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Can Some Brain Lesions Be Linked to Criminal Behavior?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / CE Released: 3/2/2018
  • Valid for credit through: 3/2/2019, 11:59 PM EST
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Target Audience and Goal Statement

This article is intended for primary care clinicians, psychiatrists, emergency medicine practitioners, family medicine practitioners, internists, neurologists, nurses, public health officials, radiologists, and other members of the healthcare team who treat and manage patients with brain lesions that may be linked to criminal behavior.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  1. Identify brain lesions and networks in patients who exhibited criminal behavior after, but not before, development of brain tumors or other brain lesions, based on a retrospective study
  2. Identify potential neuroscience, medical, and legal implications of findings from this retrospective study


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  • Megan Brooks

    Freelance writer, Medscape


    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author(s)

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Pfizer

Editor/CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC


    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.

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Can Some Brain Lesions Be Linked to Criminal Behavior?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / CE Released: 3/2/2018

Valid for credit through: 3/2/2019, 11:59 PM EST


Clinical Context

Case reports of serial killings or other crimes in patients with brain tumors or other brain lesions raise the question of why some brain lesions, but not others, may be associated with criminal behavior. The goal of this study was to systematically characterize such lesions and compare them with lesions that cause symptoms other than criminality, which could have potential neuroscience, medical, and legal implications.

The investigators used a new technique of lesion network mapping, which uses a database of resting state functional connectivity from normal subjects to identify regions functionally connected to each lesion location. Because neurologic symptoms can arise from dysfunction in remote brain regions connected to the lesion location, rather than from the lesion location itself, lesions resulting in the same symptom tend to share functional connectivity to the same brain regions. This technique has helped explain hallucinations, involuntary movements, delusions, loss of consciousness, and other complex neurologic symptoms.

Study Synopsis and Perspective

Brain lesions temporally associated with criminal behavior map to a common functional brain network involved in aspects of moral decision making, a finding that may help explain why certain brain lesions may predispose individuals to criminal behavior, new research suggests.

"Prior case reports have noted that lesions can cause a previously normal person to be prone to criminal behavior. However, lesions in several different locations are able to cause this same behavior. We used a new technique and a map of the human brain's connectivity to show that all of these lesions were connected to the same brain network involved in morality," lead author Richard Darby, MD, from Vanderbilt University Medical Center in Nashville, Tennessee, told Medscape Medical News.

The study was published online December 18 in the Proceedings of the National Academy of Sciences.

Criminality-Associated Connectivity Pattern

The investigators systematically mapped brain lesions in 17 patients from the literature whose lesions were temporally associated with criminal behavior. The patients all exhibited criminal behavior after, but not before, the lesions occurred. The causes of the brain lesions included stroke, trauma, and tumors.

The lesions were located in spatially diverse brain regions. All the regions were functionally connected to the network involved in morality, value-based decision making, and theory of mind, but not cognitive control or empathy.

The lesions involved in the "criminality-associated connectivity pattern" differed from lesions causing 4 other neuropsychiatric syndromes, the researchers report in their article. The researchers replicated their results in a separate cohort of 23 cases in which a temporal relationship between brain lesions and criminal behavior was implied but not definitive.

"Our results suggest that lesions in criminals occur in different brain locations, but localize to a unique resting state network, providing insight into the neurobiology of criminal behavior," they write.

It is important to note, say the researchers, that not all individuals with brain lesions within this network commit crimes. Genetic, environmental, and social factors are also likely to be important.

"We don't yet know the predictive value of this approach," Dr Fox said in a news release. "For example, if a brain lesion falls outside our network, does that mean it has nothing to do with criminal behavior? Similarly, we don't know the percentage of patients with lesions within our network who will commit crimes."

"Our study adds to the understanding of how the brain regulates moral behavior. Future studies are needed to see if our findings align with other diseases that may predispose patients to criminal behavior, such as frontotemporal dementia," Dr Darby told Medscape Medical News.

"Criminal responsibility is complex and ultimately determined by the legal system, not science. Usually, diminished responsibility requires that a patient have an impairment in their mental state that prevents them from understanding that their behavior was wrong or from conforming their behavior to the law," he added.

"Whether the patient has a brain lesion or another reason for this impairment doesn't necessarily matter, although the presence of a lesion can give an explanation for why someone's behavior would change in this way."

Brain Imaging for New Criminals?

Commenting on the findings for Medscape Medical News, Virginia A. De Sanctis, PhD, chief of neuropsychology at Lenox Hill Hospital in New York City, said this is "an interesting article and topic."

"The notion that frontal lobe abnormalities or dysfunctional frontal systems are involved in abhorrent/criminal/pathological behavior is nothing new. It echoes back to a time when surgical interventions...that targeted the frontal lobes rose to popularity in the mid-20th century. The popularity of these surgical procedures preceded the invention of brain the 70s. Many of these procedures were probably effective because they were disrupting an abnormal network stemming from an undetected lesion," said Dr De Sanctis, who is also affiliated with Northwell Health Neuroscience Institute in New York. This new study, she said, "highlights the importance of the lesion 'network' over the specific location of the lesion. The most hopeful aspect of the study results is the implication that treatment of lesions could prevent further criminal acts. 'Rehabilitation' of criminals could include surgical intervention for those with resectable lesions.

"Should all individuals who develop criminal behavior undergo brain imaging? Perhaps," said Dr De Sanctis.

The study was supported by funding from the Sidney R. Baer, Jr, Foundation, the National Institutes of Health, the Dystonia Foundation, the Nancy Lurie Marks Foundation, the Alzheimer's Association, and the BrightFocus Foundation. The authors and Dr De Sanctis have disclosed no relevant financial relationships.

Proc Natl Acad Sci. Published online December 18, 2017.[1]

Study Highlights

  • Seventeen patients exhibiting criminal behavior after, but not before, development of brain lesions, underwent systematic brain mapping.
  • The lesions occurred in different regions, including the medial prefrontal cortex, orbitofrontal cortex, and different locations within the bilateral temporal lobes.
  • No single brain region was damaged in all cases.
  • Lesion network mapping showed that all lesions were functionally connected to the same network of brain regions, and that this criminality-associated connectivity pattern was different from lesions causing 4 other neuropsychiatric syndromes.
  • This single brain network connected to all 17 lesions included the orbitofrontal cortex, ventromedial prefrontal cortex, and anterior temporal lobes.
  • This unique network included regions involved in morality, value-based decision making, and theory of mind in normal subjects, but not those involved in cognitive control or empathy.
  • Abnormalities in these same brain regions have been identified in other patient populations, such as those with frontotemporal dementia or psychopathy, tending to exhibit criminal behavior.
  • Lesions temporally associated with criminal behavior showed opposite connectivity to brain regions activated by competing moral choices, which may help explain the choices made by these patients.
  • The investigators replicated their findings, with nearly identical results, in an independent cohort of 23 cases in which there was thought, but not proven, to be a temporal relationship between brain lesions and criminal behavior.
  • On the basis of their findings, the investigators concluded that lesions in criminals occur in different brain locations, but localize to a unique resting state network, providing insight into the neurobiology of criminal behavior.
  • Future research should test the hypothesis that patients whose lesions are connected to brain regions involved in specific aspects of moral decision making will have behavioral deficits in those tasks.
  • Previous research has shown that the relative balance in activation between 2 different networks of brain regions is associated with different choices in moral dilemmas, suggesting "competition" between opponent networks during moral decision making.
  • This "competition" is supported by evidence that these networks are normally anticorrelated at rest, and by the findings from this study that lesions temporally associated with criminal behavior were connected to both sets of brain regions, but in opposite directions.
  • In a judicial setting, it is helpful to know whether a lesion contributed to criminality or was an incidental finding, but the implications of the study results are unclear in this regard.
  • The investigators warn against overinterpreting their findings by attempting to predict criminal behavior, as genetics, age at lesion onset, lesion etiology, environment, social support, and premorbid personality traits may contribute to criminal behavior, either independently or by interacting with the lesion location.
  • They note that only ∼9% of patients with traumatic brain injury commit violence or crime, as do 14% of patients with frontal lobe injury, and up to 57% of patients with frontal temporal dementia.
  • Lesions within their identified network may increase the risk for criminal behavior, but should not be interpreted as an inevitable or sole cause of criminal behavior.
  • To determine whether a lesion with connectivity to the regions identified in this study will result in criminal behavior, and to identify other contributing factors, prospective studies are needed.
  • Study limitations include potential confounders associated with lesion network mapping; lack of functional imaging or behavioral testing in patients with lesion-induced criminal behavior; and retrospective design vulnerable to bias.

Clinical Implications

  • Brain lesions temporally associated with criminal behavior occur in multiple different brain regions, but are all characterized by a unique pattern of brain connectivity, according to a retrospective study.
  • These findings may facilitate ongoing efforts to understand, predict, and assign responsibility to criminal acts.
  • Implications for the Healthcare Team: Members of the healthcare team need to be aware that other factors contribute to criminal behavior, and presence of a lesion within the network does not necessarily predict criminal behavior.

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