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  • Updated 10.10.2023
  • Released 08.23.2019
  • Expires For CME 10.10.2026

Automatic-voluntary dissociation



Automatic-voluntary dissociation is the differential completion of an action depending on the patients attention to the task. Activities can be performed either attentively (voluntarily) or inattentively (automatically). Two kinds of automatic-voluntary dissociation can therefore occur. The first, which is more often described, pertains to the patients inability to complete an action voluntarily (attentively), but successful or improved action completion when the task is approached automatically (inattentively). The other kind, which is less often described, is the dissociation in which activities are completed voluntarily, but not automatically, although this kind of dissociation is actually common. Recognizing automatic-voluntary dissociation in a patient may suggest potential methods for therapy, some of which have been developed. This article reviews the many different manifestations of this phenomenon and discusses its implications for patient management.

Key points

• Automatic-voluntary dissociation refers to the differential completion of an action depending on the individuals attention to it.

• The dissociation is not specific to a form of neuropathology or lesion localization.

• The dissociation can occur in either direction. Some illnesses or conditions result in relatively preserved automatic acting (involving reduced attention or effort) but impaired voluntary acting (involving increased attention or effort), whereas others have the opposite pattern. In addition, some illnesses can have both forms of dissociation.

• Automatic-voluntary dissociation teaches that formal clinical testing that requires performing on command (which requires attention to the task) may underestimate or overestimate the ability to complete the same activity under spontaneous, real-world circumstances (less attentively).

• Management for automatic-voluntary dissociation is not well developed.

Historical note and terminology

Nonreflexive activities can occur either automatically or voluntarily. Automatically refers to activities that do not involve simple reflexes and occur without conscientious initiation. Automatic behaviors are normal in health. For example, healthy preverbal infants spontaneously repeat words that they hear from other individuals, as an early part of normal language acquisition, without evident planning (97). Such learned behaviors can later be intentionally modified. Voluntarily in contrast refers to activities that are intentional, thus with a vivid mental depiction before commencing. This can pertain to a wide sort of desired skills (eg, learning to ride a bicycle or play a violin), which with practice is done to reduce perceived error and improve speed of accomplishment with repetition (79). With repeated performance, such activities can be conducted automatically (for example, driving a familiar route while mulling some other concerns). This indicates that automatic and voluntary activities have a bidirectional relationship: skills can be acquired either automatically or voluntarily, and then can be performed in the opposite condition.

Clinicians commonly note that chronic nonepileptic brain disorder symptoms are present for at least several minutes. For example, aphasia or limb paresis are considered to persist without change over short periods without rehabilitation. However, for nearly 200 years researchers have noted that the ability of some patients to accomplish specific activities can change drastically and abruptly following changes either in the immediate environment, within their bodies, or in their social interactions. The critical factor is whether the patient pays attention to the action.

Automatic-voluntary dissociation refers to the completion of an action depending on whether the patient attends to the action. By convention, voluntary mediation involves deliberate attention to the activity. Automatic mediation, in contrast, occurs inattentively or with minimal perceived effort (42). Other published terms for this phenomenon are automatico-voluntary dissociation and, in the French literature, dissociation automaticovolontaire. It has also historically been called the Baillarger-Jackson principle (69), a term that is no longer used.

Automatic-voluntary dissociation has been reported since the observation of impaired voluntary mouth closure despite preserved spontaneous smiling following stroke in a patient in the early 19th century (80). Automatic-voluntary dissociation was formally recognized, particularly in aphasia, in the contemporary but independent observations of François Baillarger (1809-1890) in France and John Hughlings Jackson (1835-1911) in England (03). Baillargers observation was, however, preceded in 1861 by Ernest Auburtin (1825-1893), though he is not generally credited in neuroscientific research with reporting automatic-voluntary dissociation (69). Jacksons observations are more widely recognized, but Jackson himself credited Baillarger with having earlier recognized this phenomenon (56).

Automatic-voluntary dissociation may be observed on novel, experimental tasks as, for example, when patients with Parkinson disease must manually track an unpredictably moving stimulus (41). However, for the most part, the behaviors that will be discussed in this article are reported during routine activities of daily living or tests of generally familiar activities.

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