Exploring Avolition: Schizophrenia And Low Motivation

Schizophrenia is a severe mental illness typically characterized by an array of symptoms that can result in significant life disruption. While most commonly associated with positive symptoms like delusions and hallucinations, schizophrenia’s negative symptoms can be just as disruptive. Chief among them may be avolition, or motivational impairment, which can affect a person’s ability to start and complete tasks. Often, treatment options like medication and therapy can be helpful for both positive and negative schizophrenia symptoms, including avolition.

What is avolition?

A person with avolition may exhibit a general disinterest in engaging in activities or pursuing personal goals. In general, avolition is not simply a matter of being unmotivated or lazy. This symptom can be seen as a significant reduction in a person’s motivation to start or complete tasks. The exact cause of this motivational impairment is not yet fully understood, but avolition is usually believed to involve dysfunction in the brain's reward system and frontal lobe, which tend to be involved in motivation, planning, and goal-directed behavior. Treatment and management of avolition are often challenging and usually involve a combination of doctor-prescribed medication and supportive psychotherapy.

Why avolition is a symptom of schizophrenia: A neurological explanation

Imagine facing a choice between an easy task with a small reward or a challenging task with a bigger payoff. Most people weigh the effort against the reward before making a decision. This process, known as effort-based decision-making, is something our brains typically do constantly, integrating information about the rewards we expect and the effort required to achieve them. However, for individuals with schizophrenia, this decision-making process can be significantly impaired.

Neuroscientists have found that our ability to make these decisions usually depends on specific neural circuits in the striatum and anterior cingulate cortex (ACC). These parts of the brain are primarily responsible for weighing potential rewards against the effort required, allowing us to quickly weigh effort against payoff. Dopamine, a neurotransmitter that typically plays a role in motivation and reward, tends to be the driver of these neurocognitive processes, encouraging us to undertake effortful tasks if the reward is deemed “worth it.” In people with schizophrenia, these brain regions usually don't function as effectively. This may be due to the dopamine abnormalities that can be associated with the condition. 

Studies using neuroimaging have shown that individuals with schizophrenia often have lower activity in areas like the cingulate cortex and the ventral striatum when making decisions about effort and rewards. This reduced activity suggests that their brains may not value rewards and efforts in the same way as those without schizophrenia, which can make it harder for them to choose and engage in more effortful tasks, even when significant rewards are at stake.

How does a lack of motivation affect people with schizophrenia?

Avolition can affect individuals with schizophrenia by significantly impairing their ability to initiate and participate in a wide range of activities, from basic self-care to more complex social and occupational engagements. Here's how avolition can impact those with schizophrenia:

• Self-neglect: People experiencing avolition may neglect self-care practices, including grooming and personal hygiene. This neglect can lead to further social isolation and health concerns.
• Withdrawal from activities: There can be a noticeable lack of interest in activities that require effort or planning. Individuals might spend excessive time in passive activities, like watching TV, without genuine engagement, potentially contributing to the deterioration of their physical and mental health.
• Social isolation: Avolition often contributes to social withdrawal, as affected individuals typically show little to no interest in maintaining social connections, engaging in conversations, or participating in group activities. This isolation can exacerbate other symptoms of schizophrenia and contribute to a decline in quality of life.
• Impaired occupational functioning: The motivation to pursue educational or vocational goals can diminish. This may result in difficulties in finding or sustaining employment and achieving academic success, further affecting the individual’s ability to live independently.
• Emotional detachment: Unlike those with depression, individuals with avolition don't always express typical signs of sadness or anxiety. Instead, they might experience an overall sense of emptiness, which can complicate the recognition and treatment of their condition.
• Cognitive and social consequences: Avolition may be linked to poorer cognitive function and social outcomes. Avolition can mediate the relationship between cognitive impairment and social difficulties, meaning that a lack of motivation can make cognitive and social challenges more pronounced.
• Challenges in treatment and management: Rating avolition and understanding its impact can be challenging due to its subjective nature and the influence of external factors, such as social and economic deprivation. This complexity can make devising effective treatment strategies more difficult.

Understanding negative symptoms of schizophrenia

Unlike positive symptoms that can add abnormal experiences (such as hallucinations and delusions), negative symptoms usually involve the absence of “normal” emotional responses or thought processes. 

Clinicians currently recognize five main negative symptoms of schizophrenia:

• Avolition: As noted above, avolition generally refers to motivational dysfunction. People experiencing avolition may not be compelled to maintain basic self-care routines, pursue work or educational goals, or engage in activities that might otherwise be enjoyable.
• Anhedonia: Anhedonia can be characterized by a diminished ability to experience pleasure in activities that might otherwise bring joy or satisfaction. 
• Emotional blunting: Those with schizophrenia often show a reduced capacity to feel or show emotions, meaning that their facial expressions, voice tone, and gestures seem diminished compared to the emotional expressions typical in others. 
• Asociality: Schizophrenia may diminish a person’s motivation for social interaction. They may show little interest in forming close relationships with others, including family members and friends, and might prefer to spend most of their time alone.
• Alogia: Alogia can describe a reduction in the amount and content of speech. Those with schizophrenia may struggle to express themselves, fail to initiate conversation, or offer brief, unelaborated responses to questions.

Treatment for schizophrenia: Medication, cognitive behavioral therapy, etc.

For those living with schizophrenia, comprehensive treatment that targets both negative and positive symptoms is generally more effective at ensuring health, safety, and stability. Clinicians may begin by assessing the person’s unique symptomatology using a specialized test battery, such as the EMOTICOM. With a nuanced understanding of how schizophrenia may be affecting the individual, they may develop a treatment approach that combines pharmacological, behavioral, and social interventions.

Adjunctive medications

In addition to antipsychotic medications for managing positive symptoms like hallucinations and delusions (also referred to as psychotic symptoms), a psychiatrist may prescribe medications like SSRIs to target negative symptoms. Always consult your doctor before starting, stopping, or changing the way you take any kind of medication.

Psychotherapy/Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) has shown some promise in helping those with schizophrenia manage their symptoms. Meanwhile, psychoeducation may be beneficial for helping individuals gain knowledge and insight related to their illness and treatment.

Family and caregiver support

Providing education and resources for family members and caregivers can significantly improve a person’s support system, fostering a more nurturing environment that is conducive to treatment adherence and management.

Occupational therapy and supported employment

Interventions designed to enhance daily living and occupational skills can promote independence and social integration for people living with schizophrenia.

Supporting someone with severe mental illness can be challenging

Address your own well-being in online therapy

Mental health support for caregivers

If your loved one is living with schizophrenia, it may be worth considering how to manage your own mental health in light of your role as a caregiver. Caring for a person with a serious mental illness can be stressful and may sometimes overwhelm your ability to care for your own needs. Mindfulness-based cognitive therapy can be effective for helping caregivers better manage the mental burden of their role. In addition, psychoeducation may be beneficial for learning practical tips and best practices as they relate to caregiving. 

Online therapy platforms like BetterHelp can connect you with clinicians who specialize in these approaches. BetterHelp can offer a flexible, convenient way to attend weekly one-on-one therapy sessions, and with added features like interactive journaling and messaging with your therapist outside of appointments, you may get more out of your mental health investment.

Research suggests that online therapy tends to be just as effective as in-person therapy, as well as frequently being more affordable.