Brain imaging of forensic patients with Dr. Kent Kiehl

Kent A. Kiehl, PhD, joins host Lorenzo Norris, MD on the MDedge Psychcast to discuss the use of MRI scans to provide information about the brains of people who exhibit antisocial behaviors. The goals are to use the information to treat patients and prevent violent crimes.

Timestamps:

• This week in Psychiatry (00:33)
• Meet the guest (03:35)
• Interview (04:25)
• Credits (54:10)

Dr. Kiehl is professor of psychology, neuroscience, and law at the University of New Mexico, Albuquerque. He also codirects a nonprofit mental health research institute called the Mind Research Network, also in Albuquerque. He also helps run a for-profit consulting firm that helps attorneys do better science, called MINDSET.

This week in Psychiatry:

Suicide attempts up in black U.S. teens
by Randy Dotinga

Overall rates of suicide dipped from 1991 to 2017, according to research published in Pediatrics. However, the rate of suicide attempts grew slightly in black adolescents during that time.

SOURCE: Lindsey MA et al, Pediatrics. 2019;144(5): e20191187, DOI: 10.1542/peds.2019-1187.

Show notes by Jacqueline Posada, MD, consultation-liaison psychiatry fellow with the Inova Fairfax Hospital/George Washington University program in Falls Church, Va.

Brain imaging can support diagnoses

• Dr. Kiehl works with cutting-edge technology using noninvasive structural and functional brain imaging; machine learning, such as artificial intelligence; and algorithms to evaluate forensic patients and understand psychopathology, predict outcomes, and measure the impact of interventions. Dr. Kiehl and his team travel to prisons across the country with two mobile MRI units imaging incarcerated individuals and forensic patients.
• More and more, brain imaging is considered in capital cases, because MRI provides valuable information for defense attorneys and prosecutors. For example, a man was charged with murder and his MRI supported a diagnosis of frontotemporal dementia with a behavioral variant, so he was able to plead not criminally responsible based on his illness – and was sent to a state mental hospital rather than to death row. The case of John W. Hinckley Jr., who shot former President Ronald Reagan and his press secretary, James Brady in 1981, was an initial case in which neuroscience and imaging influenced the verdict. The shooter's brain imaging showed enlarged ventricles and cortical atrophy, which supported a diagnosis of schizophrenia – particularly when compared with the imaging of age-matched controls.
• Structural and functional MRI is an adjunct to neuropsychological tests. Neuroscientists are elucidating patterns through artificial intelligence and algorithms that can be useful to civil and criminal cases.
• For example, age is considered a strong predictor of antisocial behaviors. To enhance accuracy, Dr. Kiehl's team has developed a neuroprediction model in which MRI quantifies brain age, which correlates closely with cognitive testing scores. So, brain age might be more useful for predicting behavior than chronological age. This study used more than 1,000 imaging studies of inmates. The data were analyzed using an algorithm called independent component analysis, which evaluates distinct neural circuits to identify components that predict age. In the next step of analysis, the algorithm identifies patterns associated with reoffending. Younger brain age in the anterior temporal lobe and orbitofrontal cortex – brain areas associated with decision making – accurately estimates the risk of reoffending better than just chronological age.
• Based on an understanding of brain plasticity, dogma suggesting that people who commit violent crimes cannot be changed should be challenged. A group at the University of Wisconsin, Madison, was asked to create an evidence-based, multimodal treatment program for the hardest-to-treat violent juvenile offenders. The program, which includes interventions such as multisystemic family therapy and positive reinforcement contingency treatment, resulted in a decrease in reoffending and violent crimes in participants who received 10 months of treatment. Dr. Kiehl's group followed up with those juvenile boys using MRI to evaluate what had changed in their brains, how much treatment is required, and how or whether those brain changes can be reinforced. Reduction in incarceration costs is a return on investment for the states that fund those types of programs.

Take-home points

• If scientists can identify useful interventions and identify brain changes though imaging, perhaps science can affect outcomes such as societal violence and incarceration rates.
• Implementation is the primary short-term obstacle. This type of research needs more funding and institutional change to identify programs that work.
• The brain has an incredible amount of plasticity, which translates into opportunities for change.

References

The Mind Research Network

Kiehl KA. The Psychopath Whisperer: The Science of Those Without Conscience. Random House, 2014.

Kiehl KA et al. Age of gray matters: Neuroprediction of recidivism. Neuroimage Clin. 2018;19:813-23.

Steele VR et al. Machine learning of structural magnetic resonance imaging predicts psychopathic traits in adolescent offenders. Neuroimage. 2017 Jan 15;145(Pt B);265-73.

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