Can’t or Won’t – An Introduction To Apathy.

 By Megan Jackson

Edited by Sam & Chiara

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Often, when a person hears the word apathy, an image comes to mind. A glassy-eyed teenager scrolling vacantly through their phone while their parent looks on in despair. While comical, it does not reflect what apathy really is clinically: a complex symptom that has important clinical significance.

In 1956, a study was published describing a group of Americans released from Chinese prison camps following the Korean war1. As a reaction to the severe stress they had suffered during their time in prison, the men were observed to be ‘listless’, ‘indifferent’ and ‘lacking emotion’. The scientists decided to call this pattern of behaviours apathy. However, at this point, there was no formal way to measure apathy. It was acknowledged that it could manifest in varying degrees, but that was the extent of it. It was over 30 years before apathy was given a proper definition and recognised as a true clinical construct.

As time went on, scientists noticed that apathy doesn’t just arise from times of extreme stress, like time in a prison camp, but that it also appears in a variety of clinical disorders. A proper definition and a way of assessing apathy was needed. In 1990, Robert Marin defined apathy as ‘a loss of motivation not attributable to current emotional distress, cognitive impairment, or diminished level of consciousness’. As this is a bit of a mouthful, it was summarised as ‘A measurable reduction in goal-directed behaviour’. This definition makes it easy to imagine an individual who no longer cares about, likes, or wants anything and therefore does nothing. However, this is not always the case. There are different subtypes of apathy that each involve different brain regions and thought-processes, these are:

Cognitive – in which the individual does not have the cognitive ability to put a plan into action. This may be due to disruption to the dorsolateral prefrontal cortex.

Emotional-affective – in which the individual can’t link their behaviour or the behaviour of others with emotions. This may be due to disruption to the orbital-medial prefrontal cortex.

Auto-activation – in which the individual can no longer self-initiate actions. This may be due to disruption to parts of the globus pallidus.

It’s much easier to picture how the different types of apathy affect behaviour. Take Bob for example. Bob has apathy, yet Bob likes cake. When somebody asks Bob whether he would like cake he responds with a yes. However, Bob makes no move to go and get it. Bob still likes cake, but he can no longer process how to obtain that cake. He has cognitive apathy. In another example, Bob may want cake but does not want to get up and get it. However if someone told him to, he probably would go and get it. This is auto-activation apathy and is the most severe and the most common kind. If Bob could no longer associate cake with the feeling of happiness or pleasure, then he has emotional-affective apathy.

So, whatever subtype of apathy Bob has, he doesn’t get his cake. A shame, but this seems a little trivial. Should we really care about apathy? Absolutely! Imagine not being able to get out of your chair and do the things you once loved. Imagine not being able to feel emotions the way you used to. Love, joy, interest, humour – all muted. Think of the impact it would have on your family and friends. It severely diminishes quality of life, and greatly increases caregiver burden. It is extremely common in people with neurodegenerative diseases like dementia2, psychiatric disorders like schizophrenia3, and in people who’ve had a stroke4. It can even occur in otherwise healthy individuals.

Elderly people are particularly at risk, though scientists haven’t yet figured out why. Could it be altered brain chemistry? Inevitable degeneration of important brain areas? One potential explanation is that apathy is caused by a disruption to the body clock. Every person has a body clock, a tiny area of the brain called the suprachiasmatic nucleus, which controls the daily rhythms of our entire bodies like when we wake up, go to sleep, and a load of other really important physiological processes like hormone release. Disruption to the body clock can cause a whole host of health problems, from diabetes to psychiatric disorders like depression. Elderly people have disrupted daily rhythms compared to young, healthy people and it is possible that the prevalence of apathy in the elderly is explained by this disrupted body clock. Much more research is needed to find out if this is indeed the case and why!

Figuring out how or why apathy develops is a vital step in developing a treatment for it, and it’s important that we do. While apathy is often a symptom rather than a disease by itself, there’s now a greater emphasis on treating neurological disorders symptom by symptom rather than as a whole, because the underlying disease mechanisms are so complex. So, developing a treatment for apathy will benefit a whole host of people, from the elderly population, to people suffering from a wide range of neurological disorders.

Key References

  • Stassman, H.D. (1956) A Prisoner of War Syndrome: Apathy as a Reaction to Severe Stress, Am.J.Psyc., 112(12):998-1003
  • Chow, T.W., (2009) Apathy Symptom Profile and Behavioral Associations in Frontotemporal Dementia vs. Alzheimer’s Disease, Arch Neurol, 66(7); 88-83
  • Chase, T.N., (2011) Apathy in neuropsychiatric disease: diagnosis, pathophysiology, and treatment Neurotox Res 266-78.
  • Willem van Dalen, J., (2013) Poststroke apathy, Stroke, 44:851-860.
  • Gillette M.U., (1999) Suprachiasmatic nucleus: the brain’s circadian clock, Recent Prog Horm Res. 54:33-58
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