What is Apathy?
The term ‘‘apathy’’ conventionally describes a lack of interest
or emotion. This usage of apathy, although it is intuitive and commonly used in
clinical descriptions of patients with such traits, does not address the
medical dentition of apathy. Marin proposed apathy as a syndrome defined as a
lack of motivation, evidenced by diminished goal-directed overt behavior (as
indicated by lack of effort, initiative, perseverance, and productivity), diminished
goal-directed cognition (as indicated by diminished importance or value, lack
of interest and concern about one’s personal, health, or financial problems),
and diminished emotional concomitants of goal-directed behavior (as indicated
by unchanging affect, lack of emotional responsiveness to positive or negative
events, absence of excitement). Apathy was considered a symptom of some other
neurological or psychiatric syndromes if lack of motivation was attributable to
intellectual impairment, emotional distress, or diminished level of
consciousness.
While there is no consensus on the apathy definition among
scientists and practitioners, the main traits of this syndrome can be defined
as follows:
- Lack of motivation
- Diminished goal-directed behavior
- Lack of initiative
- Absence of excitement
As of to date, there is still no clear consensus as to what definition
of apathy is appropriate and clinically easy to operationalize. This lack of
consensus corresponds to the Diagnostic and Statistical Manual of Mental
Disorders (DSM)-lV, where apathy is not included in the glossary and mentioned
merely as a non-specific symptom of several disorders.
Apathy and Depression
While apathy is considered as a behavioral syndrome common
in normal physiological aging, it is also part of the psychiatric spectrum of
mental illness, and of many neurodegenerative disorders like Alzheimer’s disease.
Apathy actually occurs when the individual’s systems, generating and control ling
any voluntary actions, are altered. Therefore, apathy can be defined as the
quantitative reduction of self-generated voluntary and purposeful behavior and
should not be automatically considered a clinical aspect of depression. This
diagnostic challenge comes from the apparent similarities between apathy and depression.
Diminished interest, psychomotor retardation, fatigue/hypersomnia, and a lack
of insight are common to both apathy and depression.
A potential source of confusion lies in the difficulty of
clinically and conceptually differentiating apathy from depression. Depression
is defined, according to the World Health Organization's international
classification of diseases, as a syndrome consisting in a permanent abnormal
mood (at least for two consecutive weeks) and a marked diminished interest or
pleasure and decreased energy associated to at least one of the following
symptoms: loss of confidence, excessive guilt, recurrent thoughts of death,
poor concentration, sleep disturbance, and change in appetite or weight. Apathy
is not a clinical criterion of depression but can be one of the clinical expressions
of a depressed state. Apathy can occur in the absence of depression and indeed,
in most neurological diseases, apathy is not the consequence of depression. In
short, apathy is a symptom that can be observed in depression but may also
occur without depression and, when both are present in a given patient they may
be clinically and anatomically independent.
Additional mix-up problem may be caused by the fact that apathy
can also be caused by the treatment for depression. There has been a theoretical concern that
serotonergic reuptake inhibitors (SSRIs) may affect the counterbalance of serotonin
and dopamine, which can lead to apathy, and SSRI-induced apathy has been
increasingly reported.
Mechanism of Apathy
Researchers at the
UCL Institute of Cognitive Neuroscience have performed a study 2012 to
investigate a biological mechanism that could explain apathy. The team studied
a patient experiencing profound apathy following a stroke which damaged a
particular area in his brain. Prior to the stroke, he was an exuberant and
outgoing character but the stroke transformed him into a reticent and reserved
individual, unmotivated even to maintain personal hygiene. The stroke affected
a particular region of his brain, the basal ganglion, that is known to be
important for value-based decision making and modulating behavior in response
to reward.
Professor Masud
Husain, who led the study, explained: “Apathy is difficult to study in patients
with neurodegenerative diseases as there are so many areas of the brain
affected that it is difficult to interpret the results. This patient gave us a
rare opportunity to investigate whether this area of the brain, and reward
sensitivity in particular, plays a role in apathy.”
The patient was given
experimental tasks to perform to assess his decision-making processes in
response to rewards. Throughout the tests he showed little interest in taking
risks for rewards, even when given the opportunity to maximize the overall
reward he could obtain.
The brain chemical dopamine,
often described as the ‘feel-good’ factor, is known to be important for
effort-based decision making. When the team treated the patient with a
precursor to dopamine that is converted to dopamine in the brain, he
showed a partial increase in reward sensitivity. However, a drug that mimics
the effects of dopamine on the receptors in the brain had a much more profound
effect, with the patient becoming much more motivated to take risks during the
experiment. At the same time, outside of the study, he began to go out more,
found a job and became more sociable.
Apathy and Aging
One of the recent studies (2010), performed by Brodaty and
colleagues at School of Psychiatry, University of New South Wales, Sydney,
Australia, positively answered the question "Do people become more
apathetic as they grow older?" They studied 76 healthy people between the
ages of 58 and 85 years and followed them for five years. The people underwent
neuropsychological testing and MRI scans at the start and again at the end of
the study. Each time, they administered the Apathy Evaluation Scale, and at the
end of the study, found a significant increase in apathy with aging that did
not correlate with any changes in the health status of the people.
Apathy Evaluation Scale
The Apathy Evaluation Scale (AES) was developed by Marin
(1991) as a method for measuring apathy resulting from brain-related pathology.
He defined apathy as “lack of motivation not attributable to diminished level
of consciousness, cognitive impairment, or emotional distress.” He also relates
an operational definition: “a state characterized by simultaneous diminution in
the overt behavioral, cognitive, and emotional concomitants of goal-directed
behavior.” Stemming from this definition, Marin described three domains of
apathy:
- ‘deficits in goal-directed behavior’
- ‘a decrement in goal-related thought content’
- emotional indifference with flat affect
There are three versions of the AES for use by the person with the neurological problem, i.e., self (AES-S); by an informant such as a family member (AES-I), or by a clinician (AES-C).
Apathy Evaluation
Scale (AES-S) Questions
For each
statement, circle the answer that best describes the subject’s thoughts,
feelings, and activity in the past 4 weeks:
1. I am
interested in things:
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
2. I get
things done during the day.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
3. Getting
things started on my own is important to me.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
4. I am
interested in having new experiences.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
5. I am
interested in learning new things
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
6. I put
little effort into anything.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
7. I
approach life with intensity.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
8. Seeing a
job through to the end is important to me.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
9. I spend
time doing things that interest me.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
10. Someone
has to tell me what to do each day.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
11. I am
less concerned about my problems than I should be.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
12. I have
friends.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
13. Getting
together with friends is important to me.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
14. When
something good happens, I get excited.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
15. I have
an accurate understanding of my problems.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
16. Getting
things done during the day is important to me.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
17. I have
initiative.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
18. I have
motivation.
·
NOT
AT ALL
·
SLIGHTLY
·
SOMEWHAT
·
A
LOT
Each item can be assigned the scores from 1 to 4, where the
NOT AT ALL answer gives 4, and A LOT – 1 for all positively worded items
(except #6, #10, and #11). Therefore, there range for the possible scores is
between 18 and 72. While the full evaluation should be performed by
professionals, the rule of thumb is simple – a higher score represents a higher
rate of apathy in patient. Health guideline for self-evaluation should be as
following: your total score should be in range 22 to 34. Scores, starting from
34 and up, may characterize mild apathy. Note that the scores interpretation is
still to be well standardized. There are many social and environmental factors,
impacting the results, like age, social environment, medical diagnosis, and
other factors.
Sources and Additional
Information:
Apathy: A Common
Psychiatric Syndrome in the Elderly. J Am MedDir Assoc 2009; 10: 381–393
