AKINETIC MUTISM: SYMPTOMS, CAUSES AND TREATMENT - NEUROPSYCHOLOGY - 2025

The akinetic mutism or greater apathy is a subjective lack of thought, in which the person is not able to initiate any movement or even single speech. For example, this patient, even though he is thirsty, may be sitting in front of a glass of water without drinking from it. This may be due to damage to brain structures that seem to drive motivation to carry out behaviors, being immersed in a significant state of apathy.

We can define akinetic mutism as a decrease or absence of spontaneous behaviors despite the fact that motor skills are intact, since the origin of the problem, as we said, is motivational (it affects the dopaminergic circuits of the brain).

Areas affected in akinetic mutism

It is a difficult syndrome to diagnose since it can be part of altered states of consciousness. Sometimes it appears as a continuum, the akinetic mutism being located between coma and the return to wakefulness.

The case of Emilio

Rodríguez, Triviño, Ruiz and Arnedo (2012) described a curious case of a patient who, after several brain surgeries, presented what is defined as “a blank mind”.

The patient, who we are going to call "Emilio", was 70 years old when a benign tumor (meningioma) was detected in the cerebral cortex. The patient felt that he had difficulties in naming objects and describing situations, in addition to motor clumsiness when playing the saxophone, a task that he previously performed without difficulties since he played in the band of his town.

He also liked taking care of his garden and was beginning to have problems that he did not have before.

A craniotomy was performed to remove the tumor, which was uneventful. A year later, in a review, several tumor nodules were detected, so this patient had to undergo multiple surgical and radiosurgery interventions over 6 years.

This led to different complications, as Emilio came to present right hemiparesis (it is a frequent condition after brain damage in which the right side of the body is weakened) and motor difficulties from which he recovered with treatment.

However, another MRI revealed a new tumor occupying the anterior cingulate cortex. After operating again to remove it, the patient was evaluated, diagnosing her condition as akinetic mutism.

Causes of akinetic mutism

The most common cause of akinetic mutism is vascular, although there are some cases whose origin is the exposure or ingestion of toxins, infections or degenerative processes.

The damaged structures in akinetic mutism appear to participate in the initiation and maintenance of the behavior, as well as the motivation to trigger it.

What do we mean by motivation here? In this context, it is defined as the energy necessary to achieve something that is desired or avoid something aversive and that is influenced by the emotional state. It is as if the will is lacking and the person cannot get started to meet their needs, remaining still and silent all the time.

That is why this disorder is called "having a blank mind." In fact, Damasio (1999) describes that patients who have recovered from akinetic mutism, when asked why they did not speak when they had the disease, said “it was that nothing came to mind”.

The vascular lesions that cause this disease cause heart attacks in:

Anterior cerebral artery

That damage the anterior cingulate cortex and parts of the frontal lobe. In addition, it not only appears due to injuries in the anterior cingulate cortex, but also due to damage in the connections of the frontal areas with subcortical areas.

To understand the origin of this disorder, it is important to note that one of the main areas that receives dopamine from the meso-cortical dopamine system, since it receives information from deeper areas of the brain that make up the famous brain reward system.

This system is essential to carry out survival motivating behaviors such as perpetuation of the species or search for food. Therefore, it is not surprising that if the dopamine circuits are damaged, a state of apathy develops.

Arteries supplying the basal ganglia

Damage to the frontal-basal connections of the brain will isolate the frontal areas of structures such as the caudate nucleus, globus pallidus, putamen or internal capsule, which are very important for the person to find motivation to perform behaviors.

Infarcts in arteries of the cerebellum

They damage the back of the cerebellum and the vermis area. It has been found that the cerebellum may be associated with functions such as verbal fluency, working memory, emotions, or task planning (curiously, very typical of the frontal lobe). However, more research is needed to know exactly how it manifests in akinetic mutism.

Paramedian thalamic arteries

Symptoms

The most common and distinctive symptoms are:

Hypophony and poor speech

If there is speech, it is very scarce and is characterized by hypophonia (low volume of the voice), and by dragging of words. Pronunciation and syntax are usually correct, as long as there is no damage to brain structures dedicated to language.

Limited responses

They can understand what is being asked, but it does not seem so at first glance, since when they answer they do not do so consistently. They respond mainly when asked for biographical information, such as their name or date of birth. If they are other types of questions, they prefer to answer with "yes", "no" or monosyllables.

Lack of expression

They don't normally initiate conversations, they don't ask questions, they don't even make requests regarding their basic needs: eating, drinking, going to the bathroom. They do not express what they want or seem to do anything to achieve it.

Lack of initiative

It is often the case that they can only perform actions if someone else helps them to initiate them. They can use the objects without any problem, but they never start the movement of their own free will. According to the example we gave before the glass of water, if Emilio was thirsty, he would not drink until someone else put the glass in his hand.

Motor perseverations

It means performing repetitive, purposeless motor actions. For example, in the case of Emilio, he continually folded the end of his shirt with his fingers. Which indicates that there are no problems in the performance of movements, but in the will to start them.

Reaction to harmful stimuli

Another distinctive symptom is that these patients, faced with a stimulus that is harmful, can “wake up”, that is, react by shaking and even saying words.

Variable emotional states

Regarding the emotional states, they seem to be variable in each case. Some have practically imperceptible emotional expressions while others have significant alterations, sometimes typical of frontal brain damage, such as impulsive and uninhibited emotional outbursts.

Other symptoms

- Failure to initiate spontaneous voluntary actions.

- They remain still, inactive throughout the day (akinesia). They only carry out automatic behaviors.

- Silence and lack of gesticulation (for example, they do not indicate signs that show that you are listening or understanding what others are saying).

- They do not usually answer if the questions are open or involve emotional or affective content.

However, symptoms can vary depending on the functional deficits caused by each affected brain area.

Types

Two types of akinetic mutism have been defined depending on where the lesions are in the brain and the symptoms it causes:

Frontal akinetic mutism

It is the most common and is associated with unilateral or bilateral focal lesions of the anterior cingulate cortex.

If this lesion is unilateral, patients usually recover a few weeks later, on the other hand, if it is bilateral, it will present a total loss of the onset of spontaneous behavior that is not reversible. At times, the damage can also extend to the supplementary motor area causing deficits in movement.

Akinetic diencephalon-midbrain mutism

It occurs due to the involvement of the diencephalon, especially the ascending activating reticular system. This type presents less vigilance than frontal-type mutism and is also distinguished from this in that the patient presents vertical gaze paralysis.

Differential diagnosis

Akinetic mutism is difficult to detect, as it is difficult to assess because it is difficult for patients to respond to tests and must be devised for an effective neuropsychological evaluation. For this reason, it is easy to confuse akinetic mutism with other conditions or disorders.

Therefore, caution should be taken not to confuse with:

Vegetative state

Unlike akinetic mutism, in the vegetative state there is what is known as a vigil coma, a state in which the patient cannot follow external visual stimuli with his eyes, even if they are open; they cannot express themselves or follow simple commands.

They do retain some reflexes, but they cannot carry out behaviors because they would need to process with more cortical brain structures that patients with akinetic mutism have intact.

Minimally conscious state

In akinetic mutism, it does not respond due to a severe state of apathy and apathy that causes it not to move or speak spontaneously; But unlike minimal awareness, they can emit coherent responses when prompted and initiate movements when helped.

Captivity syndrome

Movement is not produced by paralysis in the limbs caused by damage to the spinal and corticobulbar tracts, leaving intact most of the cognitive functions, vertical eye movements and blinking (which they frequently use to communicate).

Aphasia

It can be difficult to make a distinction, since in some cases akinetic mutism and aphasia can occur at the same time. The main difference is that the initiative and motivation to communicate is preserved in aphasics, while patients with akinetic mutism lack these.

Abulia

It would be at a level immediately below akinetic mutism, being milder.

Depression

Rehabilitation

The main goal is to reduce apathy. Apathy is characterized by an alteration in the ability to set goals, lack of motivation, loss of initiative and spontaneity, affective indifference.

It is also commonly related to a lack of awareness of the disease, which has a very negative impact on the person's life and their overall neuropsychological functioning. It is necessary to reduce this apathy and increase the collaboration of the patient for a satisfactory rehabilitation.

Other goals are to maximize your independence, and to carry out activities of daily living that you used to do normally.

Aspects to take into account for rehabilitation

Neuropsychological rehabilitation consists of the application of intervention strategies that seek to ensure that patients and families can reduce, cope with or manage the cognitive deficit.

For this, it will work directly improving the performance of cognitive functions through repetition of exercises. Deficits can be intervened in 3 ways:

• Through restoration (direct training, recover damaged function).
• Through compensation (using the capacities that are intact to minimize the negative consequences of those affected).
• By substitution (it is used when the two mentioned techniques are not possible, and it is about dealing with the damage by teaching the affected person to handle external devices and signals to minimize these limitations).

Important aspects to consider:

• It is important to start rehabilitation as soon as possible.
• It is essential to develop an interdisciplinary work, with several professionals from different fields.
• For a neuropsychological intervention program to be effective, it must have a hierarchical organization of the tasks according to their level of difficulty, reaching a balance each time between the patient's abilities and the difficulty of the task.
• The main objectives to be achieved will be self-care, independence and integration.
• Don't forget the emotional aspects.
• Adapt rehabilitation so that it is as generalizable as possible to everyday situations.
• Restructure the patient's environment if necessary (called environmental strategies).
• When you are in a more advanced phase of treatment, develop metacognitive strategies. That is, trying to get the patient to acquire internal strategies that allow her to control her own attention, avoid being distracted by any stimulus, plan a sequence of tasks, use mnemonic rules, make decisions appropriately, etc.

Treatment

Pharmacotherapy

To reduce apathy, mainly dopamine agonists such as levadopa or bromocriptine, since dopaminergic pathways are often affected.

Patient collaboration

Achieving a minimum level of collaboration from the patient is absolutely necessary to start working. It can start by raising awareness of the deficit, which means that we have to make the person realize that they have a problem and that they must make an effort to recover.

Family activities

Carry out family activities that are valuable to the person, that can “awaken” previously learned behaviors.

It is essential for this that the family collaborate in therapy, since they are the ones who spend most of the time with the patient. They must be educated so that they adequately manage the environment in which the patient lives, structuring the activities of daily life to make them easier.

It is appropriate that they help the patient to initiate actions, trying to make them motivating tasks, and that they adapt to the cognitive level of the affected person.

Talk with the family and carry out activities

It is useful to ask family, friends, what the patient liked to do before, what motivated him, what hobbies he had, etc. In this way we can get to know the affected person better and develop therapeutic activities that motivate and be enjoyable for them.

Break the activities down into small steps and with clear instructions on their execution. When you do it correctly, you are always given immediate feedback after each step. It is appropriate to ensure that failure does not occur so that it is not frustrated.

Some important points for the execution of activities are:

• Begin training activities related to meeting basic needs such as eating, drinking or going to the toilet, to increase the patient's autonomy as soon as possible.
• The patient is more likely to respond or engage in any behavior if they are given a choice between two alternatives.
• It is better to give him clear and firm orders.
• Do not saturate the person with activities, as they can get tired and thus there is a very common confusion between apathy and fatigue.

Emotional support from the family

One technique is back chaining. It is about breaking down the task into steps and asking the patient to do the last step. To do this, the entire task is done first (for example, brushing the teeth), taking the patient's arm and doing all the movements.

The task is then repeated with assistance, but the last step must be done by the patient alone (drying the mouth). Encourage him to do so "now you must dry your mouth with the towel, come on" and reinforce him when he does.

Then the task is repeated until the patient can brush his teeth without any help. This technique has been found to be very useful for patients with motivation problems.

Task analysis

It consists of dividing a task into small, sequential steps and writing them in a list. This allows you to verify that each case is completed. This technique makes it much easier to start, finish, and track the activity.

In addition, it reduces fatigue, so that less energy is consumed because the patient does not have to plan, organize and remember the steps necessary to reach a goal. It is very useful to establish a routine of activities that must be done daily, since if they are repeated consistently, they can become automatic habits.

In a second stage, another strategy is developed dedicated to increasing the frequency of desirable but infrequent behaviors, rewarding their performance with very pleasant consequences for the patient.

To do this, a list must be made with what the patient is known to like and another list with what he is expected to do to achieve it. In order to know if it is useful for the patient (because it is usually completed by the family), the patient must assess each point on the list from 1 to 10 according to the degree of difficulty or, according to the degree of enjoyment it produces.

Other important points

• Show the family and the patient the progress, no matter how slight.
• The patient should feel that little by little his life is normalizing: it is good to have a routine, but it is not essential to shut up at home. Visiting friends and trying to take him to places where he used to go is something positive.

References

1. Álvaro Bilbao and José Luis Díaz. (2008). State Center for Attention to Brain Damage. Ceadac, I. Guide to cognitive and behavioral management of people with brain damage. Manual for professionals working in the rehabilitation of people with brain damage: Imserso.
2. Arnedo, M., Bembibre, J., Triviño, M. (2012). Neuropsychology. Through clinical cases. Madrid: Medical-Panamericana.
3. Carrión, JL (2006). Brain Injury: A Guide for Families and Therapists: Delta.
4. Damasio, AR (1999). The Feeling of What Happens: Body and Emotion in the Making of Consciousness. New York: Harcourt.
5. Godefroy, O. (2013). The Behavioral and Cognitive Neurology of Stroke: Cambridge University Press.
6. Guallart, M., Paúl-Lapedriza, N. & Muñoz-Céspedes, J. (2003). Neuropsychological rehabilitation of apathy. II International congress of neuropsychology on Internet. May 3, 2003.
7. Martelli, MF (2000). A Behavioral Protocol for Increasing Initiation, Decreasing Adynamia. Rehabilitation Psychology News, 27 (2) 12-13.