Apathy

In the context of health care, apathy is defined as a measurable loss of goal-oriented activity relative to a patient’s previously established levels of cognitive engagement, emotional expression, and/or social interaction. Apathy can be a symptom or consequence of multiple physical and mental health conditions, including major depressive disorder (MDD), cerebrovascular disease, Parkinson’s disease, and multiple neurodegenerative conditions such as Alzheimer’s disease, frontotemporal dementia, and vascular dementia.

A related condition, avolition, is commonly described as a more severe manifestation of apathy. Patients with avolition display a functionally complete lack of motivation, even with respect to basic everyday tasks. Avolition is primarily associated with mental health and neurodegenerative conditions including Alzheimer’s disease, bipolar disorder, dysthymia (persistent depression), premenstrual dysphoric disorder, post-traumatic stress disorder (PTSD), and schizophrenia. Avolition can also result from traumatic brain injuries or present as an adverse effect of certain pharmaceutical drugs.

Background

The word “apathy” combines the prefix a- (“not” or “lack”) with the Greek word -pathos (“emotion” or “passion”). Thus, in its most general sense, the term describes a person’s lack of emotion, passion, or interest in the world around them.

Most people experience periods of apathy at various times in their lives. Clinicians generally consider transitory feelings of apathy to be normal and not necessarily indicative of an underlying illness, mood disorder, or mental health issue. Apathy becomes problematic when it persists for an extended time without interruption and begins interfering with a person’s everyday life and established routines. Importantly, as the term is used in medical contexts, apathy is also beyond the patient’s conscious control and does not result from a person’s choice-oriented decision to react indifferently toward a particular event, task, or activity.

Apathy can manifest in many ways, but researchers and clinicians have identified four primary patterns of apathetic behavior. These include withdrawals from professional, social, and personal pursuits; increasing neglect of daily activities, such as meeting financial obligations or maintaining personal hygiene, and/or rising amounts of reliance on others to carry out such tasks; a marked absence in the experience and expression of both positive and negative emotions; and an absence of concern about these behavioral changes. Similar symptoms accompany some mental health conditions, such as major depressive disorder (MDD). However, apathy is differentiated by its pervasive sense of emotional blunting: depression-related indifference is often accompanied by feelings of sadness or despair, whereas apathy is specifically characterized by an absence of emotional response.

Avolition is a more intense expression of apathy in which a patient displays a pronounced inability to begin or complete even the simplest and most routine tasks. It is differentiated from apathy by subtle but notable factors. Avolition is more strongly rooted in behavior, while apathy is more closely associated with changes in cognition, expression, and emotional engagement. In both cases, the changes in a person’s motivation, emotions, and behavioral patterns are pronounced, readily apparent, and quantifiable when compared with their previously established personal standards.

Overview

The general causes of apathy differ, depending on whether the condition is symptomatic of a physical illness or a mental health disorder. With respect to physical illnesses, apathy is usually a chronic symptom that may become intractable as the patient’s underlying condition progresses. Researchers have documented links between this form of apathy and physical changes in the brain, including damage to the frontal lobe, cerebral cortex, or ventral striatum. Each of these brain regions plays a major role in regulating rewards-based behavioral motivation and damage or degeneration within them thus disrupts the brain’s natural ability to engage in motivated, goal-oriented behavior that would normally generate reward-based neurochemical responses. By contrast, apathy arising from psychological causes and mental health conditions tends to be more situational and less severe. Such apathy can also arise episodically, intensifying alongside the patient’s other symptoms and abating as the underlying condition is brought under control.

Clinicians also note that apathy can manifest as a syndrome, particularly in military veterans, prisoners of war, and people who have survived intensely traumatic situations such as natural disasters and other forms of life-threatening danger. Experts believe these forms of apathy function as a psychological defense mechanism intended to prevent the person from experiencing more intense distress than they are already under.

In addition to mood disorders, neurodegenerative diseases, and traumatic brain injuries, apathy can also be caused by strokes and brain tumors. Approximately one-third of patients who survive a major hemorrhagic or ischemic stroke go on to develop apathy, which in such contexts is generally considered a complication associated with the recovery stage. Tumors that disrupt the normal function of brain regions that govern motivation, reward-seeking, goal-oriented behavior can also cause apathy or avolition.

Researchers identify apathy as one of the most common and pervasive markers of neurodegenerative disease advancement, especially regarding Alzheimer’s disease. In this case, apathy can have an accelerating effect on disease progression. As it takes hold, a patient’s condition and accompanying symptoms often worsen and their risk of suffering severe and irreversible functional disabilities increases.

Apathy can be difficult to diagnose, as it often presents as a comorbidity alongside other physical illnesses, neurodegenerative diseases, and mental health disorders. Treatment usually focuses on management, with the objective of preventing the condition from worsening or becoming permanent. Apathy does not always respond to treatment, with its presence and intensity instead largely depending on the state of the patient’s underlying causal condition.

Pharmaceutical interventions may improve the symptoms of apathy or prevent them from worsening. Three main classes of prescription drugs are used in its management: cholinesterase inhibitors, psychostimulants, and antidepressants. Cholinesterase inhibitors are usually reserved for people with Alzheimer’s disease, while psychostimulants may be recommended for Alzheimer’s disease and other neurodegenerative conditions. Antidepressants are typically prescribed if the patient’s symptoms are related to an underlying mood or mental health disorder. Non-medicinal management strategies, including physical exercise, music and art therapy, and support groups, may also help improve an apathy patient’s condition.

Bibliography

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