Article Text

Download PDFPDF

To clap or not to clap? Applause sign in apathetic and disinhibited/stereotypical behavioural variants of FTD
  1. S Luzzi,
  2. K Fabi,
  3. M Pesallaccia,
  4. V Cafazzo,
  5. M Silvestrini,
  6. L Provinciali
  1. Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Ancona, Italy
  1. Correspondence to Dr Simona Luzzi, Neurologic Clinic, Department of Experimental and Clinical Medicine, Polytechnic University of Marche, Via Conca, 1, 60020 Torrette di Ancona, Italy; s.luzzi{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


The nature of the applause sign, that is, the tendency to perform an automatic series of claps in response to the instructions to clap three times, has not been fully understood.1 The behavioural variant of frontotemporal dementia (bvFTD) is a good model to assess the influence of the frontal lobe dysfunction in generating the applause sign. Applause sign in FTD is a debated issue: its frequency ranges from 0% to 60% in different case series.1 ,2 BvFTD entails two distinct phenotypical patterns depending on the behavioural changes the patients show and on the distribution of atrophy3: the apathetic bvFTD, characterised by loss of initiative and volition, inertia and apathy, and the disinhibited bvFTD characterised by hyperactivity, verbal and motor disinhibition.

A third rare variant has been reported as the ‘stereotypical variant’ which is mainly characterised by aberrant motor behaviour with perseverations, mannerisms and rituals.3 Rarely repetitive behaviour can be found in the apathetic variant. By contrast, complex repetitive behavioural routines are often present in the disinhibited variant suggesting that the disinhibited and stereotypical variants tend to overlap.3 Although the atrophy spreads across the frontotemporal lobes, the distribution of atrophy tends to be more pronounced in the dorsolateral prefrontal cortex in apathetic bvFTD, in the orbitofrontal frontal cortex in the disinhibited bvFTD,4 and in the frontostriatal cortex in the stereotypical bvFTD, respectively.3

The present study aimed to verify the hypothesis that the applause sign arises from an aberrant motor behaviour. Accordingly, it is expected to be a frequent sign of the disinhibited and stereotypical variants. The apathetic variant, characterised …

View Full Text


  • Contributors SL: project design, data analysis, interpretation of data, drafting the work. KF: acquisition of data (experimental battery). MP: acquisition of data (background neuropsychological battery). VC: acquisition of data, handling data, literature revision. MS: interpretation of data, final revision of the work. LP: interpretation of data, final revision of the work. All authors approved the final version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Institutional review board.

  • Provenance and peer review Not commissioned; externally peer reviewed.