Mrs X.Y. is a 70 years old, married woman who lives with her husband, without a family history of mental disorders. Since adolescence, the patient was characterized by a cyclothymic-irritable temperament, with swings in mood, energy and irritability. In addition, the patient showed since childhood behavioral pattern characterized by difficulties in socio-emotional reciprocity, empathy alterations, strong adherence to routine without flexibility, narrow and repetitive interests, described as abnormal for their intensity, ascribable to a subthreshold Autism Spectrum without an evident impairment in global functioning, showing instead hyper-functional features in specific fields. As a teenager she excelled in humanities, to the study of which she devoted many hours of the day until she reached very high school performances. She was the first of her class and this stubbornness allowed her to achieve and maintain managerial roles, with a successful academic and work career. She was also very selective in her relations with a reduced ability to share interests. Described as a ruminative person, she was incapable of coping with stressful or mildly traumatic social situations, often as a result of her difficulties in social interactions and in understanding the typical signs of verbal and non-verbal communication. The patient also reported an increased sensitivity to caffeine and intolerance to stress, increased workload or to sudden changes in daily routine. The onset of clinical symptoms was at the age of 20, when the patient developed mood oscillations of both polarities, with depressive episodes, characterized by low energies and clinophilia lasting a few weeks as well as with episodes of mood elevation, increase in energy levels and activities, reduced need for sleep in association with irritability, verbal aggressive behavior towards other people (particularly family members) and subsyndromal panic attacks with cardiorespiratory symptoms (tachycardia, dyspnea). However, the patient did not seek medical help for these symptoms and the clinical picture resolved spontaneously. Subsequently, for several decades, Mrs. X.Y. reported subjective well-being, with satisfying levels of adjustment and global functioning, despite the presence of subsyndromal mood oscillations, tendency to irritability and prodigality and anxiety fluctuation. During 2012 (when the patient was 60 years old), in association with a stressful life event, the patient experienced a progressive worsening of mood, with sadness and loneliness, social anhedonia, asthenia, irritability associated with emotional lability, recriminatory thoughts towards family members, prodigality. Furthermore, her tendency to ruminative thinking related on life events, particularly social ones, typical of ASD full-threshold and subthreshold spectrum, caused frequent mood swings and alterations in her circadian rhythms, determining subtotal insomnia. This condition progressively worsened, with the patient showing increased social withdrawal, dysphoria, verbal and physical aggressive behaviors, with a further detrimental effect on her socio-emotional functioning, anxiety elevation with cardiorespiratory and neurovegetative symptoms, leading to a reduced global functioning. However, also in this case Mrs. X.Y., firmly convinced of being affected by a cancer, did not listen to family members and did not refer to mental health professionals, undergoing instead several somatic examinations such as repeated blood tests, echocardiography, cardiovascular consultations, abdominal computed tomography, endoscopy, all of which reported negative results. In 2014 (62 years), after a period of reduced symptom severity and better adjustment, the patient progressively developed aphasia and as a consequence she was examined by a neurologist, undergoing a brain Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET). According to neuroimaging examination, cortical metabolic changes were observable especially in the frontal and left temporal areas, presumably related to a neurodegenerative condition. Mrs. X.Y., was diagnosed with Primary Progressive Aphasia and a FTD (Semantic Variant). In April 2015 (63 years), the patient developed a new episode of the mood disorder, characterized by dysphoric mood, frequent crying, high anxiety levels, motor restlessness, aggressive behaviors and prodigality, with frequent pantoclastic episodes. Subsequently the patient was examined for the first time at a Psychiatric Clinic, where she was admitted and then discharged with a diagnosis of "BD, mixed episode, in patient with FTD, type II diabetes mellitus and essential hypertension". The pharmacological therapy featured mood stabilizers (Valproic Acid 500 mg/day), antipsychotics (Perphenazine 6 mg/day), antidepressants (Paroxetine 10 mg/day) and benzodiazepines (Lorazepam 2 mg/day), with reported clinical benefit. During the following months, the patient enjoyed a partial global functioning, despite the presence of anxiety and irritability fluctuation with episodes of verbal aggressiveness. However, from 2015 to 2018 the patient experienced other three episodes of mood alteration similar to the one reported at 63 years, in particular during spring (March–April), and a progressive worsening of the global conditions, with the development of chronic impairment in linguistic expression, increasing aggressive behaviors, apathy, abulia and hypochondriac thoughts, leading to a loss of autonomy in common daily activities and personal care, requiring continuous daily assistance. In August 2018, she was admitted to a Neurology Clinic. The diagnosis of Fronto- Temporal Cognitive Decay (semantic variant type) was confirmed. In April 2021 (69 years), the patient was admitted for a second time in a Psychiatric Clinic, where she was discharged with the diagnosis of "Bipolar Affective Syndrome, maniacal episode, moderate; aphasia" and a psychopharmacological therapy based on mood stabilizers (Lithium Carbonate 300 mg/day), antipsychotics (Clozapina 75 mg/day), antidepressants (Paroxetine 20 mg/day, Sertraline 25 mg/day) with partial clinical benefit. However, due to the remaining psychopathological symptoms, associated with severe aphasia and the progressive reduction of the overall functioning, the patient was no longer self-sufficient in her daily routine and needed constant support from her family members. In February 2022 (70 years) the caregivers seek the help of another psychiatrist who changed the psychopharmacological therapy based on mood stabilizers (Lithium Carbonate 300 mg/day, Valproic Acid 250 mg/day), antipsychotics (Clozapine 100 mg/day) and antidepressants (Paroxetine 5 mg/day). Subsequently, the patient was addressed to our clinic, where she was admitted on 4 March 2022 for the treatment and investigation of the case. At a first physical examination the patient presented catatonic symptoms, including waxy flexibility, grimacing, mutism, negativism, echolalia. The patient spoke only on few occasions, with a very poor language characterized by pass-par-tout words. Furthermore, she showed an oppositional behavior, refusing food and hydration and thus requiring enteral nutrition through nasogastric intubation, temporarily replaced with parenteral nutrition for a suspected aspiration pneumonia. She was not oriented in place, time and person, and scarcely responsive to verbal and physical stimuli. In agreement with the relatives, she was transferred to Intermediate Care and subsequently in a long-term structure.