On this occasion, we bring you a post that discusses FCD and the importance it plays in rehabilitation. Due to the length and relevance of the content, it will be published in two parts. The first part can be found below.
What is Lack of Deficit Awareness (FCD)?
In 1991, Prigatano and Schacter defined awareness as the ability to perceive ourselves relatively objectively, while maintaining a sense of subjectivity. In this definition, the authors differentiate between distinct processes: the conscious experience of oneself (self-awareness) and the ability to perceive ourselves objectively (related to abstract thought) and to realize how we are and how we feel in specific situations.
Based on the previous definition, Lack of Deficit Awareness (FCD) is the clinical phenomenon in which the person does not seem to be realistically aware of their own neurological, neuropsychological, and socio-functional impairment, which is obvious to the professional and those around them.
The influence of FCD on the rehabilitation of individuals with neurological disorders
The importance of assessing FCD in individuals with neurological diseases lies in the relevance its presence can have for developing the rehabilitation program, from objective planning to the execution of the exercises, activities, and guidelines themselves. In other words, its presence will inevitably have an impact on the planning and execution of neuro-psycho-social intervention.
The presence of lack of deficit awareness negatively interferes with different aspects of rehabilitation, posing a barrier that the professional must decide whether to confront or circumvent. In fact, various pioneering authors in the study of this phenomenon and its implications in the rehabilitation of individuals with brain injury (among whom Prigatano, Klonof, Schacter, and Fleming stand out), suggest that FCD should be addressed as an important step in any rehabilitation process, provided the person is able to actively participate in said process, and can establish a bidirectional relationship between themselves and the physical and social environment.
Therefore, the first step should be to consider the cost-benefit of an intervention aimed at improving self-awareness of the illness, taking into account the possible emotional and behavioral problems that may emerge as a result of a more realistic understanding of their situation.
Undoubtedly, as we mentioned, the lack of deficit awareness poses a barrier to rehabilitation insofar as it causes a distorted self-perception and an unrealistic understanding of the environment. For this reason, it often leads to motivation problems and lack of involvement in treatment. Furthermore, the lack of deficit awareness can pose an added problem for the functional independence of the person who is unaware of their limitations and their need for support, whether physical or human.
Since awareness is our vehicle for interaction with the world, FCD inevitably affects the person-environment relationship. Therefore, not only do they perceive it in a distorted way, but they are also not able to adaptively and functionally manage the demands of the environment, which in turn can trigger certain emotional and/or behavioral problems.
However, on the other hand, the presence of lack of deficit awareness can act as an “emotional protector”, because the lack of awareness of reality prevents the appearance of emotional symptoms linked to the sense of loss (which would appear in the context of a grieving process in a person with ABI and awareness of the problem).
All in all, it seems important to at least take this phenomenon into account and assess the presence of FCD in the face of a neurological disorder. In doing so, we must understand that lack of deficit awareness could be considered a disorder in itself due to the complexity of factors involved in its presence and manifestation. Over the years, several authors have proposed theoretical models to explain FCD and provide guidelines or keys for its intervention. Among them, the Dynamic Model proposed by Toglia and Kirk stands out. These models, although they differ in some points or approaches, agree in determining that FCD is a continuum, and therefore, its presence or absence should not be determined in absolute terms. Thus, we would say that partial FCD exists.
One way to understand partial FCD from a neuro-psycho-social point of view is the one proposed by Fleming, Strong, and Ashton in 1996, in which they identify three levels: awareness of problems understood as knowledge of deficits, the implication of these problems on functional and occupational capacity, and finally, awareness of the need to use compensatory resources to reduce their impact on daily life.
Thus, taking this model into account can serve as a guide to evaluate this phenomenon, understanding that identifying a lack of awareness in certain aspects can be key to adapting the rehabilitation process to the personal needs of the target case, which is a primary objective in any neuropsychological intervention.