Friday, 12 November 2010

Diogenes Syndrome and the Mental Health Act

Members of the public often become very alarmed and even affronted and incensed about people in the community who chose to live in unusually squalid or insanitary conditions. Complaints may be made to the police or social services, with demands that “something” must be done about them. In extreme cases, there can be considerable media publicity about people found dead in their homes surrounded by filth and clutter.

Social Services are often the first to be contacted about such people, as are secondary mental health services. Over the 35 or so years I have been a social worker, I have worked with many of these people. While the majority of them exhibit signs of eccentricity and often an unwillingness or inability to engage in social interaction with others, I have found few of them to have had any significant mental illness or disorder. Often, the focus of work with them has been, not necessarily to significantly change their living conditions, but to support them in the way of life they have chosen while trying to reduce risks to their health and safety, and to protect them from the antagonism of the local community.

I’ve already written on this blog about a couple of cases where I have assessed people who were living in conditions deemed unacceptable or hazardous: Harry, an elderly man, whom I wrote about in July and December 2009, and Stella, a middle aged woman, in October 2010. The psychiatric grounds for detention of Harry were tenuous, and Stella, although eccentric, showed no signs of mental illness.

I was recently asked to assess Bernard, a man in his 50’s who was living alone in such conditions. His GP had made an urgent referral after being called out to him by the local Police Community Support Unit. She reported that: “The house is uninhabitable and is a health risk to the patient and his neighbours. There are strewn newspapers and garbage piled high to the ceiling in the rooms, the walls are coated with black dirt. His feet are purple and his toenails are about 10 cm in length. I could not see beyond the dirt on his feet to tell if he has gangrene. He will need a mental health assessment for the possibility of Diogenes Syndrome.”

Pretty nasty, then. Very alarming. Something certainly had to be done. So I decided to see him for a preliminary assessment with a nurse from the CMHT. In the meantime, something niggled at me. Bernard? Bernard? Hadn’t I assessed someone under the MHA in the dim and distant past with that name? Looking through my records, I discovered that I had indeed assessed someone of the same name and age, but with a different address, all of 18 years ago. I had a dim recollection of the circumstances: he had been living with an elderly aunt and uncle who had both died and he was in the process of being evicted from their council house as he did not have a tenancy. All I could now recall was that I had not detained him under the MHA, and he had not become a patient of the CMHT.

When we arrived his front door was open and he was standing in the lobby with a pile of shoes in front of him trying to find a pair that would fit. This meant that we could see the state of his feet. I could confirm that his toenails were actually only 1 or 2 cm long ( ½ inch rather than 4 inches), and that his feet were extremely dirty. He eventually managed to put a suitable pair of shoes on and was able to attend to our visit. He had long, greasy hair, a straggly beard partially obscuring his grimy chest, and was wearing a stained and filthy waxed jacket, and, as far as we could see without looking too closely, very little else.

Although he invited us into the flat, in view of the smell emanating from the open doorway, and the fact that the door could only open a little way because of the junk in his hallway, meaning that we would have to squeeze through the narrow, and very dirty opening, we decided to conduct the assessment in the lobby outside.

Throughout the assessment, he presented with excellent recall of dates and events throughout his life. He immediately recognised me from our encounter 18 years previously, and recalled the exact year and the circumstances. He was orientated in time and place. There was no evidence of dementia.

In fact, on interview, Bernard presented with no evidence of mental disorder. He certainly fulfilled the criteria for a diagnosis of “Diogenes Syndrome”, but as I have observed before, that is not in itself a mental disorder. There was no evidence of psychosis or delusional thinking. Objectively he did not appear depressed, and stated that he did not think he had any mental health problems. Although there appeared to be a history of anxiety, he did not present as anxious, and in fact welcomed the opportunity to converse with us. He did not express any significant concern about his living conditions, although did admit that the house was untidy, and did not feel that he needed any help to sort it out. In short, despite the objectively appalling state of his living conditions and personal hygiene, there was no evidence that this had arisen as a result of a mental disorder, and there was consequently no evidence at all that could justify his detention in hospital under the Mental Health Act. Indeed, he did not even meet the eligibility criteria for receiving services from the CMHT.

An interesting article in Clinical Geriatrics (Volume 13 - Issue 8 - August 2005: “Diogenes Syndrome: When Self-Neglect is Nearly Life Threatening” -- Badr, A, Hossain, A , and Iqbal, J) gave a similar case study. Although concentrating on the geriatric aspects of Diogenes Syndrome (most of the people I have seen have not been elderly) the article reaches some interesting conclusions. The authors quote Karl Jaspers, who: “proposed that this condition does not constitute a newly occurring psychopathological entity, as the whole picture is understandable from each subject’s personality and stressful life events. He emphasized that the characteristics of the premorbid personality play an integral role in the pathogenesis of the syndrome. His view of this syndrome was that it represents a lifelong subclinical personality disorder, probably of a schizoid or paranoid type, that turns gradually into gross self-neglect and social isolation.” In other words, it is something that can slowly creep up on slightly odd people over a long period of time

This analysis would certainly accord with my own experience of people with this presentation, and would certainly apply to Bernard, who reported that he had received psychiatric care, including ECT, as a teenager, although it was unclear why, and until his aunt and uncle had died had always lived in the households of others, and had therefore probably never acquired the skills to maintain his own household.

So what could be done with Bernard, and others like him? Since he could not be said to lack capacity, the “best interests” powers under the Mental Capacity Act, which permit people to take actions on behalf of a mentally incapacitated person on the basis that the action is in their best interests, would not apply to him. People have a right to make “unwise decisions”, providing they have capacity to do so. This could include such “unwise” actions as drinking too much alcohol, marrying someone you hardly know on a whim in Las Vegas, or refusing to wash for months or years.

Possibly the only route to addressing Bernard’s circumstances through legislation rather than gentle persuasion would be Sec.47 of the National Assistance Act 1948, which provides powers of “removal to suitable premises of persons in need of care and attention.” Although it might be thought that an Act created by the new landslide Labour Government just after the Second World War would long ago have been repealed, this still remains on the statute books.

This is a legal power that is quite often talked about in social work circles, but very rarely used. It has to be established that "The person is suffering from grave chronic disease OR being aged, infirm, or physically incapacitated, is living in unsanitary conditions AND the person is unable to devote to himself and is not receiving from other persons proper care and attention AND his removal from home is necessary either in his own interests or for preventing injury to the health of, or serious nuisance to, other persons". If all of these conditions can be satisfied, the person can then be taken to a hospital or a care home for medical treatment or care against their will.

I have only ever been involved in one such case in my entire career, and that was over 30 years ago. It involved an elderly lady living alone who was no longer able to manage and was becoming increasingly frail and weak. Although she did not have dementia, she consistently refused all offers of help and support. An assessment under Sec.47 of the National Assistance Act 1948 was undertaken, involving a “community physician” but when it came to it the lady, clearly impressed by this doctor’s title, agreed to go into hospital voluntarily.

However, even this power is now more than likely to fall foul of more recent legislation. The Department of Health has suggested that Sec.47 could be in breach of the Human Rights Act. In a brief guidance document published in August 2000 ("The Human Rights Act, Section 47 of the National Assistance Act 1948 and Section 1 of the National Assistance (Amendment) Act 1951"), it reasonably notes that use of this section may breach Article 5 – the right to liberty, and Article 8 – the right to respect for private and family life. So gentle and persistent persuasion to accept assistance probably remains the only option for trying to help people like Bernard.

Phew! A bit of a dry and technical post today, perhaps. Back to foul language and more threats of bodily harm to AMHP’s next time.


  1. I couldn't find an email/contact button on the blog, but could i ask if there are any long term implications from being sectioned? Will it impact on any future decisions at all, that you know of?

  2. That is a fairly complex question.
    Being detained under the MHA can have an effect on obtaining a visa to enter the USA.
    In the UK, there is extensive antidiscriminatory legislation that prevents employers from discriminating on the grounds of disability, including mental illness. Local authorities are generally particularly good at antidiscriminatory employment practice. I have known social workers and health care professionals who have been detained under the MHA with severe mental illness, including bipolar affective disorder, who have subsequently gone on to obtain professional posts despite their history.

  3. thanks for this post -i often get called out to see people in similar positions as bernard and i often reflect about what we can do or even whether we should do anything, i have always been interested in social norms and how some other professionals expect us as social workers to have the powers to make people conform.

  4. From a S12 doctor point of view, I quite enjoy assessing people with potential Diogenes Syndrome (provided I don't sit down anywhere too grubby inside their home!). It's relatively straightforward to exclude mental disorder and get a grip on what can (or more usually, as you suggest, can't) be done, then you can enjoy listening to their eccentricities for the rest of the assessment.

    They always seem to have some unusual stories, hobbies or interests. Which, I guess, would be consistent with the idea of it being a subclinical personality trait which is later elaborated upon rather than a separate mental disorder.

    The last fellow I assessed with a similar presentation a few weeks ago had a hobby of making model aircraft. The contrast between the neatly-assembled, carefully-painted aircraft and the squalid nature of the property and himself was quite striking.

  5. I can't go into the long story of why I am asking, but do you know why our LA would have no AMHP in Children's Services?

  6. Our LA also, as far as I know, have no AMHP's who work in Children's Services. One reason is that Adult Services and Children's Services are now completely separate parts of the LA. Another is a children's services manager would tend not to think it a priority to send one of their social workers on a long course to train as an AMHP, only to lose them for 3-4 days a month when they're on the AMHP rota. In fact, there are precious few AMHP's from Older People's or Learning Difficulties teams for much the same reasons. In fact, it would be useful and professionally appropriate to have Social Workers who specialise in those service user groups to conduct MHA assessments on their own service users. Personally, I am most comfortable assessing adults with mental health problems, as they are the people I work with every day.

  7. I happened across this blog post whilst turning to 'google' for some reassurance about my approach to managing my father in law who like 'Bernard'lives in an environment that to most is just not acceptable.

    As an occuaptional therapist with experience in acute and community mental health services, i feel confident in saying that like Bernard my father in law does not demonstrate any true mental disorder and whilst he too may meet the criteria for diogenes syndrome, i aks the question....what difference would it make to slap that label on him?

    Does he live in squalor?..... Yep......Is he a recluse?......Yep........Does he prioritise whiskey and cigarettes over food and paying the bills?....Yep.....Does he refuse to see his GP despite multiple physical health needs?......Yep..........Does he only get in touch when the bailifs are coming?.....Yep....... But can he keep his car imacualtely clean and complete the times cross word every day? Yes he can!......Is he aware of the choices he makes and in control of his actions and decisions?........sadly for my husband.....Yes he is.
    Which is why now and again i feel the need to seek some reassurance from somewhere that my refusal to accept and support the belief that my father in law is 'mental and needs sectioning' inorder to make my husband and in laws feel better about the circumstances is justified.
    Despite my training and expereince as an OT i have to admit that trying to support some one who is in the situation like my father in law and Bernard is a mighty big challenge. Supporting a person to accept that their dad can't be taken to hospital or given a magic pill to change things is even harder.

    So the unconditional love and support continues, trying to instill new roles and motivation won't stop, the attempts made in vain to sort out the house and prevent eviction will carry one, the crisis calls from those in the affluent rural village where he lives won't stop......... And sadly neither will the heart ache that my husband carries because he can't understand who or what his father has become.

    Keep up the good work Masked AMHP!

  8. Is there a link with Diogenes and aspergers I wonder?

  9. Re: the comment about AMHPs outside CMHT settings. Small and rural counties are generally better about having AMHPs based in other team settings and I think this genuinely helps. I've encountered childcare background social workers who've been Approved after transferring to out of hours teams. This is a good thing but the most serous gap is the striking lack of AMHPs employed in Child and Adolescent Mental Health Services. There is a requirement for organisations considering commissioning assessments from Best Interest Assessors under the Deprivation of Liberty Safeguards to try and find staff with appropriate professional experience, one presumes so that this can inform their judgements. A very sound principle. I find know-it-all AMHPs from under 65 Mental Health settings who try to relate everything to their practice with relatively young and fit people with psychotic illnesses can be a bit of an occupational hazard. (Although obviously, I have no problem with appropriately humble and thoughtful AMHPs such as the Masked AMHP).

  10. My eldely neighbour (86) is happily living in her own feces, her fecal matter covers every surface of her home. She pushes it by hand down the plug hole of her kitchen sink. The place is infested with maggots, roaches, mice and flies. Because of the stench I called the Environmental Health team and officers have condemned the property and will be gutting it some time next week, including all santitary ware and fitted kitchen.

    Both Adult social services and her GP say they cannot force her to leave and have refused to assist us (her neighbours in a private block of flats), indeed her GP suggested that we get her evicted! Social Svs best offer was that she walk to a homeless hostel.

    At what point can such behaviour be classed as a danger to the individual and others?

  11. An elderly person should be regarded as vulnerable by both social services and the local housing dept. and should therefore be entitled to assistance, eg with housing -- possibly sheltered housing or a care home. However, she would have to agree to this, unless it can be established that she has a mental disorder -- in her case, probably dementia. If she is assessed as having dementia and lacking capacity, then things can be done to help her even if she does not agree as long as these are considered to be in her best interests, under the Mental Capacity Act.
    The trouble is, many people who live in unacceptable conditions often have capacity, as in the two examples I have given in my blog. In such cases, legal enforcement through environmental health, injunctions, or even ASBO's, is the only option.

  12. Thank you for a prompt response, it appears we are going down the environmental health route for the moment. They are comming on Wednesday.

    She passed the mini mental health test delivered by her GP on friday but becomes agitated and upset as soon as her double incontinence and smearing activities are mentioned, refusing to talk about it. By the end of this week she will be living in an empty shell with no toilet, bath, sink or furniture of any kind. I wonder how much more unacceptable her behaviour will have to be before someone in social svs agrees to take some sort of action to support this poor old woman.

    Even if she does survive in an empty concrete shell for a few weeks, her smearing will lead us to the Environmental Health route as the stench returns.

    I find it very hard to get my head around the idea that living in your own feces is not a indicator of a mental health probelm... sheesh!

  13. It sounds like she needs a proper assessment by a psychogeriatrician. If she has a nearest relative (or any relative) they can ask for a formal assessment under the MHA (Sec.13(4)). The GP really ought to ask for a formal assessment by a psychiatrist and AMHP in this case. That is not to say that she actually has a mental disorder; however, like the elderly man I didn't, then did, section, it would probably not be difficult to find evidence of dementia which could at least justify assessment under Sec.2 in hospital.

  14. Dear Masked AMHP, I am impressed with your blog. Many of the case studies I have read so far are familiar to my own experience as an AMHP in the north-east. thanks

  15. I find it totally outrageous that they are removing everything, even the bath and toilet, instead of trying to clean the house. I realize that many items are probably beyond cleaning, but they are just throwing her property away, including the very equipment that could be used to ensure hygiene.

    1. Thank you for speaking up.
      Who has the problem?
      The elderly lady making her own choices?
      Or noisy neighbours trying to control everyone's behaviour?
      Improve yourself not your neighbours that you are passing judgement on.

  16. Incredible - after YEARS and YEARS of trying to understand the CRAZY behaviour of a relative - this is it. Thank you for this blog, it doesn't change anything but to read this happens... it's felt like a never ending nightmare and at times as if I was the crazy one for imagining what was happening.

  17. As an AMHP I have encountered this syndrome a few times. I am concerned in the case you describe that you decided this person had no mental illness without arranging for a doctor to see the person. The first two people in the community who were referred to me because of their self-neglect and squalor would, like your service user, have not appeared to have a mental illness. They could answer well, had good memory especially of events in the past, and had no apparent psychosis or other obvious signs. Both in fact had Picks Disease in Dementia, a frontal lobe type of degenerative brain disorder which can manifest slowly over 20 or 30 years with never enough obvious signs to be formally assessed until the very late stages but giving rise to all sorts of odd personality and self-neglecting behaviour, inability to parent adequately, etc. Both my service users died within 18 months of first coming into contact with MH services (one after being discharged by the MH team whilst I was away training). A third is now in 24 hour specialist hospital care for early onset dementia. AMHPs have no medical training and shouod be careful about assuming someone 'has no mental illness'. We also need to be sensitive to the context of referral and care, and to provide holistic assessment which includes drawing together the relevant experts in psychiatry and neurology to give the best possible service to vulnerable adults in our care.

  18. I have had a very prolonged and continuing very stressful problem with my mum behaving like this - it's now 2 years since I contacted her GP (but the problem has been there steadily getting worse and worse for many years ... and she is a chronic agoraphobic) -which subsequently triggered off visits from health vistors; psychiatric doctor and nurses; psychologists ... we are no further on trying to help her as she continually and aggressively refuses any offers of help - NO is the word she uses most frequently (since we insisted on going in 2 years ago, cleaned/tidied for a week - she has not done any cleaning since); she has (outdoor) plants in every room; soil on the floor; dirt everywhere; doesn't wash herself properly; hair not washed (self cut); clothes worn day after day, not washed; somehow sleeps (badly) on a bed without bedding but cluttered with everything else; has purchased every cleaning product available (uses none); expensive beauty products; multiple items such as foot spas, kettles, bedding, curtains ...; her general health is slowly getting worse; she denies EVERYING - she and her house are clean and tidy basically. Yet because she exhibited no memory problems NOTHING evidently can be done - she is CHOOSING to live (exist)like this ... to see her like this is soul destroying, frustrating and it's making me ill - PLEASE someone suggest something to help ... really am desperate ...

  19. To add to the above: when we went in to clean we tried to involve her and at times she did respond to my daughters. We found she had not washed up (sink was over full with dirty pots) - instead she had kept buying, using and then storing dirty pots and cutlery - we found something like 100 of each - plates, mugs, bowls, and cutlery in boxes all over the house.

  20. I am a trainee AMHP and a relatively experienced social worker working with homeless people with mental health problems. My anecdotal experience of working with people who do not initially appear to have any major mental health problems despite levels of self-care that pose significant risks to themselves (from food poisoning to continued homelessness following amputations for frost bite, living in a bin cupboard etc) is that there usually are underlying psychotic, paranoid and delusional ideas. My concern is that as an amhp in a 30 minute assessment you do not identify what it may take 6 months of careful relationship building to ascertain. While I understand that the doctors cannot make their recommendations without such background information and hence compulsory treatment is not possible, i am dubious of the conclusion that there is often no mental illness underlying this behaviour. Services should be alert to the risks posed by such behaviour and actively engage with the clients on whatever terms they will tolerate rather than just saying there is nothing we can do - s/he is not detainable.

  21. Where can I find information on Diogenes in younger people. My daughter is only 20 and shows signs of having Diogenes. She has a job and is really good at her job, she is very fastidious with cleanliness at work. But at home she lives in absolute squalor. She is a very caring and giving person, but doesn't have any friends. I would like to know how I can help her to live a normal life, she is to young to spend it this way.

  22. Do not pathologise your daughter -- what you are describing could be regarded as perfectly normal. If she is tidy in her public life but leaves her room in a state, this is definitely not unusual for teenagers or even 20 year olds. I am not sure there is any such thing as a diagnosis of Diogenes Syndrome in young people, if indeed you can really describe Diogenes Syndrome as a disorder in itself.

    1. Then what do you call a 29 yr old who fits all the above except for age? She refuses to let me clean for her or go to counseling. She lives in total filth and I am scared to death she will get pregnant and bring a child into her world of filth, garbage, animal excrement, rotting walls and rotting floors.
      People like you give the ridiculous answer of, "It's perfectly normal for that age." Then when they enter adulthood, they say, "Why didn't you do something when they were younger"! BEYOND frustrating!

  23. As per the poster above,I have a friend who is in her mid 20s. She is the mother of two small children. It has only just come to my attention that she is living in squalor. Not really sure where to go to from here. The squalor includes broken glass, dirty dishes that have been there for weeks and curtains nailed to the windows. My concern is primarily for the children, but want her to get help too. She seems to fit most of the symptoms of this syndrome, including a reluctance to seek or be helped.

  24. Ah, I've just lost a longer comment; apologies if it somehow appears and I repeat myself.

    Question: Is reclusiveness and a fearful/paranoid orientation absolutely central in this syndrome? My Diogenes has always been highly extroverted (though relationships have been superficial) and charming. All other behaviours, including superstitious and compulsive ones, are present.

    Response to other family members: I am coming to believe that harm reduction is the only reasonable family/social response as of 2012. Google 'harm reduction hoarding' for more on this idea. While I feel quite sure this is neurologically grounded*, as of now there are no effective treatments. You can, if you want, get them loaded up on antipsychotics or antidepressants; call in the city; but nothing will change, really. It will only amplify the misery, isolation, and despair. And cost.

    Harm reduction involves:
    - accepting the intractiability of the problem and
    - mitigating health risks.

    I.e.: accept that this is a permanent situation. Expect no change, and work towards a long-term strategy that the person does not perceive as hostile.

    Choose your battles (pest control is more important than dust) and key areas (kitchen, bathroom, sleeping area matter more than the den). Get help with the heavy work, from people the Diogenes trusts, vs authorities.

    Health events, in my experience, elicit more compliant behaviour than legal ones, and may present opportunities to get 'in'. (It's about them, right?) Concern expressed in a loving, respectful way gets a better response than anger or fear-driven attempts to communicate.

    My plan now is to plan - to do what I can do, and think is reasonably safe, and hope for no more. Shooting for 1-2 monthly deepish cleans of the key areas mentioned above, with weekly light cleaning, and an all-round clean 1-2 times a year. Will limit my time doing this to save myself and everyone else - it's nerve-wracking for him as well. Luckily I have two local siblings who are on board for now; we can each do an hour a week.

    Something else: on the first sign of hostile and energized opposition, give up. Fast. Move on to some other activity or discussion, which engenders trust. Something Diogenes cares about, or something else positive or at least neutral. Try your luck another day.

    I have better luck when I have spent more time with my person. On the order of a full day. He then relaxes around me. There is room for a dynamic *not* about hoarding or hygiene. More is permitted, then.

    Finally: I guess most of those who worry about people in this situation are family. I feel we have to think very much not like family to be of use. It's difficult not to think of what we see as the degeneration of a parent. Or to still anger that comes from a lifetime of living with a 'difficult' person. Or be shocked by what we see. Forget all that.

    For one hour, you have before you not your father or mother, but an old, vulnerable person, whose health is compromised by breathing in fecal matter made by rats. Don't feel or poeticize it. Get rid of the rats.

    I don't believe there's any way this is merely psychological. It's just that our legal, societal, and medical views of personhood, capacity, and free will are simplistic and confused.

  25. For family members: I would like to recommend the book 'Digging Out: Helping Your Loved One Manage Clutter, Hoarding & Compulsive Acquiring' by Michael Tompkins et al. It's a guide to using the harm reduction approach (involves a risk assessment & action plan; offers advice on communicating with a hoarder, feelings and practicalities around dealing with authorities (eg, 'when to include legal help'), financial and legal issues, dementia, self-neglect... all written with the aim of supporting family members in dealing with the ups and downs of these processes. It addresses the shame and resentments family have, and offers initial advice on empathy and mutual forgiveness (though of coure it cannot fully address this, further resources are recommended). Highly sympathetic and practical.

    Professionals might be interested in looking at the Gatekeeper model, a client-centred, harm reduction approach that respects the hoarder's autonomy (legal and otherwise), and emphasizes easy referral. An example is the Gatekeeper program run by Hamilton Catholic Family Services, in Hamilton, Canada.

  26. I met a man about a year ago, and if you hadn't said this man's name was Bernard, I would have thought you were talking about him. I wanted to help him, and my husband and I visited often enough that we gained his trust and he asked us if we wanted to move in. We agreed, and are living here now. We've spent the last year cleaning up the house, painting the walls, as they were covered with grime, and hiring help to fix plumbing issues and structural faults in the house. We still have a lot of work to do, though. We've made a lot of process as far as his environment goes, but we've been unsuccessful so far in coercing him to bathe, eat regularly, or get up out of his chair and move around a bit. He's extremely malnutritioned. His calves are as big around as my wrists. I thought that he was just odd and severely depressed, and needed some people in his life to encourage him to get up and moving again, but after a year of failed attempts, and researching conditions such as his, I think he needs professional help, but I'm afraid that if we push unwanted help on him, he'll view that as a betrayal of trust on our part and everything we've worked for in the last year will be for nothing. I guess all that is to say, what are our options? If he continues the way he's going, he will die. I feel that seeking professional help will do more harm than good, since it may cause him to deny the help from professionals, as well as the help he's receiving from us, but I also feel that I'm in way over my head, and if he passes away I don't want that to be on my conscience, and I especially don't want to be held legally responsible for his death, if we knew of his condition but failed to seek professional help.

  27. Steve Macfarlane6 July 2017 at 04:37

    Next time you assess someone living in squalor, I suggest you perform some bedside tests of frontal lobe function. Complex problem solving, abstract thought, planning and organisation are all likely to be impaired. Remember, the MMSE is insensitive to frontal deficits, and is an insufficient cognitive screen for such cases.
    Where does 'mental disorder' end and 'neurological impairment' begin under the MHA?
    To respect the decisions of someone with capacity is to empower them. To respect those of someone lacking capacity is to abandon them.