Frontotemporal

dementia and

criminal behavior

Criteria for bvFTD, Salience

network, Moral dilemmas,

Capacity and Competency

to stand trial in bvFTD,

Increasing life expectancy

In the general population the number of people

over 65 is growing rapidly.

In 1870 there were 1 million people over 65 in the

US.

In 2000 there were 35 million people over 65.

The number of inmates over 65 in state and federal

prisons tripled between 1990 and 2001.

Dementia in prison

40,000 inmates with dementia are currently incarcerated in US

prisons.

It is estimated that by 2050 this number will be 250,000.

Wilson, J., & Barboza, S. The looming challenge of dementia in prisons. Correctional Care (2010) 24(2), 10–13.

Reasons for the graying of prison

population

Longer incarceration periods

Mandatory prison sentences

Increased number of older first offenders

People in prison age at a faster rate than the

general population

Older first offenders The new court commitments grew by 109%

between 1995-2009.

bvFTD patients are likely to be found among this

group

Bureau of Justice Statistics. Human Rights Watch. American Civil Liberties Union. Pew Center for the States.

bvFTD patients prone to criminal violations

FTD represents 5-6% of all dementias.

54% of patients with bvFTD are involved in criminal

behavior.

Only 12% of AD are involved in criminal behavior.

Frontotemporal lesions and antisocial acts

It has been known for almost a century that

frontotemporal lesions lead to antisocial acts.

Hypothesis

The anterior insular cortex (AIC) and anterior

cingulate cortex (ACC), especially in the right

hemisphere, harbor pro-social cognition,

including:

-moral emotions

-moral drives

-avoidance of harm to others

-the need for fairness

-punishment of violators

Lesions of AIC and/or ACC lead to antisocial acts.

The insula (insular cortex)

Anterior Cingulate Cortex (ACC)

Santillo AF, Mårtensson J, Lindberg O, Nilsson M, et al. (2013) Diffusion Tensor Tractography versus Volumetric

Imaging in the Diagnosis of Behavioral Variant Frontotemporal Dementia. PLoS ONE 8(7): e66932.

doi:10.1371/journal.pone.0066932 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0066932

The hallmark – frontotemporal lobar degeneration

(FTLD)

Neuronal cytoplasmic inclusions

Inability to solve moral dilemmas

Frontotemporal lobar degeneration (FTLD) in the

right AIC and ACC impairs moral cognition.

When patients present with dysmoral behavior for

the first time, as a change from a prior pervasive

pattern of behavior, clinicians need to consider a

possible, causative brain disorder.

Moral dilemma 1

Moral dilemma 2

Moral dilemma 3

Enemy soldiers have taken over your village. They have orders to kill everyone. You have hidden in the basement of a large house along with other people. Outside you hear the voices of soldiers who have come to search the house. Your baby begins to cry loudly. You cover his mouth to block the sound. If you remove your hand from his mouth the soldiers will hear his crying and will kill you, your baby, and the other people hiding in the basement. To save yourself and the others you must smother your child to death. Would you smother your child in order to save yourself and the other people?

Characteristics of bvFTD

Young onset (midlife)

Behavioral changes usually misdiagnosed as psychiatric d/o

20-50% of cases are hereditary

15% autosomal dominant

TAU protein misfolded, but not amyloid beta protein

VENs are specifically and selectively attacked (reduced by an average of 74%)

John M. Allman, Nicole A. Tetreault, Atiya Y. Hakeem, Kebreten F. Manaye, Katerina Semendeferi, Joseph M. Erwin, Soyoung Park, Virginie Goubert, and Patrick R. Hof. The von Economo neurons in the frontoinsular and anterior cingulate cortex. ANNALS OF THE NEW YORK ACADEMY OF SCIENCES, ISSN 0077-8923

Criteria of the 2011 International Behavioral Variant

Frontotemporal Dementia Criteria Consortium

(BVFDC)

six clinical hallmarks, including: disinhibition, apathy/inertia, loss of sympathy/empathy, perseverative/compulsive behaviors, hyperorality and dysexecutive neuropsychological profile.

three of these features must be present for the diagnosis of “possible” bvFTD.

“Probable” bvFTD requires the presence of functional disability and characteristic neuroimaging in addition to clinical symptoms.

“Definite” diagnosis of bvFTD needs either documentation of frontotemporal lobar degeneration by histopathologicalconfirmation or a pathogenic mutation.

Types of bvFTD

White matter tractography

The network

von Economo neurons (VENs)

The Intrinsic connective networks

ICNs

SN functions

Criminal Behavior in Frontotemporal Dementia

and Alzheimer’s Disease

A retrospective medical record review of 2397 patients who were seen at the University of California, San Francisco, Memory and Aging Center between 1999 and 2012.

Criminal behavior can be the first manifestation of patients with FTD

Patients with FTD were seven times more likely to present with criminal violations

Criminal Behavior in Frontotemporal Dementia and Alzheimer DiseaseMadeleine Liljegren, MD; Georges Naasan, MD; Julia Temlett, MBBS; David C. Perry, MD; Katherine P. Rankin, PhD;Jennifer Merrilees, PhD; Lea T. Grinberg, MD, PhD; WilliamW. Seeley, MD; Elisabet Englund, MD; Bruce L Miller,MD. JAMA Neurol. doi:10.1001/jamaneurol.2014.378. Published online January 5, 2015.

Capacity to stand trial (CST)

The legal standard for CST is “whether the individual has

sufficient present ability to consult with his lawyer with a

reasonable degree of rational understanding and

whether he/she has a rational as well as factual

understanding of the proceedings against him/her.”

This standard is based on the Supreme Court decision

Dusky v. United States in which the Court affirmed a

defendant's right to have a competency evaluation

before proceeding to trial.

CST in bvFTD

In bvFTD assessing capacity to stand trial and

determining culpability and suitable sentencing is

challenging because these defendants are

sometimes able to appreciate the wrongfulness of

their acts and might understand societal rules, but

may be organically incapable of regulating their

behavior .

Sapolsky RM. The frontal cortex and the criminal justice system. Philos Trans R Soc Lond B Biol Sci (2004)

359(1451):1787–96. doi:10.1098/rstb.2004.

“Regaining competency”

Frequently psychiatric reviews leave accused

individuals in legal limbo, waiting to regain

competency in facilities embracing recovery

models.

Task force

Neurodegeneration in state hospitals and

correctional facilities should be studied at both

federal and state level in order to help create an

adequate system of placement for this growing

segment of our population.

Screening

We advocate for screening of all first offenders

55 years of age or older via neuropsychological

testing and/or positron emission tomography

(PET).

Placement

We are in need of a modern system for placement

of individuals with neurodegenerative disorders.

Such a system should be based on the palliative,

rather than recovery model.

Such a system would benefit elderly offenders

diagnosed with dementia, while at the same time

decongest correctional facilities.