The Dictionary of Neurological Signs defines abulia as a "syndrome of hypofunction," characterized by lack of initiative, spontaneity, and drive, apathy, slowness of thought (bradyphrenia), and blunting of emotional responses and response to external stimuli.
In other words, abulia refers to a lack of will, drive, or initiative for action, speech, and thought. This term is derived from the Greek word aboulia, meaning “non-will.” This has to be distinguished from the inability to perform an activity due to cognitive or physical disability. This phenomenon has been known since 1838. Several terms have been used interchangeably with abulia: apathy, psychic akinesia, loss of psychic self-activation, and athymia.
Potential causes include:
Abulia is thought to be a common problem, but the national and international frequency is not reported.
Abulia is supposed to occur because of a malfunction of the brain’s dopamine-dependent circuitry. Lesions anywhere in the "centro-medial core" of brain frontal-subcortical circuitry, from frontal lobes to the brainstem, may produce this condition.
Diaschisis is the neurological phenomenon in which damage in one part of the brain results in functional impairment in a remote but interconnected location. This can be the mechanism behind the appearance of abulia in basal ganglia and thalamic lesions because of the complex frontal-basal ganglia-thalamic circuits.
The following structural lesions have been attributed in the etiology of abulia:
Classification and Clinical Features
Abulia Minor (Apathy)
Patients with abulia minor may comply with requests of others and participate in activities that other initiate, but will not initiate plans or activities of their own. Enjoyment and motivation and may or may not be present. They may say little spontaneously, but give brief responses when others speak to them. Some patients may “talk a good game,” telling others about some plans, but never follows through on them. Initiation is dissociated from volition.
Abulia Major (Akinetic Mutism)
The patient will initiate nothing at all, including speaking and eating, and may ultimately require total personal care. Akinetic mutism is a state of limited verbal and motor responsiveness to the environment in those without paralysis and coma. Patients may have open eyes and brief movements. In lesions involving the anteromedial lobes, speech and agitation to unpleasant stimuli may develop. The eyes of these patients are open and follow objects, and they are more alert than those with mesencephalic or thalamic lesions. The patients may also make brief, monosyllabic, but an appropriate response to questions.
"Miller Fisher's telephone effect" - Patients with abulia may sometimes talk at length fluently and animatedly over the telephone.
Diagnosis is mainly based clinically. Fisher’s “telephone test” where the patient responds during a telephone conversation but not during personal face-to-face contact, may be used to diagnose abulia minor.
Criteria for the diagnosis of abulia:
The treatment of abulia is by treating the underlying cause, if possible. Otherwise, it depends mainly on the drugs that increase the dopamine levels in the dopaminergic circuitry. These include:
The prognosis depends on the underlying condition causing abulia.
Patients with abulia may suffer from the following complications due to lack of initiative:
Patients with abulia are difficult to be motivated. Still, an active role played by a neuroscience nurse, rehabilitation physician, neurologist, and a psychiatrist can bring an effective outcome to the patient.
Healthcare workers should be familiar with abulia because it has a varied presentation that may lead to very high morbidity. Both the primary care provider and nurse practitioner should refer these patients to a mental health worker because the management is complex and long-term. The treatment generally depends on the cause, but not all treatments work. For treatments to work, the patient must also be compliant and have a mindset of improvement. Besides medications, cognitive behavior therapy has been used, but relapse rates are high. To date, there is no way to prevent abulia, and the disorder can affect any individual irrespective of age, race, gender, or ethnicity. Neuroscience and rehabilitation nurses work with occupational therapists and physicians to treat these patients. Pharmacists review prescribed medications and educate the patients and their families about side effects and compliance. The interprofessional team can improve outcomes. [Level 5]
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