Every practicing psychiatrist has seen a patient whose presentation resembles Chad’s. Chad consulted me almost 2 decades ago, but I remember him well. It was a few months before his 60th birthday. He was “facing mortality” and thought he might be getting depressed. Chad complained of trouble concentrating and said that simple tasks like balancing his checkbook had become more difficult. His legal work no longer engaged him, and he was spending more time on the Internet.
Chad still enjoyed working in his garden and was busy preparing the flowerbeds for a late-summer celebration of his wedding anniversary. He dearly loved his wife, but he was living with a long-standing conflict. He had “always known” that he was gay, and he had kept this a secret for his entire marriage. Now that he was turning 60, he had regrets. It was in this context that he had discovered gay pornography on the Internet. He told me that he was “becoming addicted to the porn,” and that sometimes he even watched while in his law office.
The changes in Chad seemed psychologically understandable and, yet, I had a nagging feeling that this was not an ordinary depression or “late-in-life crisis.” Chad seemed to be lacking in motivation more than suffering from a depressive mood. I also worried that perhaps his judgment was becoming impaired. In other words, Chad was an almost 60-year-old man who was reflecting on his life, rethinking choices he had made, and feeling mildly depressed; but it was possible that, in addition, Chad had a covert medical condition such as a sleep disorder or perhaps an early dementia.
A medical work-up, including a neurology consultation, found no evidence of dementia. The patient’s symptoms were attributed to depression, and reassurance was recommended.
Chad stopped seeing me after 8 months. He felt somewhat better after talking about his life in psychotherapy and taking an SSRI. But his sexual preoccupations continued, and he planned to seek help from a psychologist who specialized in “sexual addiction.”
Chad’s story does not end well. He was suffering from a disease that would end his life, but it took 2 years of declining functioning before MRI evidence of his disorder became clear. Chad’s wife wrote to tell me that Chad had received a diagnosis of frontotemporal dementia (FTD). I always think of Chad when I learn of new findings about FTD. Much has been discovered about this disorder in the years since I saw him.
Dr. Schildkrout is Assistant Professor of Psychiatry, Part-time, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA. She is the author of 2 books, Unmasking Psychological Symptoms: How Therapists Can Learn to Recognize the Psychological Presentation of Medical Disorders and Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems.
1. Olney NT, Spina S, Miller BL. Frontotemporal dementia. Neurol Clin. 2017;35:339-374.
2. Ducharme S, Bajestan S, Dickerson BC, Voon V. Psychiatric presentations of C9orf72 mutation: what are the diagnostic implications for clinicians? J Neuropsychiatry Clin Neurosci. 2017;29:195-205.
3. Zhou J, Seeley WW. Network dysfunction in Alzheimer’s disease and frontotemporal dementia: implications for psychiatry. Biol Psychiatry. 2014; 75:565-573.
4. Miller BL, Dickerson BC, Lucente DE, et al. Case 9-2015: a 31-year-old man with personality changes and progressive neurologic decline. N Engl J Med. 2015;372:1151-1162.
5. Block NR, Sharon JS, Karydas AM, et al. Frontotemporal dementia and psychiatric illness: emerging clinical and biological links in gene carriers. Am J Geriatr Psychiatry. 2016;24:107-116.