Gym, Tan, Laundry?

In the many years that I have been practicing therapy, I have heard countless clients struggling with their mental health identify themselves as “lazy” because they were not able to exercise or consistently work out. 

As a therapist, I work with my clients to challenge this criticism and negative self-attribute as it is often not an identity characteristic, rather a symptom of their existing mental health issue. 

It is important to remember, when you are struggling with inactivity or getting yourself going, “laziness” is a symptom of your mental health, not who you are. ​

Aside from my work as a licensed psychotherapist, I am a certified personal trainer, and use both fields of study to craft an expertise in woking with people who experience significant problems with motivation (volition) and engaging in goal-directed behaviors. ​

Many individuals struggling with their mental health can experience significant motivational challenges to such an extent that they are unable to perform complex motor functions like exercise.  There are a variety of symptoms that create problems with maintaining a work out routine, ranging from fatigue to paralysis. 

First, we have to identify how you are personally affected by your mental health condition (symptoms, severity, frequency, capacity):

Often times mental health issues are exacerbated by significant deficits in motivation including symptoms of fatigue, avolition, catatonia or even paralysis, where anxiety and depression are triggered secondary after losses in motor or behavioral functioning. Interestingly, symptoms like this are best explained and understood as a result of the research on “Catatonic Subtype of Schizophrenia.” In fact, the research on Catatonia has allowed us to identify it’s presence and spectrum of symptoms in other mental health conditions as well as expand our understanding of how a person experiences the inability to perform goal directed behaviors like exercise.  In as such, the research on Catatonia can be extended to other mental health diagnosis to understand how motivation,  behavior, and goal directed activities like working out are impacted by co-occurring symptoms of fatigue, avolition, catatonia and paralysis

As of the last 10 years, Cataonia is recognized as a standalone disorder which expands our understanding of  motivation and motor functions, specifically how Catalonia and Catatonic-like behaviors (fatigue, avoilition, paralysis) impact and are impacted by other mental health conditions.  This research gives us insight into the lived experiences of people struggling with their motivation and how each person may be uniquely affected. Catatonia is defined as a nueropsychiatric and behavioral condition that leads to immobility, abnormal or repetitive behaviors, and withdrawal. Individuals with Catatonia may experience extreme fatigue and psychomotor slowing, feel immobile, or even get stuck engaging in stereotypic and repetitive behaviors that impact their ability to initiate, maintain, or complete tasks.  While Catatonia is it's own distinct symptom and varies greatly in its severity and presentation, there is a spectrum of symptoms with similar features that impact people with mental health issues at varying degrees. 

Avolition is an intense lack of motivation that inhibits your ability to participate in goal-directed tasks and complete activities of daily living, often occurring with indifference to the environment or lack of behavioral arousal. In some cases, people experiencing avolition report not being able to move their body at all.

Catatonia and avolition share many similar behavioral deficits including loss of affective, communicative, and motor functioning. Both catatonia and avolition share features of significant under activity or slowing in alertness, responsiveness, and sustained ability. In episodes of catatonia or avolition individuals may find it hard to initiate activities, demonstrate emotional expression, participate in speaking and communication, or coordinate body movements.

While the pathophysiology of catanoia and avolition are not well understood, there are significant associations with neurological and autonomic dysfunction and symptoms of catatonia or avolition*.
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Individuals experiencing symptoms of avolition and catatonia are influenced by altered levels of activity in the front part of the brain and can often experience changes in autonomic nervous system functions like body regulation. During states of avolition or catatonia, a person’s executive functioning abilities are impaired and their physiology is in a state similar to a stress response (fight or flight). This means that one’s ability to plan and organize multistep demands are impaired and simultaneously may be experiencing intense physical sensations like fatigue, restlessness or paralysis. In some cases, individuals may experience changes in body temperature, heart rate, or blood pressure leading to blurred vision, dizziness, or shortness of breath.

Rather than looking at behavioral deficits, however, we should attune to the underlying physiological and cognitive processes and how that influences our physical capacity.

Catatonic behaviors are just as much a physical illness as they are a mental health issue.

It is important to conceptualize avolition and catatonia as a physical illness in order to best manage the symptoms. Interventions and treatment for catatonic-like behaviors should attune to the biological and cognitive changes that occur during episodes like avolition. In such a case, it is important to consider how motivation is impacted by sensory perception and regulation, cognition, and motor planning. Catatonia and avolition can be seen as an intense, unprompted affective response which affects cognition, ultimately leading to a loss of physical capacity. 

​Symptoms of catatonic behaviors, like avolition, can range in intensity, frequency, and persistence creating ranges in functional ability and symptom presentation. In general it is recommend that individuals experiencing chronic avoiltion seek pharmacological or psychiatric services, counseling, neuro/biofeedback, and behavioral intervention treatment.

The research suggest that attention should be paid to regulating one’s sensory experiences in order to alleviate the autonomic nervous system’s dysfunction. For example, sensory tools like music or compression/weighted clothes may assist in regulating anxieties that prompt poor task initiation or maintenance. Further, attuning to interceptive sensory experiences like taste, smell, hunger, or thirst can help regulate impaired sensory or bodily experiences. It is also recommended to assess environmental stimuli that may be triggering episodes of catatonia or avolition.

In addition, individuals with avolition demonstrate an inability to experience pleasure in response to rewarding stimuli or outcomes but when exposed to a variety of rewarding stimuli indicate significant increases in levels of positive emotions*. In order to regain one’s sense of motivation it is important to offer a consistent and varied reward schedule, and to elicit positive associations with task initiation, maintenance, and completion. During periods of avolition and catatonia it may be necessary implement rewards for small tasks or deliver positive reinforcement upon completion of steps toward a larger goal. For example, adjusting expectations for performance and rewarding goal-directed behavior as compared to goal completion can assist with building stamina and task participation. I would recommend isolating tasks in multistep activities and breaking goal based activities into segments as to not overwhelm an already impaired cognition and motor functioning. Creating specific task lists or step by step instructions toward goal completion and providing continuous positive reinforcement or feedback can assist with goal-directed behaviors. Ultimately, basic behavioral data suggests that persistence of goal-directed responding is dependent on reward history.

A range of studies confirm that people affected by avolition and catatonia experience diminished pleasure or positive feelings that typically promote behavioral arousal. Other studies have found that although reward based approaches encourage the initiation of tasks, sustained participation in an activity or behavior is more influenced by anticipatory pleasure. Anticipatory pleasure reflects the pleasurable emotions derived in the present related to the thought of participating in an event or future event (as compared to the thoughts about how one might feel while participating in the event). For example, motivation techniques that focus on positive self-talk like, “Exercise is good for you, it will make you feel good” may not be effective in promoting goal-directed behavior or task completion. Rather, self-talk that promotes acceptance and commitment may be more beneficial in motivating one’s self and maintaining long-term behaviors. For example, “Right now I do not feel like exercising, what steps do I need to do to complete the task?”

In terms of exercising amidst an episode of avolition, it is important to consider the intensity of your symptoms and it's impact on your physical capacity. In some situations it may not be safe to perform complex or strenuous exercise. I would suggest developing variety of fitness plans that compliment your varying emotional and behavioral capacities.

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If you or someone you love is impacted by their mental health, please visit www.TherapywithRaquel.com for more information. 

*Referenced from (Burrows, Spurling, Marwaha, 2020); (DeRosse, Barber, Fales, Malhotra, 2019)