Behavioural disinhibition in the syndromes associated with frontotemporal lobar degeneration

The different clinical syndromes caused by frontotemporal lobar degeneration (FTLD) have highly heterogenous and overlapping features which complicate clinical and research practice. Behavioural impairments are associated with all FTLD syndromes, cause high morbidity and lack proven symptomatic treatments. Treatments for cognitive and behavioural impairment in other neurodegenerative diseases include restoration of neurotransmitter deficits. Deficits in the neurotransmitters glutamate and GABA occur in FTLD syndromes and are associated with behavioural disinhibition in other diseases. I propose that these neurotransmitter deficits contribute to behavioural change in FTLD syndromes. This thesis has two main aims. First, to develop a transdiagnostic approach to FTLD syndromes to facilitate a better understanding of aetiology, pathophysiology and in due course their symptomatic treatment. Second, to use this approach to test the hypothesis that glutamate and GABA deficits are associated with behavioural disinhibition in FTLD syndromes. In a cross-sectional epidemiological study, I examined 310 of 365 regional patients with a FTLD-associated syndrome, including behavioural variant frontotemporal dementia, the nonfluent and semantic variants of primary progressive aphasia, progressive supranuclear palsy and corticobasal syndrome. Multivariate analyses of clinical features and brain morphometry identified components that showed considerable overlap across the diagnostic groups. The transdiagnostic components of clinical features predicted neuropathology better than the current FTLD diagnostic labels. Behavioural disturbance, including disinhibition, was associated with reduced functionally independent survival, irrespective of diagnosis. Next, I investigated the role of glutamate and GABA in behavioural disinhibition. Ultrahigh-field magnetic resonance spectroscopy was used to measure glutamate and GABA in the frontal cortex of 44 patients with a FTLD syndrome and 20 healthy controls. Bayesian modelling of a response inhibition task was used to quantify behavioural disinhibition. Both neurotransmitters were reduced in the frontal cortex, but not occipital cortex, of patients compared to controls. Glutamate and GABA concentrations in the frontal cortex were inversely associated with behavioural disinhibition. In summary, the transdiagnostic approach provided new insights into the phenotypic heterogeneity in FTLD syndromes. Behavioural disinhibition, which can occur to a variable degree in all FTLD syndromes, was associated with reduced functionally independent survival. GABA and glutamate deficits in the frontal cortex are associated with behavioural disinhibition and are a potential target for future treatments.Holt Fellowshi