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   J Am Acad Psychiatry Law. Author manuscript; available in PMC 2011 Jul 19.   
   Published in final edited form as:   
   J Am Acad Psychiatry Law. 2010; 38(3): 318–323.   
   PMCID: PMC3139561   
   NIHMSID: NIHMS296406   
   The Unique Predisposition to Criminal Violations in Frontotemporal Dementia   
   Mario F. Mendez, MD, PhD, Professor of Neurology and Psychiatry   
   Author information â–º Copyright and License information â–º   
   The publisher's final edited version of this article is available at J Am Acad   
   Psychiatry Law   
   See other articles in PMC that cite the published article.   
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   Abstract   
      
   Brain disorders can lead to criminal violations. Patients with frontotemporal   
   dementia (FTD) are particularly prone to sociopathic behavior while retaining   
   knowledge of their acts and of moral and conventional rules. This report   
   describes four FTD    
   patients who committed criminal violations in the presence of clear   
   consciousness and sufficiently intact cognition. They understood the nature of   
   their acts and the potential consequences, but did not feel sufficiently   
   concerned to be deterred. FTD    
   involves a unique pathologic combination affecting the ventromedial prefrontal   
   cortex, with altered moral feelings, right anterior temporal loss of emotional   
   empathy, and orbitofrontal changes with disinhibited, compulsive behavior.   
   These case histories    
   and the literature indicate that those with right temporal FTD retain the   
   capacity to tell right from wrong but have the slow and insidious loss of the   
   capacity for moral rationality. Patients with early FTD present a challenge to   
   the criminal justice    
   system to consider alterations in moral cognition before ascribing criminal   
   responsibility.   
   Epidemiological data and clinical information indicate a relationship between   
   criminal behavior and brain disorders. As many as 94 percent of homicide   
   offenders, 61 percent of habitually aggressive persons, and 78 percent of sex   
   offenders may have brain    
   dysfunction.1 Acquired sociopathy, or antisocial acts with disturbances in the   
   moral emotions linked to the interests or welfare of others, occurs in those   
   with brain lesions affecting the inner or ventromedial prefrontal cortex   
   (vmPFC). Investigations    
   show that lesions in the vmPFC impair moral judgment,2–4 and early-life   
   lesions impair the development of moral decision-making. 5,6 Other factors   
   that may contribute to impaired moral cognition or to the mental processes   
   that underlie morality include    
   loss of empathy or sympathy and disinhibited, compulsive behavior.7   
   Frontotemporal dementia (FTD) is a progressive neurodegenerative disorder   
   previously known as Pick’s disease. It affects the frontal and anterior   
   temporal regions, especially the vmPFC, orbitofrontal cortex, and anterior   
   temporal regions.8,9 On average,   
    FTD has an age of onset in the late 50s, with an equal incidence among men   
   and women and Potential autosomal dominant inheritance.7,8 Although the   
   disorder is termed dementia, early in the course most patients have a   
   personality change with relatively    
   intact cognition (i.e., early FTD is less an impairment in memory, language,   
   or perception than a disorder of abnormal behavior).7 Subgroups of FTD   
   patients can develop primary progressive aphasia, semantic deficits,   
   parkinsonism evolving to progressive    
   supranuclear palsy (PSP), corticobasal degeneration, or motor wasting and   
   motor neuron disease (MND).8 The core features of the usual behavioral variant   
   FTD are transgression of social norms including sociopathic behavior, a loss   
   of empathy or    
   appreciation of the feelings of others, and disinhibited, compulsive acts.   
   Patients with FTD can commit criminal violations while retaining the ability   
   to know moral rules and conventions. 10   
   Among brain disorders, sociopathy is particularly associated with FTD, much   
   more so than with Alzheimer’s disease (AD), vascular dementia, or other   
   neurodegenerative disorders, with the possible exception of Huntington’s   
   disease.7 These patients pose    
   a potential dilemma for the law. Currently, the paraphrased M’Naughten   
   standard for not guilty by reason of insanity requires that the perpetrator be   
   incapable, by reason of mental illness, of understanding the nature of the   
   criminal act or of knowing    
   that the act was wrong. 11 In this report, we examine four FTD patients with   
   sociopathy from our dementia research databases. The patients gave consent to   
   be enrolled in these databases for the de-identified use of their clinical   
   information. We examined    
   their sociopathic behavior and their mental state at the time of the acts. Did   
   they commit prohibitive acts in a culpable mental state? (Access to the   
   deidentified data set was approved by the University of California Los Angeles   
   Institutional Review    
   Board.)   
   Go to:   
   Case Reports   
   Patient I   
   A left-handed male in his sixties began stalking and attempting to molest   
   children for the first time in his life.12 He followed children home from   
   school and tried to touch them. On one occasion, he put his arm around a young   
   boy and then struck him    
   when he tried to pull away. On another occasion, he stood at the foot of a   
   pool and stared at the children for a prolonged time. When he exposed himself   
   to his neighbor’s children, he was arrested. The patient did not deny his   
   actions, could describe    
   them in detail, and endorsed them as wrong and harmful. Despite this, he   
   stated that he did not feel that he was causing harm at the time of his acts.   
   The patient’s personality had deteriorated over the prior four years, with   
   decreased concern for others, disinhibition, and compulsive hoarding. He had   
   caused disturbances at work, such as intruding into others’ conversations   
   and walking into others†  
   ™ offices. He was taking supplies into his office, constantly pilfering and   
   taking samples, and hiding money. He compulsively took photographs of the   
   sunset every night. In restaurants, he filled his pockets with sugar, napkins,   
   and other items. In    
   addition, he ate indiscriminately, even going through waste containers and   
   eating garbage. He stopped showering and wore the same clothes every day. The   
   family history was positive for an unspecified dementia in his mother.   
      
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