Legal issues in frontotemporal dementia: aspects still neglected in court and clinical practice

Abstract

Frontotemporal dementia (FTD) is a neurodegenerative condition affecting between 20,000 and 30,000 individuals in the United States, with a relatively higher incidence than previously recognized, and with an equal gender representation. Mutations in Microtuble Associated Protein Tau (MAPT) and Granulin (GRN) genes, or expansion in C9orf72 are recognized as associated to the disease [1]. The major neuropathological hallmarks are characterized by abnormal deposition of tau or TAR DNA-binding protein 43 (TDP-43) in the orbitofrontal and anterior temporal regions, causing language deficits or behavioral abnormalities. Along with language phenotypes, namely the nonfluent or agrammatic variant of primary progressive aphasia (nfvPPA) or the semantic variant of PPA (svPPA), the behavioural variant of FTD (bvFTD) represents most FTD cases and is often associated with personality changes [2]. Both clinical heterogeneity in FTD and the lack of reliable biological markers constitute the major limits to the diagnosis, which is often reached years after the disease onset, when patients eventually arrive at specialized care centers, after showing a wide range of symptoms. As one of the possible initial disease manifestations, criminal behavior is highly present, prominently among FTD patients, but also among svPPA patients, and it entails a wide range of legal violations, from moving traffic contraventions up to sexual crimes, with men showing a significant involvement in sexual abuse [3, 4]. In FTD, criminal behavior is more prevalent as compared to Alzheimer’s disease (AD) or other forms of dementia, in which it is usually confined to a minority of patients, and only in advanced disease stages [4]. Conversely, the majority of reported cases of FTD sufferers committing justice violations regards those still at the onset of their disease, before a definite diagnosis, and still cognitively intact, with a retained knowledge of moral rules and social conventions. All of which therefore raises the issue of whether FTD patients could meet the criteria to be judged not guilty in a court trial by reason of mental insanity. We have recently represented an FTD patient in court, charged for damaging vehicles parked on the public road. The illegal acts were committed at the onset of the disease. The man was detained by law enforcement and a criminal proceeding was initiated against him, which included several aggrieved parties. The defense requested psychiatric assessment of the defendant so as to determine his fitness to trial, soundness of mind, and social dangerousness. The patient was found to be affected by a mild cognitive impairment associated with emotional blunting, with a brain structural magnetic resonance imaging and functional positron emission tomography, documenting frontal atrophy and frontal hypometabolism. Shortly later, he was diagnosed with bvFTD. The trial consultant found that the subject was of unsound mind at the time of the offence, due to FTD, that he was fit to stand trial and that he was not socially dangerous. By virtue of the above, the trial judge acquitted him by reason of insanity. To the best of our knowledge, this is the first FTD patient in Italy to have ever been acquitted on the grounds of an FTD diagnosis (search from database “De Jure Giuffrè”). This case has given us the opportunity to reflect on the legal issues related to FTD, and we have found that although the literature available has described criminal behavior in FTD both qualitatively and quantitatively, mainly in the United States and in Northern European countries, an * Barbara Borroni [email protected]