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Neuropsychiatry of Frontal Lobe Dysfunction in Violent and Criminal Behaviour: a Critical Review

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Neuropsychiatry of Frontal Lobe Dysfunction in Violent and Criminal Behaviour: a Critical Review J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.71.6.720 on 1 December 2001. Downloaded from 720 J Neurol Neurosurg Psychiatry 2001;71:720–726 ADVANCES IN NEUROPSYCHIATRY Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review M C Brower, B H Price Abstract impulsive, trivially motivated, or habitual Objectives—To establish the link between aggression.5–7 But whereas clinical observation frontal lobe dysfunction and violent and and current theories of prefrontal network criminal behaviour, based on a review of function suggest that frontal lobe disorders relevant literature. may contribute to violent and criminal behav- Methods—Articles relating evidence of iour, the strength of this hypothesised associ- frontal lobe dysfunction with violence or ation has yet to be established. crime were collected through a MEDLINE This paper evaluates the evidence for a search using the keyword “frontal lobe” causal relationship between abnormal frontal combined with the terms “aggression,” lobe function and violent crime, based on a “violence,” “crime,” “antisocial personal- review of current research literature. We ity disorder,” “psychopathy,” “impulse located articles using a MEDLINE search from control disorders”, and “episodic dyscon- 1966 through 2000, combining the keyword trol.” Reference lists were then searched “frontal lobe” with the terms “aggression,” for additional articles. “violence,” “crime,” “antisocial personality Results—High rates of neuropsychiatric disorder,” “psychopathy,” “impulse control abnormalities reported in persons with disorders”, and “episodic dyscontrol.” We then violent and criminal behaviour suggest an conducted a hand search of relevant reference association between aggressive dyscontrol lists. Articles were selected for review if they and brain injury, especially involving the contained clinical, laboratory, or neuropsycho- frontal lobes. The studies reviewed sup- logical test data relating frontal lobe function to port an association between frontal lobe aggression, crime, or violence. In this review, dysfunction and increased aggressive and we adopt the definition of aggression as any antisocial behaviour. Focal orbitofrontal threatening or physically assaultive behaviour injury is specifically associated with in- directed at persons or the environment. creased aggression. Deficits in frontal “Violence” refers to actions that inflict physical executive function may increase the likeli- harm in violation of social norms. We divide hood of future aggression, but no study our findings under the following headings: (1) http://jnnp.bmj.com/ Secure Care Program, has reliably demonstrated a characteristic studies relating clinical focal frontal lobe disor- Department of pattern of frontal network dysfunction ders to violent behaviour; (2) studies reporting Psychiatry, Taunton neuropsychological measures of frontal lobe State Hospital, predictive of violent crime. Taunton, MA, USA, Conclusions—Clinically significant focal function in aggressive and antisocial subjects; and Harvard Medical frontal lobe dysfunction is associated with (3) studies of clinical neurological findings in School, Boston, MA, aggressive dyscontrol, but the increased violent and criminal populations; and (4) neu- USA risk of violence seems less than is widely roimaging studies of aggressive and violent M C Brower presumed. Evidence is strongest for an subjects. We conclude by assessing the magni- on October 2, 2021 by guest. Protected copyright. tude and specificity of the hypothesised link Departments of association between focal prefrontal dam- Neurology, McLean age and an impulsive subtype of aggres- between frontal lobe dysfunction and violence, Hospital, Belmont, sive behaviour. and discuss implications for future research. MA, Massachusetts (J Neurol Neurosurg Psychiatry 2001;71:720–726) General Hospital, Boston, MA, and Keywords: frontal lobe dysfunction; aggression; vio- Harvard Medical lence Focal frontal lobe disorders and violent School, Boston, MA, behaviour USA Case studies as far back as 1835 have reported BHPrice Reports describing high rates of neuropsychiat- the onset of antisocial personality traits after frontal lobe injury.8 Such cases typically involve Correspondence to: ric abnormalities among death row inmates, Dr B H Price, Department of forensic psychiatric inpatients, and other per- damage to the orbitofrontal cortex, which Neurology, Mclean Hospital, sons with histories of violence have led to clinical observation has associated with “poor 115 Mill Street, Belmont, impulse control, explosive aggressive out- MA 02478, USA assertions that evidence of brain-behavioural [email protected] impairment may mitigate or excuse criminal bursts, inappropriate verbal lewdness, jocular- conduct.1–4 Frontal lobe dysfunction in particu- ity, and lack of interpersonal sensitivity.”9 Such Received 18 July 2000 and in gross dysregulation of aVect and behaviour final form lar, has been invoked to explain the actions of 7 June 2001 some persons charged with, or convicted of, may occur while cognitive, motor, and sensory Accepted 2 July 2001 violent crimes, who apparently fail to inhibit functioning remain relatively intact.10 Blumer www.jnnp.com J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.71.6.720 on 1 December 2001. Downloaded from Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour 721 and Benson dubbed this orbitofrontal syn- aggression, substance misuse, stability of em- drome “pseudopsychopathy,”8 based on simi- ployment, socioeconomic status, the presence larities to psychopathy—a personality type of psychiatric symptoms or disorders other that, as defined by reliable and valid checklist than depression, or criminal charges or other criteria, is strongly associated with violence and legal involvement. Without such data, it criminality.11–13 remains unclear how much of the increases in Case reports have described a similar aggressive behaviour found can be specifically syndrome of “acquired sociopathy” in persons attributed to focal frontal lobe injury. who had ventromedial prefrontal injury in adulthood.14–16 Although showing minimal im- Neuropsychological studies of aggressive pairments on standard neuropsychological and antisocial subjects tests of intelligence and executive functions, A previous comprehensive review of neuro- these subjects display marked deficits in real psychological studies by Kandel and Freed life tasks demanding judgment, awareness of (1989) found that “evidence for the association socially appropriate conduct, and the capacity between specifically violent criminal behaviour to assess future consequences.17 Persons with and frontal lobe dysfunction is weak at best.”27 frontal network damage acquired before the A subsequent review by Pennington and age of 8 have also been reported to have adult OzonoV concluded that comorbid attention histories of recurrent impulsive, aggressive, and deficit hyperactivity disorder (ADHD) most antisocial behaviour, associated with primary likely accounted for deficits in frontal executive deficits in tests of executive function, poor function linked with adolescent conduct disor- abstract conceptual thinking, inability to envi- der, but considered that ADHD might worsen sion another person’s subjective experience, aggression in such cases.28 Table 1 summarises and immature moral reasoning.18–20 One report, results of relevant neuropsychological studies however, has described two cases of improve- reported since 1989.29–36 ment in impulsive and antisocial behaviour One study reported that errors on a single after frontal traumatic brain injury in adult- subtest in a battery of executive function meas- hood.21 ures correlated significantly with a diagnosis of Large systematic studies on cohorts of war antisocial personality disorder in a male veterans with head injury have also tended to community sample.29 A small study of subjects find an association between frontal lobe lesions addicted to cocaine, all of whom met diagnos- and aggressive or antisocial behaviour, al- tic criteria for antisocial personality disorder, though the prevalence of actual violent crime found that high violence subjects as a group seems small. Among German researchers who scored significantly better than low violence described personality changes in first world subjects on a widely accepted measure of fron- war and second world war veterans with frontal tal executive functioning.30 By contrast, two lobe injuries, Kleist found a consistent relation studies using a laboratory based procedure between orbitofrontal lesions and subsequent designed to elicit aggressive behaviour have antisocial behaviour.8 Five patients (3%) in a correlated decreased performance on executive sample of 144 British second world war veter- function tests with increased aggression in ans with penetrating head injury committed community samples of male subjects without “crimes and misdemeanors,” though all five neurological, psychiatric, or substance misuse had damage limited to the frontal lobes.22 Less histories.31 32 than 5% of all subjects with frontal lobe injury A prospective study found that low scores on http://jnnp.bmj.com/ in a similar study of Finnish second world war executive function tests significantly predicted veterans had a history of criminal conviction, self reported aggression in 10 to 12 year old and only one had committed a violent boys with paternal histories of substance oVence.23 misuse, but the results
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