First episode of psychotic depression with catatonic features as an initial presentation of possible frontotemporal dementia – a case report

Introduction

Frontotemporal dementia remains a major diagnostic challenge due to its marked clinical heterogeneity and frequent overlap with other mental disorders [1]. Accumulating evidence indicates that mood disorders, particularly when accompanied by psychotic and catatonic features, may mimic neurodegenerative processes involving the frontal and temporal lobes and, in some cases, represent their prodromal phase [2,3]. Conversely, behavioral and personality changes occurring in other psychiatric conditions may be misinterpreted as manifestations of frontotemporal dementia [4]. These overlaps increase the risk of diagnostic delay and inappropriate treatment. This report describes a case in which a first episode of psychotic depression with catatonic features constituted the initial manifestation of possible frontotemporal dementia. Written informed consent for publication was obtained.

Case Presentation

A 66-year-old patient with no psychiatric history was treated in an outpatient setting for one month due to progressive cognitive decline and depressive symptoms. He was diagnosed with unspecified dementia and severe depressive episode without psychotic features, and treatment with duloxetine, olanzapine, and donepezil was initiated. Because of clinical deterioration, including behavioral disturbances and motor dysfunction, he was referred to the Psychiatric Emergency Department of the Central Teaching Hospital, Medical University of Lodz, Poland. During psychiatric assessment, the patient reported cenesthetic hallucinations and hypochondriacal and nihilistic delusions, including the belief that his esophagus was obstructed, which hindered food and fluid intake. Hospitalization was indicated; however, the patient refused consent and was involuntarily admitted in accordance with Polish law due to behavior posing a risk to his health and life. During hospitalization, he presented with depressed mood, psychomotor retardation, and catatonic features, including waxy flexibility and active negativism, with a history of posturing and motor stereotypies. Psychotic symptoms were consistent with Cotard’s syndrome, accompanied by auditory pseudohallucinations. Speech was impoverished, with stereotypies and perseverations. Extensive diagnostics excluded autoimmune encephalitis and prion disease. Despite multiple pharmacological changes, no significant improvement was observed. Consequently, a course of electroconvulsive therapy was initiated under urgent indications but yielded only borderline benefit and was temporarily interrupted due to a lower respiratory tract infection. After resumption, next 21 electroconvulsive sessions led to resolution of psychotic symptoms and improved appetite. However, apathy, withdrawal, and moderate catatonia persisted, alongside worsening language deficits progressing to anomia and mutism. Further evaluation, including single-photon emission computed tomography and neuropsychological assessment, suggested a possible non-fluent variant of primary progressive aphasia.

Discussion

This case illustrates the complexity of differentiating late-life psychotic depression from early manifestations of frontotemporal dementia. While late-life depression is relatively common form of mood disorders among the elderly and often responds to electroconvulsive therapy [5], atypical presentation and limited treatment response should prompt consideration of neurodegenerative causes. Persistent apathy, progressive language impairment, and catatonic features may indicate frontal and temporal lobe pathology involvement. Although frontotemporal dementia is mainly classified into behavioral and language variants, mixed presentations are common in clinical practice, as demonstrated here.

Conclusions

A first episode of psychotic depression with catatonic features in the elderly, particularly with poor treatment response, may indicate an underlying neurodegenerative disorder. Co-occurring language deficits and behavioral changes should raise suspicion for frontotemporal dementia.

References

1. A. Antonioni, E.M. Raho, P. Lopriore, A.P. Pace, R.R. Latino, M. Assogna, M. Mancuso, D. Gragnaniello, E. Granieri, M. Pugliatti, F. Di Lorenzo, G. Koch, Frontotemporal Dementia, Where Do We Stand? A Narrative Review, International Journal of Molecular Sciences 2023, Vol. 24, 24 (2023). https://doi.org/10.3390/IJMS241411732.
2. M. Urban-Kowalczyk, M. Kasjaniuk, J. Śmigielski, M. Kotlicka-Antczak, Major Depression and Onset of Frontotemporal Dementia, Neuropsychiatr. Dis. Treat. 18 (2022) 2807–2812. https://doi.org/10.2147/NDT.S390385.
3. G.C. de França, H.C. de B. Barreto, T. Paranhos, J.C. Nunes, R. de Oliveira-Souza, Case Report: Catatonic Stupor in Behavioral Variant Frontotemporal Dementia, Front. Neurol. 12 (2022) 798264. https://doi.org/10.3389/FNEUR.2021.798264/TEXT.
4. J. Bang, S. Spina, B.L. Miller, Frontotemporal dementia, The Lancet 386 (2015) 1672–1682. https://doi.org/10.1016/S0140-6736(15)00461-4.
5. B. Pozuelo Moyano, K. Swierkosz Lenart, J. Rosselet Amoussou, A. von Gunten, J.P. Schuster, Prediction of electroconvulsive therapy response and remission in late-life depression: a review, Swiss Med. Wkly. 154 (2024) 3684–3684. https://doi.org/10.57187/S.3684.