Early Apathy or Inertia

Apathy refers to a loss of motivation, interest, or initiative (motor, cognitive, and affective) [38]. It differs from inertia defined as the need for prompts or cues to initiate or continue activities [16]. The absence of apathy is uncommon in FTD, though it can be a distinctive feature of some C9orf72 mutations [39]. Most FTD patients disengage from usual activities, which add to carers’ emotional and physical distress [40]. Apathy, coexisting with personal neglect and memory complaints, frequently contributes to a misdiagnosis of depression. However, suicidal ideation and guilt are noticeably absent in FTD. Apathy may not coexist at all with depressive symptom but instead be associated with disinhibition, restlessness, and socially inappropriate behavior [9]. The Social Cognition and Emotional Assessment clearly distinguishes FTD (with low scores) from major depressive disorder [41]. Apathy is the focus of another chapter of this book.

Early Loss of Sympathy or Empathy

Sympathy and empathy correspond to the perception, understanding, and reaction to the distress or need of another person. While sympathy merely reflects the ability to express a similar emotional tone or to be moved by another person, empathy requires to put oneself in the other person’s situation and to share feelings as if they were experienced by the self [42]. Sympathy and apathy have three components: (i) affective, i.e., sharing and responding to the emotional experience of others; (ii) cognitive, i.e., understanding the intentions and perspectives of others; and (iii) moral, i.e., judgments about the wrongness of an action or the punishment that a perpetrator deserves [43]. Empathy and sympathy are driven by a switch in viewpoint, from a personal perspective to the perspective of a person or a group who is in need. As such, they are a component of social cognition described by the Theory of Mind (ToM). The ToM is the ability to infer mental states, thoughts, and feelings of others and to understand that they can differ from one’s own [44]. Lack of sympathy and empathy affects the social functioning of patients. Ability to recognize violations of social norms, moral and social reasoning (i.e., to integrate social knowledge with its affective connotations), facial emotions (especially anger and disgust), emotional prosody, and body gestures is frequently impaired in bvFTD [45].

Loss of sympathy manifests as emotional blunting or indifference, which is a source of distress for family members [46], and contributes to institutionalization. Using questionnaires, emotional blunting is better assessed by the carer than by the clinician and can distinguish patients with bvFTD from those with AD [47]. Emotional blunting is associated with right anterior temporal atrophy [48].

Lack of insight is an early symptom. Patients may recognize that their behavior has changed but appear to lack an emotional understanding of its consequences.

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