abulia

Aboulia or Abulia (from the Greek "αβουλία", meaning "non-will"), in neurology, refers to a lack of will or initiative and is one of the Disorders of Diminished Motivation or DDM. Aboulia falls in the middle of the spectrum of diminished motivation, with apathy being less extreme and akinetic mutism being more extreme than aboulia. ^[1] A patient with aboulia is unable to act or make decisions independently. It may range in severity from subtle to overwhelming. It is also known as Blocq's disease (which also refers to abasia and astasia-abasia).^[2] Abulia was originally considered to be a disorder of the will.^{[3] [4]}

Symptoms and Signs

Aboulia has been described as a loss of drive including the loss of spontaneous motor activity, loss of emotional affective expression, loss of behavior and speech output, slowing and prolonged speech latency, and reduction of spontaneous thought content and initiative. ^[5]

Especially in patients with progressive dementia, it may affect feeding. Patients may continue to chew or hold food in their mouths for hours without swallowing it. The behavior may be most evident after these patients have eaten part of their meals and no longer have strong appetites. Caregivers can use sweet or salty flavored foods later in meals to provide interest and increase oral intake, but must always clear the mouth of food after each meal.

Differentiating from Other Disorders

Both neurologists and psychiatrists recognize aboulia to be a distinct clinical entity but its status as a syndrome was unclear. Although aboulia, which has been known to clinicians since 1838, It has been subjected to different interpretations from a pure lack of will, in the absence of motor paralysis to, more recently, being considered a reduction in action emotion and cognition.

Most notably, aboulia is commonly confused with apathy, depression, anhedonia, akinetic mutism, and alexithymia

Causes

Many different causes of aboulia have been suggested. As a result of more and more evidence showing that the mesolimbic and the mesocortical dopamine system are key to motivation and responsiveness to reward, aboulia may be a dopamine-related dysfunction.^[5] Aboulia may result from a variety of brain injuries which cause personality change, such as dementing illnesses, trauma, or intracerebral hemorrhage (stroke), especially stroke causing diffuse injury to the right hemisphere.

Damage to the Basal Ganglia

Injuries to the frontal lobe and/or the basal ganglia can interfere with an individual's ability to initiate speech, movement, and social interaction. Studies have shown that 5-67% of all patients with traumatic brain injuries and 13% of patients with lesions on their basal ganglia suffer from some form of diminished motivation.^[1] Abulia has also been associated with amphetamine withdrawal. It may complicate rehabilitation when a stroke patient is uninterested in performing tasks like walking despite being capable of doing so. It should be differentiated from apraxia, when a brain injured patient has impairment in comprehending the movements necessary to perform a motor task despite not having any paralysis that prevents performing the task; that condition can also result in lack of initiation of activity.

Damage to the Frontal Lobe

Damage to Anterior Cingulate Circuit

Acute Caudate Vascular Lesions

In a case study of 32 acute caudate stroke patients, 48% were found to be experiencing aboulia. Most of the cases where aboulia was present were when the patients had a left caudate infact that extended into the putamen.

Diagnosis

Diagnosis for aboulia can be quite difficult due to the fact that it falls between two other disorders of diminished motivation, and one could easily see and extreme case of aboulia as akinetic mutism or a lesser case of aboulia as apathy and therefore, not appropriately treat the patient. If it were to be confused with apathy, it may lead to attempts to get the patient involved with physical rehabilitation or other interventions where a source of strong motivation would be necessary to succeed but still absent.

Illnesses where Aboulia may be present

• Depression
• Schizophrenia
• Parkinson's Disease
• Huntington's Disease
• Progressive supranuclear palsy

Current Treatment

Most current treaments for aboulia are pharmacological, including the use of antidepressants . However, antidepressant treatment is not always successful and have opened up the door for alternative methods of treatment. The first step to successful treatment of aboulia, or any other DDM, is a preliminary evaluation of the patient's general medical condition and fixing the problems that can be fixed easily. This may mean controlling seizures or headaches, arranging physical or cognitive rehabilitation for cognitive and sensorimotor loss, or ensuring optimal hearing, vision, and speech. These elementary steps also increase motivation because improved physical status may enhance functional capacity, drive, and energy and thereby increase the patient's expectation that initiative and effort will be successful.^[1]

There are 5 steps to pharmacological treatment:^[1]

1. Optimize medical status
2. Diagnose and treat other conditions more specifically associated with diminished motivation (eg, apathetic hyperthyroidism, Parkinson's disease).
3. Eliminate or reduce doses of psychotropics and other agents that aggravate motivational loss (eg, SSRIs, dopamine antagonists).
4. Treat depression efficaciously when both DDM and depression are present.
5. Increase motivation through use of stimulants, dopamine agonists, or other agents such as cholinesterase inhibitors

References