CRIME AND TRAUMATIC BRAIN INJURY

 

Introduction

 

It has been known for some time that there is a close relationship between early upbringing and future offending behaviour. Conviction of a criminal offence in adulthood is associated with a number of factors including:

 

Many of these factors were established in early studies on childhood behaviour and these have recently been emphasised in a 45-year study of over 400 males living in London who were first surveyed in 1961 and 1962. A recent follow-up enquiry of this cohort has confirmed these links above (Shepherd et al., 2002). This same study also showed that the risk of getting injured in this group was itself closely related to antisocial behaviour and offending.

 

Prevalence

 

There are a number of ways of estimating prevalence of criminal acts occurring in people with traumatic brain injury (TBI). Ideally, a total population should be studied to determine the incidence of criminal acts in those who have sustained a TBI to those who have not. In a study in Finland involving more than 10,000 subjects, comprising a general population birth cohort that was followed up for four decades, TBI during childhood or adolescence increased the risk of developing mental disorders two-fold (OR 2.1, 95% CI 1.1-3.6) and TBI was significantly related to later mental disorder with coexisting criminality in male cohort members (OR 4.1, 95% CI 1.2-13.6) (Timonen et al., 2002). Alternatively, a population of people who have committed criminal acts can be investigated in detail to determine what percentage has had a TBI. A consecutive series of 100 admissions to Broadmoor high security hospital showed that there was a high prevalence of trauma to the central nervous system in this population (Lumsden et al., 1998). Definite obstetric complications were found in 26% (compared with 8% of the general population) and 31% had a history of traumatic head injury with loss of consciousness. Almost 60% had neuropsychological impairment. Of the population with brain scans, about 36% were abnormal. Alcohol abuse, a significant risk factor for CNS damage, was found in 69%. Combined risk (obstetric complications, head injury and substance abuse) was noted in 90% of the population.

 

Relationship between traumatic brain injury and criminal behaviour

 

In an investigation of non-violent convicted offenders in America compared with a community sample, Sarapata et al. (1998) reported that people with TBI were at significantly greater risk of committing crimes. Fifty per cent of non-violent convicted offenders reported a prior history of TBI as opposed to 15% in a community sample. 83% of offenders who had reported a history of similar injury in the past also reported an injury preceding their first encounter with the law.

 

There is a relationship between sexual offending and brain injury. In a study of 476 male sexual offenders, seen at a university psychiatric hospital in Canada for forensic assessment, almost half had sustained traumatic brain injuries that led to unconsciousness, and of these nearly a quarter had evidence of neurological damage (Langevin, 2006). In another study of sexual offenders from Australia, in comparison with a group of matched individuals with a similar degree of brain injury but no sexual misbehaviour, the former group had a significantly higher incidence of post-injury psychosocial disturbance in the areas of nonsexual crime and failure to return to work (Simpson et al., 2001).

 

There are clearly links between criminal behaviour and brain injury and the evidence inclines towards the view that brain injury in the majority of those affected results from predisposing environmental and genetic factors in the victims. Other factors that affect this relationship must also be considered.

 

Substance Abuse

 

It is well established that people who abuse illicit drugs are more likely to commit criminal acts, in part to gain money to buy the drugs concerned. The higher incidence of criminal acts in those with brain injury may be related to a greater prevalence of substance misuse in this population. What is the evidence for this?

 

There is a link between substance and alcohol abuse, and brain injury. In a one year longitudinal study of 351 individuals with traumatic brain injury Bogner et al., (2001) found that almost 80 percent of persons with violence-related causes had a history of substance abuse. Although motor vehicle accidents were the most common cause of traumatic brain injury overall, persons with drug and alcohol abuse were most likely to sustain violent injuries. There is an inter- relationship between substance abuse and brain injury in that substance abuse is a factor leading to brain injury, whereas abuse of substances may also occur post-injury. As persons with brain injury, in particular those with traumatic brain injury, may experience psychiatric disorders and have associated alcohol and substance abuse problems, the question then arises as to whether they are more likely to commit criminal offences following damage to the brain. It has been suggested that brain injury and alcohol and substance abuse may increase the risk of subsequent aggressive behaviour, and therefore potentially lead to criminal convictions.

 

A recent study found that between 40% and 50% of adolescents and adults admitted to trauma centers after ABI had a history of alcohol abuse. In 1995 Kreutzer et al. in the USA examined a sample of 327 patients who had received a traumatic brain injury, looking at alcohol use patterns, arrest histories, behavioural characteristics, and psychiatric treatment histories. Relative to the uninjured population, analysis revealed relatively high incidence of heavy drinking, both pre- and post-injury, among patients with a history of arrest. In a subsequent study from the same centre significant greater injuries were found between patients with a history of pre-injury arrests compared with patients without a history of pre-injury arrests (Kolakowsky-Hayner & Kreutzer, 2001)

 

The findings do not help us greatly in assisting us in answering the question: Which comes first, the drug-seeking behaviour or an early brain injury, which led to this behaviour? However, increased drug and alcohol misuse is associated with an increased likelihood of sustaining a TBI (Lumsden et al., 1998).

 

Psychiatric Illness

 

There is developing interest in the association between traumatic brain injury and psychiatric disorders. People with TBI may experience a range of psychiatric disorders such as depression, anxiety disorders, phobic disorder, obsessive-compulsive disorder, bipolar disorder or schizophrenia. There is also emerging research that suggests people with brain injury in general, but particularly those with traumatic brain injury, are more likely to experience psychiatric disorders. In a review of research in the area, Van Reekum et al. (2000) suggest a biological rationale for traumatic brain injury causing psychiatric disorders on the basis of greater impulsive actions in this population leading to increased risk-taking behaviour.

 

Site of Brain Injury

 

It has been suggested that frontal lobe damage to the brain is particularly likely to lead to antisocial acts and consequent criminal behaviour. Case studies as far back as 1835 have reported the onset of antisocial personality traits after frontal lobe injury (Blumer & Benson, 1975). Such cases typically involve damage to the orbitofrontal cortex, which clinical observation has associated with “poor impulse control, explosive aggressive outbursts, inappropriate verbal lewdness, jocularity, and lack of interpersonal sensitivity” (Duffy et al., 1994). In a study of patients with documented orbitofrontal damage, increased impulsivity and increased subjective anger was reported compared with damage elsewhere in this part of the brain (Berlin et al., 2004). These findings occurred despite the fact that cognitive, motor, and sensory functioning remained relatively intact. Blumer and Benson (1975) dubbed this orbitofrontal syndrome “pseudopsychopathy,” based on similarities to psychopathy—a personality type that is known to be associated with violence and criminality.

 

The cumulative evidence from neuroimaging studies points to a strong association between increased aggression and reduced prefrontal cortical size or activity. Although most studies cite bilateral prefrontal abnormalities, others specifically cite left anterior frontal or orbitofrontal findings, as well as non-frontal brain regions. Neuroimaging studies have documented focal decreases in frontal cortical activity associated with various neuropsychiatric disorders, as well as transient mental states, such as induced sadness, and episodes of mood disorder. The reported reductions in prefrontal size or activity may represent a predisposition to affective states relevant to aggressive behaviour, without necessarily signifying an inability to avoid actual violent acts (Mayberg, 1996). The neuroimaging findings, which associate prefrontal abnormalities with “purposeless” or affective aggression, as opposed to premeditated or predatory behaviour, support this interpretation.

 

The evidence from a systematic review suggests that clinically significant focal frontal lobe dysfunction is associated with aggressive dyscontrol, but the increased risk of violence seems less than is widely presumed (Brower & Price, 1991). Evidence is strongest for an association between focal prefrontal damage and an impulsive subtype of aggressive behaviour.

 

Strategies to Reduce Offending Behaviour and Brain Injury

 

There is good evidence to show that offending behaviour is related to early experiences in childhood. Preventative measures should therefore be applied early. Strategies that could be employed include:

 

 

It should be possible to identify those at high risk of injury because of their behaviours. Educational and rehabilitation measures have the potential to help these individuals.

 

                                                                                                            Stephen Tyrer

                                                                                                            December 2007

 

References

 

Berlin, HA., Rolls, ET. & Kischka, U. (2004) Impulsivity, time perception, emotion and reinforcement sensitivity in patients with orbitofrontal cortex lesions. Brain, 127, 1108-26.

 ADDIN EN.REFLIST Blumer, D., & Benson, DF. (1975) Personality changes with frontal and temporal lobe lesions. In Psychiatric aspects of neurological disease (ed D. Benson, Blumer, D.). New York: Grune & Stratton.

Bogner, J. A., Corrigan, J.D., Mysiw, W.J., Clinchot,D., & Fugate, L. (2001) A comparison of substance abuse and violence in the prediction of long-term rehabilitation outcomes after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 82, 571-577.

Brower, M., & Price, BH (2001) Neuropsychiatry of frontal lobe dysfunction in violent and criminal behaviour: a critical review. Journal of Neurology, Neurosurgery & Psychiatry, 71, 720-726.

Duffy, J., & Campbell, JJ III. (1994) The regional prefrontal syndromes: a theoretical and clinical overview. Journal of Neuropsychiatry & Clinical Neuroscience, 6, 379-387.

Kolakowsky-Hayner, S., & Kreutzer, JS. (2001) Pre-injury crime, substance abuse, and neurobehavioural functioning after traumatic brain injury. Brain Injury, 15, 53-63.

Kreutzer, J., Marwitz, JH. & Witol AD. (1995) Interrelationships between crime, substance abuse, and aggressive behaviours among persons with traumatic brain injury. Brain Injury, 9, 757-768.

Langevin, R. (2006) Sexual offenses and traumatic brain injury. Brain & Cognition, 60, 206-7.

Lumsden, J., Chesterman, LP., & Hill GM. (1998) Neuropsychiatric indices in a high security admission sample I: Estimating the prevalence. Criminal Behaviour & Mental Health, 8, 285-310.

Mayberg, H. (1996) Medical-legal inferences from functional neuroimaging evidence. Seminars in Clinical Neuropsychiatry, 1, 195-201.

Sarapata, M., Hermann, D., Johnson, T., & Aycock, R. (1998) The role of head injury in cognitive functioning, emotional adjustment and criminal behaviour. Brain Injury, 12, 821-842.

Shepherd,J., Farrington, D., & Potts, J. (2002) Relations between offending, injury and illness. Journal of the Royal Society of Medicine, 95, 539-544.

Simpson G. Tate R. Ferry K. Hodgkinson A. & Blaszczynski A. (2001) Social, neuroradiologic, medical, and neuropsychologic correlates of sexually aberrant behavior after traumatic brain injury: a controlled study. Journal of Head Trauma Rehabilitation. 16, 556-72.

Timonen, M., Miettunen, J., Hakko H. Zitting P. Veijola J. von Wendt L. & Rasanen P. (2002) The association of preceding traumatic brain injury with mental disorders, alcoholism and criminality: the Northern Finland 1966 Birth Cohort Study. Psychiatry Research, 113, 217-226.

Van Reekum, R., Cohen, T., & Wong, J. (2000) Can traumatic brain injury cause psychiatric disorders? Journal of Neuropsychiatry and Clinical Neuroscience, 12, 316-327.