The quality of lack of ‘online awareness’ of deficit

1. Assessment of mental capacity can be hard in acquired brain injury particularly with the syndrome of organic personality disorder (the “frontal lobe syndrome”) where the ability to understand, retain and use or weigh information can seem present but a concern that the person ‘can talk the talk but can’t walk the walk’ is often heard by those who are familiar with the person’s behaviour.

2. Impulsivity is a common feature in these cases. A person may show awareness of this problem in their past and awareness of it during the interview giving the impression that they can/should learn from experience and be accountable for it. Additionally, impulsivity is a common human trait which is not determinative of incapacity by any means. However, before presuming capacity care must be taken in these cases to look at how a person’s awareness of impulsivity (or other problems) is integrated into their decision making. The awareness of impulsivity may not be “online” and a person may not be able to integrate the awareness into their decision-making.

3. An example from research carried out by members of the MHJ project team helps to highlight this quality. The following is an extract from an interview with a person with organic personality disorder who was aware of the negative effects that impulsivity had had on his life after brain injury.


I mean, for example, in the restaurant you had somebody kind of shout at you after you got irritated and you kind of got into an argument which had got a bit out of hand, and it sort of started because, whereas before you would have managed the situation, now you lose your temper?

Person with brain injury



Can you think of examples like that?

Person with brain injury:

Yeah it does happen. It does happen. [Noise from another patient in background.]

I’ll go out there and punch her on the f∗∗∗ing nose in a minute if she don’t shut up!

4. Here, the person is showing explicit awareness of being quick to temper. But even in the very act of expressing the awareness, engages in the behaviour that reflects the deficit.

5. Without an ability for online awareness of impulsivity, the ability to use or weigh information in the process of deciding complex matters (e.g. ongoing care needs or managing large sums of money) can be threatened. This quality of online awareness needs to be looked for carefully during interview and the interview needs to coordinate with other sources of information.

6. As for records of capacity assessments generally, it is advisable to document relevant parts of the interview with the person, describe relevant behaviour the person shows and reflect on discussions with others who know the person.

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