, it typically presents with out different typical signs of temper problems akin to low temper, guilt/worthlessness, or suicidal ideas.
These diagnostic challenges contribute to the delay within the correct analysis, remedy, prognosis defining and household counseling.4,9,10
Diagnostic Strategy
In 2020, the Neuropsychiatric Worldwide Consortium for Frontotemporal Dementia printed the primary consensus suggestions to assist clinicians distinguish between bvFTD and a main psychiatricdisorder. There are 8 main points of diagnostic analysis of late-onset behavioral change that differentiate bvFTD from a main psychiatric dysfunction.11,12
1. Affected person historical past, together with scientific scales. Clinicians ought to get hold of an in depth historical past of signs onset, danger elements, household historical past, and collateral anamnesis from a educated caregiver and one other unbiased relative or pal.
Purple flags:
-Household or private historical past of cognitive impairment, character problems, psychiatric diseases, suicide, muscle weak spot, and early sudden loss of life
-Neurological signs akin to tremor and different motion problems, falls, muscle weak spot, swallowing difficulties, visible difficulties, and cognitive modifications
2. Psychiatric evaluation. Adhere to DSM-V standards to outline the psychiatric problems. Use a scientific scale such because the Frontal Behavioral Stock’s optimistic subscale and others to scale back biases throughout scientific evaluation.
Purple flags:
-Late-onset psychiatric dysfunction that’s insidious and progressive (slightly than fluctuating, waxing and waning course, or abrupt in onset, as is seen in a main psychiatric dysfunction)
-Weird delusions and/or hallucinations are uncommon in bvFTD, however when current, increase suspicion for genetic types of bvFTD akin to C9orf72
-OCD with lack of perception that’s not accompanied by anxiousness
-Disinhibition with lack of expansive temper or sense of grandiosity or irritability13
-Apathy and temper are incongruent.
3. Bodily and neurological examination findings. Take into account indicators of different neurodegenerative problems akin to ALS, PSP, or CBS. Take into account neurological session in ambiguous circumstances.
Purple flags:
-Parkinsonism, frontal launch indicators, pyramidal indicators, weak spot
4. Bedside cognitive exams and neuropsychological examination. Focus evaluation on government dysfunctions evaluation, language, reminiscence, and Frontal Evaluation Battery.
Warning: Related deficits in government features, verbal reminiscence, and sensory processing may be seen in sufferers with bipolar problems throughout manic or depressive episodes. Working reminiscence efficiency may be decreased even in younger sufferers with bipolar dysfunction.14
5. Assessments of social cognition. Use a structured check of social cognition, such because the Ekman 60 Faces Take a look at, to evaluate the diploma of impairment of social cognition that happens in bvFTD and a main psychiatric dysfunction.
6. Structural and nuclear imaging. Use CT or MRI to exclude different etiologies, akin to frontal mind tumors or vascular illness, and to find out the presence of mind atrophy. Symmetrical or asymmetrical atrophy within the frontal and/or temporal lobes helps analysis of bvFTD within the applicable scientific setting. Practical imaging fluorodeoxyglucose PET can be utilized as an adjunct to structural imaging in sufferers with suspected bvFTD, notably if MRI findings are regular or solely questionably in keeping with FTD. Amyloid PET imaging identifies people with amyloid deposition within the mind and can be utilized to distinguish underlying AD from non-AD problems in sufferers with a bvFTD-like presentation.
7. Cerebrospinal fluid (CSF) and blood biomarkers. Rising proof signifies that plasma and CSF biomarkers are delicate and particular for AD (eg, phosphorylated tau), and these needs to be used to distinguish between AD and FTLD. FTLD has no particular blood or CSF biomarkers. Neurofilament mild chain is a delicate marker of neurodegeneration related to FTD and rises to very excessive ranges in lots of sufferers. Though excessive ranges don’t differentiate the completely different FTLD pathologies from each other, it could be helpful in differentiating between a neurodegenerative illness and a main psychiatric dysfunction in sufferers with a bvFTD-like presentation.15
Due to this fact, for at the least the subsequent few years, the function of CSF testing in a bvFTD-like presentation can be most helpful in ruling out AD and in investigating the very uncommon infectious, autoimmune/inflammatory, and paraneoplastic processes that result in a bvFTD syndrome.16
8. Genetic testing. Roughly 15% to twenty% of FTD is genetic in etiology. Mutations in C9orf72, GRN, and MAPT genes account for almost 50% of autosomal dominant inherited FTLD; furthermore, they’re related to excessive prevalence (>50%) of neuropsychiatric signs.17 MAPT mutations current earlier in life with a imply age of onset within the sixth decade, whereas GRN and C9orf72 mutations sometimes seem within the seventh decade.18 C9orf72 mutations are strongly related to ALS, whereas sufferers with GRN and MAPT mutations are predisposed to parkinsonian signs. Different mutations that trigger FTD syndromes embody TBK1, TDP-43, FUS, VCP, CHMP2B, SQSTM1, and UBQLN1. Genetic counseling is necessary when there’s a household historical past of dementia and can assist the affected person and household weigh the professionals and cons of acquiring genetic testing.12
Interventions
FTD shortly progresses to incapacity with limitations in day by day actions and social interactions, resulting in deathapproximately 8 years after first symptom onset. Interventions needs to be multidisciplinary, interprofessional, culturally delicate, and neighborhood based mostly. At the moment, pharmacological and nonpharmacological remedies primarily deal with signs and can assist handle bvFTD options. As of right this moment, there aren’t any permitted disease-modifying medication for the remedy of FTD.
Nonpharmacological remedies. Tailor-made leisure actions and behavioral assist can enhance neuropsychiatric and behavioral signs and alleviate caregiver misery. Environmental interventions needs to be thought of; these embody limiting entry to cash, meals, pornography, or alcohol; inserting locks on doorways to stop escape; and offering entry to secure actions akin to pc video games, tv, or accompanied walks. Some sufferers with FTD present a powerful curiosity within the artistic arts and music, which needs to be inspired. In sufferers with FTD mutations, latest proof means that better depth of bodily and cognitive actions is related to slower scientific decline and fee of atrophy on MRI.
The caregiver burden with FTD is profound, resulting in despair, anxiousness, and common well being decline. Not solely does this have an effect on the caregiver, but it surely additionally diminishes the chance that the affected person will obtain correct care. As well as, the profound lack of perception in people with bvFTD counsel the necessity for elevated caregiver assist.1 Strategies in cognitive reappraisal and coping can change a caregiver’s interpretation of the person’s habits and may present a way of management for caregivers, which can cut back burden. Caregiver assist ought to embody suggestions for stress discount like transcendental meditation, train, participation in caregiver assist teams, respite care, and psychiatric intervention (when wanted). In sufferers with FTD who’ve language impairment, speech and cognitive therapies are really helpful. Makes an attempt to mix language coaching with noninvasive mind stimulation, akin to transcranial direct present stimulation, want extra research earlier than they are often really helpful.12
Pharmacological remedies. No pharmacologic brokers have been permitted by the US Meals and Drug Administration for managing signs associated to bvFTD. Selective serotonin reuptake inhibitors and trazodone have the very best proof in managing behavioral modifications like compulsions, agitation, aggressiveness, impulsivity, and aberrant consuming.19 Selective and norepinephrine reuptake inhibitors (eg, venlafaxine) present comparable patterns of efficacy and could also be thought of to handle apathy. Oxytocin is presently being studied for managing lack of empathy.20
Different behavioral abnormalities or psychotic options may be managed with low doses of atypical antipsychotics, primarily quetiapine and risperidone.21 These antipsychotic remedies needs to be prescribed cautiously for aged individuals no matter their comorbidities, due to the heightened danger of mortality secondary to cardio-cerebrovascular illness, falls, and infections.22
Though cholinesterase inhibitors present a optimistic impact on behavioral signs in AD, they don’t seem to be useful and may even worsen behavioral abnormalities in sufferers with FTD.23 Memantine doesn’t enhance or delay development of FTD signs and should even have deleterious hostile results.
Advances within the diagnostics of FTD and the underlying pathobiologies will result in new potential therapeutic targets for the event of efficient disease-modifying medication. For example, the invention of the pathogenic growth in C9orf72 as the commonest reason behind inherited FTD has elevated curiosity within the growth of antisense oligonucleotides to scale back concentrations of probably poisonous mRNAs.24
Case Instance
“Mr Roman,” a 48-year-old man, offered to the psychiatric emergency division (ED) for weird habits, claiming he had been persecuted by FBI brokers due to recordsdata he saved for himself that endangered the nation. He suspected the brokers have been spying on him and sending girls to tempt him. Mr Roman was aggressive at night time and was referred to the ED whereas making an attempt to flee from his residence. He was examined within the ED by a doctor and a neurologist, and the latter determined to carry out a full workup resulting from subfebrile fever and delicate leukocytosis. The workup to rule out encephalitis, together with blood exams and a lumbar puncture, was regular. His mind CT was interpreted as regular. Outcomes of autoimmune, paraneoplastic, and poisonous panels have been all adverse.
The attending psychiatrist obtained extra intensive collateral info from Mr Roman’s spouse. She reported dwelling with him for the previous 10 years. After their marriage, she reported that he most popular to be by himself, didn’t have shut associates, and averted massive gatherings. He turned extra socially withdrawn and unempathic, inflexible, and “emotionally flat,” making it “onerous to get a response out of him.” She reported that he had been employed as an legal professional however had misplaced his job2 years earlier. His employer had described him as disorganized, fighting articulation in courtroom and typically seeming to “lose his practice of concepts.” Up to now 12 months, he couldn’t handle his funds and accrued vital bank card debt. Within the few months earlier than analysis, he began to develop into troublesome to handle at residence. He spent many hours day by day and through the night time compulsively closing home windows and doorways. He couldn’t sleep effectively. He misplaced curiosity in his hobbies and intercourse. He spent growing quantities of time “staring” on the tv.
Previous medical historical past was unrevealing, with no alcohol or drug abuse. Household historical past was adverse for neurodegenerative ailments. A nephew had autism. His mom, who died by suicide in her 40s, had a historical past of despair.
Three months later, Mr Roman got here for a follow-up go to to handle his antipsychotic remedy. He and his spouse each reported enchancment after beginning the medicine; nonetheless, she believed that he was turning into extra apathetic, demotivated, inattentive, and disorganized, and, moreover, that his gait had began to deteriorate.
He was absolutely oriented, had a flat have an effect on, and hypomimia. He was fluent with preserved naming, repetition, and comprehension. Cranial nerves have been intact, together with regular saccades. He had delicate hyperrigidity in all 4 limbs. Sensory and motor examinations have been regular. The snout reflex was adverse, whereas grasp reflexes and palmomental reflexes have been optimistic.
On cognitive testing, he scored 27 of 30 on the Mini-Psychological State Examination and 15 of 30 on the Montreal Cognitive Evaluation, dropping factors for consideration, focus, working reminiscence objects, and the Path-Making B check pattern. Semantic and phonemic fluency have been each reasonably impaired. The Advanced Benson Determine copy and recall have been regular.
A 12 months later, Mr Roman was referred to a neurologist for complaints about muscle cramps and difficulties swallowing and climbing stairs. His neurologist discovered signs of muscle atrophy in his fingers, together with intrinsic muscle mass, bilateral grip weak spot, and proximal muscle weak spot, together with a head drop. His jaw jerk was noticeable and exhibited pyramidal indicators. He accomplished an EMG check that exposed exercise that fits MND. Primarily based on these findings, the analysis of FTD-ALS was thought of.
Mr Roman was supplied palliative care and he accepted. Superior directives have been signed, which requested consolation care solely. He was taken off the antipsychotic due to the priority that it might exacerbate swallowing issue. Mr Roman had no adverse penalties from the medicine withdrawal. Swallowing issue for liquids was improved by including thickeners. Inside 3 months, Mr Roman was unable to depart his mattress. By 4 months, he was unable to absorb meals or liquids, and died comfortably at his residence with family members on the bedside.
Concluding Ideas
FTD is a typical early-onset dementia, with bvFTD constituting the commonest kind. As a result of bvFTD is characterised by predominant behavioral presenting signs that normally overlap with these of different psychiatric problems, distinguishing the preliminary modifications of this devastating neurodegenerative illness from frequent psychiatric problems is important for administration and life-planning issues.
As soon as analysis is made, a multidisciplinary administration strategy is required. Unclear or atypical circumstances with behavioral signs or atypical psychiatric presentation may have a broader evaluation routine that features neuropsychological and neurological examinations, exams of social cognition, neuroimaging, blood and cerebrospinal fluid exams, and genetic testing.
A large interprofessional collaboration between neurologists and psychiatrists is required to advance higher understanding of bvFTD and to improve the diagnostic and administration tips. This can be essential as the sphere strikes towards illness prevention, early identification, and discovering customized disease-modifying remedies.
Dr Abu Raya is a neurologist within the cognition and stroke unit at Rambam Medical Middle, Haifa, Israel, and an Atlantic Fellow on the World Mind Well being Institute. Dr Illanes-Manrique is a psychiatrist and chief of the Neurogenetics Analysis Middle on the Instituto Nacional de Ciencias Neurologicas, Lima, Peru, and an Atlantic Fellow on the World Mind Well being Institute. Dr Miller holds the A.W. and Mary Margaret Clausen Distinguished Professorship in Neurology on the College of California, San Francisco, directs the UCSF Reminiscence and Getting older Middle, and is the founding director of the World Mind Well being Institute at UCSF.
Acknowledgments: The authors thank Caroline Prioleau, College of California, San Francisco, for her help and reviewing the manuscript.
References
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