Skip to main content Accessibility help

Social inappropriateness in neurodegenerative disorders

  • Philippe Desmarais (a1) (a2) (a3) (a4), Krista L. Lanctôt (a1) (a4) (a5), Mario Masellis (a2) (a3) (a4) (a6) (a7), Sandra E. Black (a3) (a4) (a6) (a7) and Nathan Herrmann (a4) (a5) (a8)...



New onset of mood and behavioral changes in middle-aged patients are frequently the first manifestations of an unrecognized neurocognitive disorder. Impairment of social cognition, the cognitive ability to process social information coming from others, such as emotions, to attribute mental states to others, and to respond appropriately to them, is often at the origin of behavioral manifestations in neurodegenerative disorders.


This paper reviews the current literature on social cognition impairment in neurocognitive disorders, particularly in prodromal stages of behavioral-variant frontotemporal dementia (bvFTD), Alzheimer's disease (AD), idiopathic Parkinson's disease (IPD), and Lewy body dementia (LBD). The concepts of social cognition will be reviewed, including its impairment and neural basis, its clinical assessment, and the different therapeutic interventions available clinically.


Socially inappropriate behaviors, such as loss of empathy, inappropriateness of affect, and disinhibition are frequently reported in prodromal bvFTD and in prodromal AD. Lack of self-control, reduced perception of social cues, such as recognition of facial emotions and sarcastic speech, and impaired Theory of Mind all contribute to the neuropsychiatric symptoms and are secondary to neurodegeneration in specific brain regions. In contrasts to bvFTD and AD, deficits in social cognition in IPD occur later in the course of the disease and are often multifactorial in origin.


Through various manifestations, social inappropriateness is frequently the first clinical sign of a neurodegenerative process, especially in AD and bvFTD, years before noticeable impairment on classical neuropsychological assessment and brain atrophy on imaging.


Corresponding author

Correspondence should be addressed to: Philippe Desmarais, Cognitive & Movement Disorders Clinic, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room A4-55, Toronto, Ontario M4N 3M5, Canada. Phone: 1-416-480-4551. E-mail:


Hide All
Abu-Akel, A. (2003). The neurochemical hypothesis of “theory of mind”. Medical Hypotheses, 60, 382386. doi: 10.1016/S0306-9877(02)00406-1.
Abu-Akel, A. and Shamay-Tsoory, S. (2011). Neuroanatomical and neurochemical bases of theory of mind. Neuropsychologia, 49, 29712984. doi: 10.1016/j.neuropsychologia.2011.07.012.
Adolphs, R., Tranel, D. and Damasio, A. R. (2003). Dissociable neural systems for recognizing emotions. Brain and Cognition, 52, 6169. doi: 10.1016/S0278-2626(03)00009-5.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Washington, DC: American Psychiatric Association.
Amodio, D. M. and Frith, C. D. (2006). Meeting of the minds: the medial frontal cortex and social cognition. Nature Reviews Neuroscience, 7, 268277. doi: 10.1038/nrn1884.
Ariatti, A., Benuzzi, F. and Nichelli, P. (2008). Recognition of emotions from visual and prosodic cues in Parkinson's disease. Neurological Sciences, 29, 219227. doi: 10.1007/s10072-008-0971-9.
Baarendse, P. J., Counotte, D. S., O'Donnell, P. and Vanderschuren, L. J. (2013). Early social experience is critical for the development of cognitive control and dopamine modulation of prefrontal cortex function. Neuropsychopharmacology, 28, 14851494. doi: 10.1038/npp.2013.47.
Barber, R., Snowden, J. S. and Craufurd, D. (1995). Frontotemporal dementia and Alzheimer's disease: retrospective differentiation using information from informants. Journal of Neurology, Neurosurgery and Psychiatry, 59, 6170. doi: 10.1136/jnnp.59.1.61.
Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y. and Plumb, I. (2001). The “Reading the Mind in the Eyes” test revised version: a study with normal adults, and adults with asperger syndrome or high-functioning autism. Journal of Child Psychology and Psychiatry, 42, 241251. doi: 10.1111/1469-7610.00715.
Beer, J. S, John, O. P., Scabini, D. and Knight, R. T. (2006). Orbitofrontal cortex and social behavior: integrating self-monitoring and emotion-cognition interactions. Journal of Cognitive Neuroscience, 16, 871879. doi: 10.1162/jocn.2006.18.6.871.
Bertoux, M., Volle, E., Funkiewiez, A., de Souza, L. C., Leclercq, D. and Dubois, B. (2012). Social cognition and emotional assessment (SEA) is a marker of medial and orbital frontal functions: a voxel-based morphometry study in behavioral variant of frontotemporal degeneration. Journal of the International Neuropsychological Society, 18, 972985. doi: 10.1017/S1355617712001300.
Bodden, M. E., Dodel, R. and Kalbe, E. (2010). Theory of mind in Parkinson's disease and related basal ganglia disorders: a systematic review. Movement Disorders, 25, 1327. doi: 10.1002/mds.22818.
Bowers, D., Blonder, L. X. and Heilman, K. M. (1999). Florida Affect Battery. Gainesville, FL: Center for Neuropsychological Studies, University of Florida.
Cummings, J. L., Dubois, B., Molinuevo, J. L. and Scheltens, P. (2013). International work group criteria for the diagnosis of Alzheimer disease. Medical Clinics of North America, 97, 363368. doi: 10.1016/j.mcna.2013.01.001.
Cummings, J. L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D. and Gornbein, J. (1994). The neuropsychiatric inventory: comprehensive assessment of psychopathology in dementia. Neurology, 44, 23082314.
Davis, M. H. (1980). A multidimensional approach to individual differences in empathy. Journal of Southern African Studies Catalog of Selected Documents in Psychology, 10, 119.
Dermody, N. et al. (2016). Uncovering the neural bases of cognitive and affective empathy deficits in Alzheimer's disease and the behavioral-variant of Frontotemporal dementia. Journal of Alzheimer's Disease, 53, 801816. doi: 10.3233/JAD-160175.
Devinsky, O., Morrell, M. J. and Vogt, B. A. (1995). Contributions of anterior cingulate cortex to behavior. Brain, 118, 279306.
Ekman, P. and Friesen, W. V. (1976). Pictures of Facial Affect. Palo Alto, CA: Consulting Psychologists Press.
Farb, N. A.S. et al. (2013). Abnormal network connectivity in frontotemporal dementia: evidence for prefrontal isolation. Cortex, 49, 18561873. doi: 10.1016/j.cortex.2012.09.008.
Fernandez-Duque, D. and Black, S. E. (2005). Impaired recognition of negative facial emotions in patients with frontotemporal dementia. Neuropsychologia, 43, 16731687. doi: 10.1016/j.neuropsychologia.2005.01.005.
Fernandez-Duque, D., Baird, J. A. and Black, S. E. (2009). False-belief understanding in frontotemporal dementia and Alzheimer's disease. Journal of Clinical and Experimental Neuropsychology, 31, 489497. doi: 10.1080/13803390802282688.
Finger, E. C. et al. (2015). Oxytocin for frontotemporal dementia. Neurology, 84, 174181. doi: 10.1212/WNL.0000000000001133.
Freedman, M., Binns, M. A., Black, S. E., Murphy, C. and Stuss, D. T. (2013). Theory of mind and recognition of facial emotion in dementia: challenge to current concepts. Alzheimer Disease & Associated Disorders, 27, 5661. doi: 10.1097/WAD.0b013e31824ea5db.
Frith, C. D. (2008). Social cognition. Philosophical Transactions of the Royal Society, 363, 20332039. doi: 10.1098/rstb.2008.0005.
Franceschi, M. et al. (2005). Glucose metabolism and serotonin receptors in the frontotemporal lobe degeneration. Annals of Neurology, 57, 216225. doi: 10.1002/ana.20365.
Frith, C. D. and Frith, U. (2012). Mechanisms of social cognition. Annual Reviews of Psychology, 63, 287313. doi: 10.1146/annurev-psych-120710-100449.
Grace, J., Stout, J. and Malloy, P. (1999). Assessing frontal behavior syndromes with the Frontal Lobe Personality Scale. Assessment, 6, 269284.
Gregory, C. A. (1999). Frontal variant of frontotemporal dementia: a cross-sectional and longitudinal study of neuropsychiatric features. Psychological Medicine, 29, 12051217.
Gregory, C. et al. (2002). Theory of mind in patients with frontal variant frontotemporal dementia and Alzheimer's disease: theoretical and practical implications. Brain, 125, 752764. doi: 10.1093/brain/awf079.
Guastella, A. J. and MacLeod, C. (2012). A critical review of the influence of oxytocin nasal spray on social cognition in humans: evidence and future directions. Hormones and Behavior, 61, 410418. doi: 10.1016/j.yhbeh.2012.01.002.
Heitz, C. et al. (2015). Théorie de l'esprit cognitive et affective dans la démence à corps de Lewy: une étude préliminaire. Revue Neurologique, 171, 373381. doi: 10.1016/j.neurol.2015.02.010.
Henry, J. D., Von Hippel, W., Molenberghs, P., Lee, T. and Sachdev, P. S. (2016). Clinical assessment of social cognitive function in neurological disorders. Nature Reviews Neurology, 12, 2839. doi: 10.1038/nrneurol. 2015.229.
Herrmann, N., Black, S. E., Chow, T., Cappell, J., Tang-Wai, D. F. and Lanctôt, K. L. (2012). Serotonergic function and treatment on behavioral and psychological symptoms of frontotemporal dementia. American Journal of Geriatric Psychiatry, 20, 789797. doi: 10.1097/JGP.0b013e31823033f3.
Hooker, C. I. et al. (2013). The influence of combined cognitive plus social-cognitive training on amygdala response during face emotion recognition in schizophrenia. Psychiatry Research, 213, 99107. doi: 10.1016/j.pscychresns.2013.04.001.
Hsiesh, S., Irish, M., Daveson, N., Hodges, J. R. and Piguet, O. (2013). When one loses empathy: its effect on carers of patients with dementia. Journal of Geriatric Psychiatry and Neurology, 26, 174184. doi: 10.1177/0891988713495448.
Ismail, Z. et al. (2016). Neuropsychiatric symptoms as early manifestations of emergent dementia: Provisional diagnostic criteria for mild behavioral impairment. Alzheimer's and Dementia, 12, 195202. doi: 10.1016/j.jalz.2015.05.017.
Ismail, Z. et al. (2017). The Mild Behavioral Impairment Checklist (MBI-C): a rating scale for neuropsychiatric symptoms in pre-dementia populations. Journal of Alzheimer's Disease, 56, 929938. doi: 10.3233/JAD-160979.
Jessen, F. et al. (2014). AD dementia risk in late MCI, in early MCI, and in subjective memory impairment. Alzheimer's Dementia, 10, 7683. doi: 10.1016/j.jalz.2012.09.017.
Jesso, S. et al. (2011). Effects of oxytocin on social cognition and behaviour in frontotemporal dementia. Brain, 134, 24932501. doi: 10.1093/brain/awr171.
Kalbe, M. et al. (2010). Dissociating cognitive from affective theory of mind: a TMS study. Cortex, 46, 769780. doi: 10.1016/j.cortex.2009.07.010.
Kertesz, A., Davidson, W. and Fox, H. (1997). Frontal behavioral inventory: diagnostic criteria for frontal lobe dementia. Canadian Journal of Neurological Sciences, 24, 2936. doi: 10.1017/S0317167100021053.
Kucharska-Pietura, K. and Mortimer, A. (2013) Can antipsychotics improve social cognition in patients with schizophrenia?. CNS Drugs, 27, 335343. doi: 10.1007/s40263-013-0047-0.
Lanctôt, K. L., Herrmann, N., van Reekum, R., Eryavec, G. and Naranjo, C. A. (2002). Gender, aggression and serotonergic function are associated with response to sertraline for behavioral disturbances in Alzheimer's disease. International Journal of Geriatric Psychiatry, 17, 531541. doi: 10.1002/gps.636.
Lee, R., Ferris, C., Van de Kar, L. D. and Coccaro, E. F. (2009). Cerebrospinal fluid oxytocin, life history of aggression, and personality disorder. Psychoneuroendocrinology, 34, 15671573. doi: 10.1016/j.psyneuen.2009.06.002.
Liljegren, M. et al. (2015). Criminal behavior in frontotemporal dementia and Alzheimer disease. Journal of the American Medical Association Neurology, 72, 295300. doi: 10.1001/jamaneurol.2014.3781.
Lindau, M. et al. (2000). First symptoms – frontotemporal dementia versus Alzheimer's disease. Dementia and Geriatric Cognitive Disorders, 11, 286293. doi: 10.1159/000017251.
Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J. and DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment—results from the cardiovascular health study. Journal of the American Medical Association, 288, 14751483. doi: 10.1001/jama.288.12.1475.
Martinón-Torres, G., Fioravanti, M. and Grimley Evans, J. (2004). Trazodone for agitation in dementia. Cochrane Database of Systematic Reviews, 3. doi: 10.1002/14651858.CD004990.
McKeith, I. et al. (2004). Dementia with Lewy bodies. Lancet, 3, 1928. doi: 10.1016/S1474-4422(03)00619-7.
McKhann, G. M. et al. (2011). The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association Workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia, 7, 263269. doi: 10.1016/j.jalz.2011.03.005.
de Mendonca, A., Ribeiro, F., Guerreiro, M. and Garcia, C. (2004). Frontotemporal mild cognitive impairment. Journal Alzheimer's Disease, 6, 19.
Mendez, M. F. and Shapira, J. S. (2011). Loss of emotional insight in behavioral variant frontotemporal dementia or “frontal anosodiaphoria”. Consciousness and Cognition, 20, 16901696. doi: 10.1016/j.concog.2011.09.005.
Meyer-Lindenberg, A., Domes, G., Kirsch, P. and Heinrichs, M. (2011). Oxytocin and vasopressin in the human brain: social neuropeptides for translational medicine. Nature Reviews Neuroscience, 12, 524538. doi: 10.1038/nrn3044.
Moreau, N. et al. (2015). Different patterns of theory of mind impairment in mild cognitive impairment. Journal of Alzheimer's Disease, 45, 581597. doi: 10.3233/JAD-143021.
Moretti, R., Torre, P., Antonello, R. M., Cazzato, G. and Bava, A. (2003). Frontotemporal dementia: paroxetine as a possible treatment of behavior symptoms. A randomized, controlled, open 14-month study. European Neurology, 49, 1319. doi: 10.1159/000067021.
O'Callaghan, C. et al. (2016). Fair play: social norm compliance failures in behavioural variant frontotemporal dementia. Brain, 139, 204216. doi:10.1093/brain/awv315.
Pardini, M. et al. (2013). Isolated theory of mind deficits and risk for frontotemporal dementia: a longitudinal pilot study. Journal of Neurology, Neurosurgery, & Psychiatry, 84, 818821. doi: 10.1136/jnnp-2012-303684.
Péron, J. et al. (2009). Are dopaminergic pathways involved in theory of mind? A study in Parkinson's disease. Neuropsychologia, 47, 406414. doi: 10.1016/j.neuropsychologia.2008.09.008.
Peters, F. et al. (2006). Orbitofrontal dysfunction related to both apathy and dishihibition in frontotemporal dementia. Dementia and Geriatric Cognitive Disorders, 21, 373379. doi: 10.1159/000091898.
Porsteinsson, A. P. et al. (2014). Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. Journal of the American Medical Association. 311, 682691. doi: 10.1001/jama.2014.93.
Premack, D. and Woodruff, G. (1978). Does the chimpanzee have a « theory of mind »?. Behavioral and Brain Sciences, 4, 515526. doi: 10.1017/S0140525X00076512.
Peters, M. E. et al. (2013). Neuropsychiatric symptoms as risk factors for progression from CIND to dementia: the cache county study. American Journal of Geriatric Psychiatry, 21, 11161124. doi: 10.1016/j.jagp.2013.01.049.
Rankin, K. P. et al. (2006). Structural anatomy of empathy in neurodegenerative disease. Brain, 129, 29452956. doi: 10.1093/brain/awl254.
Rascovsky, K. et al. (2011). Sensitivity of revised diagnostic criteria for the behavioural variant of frontotemporal dementia. Brain, 134, 24562477. doi: 10.1093/brain/awr179.
Reisberg, B. and Gauthier, S. (2008). Current evidence for subjective cognitive impairment (SCI) as the pre-mild cognitive impairment (MCI) stage of subsequently manifest Alzheimer's disease. International Psychogeriatrics, 20, 116. doi: 10.1017/S1041610207006412.
Rosenberg, P. B., Mielke, M. M., Appleby, B. S., Oh, E. S., Geda, Y. E. and Lyketsos, C. G. (2013). The association of neuropsychiatric symptoms in MCI with incident dementia and Alzheimer disease. American Journal of Geriatric Psychiatry, 21, 685695. doi: 10.1016/j.jagp.2013.01.006.
Saltzman, J., Strauss, E., Hunter, M. and Archibald, S. (2000). Theory of mind and executive functions in normal human aging and Parkinson's disease. Journal of international Neuropsychological Society, 6, 781788.
Shany-Ur, T. et al. (2012). Comprehension of insincere communication in neurodegenerative disease: lies, sarcasms, and theory of mind. Cortex, 48, 13291341. doi: 10.1016/j.cortex.2011.08.003.
Shany-Ur, T. and Rankin, K. P. (2011). Personality and social cognition in neurodegenerative disease. Current Opinion in Neurology, 24, 550555. doi: 10.1097%2FWCO.0b013e32834cd42a.
Shinagawa, S., Ikeda, M., Fukuhara, R. and Tanabe, H. (2006). Initial symptoms in frontotemporal dementia and semantic dementia compared with Alzheimer's disease. Dementia and Geriatric Cognitive Disorders, 21, 7480. doi: 10.1159/000090139.
Stone, V. E., Baron-Cohen, S. and Knight, R. T. (1998). Frontal lobe contributions to theory of mind. Neurosciences, 10, 640656. doi: 10.1162/089892998562942.
Swartz, J. R., Miller, B. L., Lesser, I. M. and Darby, A. L. (1997). Frontotemporal dementia: treatment response to serotonin selective reuptake inhibitors. Journal of Clinical Psychiatry, 58. 212216. doi: 10.4088/JCP.v58n0506.
Taragano, F. E. and Allegri, R. (2003). Mild behavioral impairment: the early diagnosis. Presented at the 11th International Congress of the International Psychogeriatric Association, Chicago, IL, August 17–22, 2003.
Taragano, F. E. et al. (2009). Mild behavioral impairment and risk of dementia: a prospective cohort of 358 patients. Journal of Clinical Psychiatry, 70, 584592. doi: 10.4088/JCP.08m04181.
Teipel, S. J. et al. (2015). Neuropsychiatric symptoms in people screened positive for dementia in primary care. International Psychogeriatrics, 27, 3948. doi: 10.1017/S1041610214001987.
Teng, E., Lu, P. H. and Cummings, J. L. (2007). Deficits in facial emotion processing in mild cognitive impairment. Dementia and Geriatric Disorders, 23, 271279. doi: 10.1159/000100829.
Torralva, T. et al. (2009). A neuropsychological battery to detect specific executive and social cognitive impairments in early frontotemporal dementia. Brain, 132, 12991309. doi: 10.1093/brain/awp041.
Weintraub, D. et al. (2015). Clinical spectrum of impulse control disorders in Parkinson's disease. Movement Disorders, 30, 121127. doi: 10.1002/mds.26016.
Weiss, E. M. et al. (2008). Impairment in emotion recognition abilities in patients with mild cognitive impairment, early and moderate Alzheimer disease compared to healthy comparison subjects. American Journal of Geriatric Psychiatry, 16, 974980. doi: 10.1097/JGP.0b013e318186bd53.
Wimmer, H. and Perner, (1983). Beliefs about beliefs: representation and constraining function of wrong beliefs in young children's understanding of deception. Cognition, 13, 103128. doi: 10.1016/0010-0277(83)90004-5.
Woolley, J. D. et al. (2011). The diagnostic challenge of psychiatric symptoms in neurodegenerative disease; rates of and risk factors for prior psychiatric diagnosis in patients with early neurodegenerative disease. Journal of Clinical Psychiatry, 72, 126133. doi: 10.4088/JCP.10M06382oli.



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed