Letter-to-the Editor Taiwanese Journal of Psychiatry (Taipei) Vol. 28 No. 4 2014 • 271 •

Major Frontotemporal Neurocognitive Disorder Mimicking Bipolar Disorder

insidious onset and gradual progression. We fi - Case Report nally prescribed trazodone for his “major neuro- cognitive disorder due to possible frontotemporal A 67-year-old married male patient with a lobar degeneration, with behavioral disturbances” history of hypertension and anemia, was diag- correlated with criteria in DSM-5 [1]. We dis- nosed with generalized anxiety disorder and ma- charged patient after we educated his caregiver. jor depressive disorder since he was 51 years old. He had received regular treatment, and the above Comment psychiatric conditions were in full remission. In recent fi ve years, he presented himself DSM-5 terminology_major frontotemporal with agitation, poor impulse control, and violence neurocognitive disorder, previously named fron- behavior. His family stated that he had persistent- totemporal dementia (FTD) is a clinically and ly had psychomotor agitation and excessive in- pathologically heterogeneous group due to non- volvement in community activities, and then he Alzheimer’s diseases characterized collectively was often confl icted with neighbors. He also vis- by relatively selective, progressive atrophy in- ited the same temple frequently and donated a volving the frontal or temporal lobes, or both. large amount of money which differed from his Clinically, these diseases present themselves behavioral pattern in the past. He was diagnosed chiefl y as progressive aphasia or as disintegration with bipolar I disorder fi rst, and admitted to hospi- of personality and behavior that may be misdiag- tal for two weeks where he received the brain nosed as a psychiatric disorder [2-4]. Our patient computerized tomography (CT) with non-specifi c was fi rst misdiagnosed as bipolar I disorder be- fi ndings. But the symptoms even got worse after cause of his behavioral disinhibition and ritualis- he was discharged. Then, he was admitted to our tic and religious behavior with irritable mood and hospital when bipolar I disorder and pneumonia history of depressive episode. were suspected. We arranged a series of neuropsy- The frequent misdiagnosis of FTD occurs chological tests and the results revealed signifi - because of the variable behavioral presentations cant impairment of memory, visual-constructional of this disease [2, 3]. The FTD diagnosis is not function, and executive function during hospital- facilitated by any available objective biomarkers, ization. Based on a complete history from a and the accurate diagnosis of FTD depends on the knowledgeable informant, we found that his dis- recognition of clinical behavioral features [5]. Our turbing behavior can be coded as behavioral disin- patient had ever received brain CT without dispro- hibition, loss of sympathy, and ritualistic behav- portionate frontal or temporal lobes atrophy. But ior, which had appeared for 4-5 years with through completely history taking, we recognized

擬似雙相性情緒障礙症的額顳葉認知障礙症 蕭暉獻、歐陽文貞 • 272 • A Misdignosed Neurocognitive Disorder

that this patient had had core symptoms of FTD Khan AY: Frontotemporal dementia mimicking bipo- such as behavioral disinhibition, loss of sympathy, lar disorder. J Psychiatr Pract 2013; 19: 498-500. and ritualistic behavior. Besides, series of neuro- 5. Mendez MF, Shapira JS, McMurtray A: Accuracy of psychological test report revealed his signifi cantly the clinical evaluation for frontotemporal dementia. impairment of memory, visual-constructional Arch Neurol 2007; 64: 830-5. function, and executive function. All those clini- cal fi ndings differed from the features of bipolar I 1 disorder. Given the frustration that diagnostic un- Hui-Hsien Hsiao, M.D. , Wen-Chen Ouyang, 2,3,4,5* certainties so often present for behavior variant M.D., M.P.H., Ph.D. 1 FTD caregivers, the complete history as well as Department of General Psychiatry, Jianan proper psychological test such as frontal behav- Mental Hospital, Tainan, Taiwan 2 ioral inventory, Middelhelm frontality scale, and Section of Psychiatry, Lutung Christian frontal systems behavioral scale [3] are all mea- Hospital, Changhua, Taiwan 3 sures that will help clinicians consider a diagnosis Department of Psychiatry, Changhua Christian of FTD. (All two authors declare no potential con- Hospital and Changhua Christian Healthcare fl icts of interest in writing this report) System, Changhua, Taiwan 4 Department of Psychiatry, Kaohsiung Chung- References Ho Memorial Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan 5 1. American Psychiatric Association: The Diagnostic College of Medical and Life Science, Chung and Statistical Manual of Mental Disorder (DSM-5). Hwa University of Medical Technology, Arlington Virginia, USA: American Psychiatric Tainan, Taiwan Association, 2013: 591-643. Received October 7, 2014; revised: October 8, 2. Warren JD, Rohrer JD, Rossor MN: Clinical review: 2014; accepted; October 9, 2014 frontotemporal dementia. BMJ 2013; 347: f4827. *Corresponding author. No 888, Section 2, 3. Manoochehri M, Huey ED: Diagnosis and manage- Lutung Road, Lukang Township, Changhua ment of behavioral issues in frontotemporal demen- County 50550, Taiwan tia. Curr Neurol Neurosci Rep 2012; 12: 528-36. E-mail: Wen-Chen Ouyang 4. Kerstein AH, Schroeder RW, Baade LE, Lincoln J,