Avolition

1. Overview — What Is Avolition?

Avolition is a state in which a person “lacks internal drive” to the point that they cannot initiate or sustain behaviors that have clear goals (goal-directed behaviors) as they normally would. This happens even when they “know” they should do something, and even when they “want to do it in theory,” but their inner energy simply does not move. As a result, taking action becomes almost impossible, even with very simple things such as taking a shower, turning on the washing machine, or replying to a friend’s message.

A key feature of avolition is that it is not the same as ordinary “laziness.” Instead, it reaches a level that disrupts daily functioning and causes basic activities to come to a halt for long periods of time, or turns into a chronic pattern.

Avolition is categorized as one of the Negative Symptoms within the Schizophrenia Spectrum, particularly in the “Motivation–Pleasure (MAP) dimension,” together with symptoms such as anhedonia (loss of pleasure) and asociality (social withdrawal or lack of interest in social interaction). These three are core features that determine quality of life, functional capacity, and day-to-day living in people with schizophrenia — often more than delusions or hallucinations do.

This loss of inner drive appears across many domains, for example:

• Not getting up to shower for many days, even while knowing it should be done
• Not going out to buy food even when the fridge is empty
• Letting work pile up because they “can’t get started”
• Seeing a friend’s message pop up but feeling it is “too much” to reply
• Not going to doctor’s appointments or classes even when the consequences are obvious

The internal experience is often described as feeling “empty, like the engine won’t start” rather than feeling bored, sad, or discouraged in the classic depressive sense. This lack of drive often leads people around them to misunderstand and think the person is “stubborn” or “not trying,” when in reality it is a disorder of brain systems that govern motivation and reward evaluation.

In current academic literature, many studies propose that avolition may be the most central negative symptom (core negative symptom) because it strongly correlates with functional outcome in life, such as the ability to take care of oneself, work, live independently, or maintain relationships with others.

Although avolition is most commonly seen in the Schizophrenia Spectrum, it can also appear in other conditions, such as:

• Major Depressive Disorder, especially in severe episodes or those with psychotic features
• Bipolar depression
• Certain neurological conditions, such as Parkinson’s disease, dementia, traumatic brain injury
• Side effects from certain psychiatric medications

However, the pattern of avolition in schizophrenia is noticeably different from that in depression. For example, patients may feel more “clear–empty–without inner energy” rather than “sad–guilty–self-hating” like in classic depression.

In summary, avolition is a deep impairment in motivation that slows the entire system of life down, to the point that even the most basic activities become difficult to carry out despite knowing they should be done. It is also one of the most challenging factors in the long-term treatment of people with schizophrenia.

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2. Core Symptoms — The Key Symptom Profile of Avolition

2.1 Core of the Symptom — When the “Drive Toward Goals” Shuts Down
When we say Avolition = a chronic impairment of goal-directed behavior,
it means that “the brain systems that normally push us to ‘take action’ on something” are markedly weakened.

The goals in question do not have to be grand or world-changing. They range from:

• Getting out of bed → walking to the bathroom to take a shower
• Picking up dirty clothes → putting them in the basket → turning on the washing machine
• Opening emails → replying to pending work
• Picking up the phone → replying to your mom’s message
• Walking out of the room → getting in the car to go see the doctor

A person with avolition gets stuck at the “before taking action” stage.
It is as if they have all the steps in their head, but the command to initiate does not get fired.
So it becomes: “They know everything, they accept everything, but the body doesn’t start.”

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2.1.1 Self-care — The Basic Core That Starts to Fall Apart First
In the domain of self-care, avolition is very apparent because these are repetitive activities that must be done every day:

• Not showering for many days, having greasy/tangled hair and strong body odor, even though the person is not intentionally trying to “let themselves go.”
  It’s just that… getting up to grab the towel + walking into the bathroom = a mentally overwhelming task.

• Not brushing teeth, not washing the face, even when feeling physically uncomfortable

• Dirty clothes piling up in the room, knowing they should be washed, but as soon as they think about sorting the laundry, adding detergent, pressing the buttons,
  → the brain already feels “too much” before they even start

• The room becomes increasingly messy, but the person is not “happy” about the mess. They just don’t have the energy to initiate the first step.

Important: People around them often interpret this as “not being responsible / letting themselves go.”
But from the neuropsychiatric perspective, this reflects a failure of the motivation–initiation system,
not a character flaw.

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2.1.2 Work / Study — The Tasks Exist, the Deadlines Exist, but the Person “Cannot Start”
In work and academic settings, avolition creates patterns like:

• Important tasks left undone for an extremely long time, even though they know there will be serious consequences if they do nothing
• Staring at the computer screen or a book for a very long time but never actually getting down to work
• Skipping classes, missing work, or missing appointments with teachers/supervisors because they “cannot figure out how to start”
• Projects they used to be interested in turning into something they keep dragging out until the deadline passes
• Supervisors or people around them might think they “don’t care about the work / are irresponsible,”

while the person themselves often feels stressed and pressured but has no idea how to “force themselves to start.”

A real-life example:

Sitting in front of the computer with the work file already open, but only able to move the mouse around.
It feels like there are too many steps. As soon as they think they must do A → B → C → submit → talk to people,
their brain shuts down before even starting A.

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2.1.3 Leisure Activities / Hobbies — What They Once Loved Becomes “Out of Reach”
Another visible domain is the loss of previously enjoyed activities, not just a temporary “boredom,” but:

• In the past, they liked drawing, playing music, gaming, exercising, etc.
  → Now they feel that “just thinking about getting up to pick up the equipment already feels exhausting.”

• Free time turns into just sitting there, scrolling on the phone aimlessly, without truly focusing on anything

• When others invite them to do something fun → internally they respond, “That would probably be nice,”
  but at the moment of actually getting up to do it, it feels as if there is an enormous internal resistance blocking them.

This often leads many people to mistakenly think it is just anhedonia (not feeling pleasure).
But in reality, some people with avolition still think that if they could do the activity, it would probably be good or enjoyable.
The problem is not “not wanting to,” but “not being able to start.”

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2.1.4 Social / Relationships — Slowly Letting People Drift Away
In the social domain, avolition does not show up as “hating people,”
but more as patterns like:

• Not replying to chats, not calling back, even though they see the notifications and feel guilty deep down
• Letting conversations go unanswered for weeks or months because they don’t know how to start replying
• Saying no to going out more and more often, because just thinking about showering, getting dressed, traveling, and being around many people → feels mentally exhausting
• When family members invite them to go out for a meal or visit relatives → it feels like it “drains too much energy.”

To others, this may look like they don’t care / don’t value relationships,
but internally, the person often feels guilty and sad that they “cannot be the kind of friend/child/sibling they want to be.”
It’s just that their internal system no longer supports them to “get up and connect” with others.

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2.2 The Internal Experience of Someone with Avolition
This part is extremely important, because if we do not understand the subjective experience,
we can easily end up labeling them as “stubborn / not trying / useless.”

Many people describe their inner emotional state in similar ways:

• “I know I have to do it, but it’s like my brain doesn’t send the signal to move.”
  It’s not just laziness — inside their head it is “silent,” with no motivational push at all.

• “It’s not that I don’t want to do it. It’s like the engine just won’t start.”
  Like having a good car with fuel and good tires, but the key doesn’t turn fully and the ignition doesn’t catch.

• “Everything seems so far away. I feel tired even before I think about starting.”
  The brain evaluates even small tasks as overwhelmingly big, before they even begin.

Some people will say, “Inside, it feels completely flat.”
They do not necessarily feel like they want to die, and they are not always intensely sad,
but it feels as if life has turned off the active mode, leaving only passive mode.

The internal experience of avolition also often includes elements such as:

• Feeling “ineffective” or “incompetent” (low self-efficacy)
  Repeatedly failing to complete tasks → they begin to believe they never finish anything → becoming even more afraid to start new things

• Embarrassment / guilt toward others
  Because people around them don’t understand that this is a symptom of an illness
  → being frequently scolded with, “Why don’t you just do it already?” makes them feel even more inferior

• Time slipping away unnoticed
  Some say, “Before I knew it, the whole day had gone by and I didn’t manage to do anything,”
  even though they had planned to do many things in the morning.

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2.3 Distinguishing Avolition from Common Misconceptions
This is a section that is very important to use on a website or for people around the patient to read.

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2.3.1 It’s Not Just “Laziness”

Ordinary laziness:

• A person can still choose to “pull themselves together” at certain moments, for example:
  Being afraid of being scolded by their boss, so they push themselves to get the work done,
  Being too lazy to go to the gym but going anyway when a friend drags them along.
• There is still some “override switch” that can be activated by external pressure.

Avolition:

• Even when they know “If I don’t do this, my life will definitely fall apart,”
  they still cannot start in many areas of life.

• It is as if the internal system for “pressuring oneself to get up and act” is broken.

Put simply:
Laziness = having drive but choosing not to use it.
Avolition = the drive system itself is broken.

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2.3.2 How Is It Different from Depression?
Depression and avolition often overlap, and sometimes are difficult to differentiate,
but by pattern:

Depression (Major Depressive Disorder):

• Core emotions: sadness, despair, guilt, a sense of worthlessness, not wanting to live
• Thoughts: prominent self-blame, hopelessness, worthlessness
• Not doing anything is often due to feeling defeated / feeling that nothing has meaning.

Avolition in Schizophrenia:

• Emotions: some patients are “not that sad” but feel empty, numb, and flat
• Key feature: lack of drive and lack of initiation, even without intensely negative thoughts about themselves
• Some people will frankly say, “I don’t feel that bad about myself. I just can’t do anything.”

In clinical practice, doctors must try to distinguish:

• Negative symptoms (primary) = core to schizophrenia
• Depressive symptoms (secondary) = arise later or due to context

Because treatment strategies and medications differ, if everything is lumped together as “depression”
and only antidepressants are given without assessing negative symptoms, → outcomes will be poor.

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2.3.3 How Is It Different from Anhedonia (Loss of Pleasure)?
This is subtle but very important on a “nerdy” level:

• Anhedonia = the brain “does not receive or register pleasure from activities very well.”
  Doing things does not feel good, or feels only slightly good → so they do not want to repeat them.
  
  
• Avolition = a lack of energy to “start doing” something,
  even if they theoretically believe that the activity is good or enjoyable.

In reality, the two symptoms often come together,
but in detail:

• Some people still think, “If I could sit down and draw, that would probably be nice,” →
  this means the pleasure system is not completely destroyed,
  but they lack the starting engine (avolition is more prominent).

• Others: “Even if I go on a trip, I don’t feel better,” → anhedonia is very prominent,

combined with total loss of starting energy → a brutal duo.

In research, these three (avolition, anhedonia, asociality)
are grouped together as the Motivation–Pleasure (MAP) dimension
because they directly reflect “the brain’s reward–motivation system.”

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2.4 Levels of Severity and Patterns Over Time (Added for Deeper Explanation)

• For some people, it starts as “just slowing down and finding it harder to start anything.”
• Then it becomes “able to start only certain things, such as using the phone, but not able to work.”
• In severe stages, “even basic daily routines require someone else to remind and help organize almost everything.”

The severity of avolition is also related to:

• How long they have had schizophrenia
• Whether treatment was delayed / interrupted
• Additional aggravating factors, such as being unable to keep a job, losing relationships, or being stigmatized

All of these heavily impact the overall functional picture of life.

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3. Diagnostic Criteria — How Do We Diagnose Avolition?

First, it must be emphasized that:

• In DSM-5-TR, there is no separate disorder named “Avolition.”

• Avolition is one component of the negative symptoms
  that are used to diagnose conditions such as:
• Schizophrenia
• Schizoaffective disorder
• Some cases of Major Depressive Disorder with psychotic features
• Bipolar disorder with psychotic features
• And certain neurological conditions

When clinicians talk about “diagnosing avolition,” what they really mean is:
“Confirming that this person has negative symptoms in the avolition dimension at a clinically significant level.”

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3.1 Qualitative Criteria — What Do Clinicians Look at Overall?
Broadly, there are a few key pillars:

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3.1.1 A Clear Reduction in Goal-Directed Behavior Across Multiple Domains
Clinicians will ask about and observe:

• Has self-care decreased noticeably compared to before?
  For example, they used to take care of themselves adequately, but now they “let themselves go” in a way that isn’t their previous style.

• Has work or study stalled, or has performance dropped significantly?

• Leisure activities / hobbies / interests they once had — have they disappeared?

• Relationships with others — is there loss of contact, letting connections drift away over time?

What matters is there must be a “Before & After” pattern,
not a situation where the person has never been interested in anything since childhood
(in that case, one must consider other conditions, such as ASD or certain personality patterns).

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3.1.2 Persistent Over Time (Chronic / Persistent)
These symptoms must be a chronic pattern lasting months,
not just 1–2 weeks of a busy or stressful period where they slow down.

In the context of schizophrenia, we often talk about symptoms that have been present for “months to years.”

Everyone has periods of “temporary burnout,”
but Avolition = the drive system is shut down at a structural level, not just during a brief crisis.

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3.1.3 Significant Impact on Functioning and Quality of Life
This is a keyword in DSM for almost all mental disorders:

• It causes them to be unable to work, fail to complete school, need to quit jobs, or have severely declining grades.
• They increasingly depend on others for basic things, such as needing reminders to eat or shower.
• Deterioration of relationships: drifting from friends, frequent family conflicts.
• Difficulty living independently, requiring more care from others.

If symptoms are present but do not affect real-life roles at all,
we usually do not call them “clinical-level symptoms.”

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3.1.4 Not Fully Explained by Other Single Causes
This is where clinicians spend a lot of thought, because negative-symptom–like behavior can be caused by many things, for example:

• Severe positive symptoms
  e.g., intense hallucinations or delusions that make the person so fearful they do not dare leave the house
  → looks like avolition, but is actually more “hiding from psychosis.”

• Sedation / overmedication / side effects from antipsychotics or benzodiazepines
  drowsiness, heaviness, feeling numb all day → not getting up to do anything

• Major depression, bipolar depression
  where hopelessness and worthlessness are more prominent than pure motivation deficits

• Substance use / withdrawal
  e.g., cannabis, alcohol, sedatives, etc.

• Medical conditions such as hypothyroidism, anemia, chronic infections, brain injury, etc.
  Therefore, when a clinician wants to say:

“This is primary negative-symptom avolition,”

they must rule out other possibilities as much as possible.

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3.1.5 Primary vs Secondary Avolition — A Crucial Conceptual Distinction

Primary Avolition

• Is directly part of schizophrenia itself
• Persists even when psychosis improves (no prominent delusions/hallucinations)
• Not due to depression, not due to excessive medication
• Tends to be relatively stable over the long term

Secondary Avolition

• Occurs secondary to other factors, such as:
• Depression
• Severe positive symptoms
• Sedation from medication
• Severe environmental factors (e.g., long-term institutionalization)

• If the underlying cause is treated (e.g., depression improves / sedating medication is reduced)
  → avolition often improves accordingly

Distinguishing between these two is extremely important because treatment strategies differ.

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3.2 How Is It Assessed in the Real World — Not Just a Checklist
When seeing a real patient, clinicians do not rely solely on DSM items 1, 2, 3 in a dry way.
They use:

• Clinical interviews with the patient
• Conversations with family members / caregivers
• Observation of real behavior during the session
• Standardized rating scales

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3.2.1 Clinical Interview — Deep Dive into Daily Life
Clinicians ask for details like:

• “What time do you usually wake up? What’s the first thing you do?”
• “How have showering and brushing your teeth been lately compared to before?”
• “What work or studies are you currently doing? Have you been able to keep up lately?”
• “What hobbies did you use to have? Do you still do them now?”
• “Tell me what a day looks like if nobody disturbs you at all. How do you spend your time?”

While listening, the clinician evaluates:

• Does the patient still have “cognitive interest” in things?
• How do they view themselves — do they feel guilty, or just numb?
• Is the emotional tone more depressed or more flat/blunted?
• What reasons do they give for “not doing anything”?

Sometimes patients respond with:

• “I do know I should do it, but I don’t know… when I’m about to start, it just feels exhausting.”
• “It’s not that I don’t want to do it. I just never end up doing it.”

Answers like these make clinicians think more seriously about avolition.

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3.2.2 Information from Family / Close Others
Information from close others is extremely valuable because:

• They see the real patterns in daily life.
• They can compare “what they were like before getting ill” vs “how they are now.”

Examples of what family might say:

• “In the past, they loved dressing up and playing sports all the time. Now they stay at home all day and don’t go anywhere.”
• “We have to remind them to shower and eat. If we don’t remind them, sometimes they don’t do anything all day.”
• “When we invite them to go out, they often say they’re tired and don’t want to go.”

Clinicians use this information to differentiate between:

• Genuine negative symptoms

vs

• Behavior that might arise from family conflict or situational factors

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3.2.3 Use of Standardized Rating Scales
These tools don’t replace diagnosis but help quantify severity and monitor progress.

1) BNSS (Brief Negative Symptom Scale)

• Has separate items for:
• Avolition (work, social, self-initiated activity)
• Anhedonia
• Asociality
• Blunted affect
• Alogia

• For each item, clinicians ask:
• What activities have you done in the past week–month?
• How much did you feel like doing them? How much did you actually do?
• If you didn’t do them, why?

• Each item is rated on a scale (e.g., 0–6) to assess severity.

2) CAINS (Clinical Assessment Interview for Negative Symptoms)

• Divided into two major domains:
• Motivation–Pleasure (including avolition, anhedonia, asociality)
• Expression (facial expression, vocal tone, gestures)

• Uses qualitative questions such as:
• “On a typical day, what do you do for enjoyment?”
• “Do you have any plans to meet or connect with anyone this week?”
• “What are things you used to do that you’ve stopped doing now, and why?”

• Emphasizes showing the difference between “wanting” and “doing.”

3) PANSS – Negative Subscale

• A broad measure of schizophrenia often used in research

• Includes sub-items such as:
• Emotional withdrawal
• Passive/apathetic social withdrawal
• Lack of spontaneity and flow of conversation, etc.

• It is not as detailed on avolition specifically as BNSS/CAINS, but helps provide an overall picture.

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3.3 Differential Diagnosis & Context
To stay focused, here is a section you can directly use in an article:

Clinicians must always ask, “Which disorder best explains these avolition-like symptoms?”

Examples that must be differentiated:

• Major Depressive Disorder
• If sadness, guilt, and suicidal thoughts are very prominent → depression may be the core
• But if numbness, emptiness, and lack of drive are more prominent, both sides must be carefully considered

• Bipolar Depression
• Look for past episodes of abnormally elevated mood / mania / hypomania

• Substance-Related Disorders
• Alcohol, recreational drugs, sleeping pills, or other substances

• Neurocognitive Disorders / Neurological Conditions
• Dementia, Parkinson’s disease, head injury, etc.
• Some conditions have “apathy” very similar to avolition

• Personality Factors / Long-standing Traits
• People who have been extremely introverted or indifferent to social stimuli all their lives
• Must distinguish: “Is this their baseline personality?” or “Did this change after illness began?”

All of this shows that
to confidently say, “This is avolition within the framework of schizophrenia negative symptoms,”
requires time, information from multiple sources, and clinical expertise.

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3.4 Clinical Summary You Can Use Directly in an Article

• Avolition is not a standalone disorder but one of the core Negative Symptoms.

• The features that indicate “this is a clinical-level symptom” are:
• A clear reduction in goal-directed behavior
• Persistent over time
• Significant impact on real-life functioning
• Not fully explained by other single causes, such as medications, depression, or severe psychosis

• Good assessment must:
• Include in-depth clinical interviews
• Incorporate information from family members
• Use direct behavioral observation
• Utilize rating scales such as BNSS, CAINS, PANSS to quantify severity

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4. Subtypes or Specifiers — How Can Avolition Be Subgrouped?

Although there are no formal subtypes in DSM, research literature breaks it down conceptually as follows:

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4.1 Primary vs Secondary Avolition

Primary Avolition (intrinsic negative symptom)

• Is part of schizophrenia itself
• Remains relatively stable even when positive symptoms improve
• Is linked to abnormalities in reward/frontostriatal brain networks

Secondary Avolition

• Arises from other factors, such as:
• Depression
• Severe positive symptoms (paranoia, hallucinations)
• Side effects of medication (sedation, extrapyramidal symptoms)
• Environmental factors (social deprivation, lack of opportunities)

• If the root cause is treated (e.g., depression improves / sedating dose is reduced)
  → avolition often improves accordingly

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4.2 Motivation–Pleasure vs Expressive Deficit Dimensions

Many studies suggest that negative symptoms can be divided into two major dimensionsScienceDirect+1:

• Motivation–Pleasure (MAP) dimension
• Includes: Avolition, Anhedonia, Asociality
• Directly related to the reward circuit

• Expressive Deficit dimension
• Includes: Blunted Affect, Alogia (poverty of speech)
• Related to networks controlling facial expression and language

Avolition is viewed as the “heart” of the MAP dimension and a strong predictor of real-life functioning (e.g., ability to work, take care of oneself, and live independently).PMC+1

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5. Brain & Neurobiology — What Happens in the Brain of Someone with Avolition?

In contemporary neuroscience, avolition is not considered merely an emotional symptom but rather “a dysfunction of multiple brain circuits that control motivation, value evaluation, and decision-making to act.”
What is lost is not only “low dopamine levels,” but a network-level disorder connecting the prefrontal cortex, striatum, limbic system, white-matter tracts, and multiple neurotransmitters (dopamine, glutamate, GABA).

The overall brain profile of someone with avolition is characterized by:

• A low reward anticipation system → the brain does not expect “good outcomes” from doing things
• Distorted effort computation → the brain evaluates tasks as “too exhausting for the payoff”
• A non-functioning initiation system → when it is time to start, the brain does not send the “go!” signal
• A damaged sustain-action system → they may be able to do something for a few minutes, then stop because they lack drive

All of this arises from combined dysfunction in several brain circuits.

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5.1 Frontostriatal Circuits — The Central Axis of Motivation in the Brain
Frontostriatal circuits are systems that allow humans to “think–evaluate–initiate.”
In avolition, these circuits operate more slowly or out of sync.
We can break them down as follows:

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(1) Dorsolateral Prefrontal Cortex (DLPFC)
This is the center for planning and coordinating goal-directed activities, such as sequencing tasks and holding information in working memory.

In patients with avolition:

• DLPFC activity is reduced
• They lack the ability to plan step by step
• They cannot convert “plans in the head” into “actual initiation of action”

This is why patients say:

“I know I need to do it, but when it’s time to get up, I don’t know how to start.”

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(2) Ventromedial PFC / Orbitofrontal Cortex (vmPFC / OFC)
This is the center that evaluates the “value of rewards” of activities, such as:

• Doing this work → getting paid
• Cleaning up → having a comfortable room
• Taking a shower → feeling refreshed

In avolition:

• vmPFC/OFC responds less → the brain undervalues rewards
• So they feel, “There’s not much point in doing this.”
• Their expectation of positive outcomes decreases → lowering the drive to begin.

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(3) Ventral Striatum (Nucleus Accumbens)
This is the “heart of wanting” in the brain.
It processes reward anticipation = the feeling of wanting to start because they expect it to be “worth it.”

Neuroimaging studies show that:

• When reward signals (such as money or enjoyable activities) are presented to people with avolition
  → the ventral striatum responds less than in healthy controls

• The ability to feel “good in advance” or “anticipatory excitement” is reduced

This explains why:

• They look at things and don’t feel like doing them
• There is no internal push even when they know they should act
• Activities that were once fun no longer stimulate the brain as much.

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(4) Anterior Cingulate Cortex (ACC)
The ACC is the center for “effort computation,” asking:

• How demanding is this task?
• Is the reward worth the effort?
• If yes → send the signal to the body to “go for it!”

In people with avolition:

• ACC activity is reduced → the brain overestimates effort
• It makes everything feel “too exhausting” even before starting
• Even small tasks, like picking up a towel to take a shower, are judged as too heavy relative to the payoff

This helps us understand:

Why simple activities appear like “huge mountains” for no obvious reason.

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5.2 Dopamine and Glutamate Systems — The “Music” of the Motivation Circuits

Dopamine is not low everywhere in the brain — it is “out of rhythm.”

In schizophrenia:

• Subcortical (striatal) dopamine is excessively high → related to psychosis
• Prefrontal cortex dopamine is too low → related to cognitive deficits + negative symptoms

This imbalance in dopamine causes:

• Reward circuits to fail to push behavior adequately
• Low reward expectation
• Slow initiation of activities
• Thinking without acting because reward prediction error is impaired

Glutamate from the PFC governs dopamine

Glutamate is the main neurotransmitter for thinking and planning in the prefrontal cortex.

When glutamate dysregulation occurs (common in schizophrenia):

• The PFC can no longer properly control dopamine in the striatum
• This makes the reward circuit inaccurate and unstable
• The brain miscalculates value or payoff → causing an automatic “not wanting to start.”

In other words,
the combined imbalance of glutamate + dopamine = the extinction of drive.

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5.3 GABA Dysfunction — When the Balance Between Braking and Accelerating Breaks Down
GABA is the brain’s “brake.” If the braking system malfunctions:

• Control over motivational circuits worsens
• The brain cannot properly filter relevant vs irrelevant information
• The ability to start–stop–switch tasks decreases

Many studies point to dysregulated GABAergic interneurons in the PFC
as one of the key causes of negative symptoms.

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5.4 Neuroinflammation — Brain Inflammation
Recent studies have found that:

• Certain cytokines are elevated in individuals with prominent negative symptoms

• Low-grade chronic inflammation
  → reduces connectivity in frontostriatal networks

• This makes reward circuits less responsive to signals

This is evidence that avolition also has an immunological dimension in the brain.

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5.5 White-Matter Connectivity — The Damaged “Roads” in the Brain
White-matter tracts such as:

• Anterior limb of the internal capsule
• Cingulum bundle
• Uncinate fasciculus

Carry motivational information from PFC → Striatum → Limbic system.

When white-matter integrity is reduced:

• Motivational information travels more slowly or unreliably
• The link between “intending to act” → “actually acting” is cut somewhere in the middle

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5.6 Impaired Reward Learning & Prediction Error
In a healthy brain:

• If an action has a good outcome → dopamine increases → we are reinforced → we want to do it again
• If it doesn’t work → dopamine decreases → we adjust our behavior

But in avolition:

• The brain has a reduced capacity to learn from reinforcement
• Dopamine does not respond accurately → rewards are obtained but do not feel rewarding
• This damages the system that “learns to want to act.”

Thus, we see the pattern:
“Knowing something is good, but not feeling like wanting it.”

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6. Causes & Risk Factors — What Causes Avolition?

Avolition does not arise from a single cause. It comes from a multifactorial model, combining biology → brain development → neurochemistry → psychosocial factors → environment.

For clarity, we can divide it into three major groups.

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6.1 Biological / Genetic / Neurodevelopmental Factors

(1) Genetic Vulnerability
Schizophrenia has a strong genetic basis (around 60–80%),
and genes associated with negative symptoms are often linked to functions such as:

• Dopamine regulation (e.g., DRD2, COMT)
• Glutamatergic system
• Synaptic pruning and formation of brain networks

Genetic vulnerability makes the brain’s “motivational circuits” less robust from the outset.

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(2) Prenatal and Perinatal Factors (Neurodevelopmental Insults)
For example:

• Maternal viral infections during pregnancy
• Perinatal hypoxia (lack of oxygen at birth)
• Low birth weight
• Inadequate nutrition
• Obstetric complications

These factors disrupt early brain wiring,
increasing the risk of negative symptoms later on.

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(3) Network Dysfunction
Especially in:

• Frontostriatal circuits (motivation)
• Default Mode Network (DMN) (self-referential thought / rumination)
• Salience Network (selecting what is important)

When these networks are impaired:

• The brain cannot properly choose “what should be done”
• It cannot identify which steps are important
• It overestimates how exhausting tasks will be
• Reward circuits function at a low level

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6.2 Illness- and Treatment-Related Factors

(1) Chronicity of Illness
People who go a long time without treatment for psychosis (high DUP = Duration of Untreated Psychosis)
tend to have more deeply entrenched negative symptoms.

Repeated relapses can gradually reduce the efficiency of brain circuits,
especially in the ACC and striatum.

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(2) Secondary Depression
Secondary avolition can result from:

• Hopeless thoughts
• Feelings of worthlessness
• Fear of failure
• Fatigue characteristic of depressive illness

Key point:

• Depression = presence of emotional pain
• Primary avolition = “quiet–empty–numb.”

If depression is prominent → it must be treated alongside avolition.

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(3) Medication-Induced Factors
Some antipsychotic medications can cause:

• Sedation (very sleepy)
• Motor slowing (moves slowly)
• Emotional blunting (flattened affect)
• Akinesia (difficulty initiating movement)

These can mimic avolition,
but they are considered secondary, not true primary negative symptoms.

They can be addressed by:

• Adjusting the dose
• Switching medications
• Choosing drugs with fewer such side effects

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(4) Cognitive Deficits
Many people with avolition also have:

• Low working memory
• Weak executive function
• Poor planning skills
• Difficulty prioritizing

When thinking about tasks becomes cognitively demanding → they can’t start → circuits deteriorate further → forming a vicious cycle.

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6.3 Psychosocial & Environmental Factors

(1) Lack of Structured Routines and Opportunities
If a person lives in circumstances where:

• Nobody invites them to do anything
• There are no clear responsibilities
• There are no small, achievable goals
• They sit idle all day

Their motivation circuits will weaken rapidly.

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(2) Social Isolation
Cutting oneself off from others leads to:

• Lack of external stimuli
• Lack of social reinforcement
• Feeling like they are not part of anything
• Worsening avolition over time

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(3) Stigma and Loss of Role & Identity
When people around them label them as “lazy / irresponsible” → self-esteem drops.
When they lose jobs, family roles, or the ability to do things → identity becomes unstable.
These experiences overlap with negative symptoms and further reduce motivation.

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(4) Chronic Stress
Prolonged low-grade stress causes:

• Worsened dopamine regulation
• Reduced ability to learn from rewards
• Loss of energy to start doing things that were not a problem before

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(5) Environments Without Reinforcement
For example:

• Living in a home where everything is done for them
• No positive reinforcement
• No feedback
• No concrete, meaningful goals

The brain learns that “whether I do something or not, nothing changes,”
→ the motivation system shuts down.

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7. Treatment & Management — How Do We Manage Avolition?

Avolition is one of the most treatment-resistant symptoms in schizophrenia,
but there are strategies that can help “boost life functioning.”

Important: Everything here is a general overview. For safety, it must be applied together with care from a psychiatrist and a multidisciplinary team.

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7.1 Pharmacological Treatment

• Optimizing Antipsychotic Medication
• Reduce sedation as much as possible
• Choose medications with a better profile for negative symptoms in some cases (e.g., cariprazine, lumateperone in some guidelines/research)Dove Medical Press+1

• Treat Comorbid Depression / Anxiety
• May use antidepressants or mood stabilizers at the clinician’s discretion

• Experimental / Adjunctive Approaches
• Medications modulating the glutamatergic system, anti-inflammatory agents, etc.
• Many are still under investigation / in research phases

Never adjust or stop medication on your own; this must always be done by a physician.

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7.2 Psychosocial & Rehabilitation Approaches

• CBT for Psychosis + Behavioral Activation
• Helps address beliefs such as “There’s no point in doing anything.”
• Uses techniques of breaking tasks into small steps + reinforcing small achievements.

• Cognitive Remediation
• Training attention, planning, working memory, and executive function
• When the brain manages goals more effectively → avolition can decrease to some extentcnl.psy.msu.edu+1

• Social Skills Training & Social Recovery Programs
• Training social interaction skills
• Practicing roles in simulated situations → increasing self-efficacy

• Supported Employment / Education
• Programs that help patients return to work or study in a structured way
• Focus on tasks with clear steps, frequent feedback, and flexible adjustment based on capacity

• Family Psychoeducation
• Teaching families that “this is not just laziness”
• Reducing statements like “Why don’t you just get up and do it?” → shifting toward structural support

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7.3 Environmental Structuring and Supported Self-Management

Even though people with avolition often find it “hard to do things on their own,”
if those around them help build systems, things can become much easier:

• Establishing simple but clear routines, such as:
• Wake up – shower – eat – walk for 10 minutes – rest – do one household task

• Using visual schedules/checklists on walls or in phones

• Setting very small goals, for example:
• Today: just wash 5 dishes → (tomorrow add a bit more)

• Applying the principle of “Do it together”
• Family members do activities with them rather than simply ordering them to do things alone

• Providing positive feedback for every small step of progress
• Not focusing on what they still cannot do

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8. Notes — Additional Points to Know

• Avolition is the negative symptom that occupies the most space in a person’s life.

• It makes patients appear “indifferent” or “not wanting anything,” even though internally, it’s far from easy.

• There may be no obvious sadness, but it is as if the bassline of life has been muted.

• Labeling them as “lazy” makes everything worse:
• Self-esteem drops
• Treatment adherence declines
• Family relationships deteriorate

• It is crucial to distinguish “not doing” due to fear (from delusions/paranoia) vs “not doing” due to lack of inner drive.
  Treatment planning will differ accordingly.

• In modern research, there is a clear trend showing that focusing on the assessment and treatment of avolition / MAP dimension leads to better functional outcomes than focusing only on positive symptoms.PMC+2Dove Medical Press+2

If someone reads all of this and feels, “This is exactly me,” →
the safest next step is to talk to a psychiatrist or clinical psychologist who can assess the entire context (other symptoms, medications, physical illnesses, etc.).
Educational posts should never be used as a substitute for a professional diagnostic evaluation.

Read Schizophrenia

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📚 References (Avolition / Brain & Neurobiology / Causes & Risk Factors)

Strauss GP, Bartolomeo LA, Harvey PD. Avolition as the core negative symptom in schizophrenia: relevance to pharmacological treatment development. NPJ Schizophrenia. 2021;7(1):16. PMC+1

Galderisi S, Mucci A, Buchanan RW, Arango C. EPA guidance on assessment of negative symptoms in schizophrenia. European Psychiatry. 2021;64(1):e23. PMC+1

Kaiser S, et al. EPA guidance on treatment of negative symptoms in schizophrenia. European Psychiatric Association; 2021 (guideline PDF). Europsy+1

Mucci A, et al. Assessment of negative symptoms in schizophrenia. Brain Sciences. 2025;15(1):83. MDPI

Mosolov SN, et al. Primary and Secondary Negative Symptoms in Schizophrenia. Frontiers in Psychiatry. 2022;12:766692. Frontiers

Collo G, et al. Negative Symptoms of Schizophrenia and Dopaminergic Transmission: Pathophysiological Aspects and Therapeutic Perspectives. Frontiers in Neuroscience. 2020;14:632. Frontiers

Robison AJ, Thakkar KN, Diwadkar VA. Cognition and Reward Circuits in Schizophrenia: Synergistic, Not Separate. Biological Psychiatry. 2020. SciSpace+3PubMed+3cnl.psy.msu.edu+3

Zeng J, et al. Neural substrates of reward anticipation and outcome in schizophrenia: association with negative symptoms. Psychological Medicine. 2022. PMC

Bègue I, et al. Pathophysiology of negative symptom dimensions of schizophrenia: current developments and implications for treatment. (Review). ZORA

Kesby JP, et al. Neural circuitry of salience and reward processing in psychosis: a translational review. Schizophrenia Research. 2023. ScienceDirect

Marder SR, Galderisi S. Defining and measuring negative symptoms of schizophrenia. European Neuropsychopharmacology. 2014. ScienceDirect

Chapter: Negative Symptoms in Psychosis: An Introduction to the Construct. In: Negative Symptoms in Psychosis (book chapter, 2024). OUP Academic

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