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Liljegren M, Naasan G, Temlett J, Perry DC, Rankin KP, Merrilees J, Grinberg LT, Seeley WW, Englund E, Miller BL. Criminal behavior in frontotemporal dementia and Alzheimer disease. JAMA Neurol. 2015 Mar;72(3):295-300. PubMed.
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Massachusetts General Hospital
This study is important because there has been little investigation of criminal behaviors in patients with FTD or other neurodegenerative diseases, although clinicians working in this field recognize that many patients come to clinical attention in part due to acquired behaviors that are considered criminal. Strengths of this study include its very large sample size, comparison between patient groups with different neurodegenerative diseases, and analysis of the specific types of criminal behaviors reported. An important weakness, noted by the authors, is that it is a retrospective study based on key word searches in medical records. Prospective research on this topic is needed.
Furthermore, additional investigation of the behaviors contributing to criminal acts would be of interest, particularly an investigation of whether the individual has insight into the criminal nature of his or her actions and the potential consequences. Based on my own experience with such individuals, I would predict that a subset of persons with FTD are aware of the criminal nature of their actions and potential consequences, but lack inhibitory control and restraint or simply may not be concerned about the aversive value of the consequences. Other patients may lack conceptual understanding of the violation of normative societal behavior. Additional research on this topic is not only of scientific interest with regard to investigations of moral decision-making and the like, but of course of practical importance when it comes to determining how to treat such individuals in the legal system.
This is a great study. Given that this is a single-center study, the number of patients is extremely impressive. The results are similar to the findings of previous studies, but the large numbers give the results more significance. The results emphasize the importance of clinicians asking for criminal behavior when obtaining the patient’s history. I am somewhat puzzled about the low number of speeding and traffic violations in the bvFTD/SD subgroup. In a previous study, we found higher numbers, i.e. one third of patients with bvFTD/ SD (Ernst et al., 2010). It’s unclear if traffic violations were only identified as such in the Liljegren study when patients got a ticket, or whether a caregiver’s report sufficed.
We previously reported higher incidences of criminal behavior in FTD (Diehl-Schmid et al., 2013). That might be in part because we conducted caregiver interviews exclusively focused on criminal behavior; these might have detected more cases than a retrospective record review. It can be awkward for caregivers to mention this kind of thing during an overall clinical interview, or they may deny it out of worry about future legal problems. In an interview study focused on criminal behavior, much time can be taken to explain the objectives of such a study. Furthermore, we used only one interviewer, while in the Liljegren study it’s probable that numerous persons had obtained the patient history and had found certain kinds of criminal behavior more or less noteworthy. On the other hand, it must be taken into account that our study overestimated the frequency of criminal behavior. As our memory clinic belongs to the Department of Psychiatry, we get more referrals of patients with unusual behavioral disturbances than a neurology department.
In Germany, a person with FTD is not protected from prosecution, but their dementia is considered in setting the penalty. When a person with dementia and therefore diminished capability poses a danger to others, he or she is generally placed in forensic psychiatry units or closed wards of nursing homes, not prison.
I see many FTD patients who were misdiagnosed as having depression, but in most cases only because someone doubted that diagnosis and referred them to us for further evaluation.
Awareness of FTD has increased in the last decade. If patients go undiagnosed or misdiagnosed, that is mostly due to atypical presentations. Thanks to the Internet, some caregivers even diagnose the patients themselves, if not always correctly, as bvFTD. In 2011 the German FTLD Consortium was initiated, a multicenter research network of more than 10 clinical centers throughout Germany. All these centers have expertise in FTLD and raise awareness among the doctors in their respective regional areas.
In order to protect people with neurodegenerative diseases from criminal prosecution, all first-time offenders over age 50 could be screened. I would also like to educate judges about the fact that criminal behavior might be a symptom of dementia, so that, when in doubt, they call expert witnesses.
I find it interesting that no “major” crimes have been committed. Why is this so? More research should explore why people with FTD commit crimes, what they think about it, how they judge criminal behavior compared to the general population, and what would they say if they were the victim of criminal behavior. It would be extremely interesting to conduct a large study with prison inmates and persons in forensic psychiatry to screen them for potential neurodegenerative disorders.
References:
Ernst J, Krapp S, Schuster T, Förstl H, Kurz A, Diehl-Schmid J. [Car driving ability of patients with frontotemporal lobar degeneration and Alzheimer's disease]. Nervenarzt. 2010 Jan;81(1):79-85. PubMed.
Diehl-Schmid J, Perneczky R, Koch J, Nedopil N, Kurz A. Guilty by suspicion? Criminal behavior in frontotemporal lobar degeneration. Cogn Behav Neurol. 2013 Jun;26(2):73-7. PubMed.
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