“My husband’s only 58 but he’s become rude, reckless with money and oddly uncaring — it’s like his personality’s changed”

FRONTOTEMPORAL DEMENTIA (FTD), here the behavioural variant (bvFTD; Pick’s disease is a pathological subtype, not a synonym), is a YOUNG-ONSET dementia (often 50s–60s) presenting with early PERSONALITY and BEHAVIOUR change — disinhibition (socially inappropriate remarks/actions), loss of EMPATHY, apathy, impulsivity and poor judgement (e.g. reckless spending), repetitive/compulsive behaviours and altered eating — with relatively PRESERVED memory early on and often POOR INSIGHT (a language variant presents with progressive speech/language decline). It is frequently MISATTRIBUTED to a midlife crisis, stress, relationship breakdown, depression or primary psychiatric illness, causing diagnostic delay, so personality change of this kind in a younger adult — especially with a clear timeline and collateral history — should prompt consideration of an organic/neurodegenerative cause rather than "just stress". Take a COLLATERAL history with the patient’s consent (the spouse is essential given poor insight) and screen the differential (depression, bipolar/mania, psychosis, alcohol/substance misuse, other dementias such as Alzheimer’s which is memory-led, FTD–motor neurone disease overlap, family history, and structural/endocrine/metabolic causes — examination face to face, NICE NG97 bloods (FBC, calcium, glucose, renal and liver function, thyroid function, B12 and folate) and a cognitive assessment, remembering NG97 advises not ruling out dementia on a normal cognitive score alone). Assess RISK and safeguarding: financial vulnerability/reckless spending (lasting power of attorney discussed now, while he may have capacity — Mental Capacity Act 2005), behavioural risk, and DRIVING (a person diagnosed with dementia must notify the DVLA; advise not driving while assessed if judgement is a concern). Refer to a specialist dementia diagnostic service — a YOUNG-ONSET DEMENTIA service/cognitive neurology clinic at this age — for detailed cognitive testing and neuroimaging (NG97 advises against acetylcholinesterase inhibitors or memantine in FTD), and crucially SUPPORT THE CARER — validating the distress, explaining it is an illness not a choice (so the patient is not blamed), offering a carer’s assessment (Care Act 2014; NICE NG150) and signposting carer support. The skill is recognising young-onset behavioural-variant dementia, taking a collateral history, excluding mimics, addressing risk/driving, referring, and supporting the family — not mislabelling it stress.