Malapropisms, or “The Archie Bunker Syndrome,” and Frontotemporal Dementia

To the Editor

To our knowledge, there are no previous reports of malapropisms among patients with frontotemporal dementia (FTD).^1-3 We report on an FTD patient who developed a new tendency to mis-speak, substituting words of a similar sound, often with a comic effect.

Case Report

A 53-year-old, right-handed man with 14-years of education presented with a 1-year history of progressive neuropsychiatric changes. He became disinhibited in conversation and in approaching strangers, unempathic in his response to friends and family, compulsive in making 10–20 phone calls per day and calling 800-numbers, and apathetic and disengaged from productive activities. He also developed an inordinate “sweet tooth,” with a preference for strawberry milkshakes. The past medical history and family histories were nonsignificant. Along with these changes, the patient struggled to find the right word to use and began to misuse words. When asked about the name of the clinic, he replied “phallic” instead of “neurologic,” but could not explain why. He states that he was making “innuendos” for errors. He described his problem as a “medieval condition,” and he pointed to his head. Later, he said that he had a “molecular problem” that affected his thinking. The patient described himself as very “aesthetic” and “coexistent.” He made multiple other word substitutions throughout the interview. On examination, he had word-finding difficulty and decreased words per minute. On the Mini-Mental State Exam, he scored 21/30. He generated 11 animals/minute and 6 “F” words/minute, with frequent perseverations. On the 15-item Mini-Boston Naming Test, he named 11 items. On 10-word list learning, he recalled only 1, but recognized all 10. His visuospatial constructions were normal, but he was concrete on proverb interpretation and made errors on reciprocal programs. The rest of his neurological examination was normal. MRI was within normal limits, but positron emission tomography showed marked bifrontal and mild bitemporal hypometabolism, left greater than right, consistent with FTD. Management included 0.5 mg risperidone and 75 mg sertraline, resulting in a decrease in his compulsive behaviors.

Discussion

This patient showed malapropisms associated with the development of FTD. He met diagnostic criteria for FTD, including inertia, disinhibition, decreased empathy, compulsive behaviors, and dietary changes.^1,2 He also had alterations in word usage along with word-finding difficulty and a reduction in verbal output, common findings in the frontotemporal lobar degenerations.³ His mis-speech was consistent with malapropisms, as they were often humorous or incongruous word substitutions that had some similarity in sound to the intended words;⁴ for example, “medieval” for mental. The emergence of malapropisms in FTD may be due to word-finding difficulty coupled with a combination of deficits evident in these patients. As they struggle for words, patients with malapropisms may resort to accessing words in the same “phonological neighborhood.”⁴ Frontally-mediated deficits in working memory,⁵ as well as lack of self-monitoring or self-correction seen in frontally-injured patients, may sustain the malapropisms. In sum, the new tendency to malapropisms can be a symptom of a frontally predominant disorder, and clinicians should consider conditions such as FTD when they encounter a newly-developed “Archie Bunker.”