Understanding emotions in frontotemporal dementia: The explicit and implicit emotional cue mismatch

Background: Previous studies have reported significant deficits in emotion recognition among individuals along the frontotemporal dementia (FTD) spectrum. The basis of emotional impairment is still poorly understood and explicit (emotion appraisal) and implicit (autonomic system activity) responses have not been carefully evaluated. Objective: We investigated explicit evaluation of emotions by testing valence and arousal using self-report measures and we also assessed automatic responses to emotional cues, using autonomic measures (skin conductance response and heart rate). Methods: 16 behavioral variant FTD and 12 agrammatic variants of primary progressive aphasia patients were included. The performance of these patients was compared to a group of 14 patients with Alzheimer's disease and 20 healthy controls. Each subject was required to observe and evaluate affective pictures while autonomic parameters were recorded. Results: FTD patients preserved a functional general competency in terms of valence (correct positive versus negative attribution) and arousal (correct dichotomy between high versus lowarousal category) distinction. These patients showed significant changes in autonomic implicit response compared to the other groups. The mismatch between explicit and implicit responsiveness to emotional cues was found both in behavioral variant FTD and in agrammatic variants of primary progressive aphasia. Emotional responsiveness was related to the severity of behavioral abnormalities as measured by the Frontal Behavioral Inventory and associated with atrophy of the left putamen. Conclusion: The present findings indicate that FTD patients are able to explicitly "appraise" the emotion, but they cannot implicitly "feel" the emotion. This mismatch between the two levels may help explain the general emotional behavior impairment found in these patients.