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   When Frontotemporal Dementia Leads to Crime--Prosecution or Protection?   
      
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   13 Jan 2015   
   For some, it starts with stealing candy. For others, it's a reckless car   
   crash, or a sudden penchant to urinate in public. The type of incident varies,   
   but according to a study published January 5 in JAMA Neurology, more than a   
   third of people with    
   frontotemporal dementia (FTD) act out criminal behaviors. In some cases, the   
   odd conduct is the first clear signal to their loved ones that something is   
   way off. Led by Bruce Miller at the University of California, San Francisco,   
   the study also reported    
   bad behavior in people with Alzheimer's and Huntington's diseases; however,   
   those patients' misconduct tended to surface later in the disease and to a   
   lesser degree than it did in people with FTD. The study raises questions about   
   how the criminal justice    
   system should handle people with FTD and, even more pressingly, concerns about   
   the plight of undiagnosed patients who may be languishing in prisons or on the   
   streets.   
      
      
   FTD Behind Bars?   
   More than a third of people with FTD act out criminal behavior. How many of   
   them wind up in prison is an open question, particularly for the undiagnosed.   
   [Image courtesy of Auntie P., Flickr Creative Commons.]   
   Dealing with wayward behavior is nothing new to Miller and other seasoned   
   clinicians who work with FTD patients. "We have seen many examples of these   
   cases over the years, so we thought it was time to put them into the   
   literature," Miller told Alzforum. "   
   We want people to understand that you have to think very seriously about the   
   brain whenever someone commits a crime, particularly when they commit a crime   
   for the first time after age 50."   
      
   Frontotemporal lobar degeneration (FTLD) chips away at regions of the brain   
   that rein in impulsivity and support inhibition and empathy, thus creating a   
   prime environment for behavior that defies social norms. These problems often   
   emerge while cognition    
   remains intact, so family, friends, and co-workers tend to see the person as   
   rude, odd, or worse, rather than as someone suffering from a neurodegenerative   
   disorder, said co-first author Madeleine Liljegren of Lund University in   
   Sweden. "They get judged    
   as a weird person or sent to a psychiatrist, where they might be misdiagnosed   
   with bipolar disorder or depression," she said. "If society in general were   
   more aware of these disorders, people could receive proper care from the start   
   and avoid getting    
   into trouble."   
      
   Smaller studies have reported a high incidence of criminal behavior in people   
   with FTD. A collection of case studies reported people with FTD stealing,   
   exposing themselves to children, sexually harassing others, and leaving the   
   scene of an accident they    
   caused (see Mendez, 2010). In 2013, a German study of 83 patients reported   
   criminal behavior in more than half of people with behavioral variant FTD or   
   semantic dementia, but only 12 percent of AD patients (see Diehl-Schmid et   
   al., 2013).   
      
   In the present study, first authors Georges Naasan from the University of   
   California, San Francisco, and Liljegren teamed up to measure criminal   
   activity in a much larger cohort. They scanned medical records from more than   
   2,000 patients with different    
   neurodegenerative diseases at the UCSF Memory and Aging Center for words   
   relating to criminal behavior, such as "theft," "hit and run," "shoplifting,"   
   and "police." They found 204 records containing at least one of these   
   buzzwords. Of these, 37.4 percent    
   of behavioral variant FTD patients had records, followed by 27.4 percent of   
   patients with the semantic variant of primary progressive aphasia (svPPA, a   
   type of FTLD), 20 percent of HD patients, and just 7.7 percent of AD patients.   
   Crimes included    
   trespassing, public urination, theft, sexual advances, violence toward others,   
   and driving infractions such as speeding, hit-and-run accidents, and driving   
   under the influence.   
      
   On average, people with bvFTD and svPPA were about a decade younger than AD   
   patients when their moral or legal lapses were first noted. Criminal behavior   
   was the first presentation of disease in 14 percent of people with bvFTD,   
   compared with nearly 8    
   percent of svPPA and just 2 percent of AD patients.   
      
   Without access to police records the researchers could not determine whether   
   patients were charged or convicted, but notations in their medical records   
   indicated that nearly 20 percent of bvFTD patients, 14.6 percent of svPPA   
   patients, and 5 percent of    
   those with AD were reported to the police. These numbers are likely an   
   underestimate, the authors speculate, as some caregivers could have held back   
   such information.   
      
   Janine Diehl-Schmid of the Technical University of Munich in Germany, who was   
   not involved in the study, agreed. Her previous study interviewed caregivers   
   to look for criminal behaviors in FTD patients, and found a higher incidence   
   than Liljegren's study    
   did. Nevertheless, Diehl-Schmid said the large number of patients included in   
   Liljegren's study was impressive and resonated with her findings (see full   
   comment below). Liljegren told Alzforum that she is currently performing the   
   same medical records    
   search of FTD patients at Lund University.   
      
   While retrospectively examining medical records did allow the researchers to   
   sift through a large number of patients, prospective studies will be crucial   
   to understand why the patients behaved the way they did, and whether they   
   grasped the moral or legal    
   implications of their actions, wrote Brad Dickerson, who runs a large FTD   
   clinic at Massachusetts General Hospital (see full comment below).   
      
   The researchers described some cases in each disease category. A woman with   
   bvFTD was arrested for trespassing after visiting the same property every day   
   despite being told she would be prosecuted. A man with bvFTD became obsessed   
   with asking random    
   people for their phone number, and told police he had no remorse about doing   
   so. Compelled by her sudden attraction to candy and shiny objects, a woman   
   with svPPA started shoplifting and stealing money from strangers' purses.   
      
      
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