4. History
• Admitted 3 times to the psychiatry ward
HUSM.
• 1st admission was in 1992
– warded for about 1 month
– pseudodementia.
• Poor compliance & hardly came for follow up.
5. Year 2005
• Complaints from the villagers that patient has
increasing sodomizing and causing death of animals
including chickens, goats and cows.
• Many chickens have died and the villagers started to
worry that he would posses danger to human being
especially girls.
• The exact duration of such act is vaguely known but
the villagers had started to complain early February
2005.
6. • Patient strongly denied such act.
• Tactful questions - he actually said that the chickens
entered his premises and passing motion making his
place dirty and smelly.
– Thus, he taught them a lesson by strangle them and
squeeze them until feces came out from their anus.
• He choose small chickens because he enjoyed small
anus and claimed the anus only became widened if
the chickens died.
7. Exhibitionism
• He was wandering around the village aimlessly and
rather exposed his genitalia to the public especially
to the primary school girl.
• He also showed interest to female’s underware.
• He also started to molested his
granddaughter breast and their
private part.
• He likes to use obscene language
when communicate with others.
8. • Previously he prays regularly but for the past 6 years he didn’t
even bother about his prayer.
• His sleep pattern also started to change for the past 6 years.
He slept more during day time. He didn’t sleep at night and if
he sleeps only for a short duration. He would lie down on the
bed with both eyes opened and talked alone.
• There were no psychotic symptoms such as talking or smiling
to self. No history of persistently elevated or depressed mood.
• There was no history of MVA or head trauma with altered
conscious level or epilepsy prior to the illness.
9. Cognitive Impairment
• The family members noted slight cognitive
deterioration in patient’s activities of daily living as
well as his instrumental activities of daily living after
he got the illness.
• However, he was able to walk and go to the toilet by
himself and was able to dress and feed himself
properly. There was no history of misplacing things
and loosing his way at that moment. He was able to
recognize familiar faces.
10. Mental State Examination
• A thin build Malay old man, fairly kempt and groomed.
• Calm and cooperative with a bit childish in his way of talking
and giggling but maintain his respect towards doctors and
staff.
• He spoke with strong kelantanese slang and was relevant and
coherent.
• Mood was euthymic and his affect was appropriate.
• There were no perceptual disturbances or delusions.
• Poor short term memory, abstract thinking and his insight
• MMSE score - 20/30 and ECAQ score - 7/10
11. Investigations
• Baseline blood investigation revealed normal
– except for the ECG changes and the cardiac markers and
was treated as ischemic heart disease during the last
admission.
• Blood investigations to look for the causes of
dementia also ordered but revealed normal.
• CT brain revealed multifocal cerebellar infarction and
old right occipital infarct, with left chronic
mastoiditis. He was suggested for MRI but the eldest
daughter refused to give consent.
12. Neuropsychological Assessment
• He was also referred to Clinical Psychologist
• The report revealed frontal lobe deficits in terms
of poor melokinetic ability, delayed response and
personality change
– Predominantly right temporal lobe deficits were
evident in terms of poor visual learning and memory.
• The assessment rules out the possibility of global /
diffuse involvement.
13. Diagnosis
• Frontal Temporal Lobe Dementia
• He was given i/m Modecate 25mg 2
weekly with Tab Perphenazine 4mg on
and was referred to the community
team in view of his problem with
compliance.
14.
15. Bestiality / Zoophilia
• Zoophilia, from the Greek (zôon,
"animal") and (philia, "friendship"
or "love"), is a paraphilia, defined
as an affinity or sexual attraction
by a human to a non-human
animal.
16. Hugh Series & Pilar Dégano, Hypersexuality in dementia, Advances in Psychiatric Treatment (2005), vol. 11, 424–431
19. Core Diagnostic Features
Behavioral Disorder
• Insidious onset and slow progression
• Early loss of personal awareness
• Early loss of social awareness
• Early signs of disinhibition: Witzelsucht
• Mental rigidity and inflexibility
• Hyperorality
Lund and Manchester Groups (1994), J Neurol Neurosurg Psychiatry 57(4):416-418
20. Core Diagnostic Features
Behavioral Disorder
• Stereotyped and perseverative behavior
• Utilization behavior
• Distractibility, impulsivity, impersistence
• Early loss of insight into the fact that the
altered condition is due to a pathological
change of own mental state
Lund and Manchester Groups (1994), J Neurol Neurosurg Psychiatry 57(4):416-418
21. Core Diagnostic Features
Affective Symptoms
• Depression, anxiety, excessive sentimentality,
suicidal and fixed ideation, delusion (early
and evanescent)
• Hypochondriasis, bizarre somatic
preoccupation (early and evanescent)
• Emotional unconcern
• Amimia (inertia, aspontaneity)
Lund and Manchester Groups (1994), J Neurol Neurosurg Psychiatry 57(4):416-418
22. Core Diagnostic Features
Language
• Speech disorder
– Progressive reduction of speech
– Stereotypy of speech
– Echolalia and perseveration
– Late mutism
• Spatial orientation and praxis preserved
Lund and Manchester Groups (1994), J Neurol Neurosurg Psychiatry 57(4):416-418
23. Core Diagnostic Features
Physical Signs
• Early primitive reflexes
• Early incontinence
• Late akinesia, rigidity, tremor
• Low and labile blood pressure
Lund and Manchester Groups (1994), J Neurol Neurosurg Psychiatry 57(4):416-418
24. Core Diagnostic Features
Investigations
• Normal EEG despite evident dementia
• Brain imaging: predominant frontal or
anterior temporal abnormality, or both
• Neuropsychology: profound failure on
“frontal lobe” tests in the absence of severe
amnesia, aphasia or perceptual-spatial
disorder
Lund and Manchester Groups (1994), J Neurol Neurosurg Psychiatry 57(4):416-418
25. Behavioral Presentation of FTD
• Most common presentation of FTD is an early
change in social and personal conduct
• Difficulty modulating behavior to the social
demands of a situation: lack of inhibition, impulsive
or inappropriate behavior
– Swearing at inappropriate times
– Outbursts of frustration
– Lack of social tact
McKhann GM et al. (2001), Arch Neurol 58(11):1803-1809
26. FTD vs. AD
• Amnesia late
• V/S decline late
• Calculation OK early
• Personality change early
• Klüver-Bucy early
• Language
• Stereotypy
• Mutism
• Seizures uncommon
• Amnesia early
• V/S decline early
• Acalculia early
• Personality change later
• Klüver-Bucy late
• Language
• Paraphasia, anomia
• Palilalia
• Seizures more common
V/S = visuospatial; Cummings JL, Benson DF (1992), Dementia: A Clinical Approach, 2nd ed. Boston: Butterworth-Heinemann
27. Pharmacologic Treatment
• SSRI = currently medication of choice for
behavioral control in FTD
• Lowest dose atypical antipsychotic for
aggression or propranolol
• Hormones for sexual aggression:
– (medroxyprogesterone acetate [Provera] 150 mg
IM q 4 weeks)
• Cholinesterase inhibitors
