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Clinical Atlas Prestige · Evidence-first

Psych VivasOld age psychiatry — neurocognitive disorders

Psych Vivas · Old age psychiatry — neurocognitive disorders

Frontotemporal dementia — structured clinical viva

Fellowship viva covering Rascovsky bvFTD, psychiatric misdiagnosis, C9orf72/MAPT/GRN, treatment limits, ALS spectrum, and medicolegal risk.

clinical
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Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the old-age psychiatry registrar. A 61-year-old woman with progressive social disinhibition, apathy, and hyperorality over two years is referred as 'treatment-resistant bipolar disorder.' MRI report (provided) notes preferential frontal and anterior temporal atrophy. Her father died of motor neuron disease. Discuss diagnostic criteria, differentials from primary psychiatric disease, genetics, investigation plan, pharmacologic limits including antipsychotics, and capacity/driving advice.

Interpretation

Reveal interpretation

Formulate as probable bvFTD (Rascovsky): multiple core behavioural features with progressive functional change and imaging support for frontotemporal involvement — not "treatment-resistant bipolar" until a neurodegenerative work-up is complete. Psychiatric misdiagnosis is well documented before FTD is recognised.[1][3][7]

Genetics: paternal MND plus behavioural FTD phenotype prioritises C9orf72 expansion counselling/testing; still mention MAPT and GRN as the exam triad.[2][7] Examine carefully for ALS-FTSD motor signs and co-manage with neurology.[8]

Management: non-drug behavioural strategies and carer support first; limited symptomatic roles for SSRIs/trazodone; avoid routine AChEI in pure FTD; antipsychotics only if severe risk, short course, mortality counselling.[4][5][7] Capacity is decision-specific (Appelbaum); advise on driving and finances early.[6]

Key points

Rascovsky probable needs imaging support

Core features + functional decline + frontotemporal imaging pattern — not bipolar by default.

C9orf72 bridges FTD and ALS

Hexanucleotide expansion explains many familial FTD±ALS pedigrees.

Drugs are symptomatic only

No standard disease-modifying FTD pharmacotherapy; AChEI not first-line for pure FTD.
[1] [2] [4] [7]

References

  1. [1]Rascovsky K, Hodges JR, Knopman D, et al. Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia Brain, 2011.PMID 21810890
  2. [2]DeJesus-Hernandez M, Mackenzie IR, Boeve BF, et al. Expanded GGGGCC hexanucleotide repeat in noncoding region of C9ORF72 causes chromosome 9p-linked FTD and ALS Neuron, 2011.PMID 21944778
  3. [3]Woolley JD, Khan BK, Murthy NK, et al. The diagnostic challenge of psychiatric symptoms in neurodegenerative disease J Clin Psychiatry, 2011.PMID 21382304
  4. [4]Huey ED, Putnam KT, Grafman J A systematic review of neurotransmitter deficits and treatments in frontotemporal dementia Neurology, 2006.PMID 16401839
  5. [5]Schneider LS, Dagerman KS, Insel P Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials JAMA, 2005.PMID 16234500
  6. [6]Appelbaum PS Clinical practice. Assessment of patients' competence to consent to treatment N Engl J Med, 2007.PMID 17978292
  7. [7]Bang J, Spina S, Miller BL Frontotemporal dementia Lancet, 2015.PMID 26595641
  8. [8]Strong MJ, Abrahams S, Goldstein LH, et al. Amyotrophic lateral sclerosis - frontotemporal spectrum disorder (ALS-FTSD): Revised diagnostic criteria Amyotroph Lateral Scler Frontotemporal Degener, 2017.PMID 28054827