Patients with behavioral variant frontotemporal dementia (bvFTD) may overadhere to social norms to determine embarrassment responses, according to a study published in the Journal of Neuropsychiatry and Clinical Neurosciences. This finding suggests that self-centered, rule-based reasoning plays a role in the context of social dysfunction and emotional blunting.

Behavioral variant frontotemporal dementia, a neurodegenerative disease that affects the frontal and anterior temporal lobes, results in disordered socioemotional behavior. Patients are particularly impaired in shame, guilt, pride, and embarrassment.

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Mario F. Mendez, MD, PhD, from the departments of neurology, psychiatry, and biobehavioral sciences, David Geffen School of Medicine, University of California, Los Angeles, and colleagues examined self-reported embarrassment in 18 patients with early bvFTD, and in 23 healthy controls. The researchers used the 36-item Embarrassability Scale to assess self-embarrassment and vicarious embarrassment, or “Fremdscham” in German.

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Both groups were also compared with the Social Norms Questionnaire, and correlations were made for the Social Norms Questionnaire results and the Embarrassability Scale scores. Caregivers administered the Social Dysfunction Scale and the Scale for Emotional Blunting.

As expected, the patient group displayed social dysfunction and emotional blunting. Although patients with bvFTD (mean age, 61.25±10.1 years; 9 women) did not differ from healthy controls on total or self-embarrassment scores, vicarious embarrassment was significantly higher among patients than controls (P =.032). In contrast to the healthy control group, reports of vicarious embarrassment did not differ from reports of self-embarrassment in the bvFTD group.

Notably, patients with bvFTD displayed more social norm errors compared with controls, particularly overadherence errors (P <.001). Furthermore, the Embarrassability Scale total score demonstrated a correlation with overadherence errors (P <.05), although vicarious embarrassment only displayed a nonsignificant correlation (P =.056).

The study was limited by a small sample size and lack of scale validity in large populations. The investigators concluded, “Given the social behavioral changes in patients with bvFTD, and the relative insensitivity of traditional neuropsychological measures for early bvFTD, a self-rating scale of vicarious embarrassment could be useful in the initial recognition of this disorder.”


Mendez MF, Yerstein O, Jimenez EE. Vicarious embarrassment or “fremdscham”: overendorsement in frontotemporal dementia. J Neuropsychiatry Clin Neurosci. doi:10.1176/appi.neuropsych.19030053.