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Following severe trauma, people can feel so hopeless that they can’t see any point to living anymore. Faced with the ultimate defeat, some individuals can die because they can’t muster the strength and motivation to keep on living. In a new study,  Dr. John Leach, a senior research fellow at the University of Portsmouth, has now described the five stages a person with ‘given-up-itis’ goes through before they die.

“The term ‘give-up-itis’ describes people who respond to traumatic stress by developing extreme apathy, give up hope, relinquish the will to live and die, despite no obvious organic cause,” Leach wrote in the journal Medical Hypotheses.

Give-up-itis, or psychogenic death as it’s called medically, has five stages.

1. Social withdrawal. In the first stage, a person undergoing psychological trauma will choose to stay away from other people and social activities. The social withdrawal is coupled with a lack of emotion as well as indifference and self-absorption.

According to Leach, the withdrawal is a sort of coping mechanism which helps the traumatized person to take a break in order to find emotional stability. However, if left unchecked, withdrawal can progress into the second stage of psychogenic death.

2. Apathy. Prisoners of war or shipwreck survivors are often struck by a demoralizing melancholy which some have described as no longer striving for self-preservation. During this stage, people will stop caring for themselves, becoming untidy. Even the smallest task will feel like a colossal effort.

3. Aboulia. People in this lethargic stage speak very little, forego frequent washing or eating and withdraw deeper into themselves.

Passive behavior, few and disinterested social interactions, late response to interactions and emotions, and lack of desire to move or sustain movements are some of the symptoms of this disorder

“An interesting thing about aboulia is there appears to be an empty mind or a consciousness devoid of content. People at this stage who have recovered describe it as having a mind like mush, or of having no thought whatsoever. In aboulia, the mind is on stand-by and a person has lost the drive for goal directed behaviour,” said Dr. Leach, whose career has focused on the psychology of survival.

4. Psychic akinesia. This stage features an ever deeper drop in motivation. The person is engulfed by such a profound state of apathy that they even become insensitive to pain. Leach’s paper features a case study describing a woman who suffered second-degree burns while at the beach simply because she wasn’t motivated enough to remove herself from the sun. Stage four typically takes 3-4 days to progress into stage five (death).

5. Psychogenic death. At this point, the person’s will to live is completely gone, leading to disintegration.

“It’s when someone then gives up. They might be lying in their own excreta and nothing – no warning, no beating, no pleading can make them want to live,” Leach said.

The psychologist wrote that prisoners in Nazi concentration camps were often known to be nearing death by their fellow inmates when they would take out a hidden cigarette to smoke it. Cigarettes were prized possessions that could be traded for food and other valuable commodities.

“When a prisoner took out a cigarette and lit it, their campmates knew the person had truly given up, had lost faith in their ability to carry on and would soon be dead,” Leach said.

Ironically, gestures such as the concentration camp prisoner’s lighting of the cigarette can be viewed as hopeful. However, it doesn’t last long.

 “It appears briefly as if the ’empty mind’ stage has passed and has been replaced by what could be described as goal-directed behaviour. But the paradox is that while a flicker of goal-directed behaviour often takes place, the goal itself appears to have become relinquishing life,” Leach added.

The study suggests that this strange condition might be triggered by changes in the anterior cingulate circuit, which is responsible for motivation and goal-directed behaviors. Severe trauma may cause this circuit to malfunction.

Psychogenic death isn’t inevitable. Those suffering from ‘give-up-itis’ can be steered onto the right path by different things at each stage. Physical activity and the re-framing of a situation such that the person feels back in control are some of the most common and most effective methods for reversing the condition.