Clinical assessment of decision-making capacity in acquired brain injury with personality change

Gareth S Owen,Fabian Freyenhagen,Wayne Martin,Anthony S David

doi:10.1080/09602011.2015.1053948

Gareth S Owen, Fabian Freyenhagen + Show 2 more

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https://doi.org/10.1080/09602011.2015.1053948

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Abstract

Assessment of decision-making capacity (DMC) can be difficult in acquired brain injury (ABI) particularly with the syndrome of organic personality disorder (OPD) (the “frontal lobe syndrome”). Clinical neuroscience may help but there are challenges translating its constructs to the decision-making abilities considered relevant by law and ethics. An in-depth interview study of DMC in OPD was undertaken. Six patients were purposefully sampled and rich interview data were acquired for scrutiny using interpretative phenomenological analysis. Interview data revealed that awareness of deficit and thinking about psychological states can be present. However, the awareness of deficit may not be “online” and effectively integrated into decision-making. Without this online awareness of deficit the ability to appreciate or use and weigh information in the process of deciding some matters appeared absent. We argue that the decision-making abilities discussed are: (1) necessary for DMC, (2) threatened by ABI , and (3) assessable at interview. Some advice for practically incorporating these abilities within assessments of DMC in patients with OPD is outlined.

Highlights

Assessment of mental capacity or “competence” is part of the medico-legal landscape in many jurisdictions
Brutton & Co. [2002]) (Rose, 2003). This is true of the subset of acquired brain injury (ABI) patients with frontal brain injury and organic personality disorder (OPD)—sometimes called the “frontal lobe syndrome” (F07.0; The ICD-10 Classification of Mental and Behavioural Disorders, 1992)
Patients did show evidence of awareness of deficit and thinking about thinking at interview. This phenomenon is important to make explicit at the outset and attests to the challenge of decision-making capacity” (DMC) assessment in this group and the problems that have been reported about face-to-face interviews

Summary

Introduction

Assessment of mental capacity or “competence” is part of the medico-legal landscape in many jurisdictions. Reflecting the decision-specific nature of the concept, the international literature is increasingly using the term “decision-making capacity” (DMC) and we use this term here. Patients with acquired brain injury (ABI) can present challenges for the assessment of DMC This is true of the subset of ABI patients with frontal brain injury and organic personality disorder (OPD)—sometimes called the “frontal lobe syndrome” (F07.0; The ICD-10 Classification of Mental and Behavioural Disorders, 1992). The primary tool in DMC assessment is the interview but the forms of dysfunction associated with this group may manifest more readily outside the interview than in it— as impulsive or unwise decision-making—and during the interview patients may appear surprisingly unimpaired

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