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Apathy: A Neuropsychiatnc Syndrome Robert

Traditionally, apathy has been viewed as a symptom indicating loss of interest or emotions. This paper evaluates evidence that neuropsychiatric disorders also produce a syndrome of apathy. Both the symptom and the syndrome of apathy are of conceptual interest because they signify loss of motivation. An apathy syndrome is defined as a syndrome of primary motivational loss, that is, loss of motivation not attributable to emotional distress, intellectual impairment, or diminished level of consciousness. Loss of motivation due to disturbance of intellect, emotion, or level of consciousness defines the symptom of apathy. Neuro psychiatric literature dealing with apathy is reviewed within the framework of three approaches to defining the concept of a syndrome. Clinical and investigative approaches for evaluating apathy when it occurs in association with other syndromes are described. (The Journal Neurosciences

of Neuropsychiatry 1991; 3:243-254)

and

Clinical

T

S. Mann,

he term

or dimension address status. object

lack

of motivation

to describe such loss of emotions,

of behavior.

seen

It is em-

disorders.1 familiar flattening

which

is also reflected

and that

It does

attributes of affect,

clinical apathy not,

in

descriptions is a symptom

however,

directly

either the definition of apathy or its nosological Indeed, apathy per se only recently has been the of research, and this work has dealt primarily

with evaluating behavior, rather status. Although clinical

sition

have

been

been

of apathy considering

proposed

syndrome,1 not

drome as DSM-ffl-R consist

the validity than with

it has

valid

only

for

described.

of a single

as a dimension its nosological

that

criteria

apathy

may

evaluating

DSM-III-R

a group of symptoms uses the term to refer

disorder). Others quires heterogeneity

be a

this

defines

po-

a syn-

that covary, and, to some disorders

symptom

(e.g.,

of

organic

yet, that

amnestic

have

suggested among the

the syndrome (R. Jacob, personal communication).

J. Mezzich,

a syndrome

the presence

of a common

phys-

(as, for example,

in congestive

heart

emphasizes

iological

mechanism

failure); symptoms

the

From

Address and

NEUROPSYCHIATRY

the

or loss of energy. This usage, scales, factor analytic studies, (reviewed by Mann1), suggests

1991.

OF

describes

of neuropsychiatric

by clinicians of interests,

Received

JOURNAL

apathy

in a variety ployed as loss

M.D.

Clinic, Copyright

various through

requests

J. Zubin, approach

A third

re-

May, 1990, to defining

etiologies of the syndrome produce this mechanism. This definition, like

August17, 1990; revised the Western Psychiatric reprint

that a syndrome symptoms comprising

to Dr.

3811 O’Hara Street, © 1991 American

January

8,1991;

Institute Mann,

Pittsburgh, Psychiatric

and

Western

accepted Clinic, Psychiatric

January25, Pittsburgh.

Institute

PA 15213. Press, Inc.

243

APATHY

the

others,

has

its own

weaknesses,

but

also

its

advan-

This

tages.7 The primary purpose to provide a conceptual dence drome.

of discussing framework

that apathy represents In the process, it will

of the

neuropsychiatric

curs,

to

some and

to

of

definitions of syndrome will be presented, and will be specified. Next, apathy to these

various

approaches

is not

to answer

there

in which

the

some

synsome

its

oc-

its

phe-

underlying

a brief introduction to the prothe general nosological probwill be discussed. The three that have been their strengths neuropsychiatric

as a syndrome three definitions.

will

to defining

is a correct

in

of

is evi-

apathy

variations

suggest

mechanisms. Thus, after posed definition of apathy, lem of defining a syndrome

porting respect

a neuropsychiatric be possible to indicate

disorders

describe

nomenology,

these definitions for evaluating

introduced above and weaknesses literature sup-

be evaluated In considering

a syndrome,

definitively

the

or preferred

definition.

with these

the

purpose

of

whether

question

definition

poor

initiative,

chosocial applicable

flat

events, to the

consistent

with

the

affect,

lack

etc. The depressed

way

of engagement

clini-

with

same definition patient who

syndromic standpoint it may be misleading ize the depressed patient as apathetic; characterize

someone

“passions.” who shows

in

This contrasts exclusively

emotional

Similar

is dysphoric, an overall

or

to characterit is ifiogical

to

pain

as

apply

loss.

to interpreting

the

This

will

presence

of

that experts will differ in their conception of a syndrome according to their theoretical inclinations and investigative purposes. Rather, the intention is to ask, if we were

apathy interests

to regard then say

one that

according section,

to the criteria of that clinical and investigative

logical or effective manner. Therefore, the lack of interests that one sees in some demented individuals may be due to the cognitive impairment that defines dementia.

guishing

the

of these apathy

definitions as preferable, could we should be regarded as a syndrome

symptom

and

definition? strategies

syndrome

In the last for distin-

of apathy

will

be

described.

to the

when it occurs in dementia in a person with dementia

in

patient In the ab-

overall behavas apathetic. For of dysphoria com-

interpretation of motivational further below. caveats

lacking

with the schizophrenic negative symptoms.

sence of dysphoria, the schizophrenic’s ioral state can be accurately described the depressed individual, the presence

psy-

of apathy is shows apathy.

However, the fact that the depressed subject i.e., in emotional pain, suggests that from

plicates the be discussed

It is expected

seems

cians use the term. For example, a schizophrenic with negative symptoms may be characterized as apathetic from a syndromic standpoint because of lack of interests,

inability

of a demented

OF APATHY

and

other

evaluating

Etymologically, thos,”

apathy

meaning

that

is, to apathy-may

who

states Madness

derives

passions.

in his comes

have Sacred

from

from

Reference

the

to lack

its source

Greek,

in Hippocrates,8

Disease:

moistness....

The

corruption

of the

brain

is caused not only them thus. Those

by phlegm but by bile. You may distinguish who are mad through phlegm are quiet, and

neither

make

bile

shout are

noisy,

inopportune

nor

or emotion. (discussed

a disturbance;

evildoers,

and

restless,

those always

maddened doing

When below)

apathy

is defined

as a lack

of interest

the clinical features defined as apathy are considered, however, it is apparent emotions, that, in the as lack of whether it loss of

case

of dementia,

psychiatric

syndromes,

the

athy, is whether tive impairment,

to think

significance

depression, the

in a

the symptoms are emotional distress,

intellect, motivation

emotion, or level is attributable

emotion,

or level

terminology ple, to some

a syndrome has immediate because it characterizes of some

patients

who

of

apathy

is considered would

be to refer

depending syndrome.

entity itself. conceptualizing benefits overall

would

not

defof that of

If loss of intellect,

difficulties, however. For will suggest mistakenly

the

ap-

underlie the The syndrome of motivation, to disturbance

or secondary, to some other

“primary” apathy is a disease seems doubtful. Furthermore,

in

i.e.,

attributable to cognior diminished level

terminology

has its own the distinction

factor loss,

of consciousness. to disturbance

of consciousness,

An alternative

to apathy as primary whether it is attributable

delirium,

critical

of motivational

of consciousness. These considerations initions of apathy used in this paper. apathy is defined as primary absence is, lack of motivation not attributable

a symptom.

that apathy embraces not simply interests and but a variety of other psychological features author’s view, can be conceptualized best motivation. It is for this reason that apathy, refers to a symptom or a syndrome, denotes motivation.

through something

[p. 151.

Conventionally,

244

“pa-

of passion-

individual

of

Similarly, in a delirious patient, lack of interest or emotion may be attributable simply to the fact that the patient shows drowsiness or poor attention, i.e., diminished level of consciousness. Thus, in the

DEFINITION

and delirium. Lack might be attributable

on This examthat

At present, apathy

this as

for clinical discourse clinical presentation otherwise

be described

as well.

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#{149}

3

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#{149}

1991

MARIN

Since

the

concept

standing apathy, and to distinguish traditions

of motivation

in psychology

as a superordinate and determinants Atkinson,

or theory.. conventional

for the direction, (p

can

vigor,

to the

of theoretical with

such

therefore,

motivational

concepts

of

as initi-

i.e.,

useful

to

mental

clinicians

are

clearly

to emoapathy

influenced

emotional responsivity provide the motivational significance

events.

Thus,

the

(e.g.,

plans

and

curiosity)

cord

injury

yet,

based

with

her

to as emotion

evaluation

presence

because

they

and tion

dynamics are

motivational behavior (e.g., ity,

used

persistence, in

(Table

OF

lack

the

overt

interests, with

responsibilities, a patient about his would

and,

concerned or

of

spinal

be inactive

profoundly

is evaluation

us

the

goals

in

patient’s

life. emo-

with depression inactivity, whereas

demonstrate

will an

indifference, cheerfuldiagnosis

the

overt of

of interests,

A.

presence

as

of apathy:

of

syndrome lack

apathy

of motivation

emotional

(drowsiness

that

distress,

and/or

is not

attributable

or diminished

diminished

Lack

of motivation,

level

attentional

by all three

Lack

of productivity

Lack

of effort

Lack

of time

2.

previous age

and

level culture,

following: overt

in activities

socialization

Diminished Lack

behavior

as indicated

by:

of interest on others

to structure

or recreation

goal-directed

of interests,

lack

cognition

problems Diminished

importance

domains

as socialization,

3.

Diminished

personal,

or value

emotional

distress, diminished syndrome

concomitants

of excitement

lack

or functional to such

goal-related

productivity,

initiative,

of goal-directed

to positive

or emotional is not

attributable

distress, or diminished level is attributable to intellectual

or diminished attention), such

health,

things,

behavior

by:

of motivation

emotional of motivation

by: new

attributed

recreation,

Unchanging affect Lack of emotional responsivity Euphoric or flat affect Absence

in learning

curiousity

as indicated

Lack

as indicated

of interest

of interest in new experiences Lack of concern about one’s

perseverance,

of

of the

spent

patient’s

of his or her

goal-directed

Diminished

of apa-

to the

standards

activity

or

cogni-

relative

or the

Lack of initiative or perseverance Behavioral compliance or dependency

curios-

to the standards level of functioning-

the

impairment,

1.Diminished

the

behavioral,

the

syndrome

for

capacity).

of emo-

interpret

Criteria

of consciousness

of goal-directed behavoperational definition of

instances,

by a deficit-relative culture, or previous

NEUROPSYCHIATRY

may

content,

syndrome cognitive,

to intellectual

B.

1). In most

thy is suggested one’s own age,

JOURNAL

or fixity)

helping

or goals,

tive, and emotional concomitants ior has direct relevance to the apathy

disease

individual

1.

palsy.’4”5 the quality

of diminished goal-directed concomitants in thought content

between

roles,

and

requires reduction in the and emotional concomitants

by clinicians

use

etc.). The distinction

usual

values A patient

of an apathy behavioral,

to the

significance or its cognitive plans

thought

as evidenced

such

of immediate

diminished

on

future,

diminished.

or Parkinson’s

of functioning

potential incentive are of motivational

or pseudobulbar of affect, however,

(intensity,

for the

behavior

or inappropriate in clinical practice,

significance to the patient. As a clinical caveat, it is necessary to exclude the presence of disorders of affect that may alter the interpretation or expression of emotional e.g., aprosodia such disorders

of goal-directed

emotional unresponsiveness, ness. For these reasons,

The

by

relevant are

to assess the extent to which the reward features of the environment

information, Absenting

goals are also

important

TABLE

informaof environ-

of emotions

or affection’3’4-are

of apathy

and

apathetic

anger, the intensity and duration of their expression, the presence of flat affect, and reports of mood and feeling tone-all of which fall within the domain generally referred

concomitants

per se is to know

apathy.

affect, mood, feeling tone, and other emotional descriptors when evaluating whether a patient shows apathy. Their relevance to apathy is that emotional state and, particularly, tion regarding

cognitive

tional state. For example, typically be dysphoric

in under-

the relationship of apathy interest and emotion define

and

that

behavprolack of

and so on. However, inactivity to diagnose apathy. It is necessary

Equally

with autonomic, or anatomical function. These

potentially loss,

What then about tions? Diminished conventionally,

study directions

level of aspiration, goal-hierarchies, on. Biological approaches attempt

are,

standing

by

a con-

of an individual’s

these psychological concepts physiological, biochemical, of brain and general bodily

approaches

persistence, insufficient

explain, more what accounts

approaches deal

in the overt behavioral evidence of goal-directed ior. Thus, apathy may be suggested by diminished ductivity, lack of effort, diminished initiative,

“motivation”

to “develop

persistence

a number

be distinguished,’2

ation, persistence, motives, and so

term

to the characteristics behavior. As stated

.which will wisdom,

and

of which

correlate endocrine, concepts

the

aim

Psychological

4)9

motivation,

use

of motivation

scheme, than

actions”

that

to under-

to define motivation I will adhere to those

concept referring of goal-directed

theories

ceptual adequately

is central

it may be helpful it from emotion.

is absent

delirium,

events

intensity to intellectual of consciousness. impairment,

level of consciousness then apathy is a symptom

as dementia,

C. Emotional distress lack of motivation.

or negative

impairment, When emotional

(drowsiness of some

lack

or other

or depression.

or is insufficient

to account

for the

245

APATHY

goal-directed

behavior. The interested reader is referred to a previous publication for further discussion of this definition and its use in differential diagnosis.’

symptom underlying

This which

DEFINITION OF SYMPTOM, AND SYNDROME

that

SIGN,

but nevertheless pathophysiological

definition states that

occur

Virtually all classifications of psychiatric disorders use symptoms and signs as the clinical constructs for determining the presence of a mental disorder.’6 However, a variety of epistemological problems arise when the process of symptom description’7 and classification’8 is carefully examined. Conclusions about what a patient has said, showed, presented, etc., are structured by the training, education, psychological state, personal development, and cultur&92#{176}of both the clinician and the patient. Such complexities are particularly salient in psychiatry because

of the ways

language

in which

determine

constructions

and

observer

descriptions

characteristics

or, more

interpretations

and

properly,

of what

is and

the what

is

not the case. These

considerations

standing

the

provide

process

the

context

of characterizing

for

and

under-

classifying

psychiatric phenomena. Symptoms and signs remain the conceptual building blocks for describing higher level nosological categories, specifically syndromes and diseases. The concept of symptom is, of course, derived from the realm of general medicine where it names the pain, suffering, or disability that a patient reports. Signs of diseases traditionally are considered the observable features of a clinical disorder and, therefore, are regarded as possessing an objectivity and verifiability that symptoms do not have. Syndromes, on the other hand, are groups of signs and symptoms that have heuristic value for describing, diagnosing, or treating patients, while a disease “implies knowledge of etiology” (p. 29).16 We can distinguish the syndrome definitions discussed below according to the answers they provide to two

questions:

First,

do the

symptoms

comprising

a syn-

drome represent a homogeneous or heterogeneous group of symptoms from a categorical standpoint? Second, must the symptoms defining the syndrome reflect a single pathological mechanism? Definition 1: The simplest notion of a syndrome group of symptoms that constitute a recurring, pattern. As stated by Spitzer and Endicott’6: A symptom different predict symptoms

246

is a condition disorders other

facts (or

that

and signs)

of

therefore interest.

that

covary

may

be has

associated only

A syndrome and

has

is that it is a discriminable

with

limited

is a collection more

power

to of

than

The

term

a

to that is a “group

that

specific

‘disease’

a variety

a recognizable than

generally

of

of DSM-III-R, of symptoms

constitute

is less

‘disorder’

implies

or

a specific

etiology or pathophysiologic process. In DSM-III-R most of the disorders are, in fact, syndromes” (p. 405). Dementia, for instance, is regarded as a syndrome of memory and other intellectual impairments. Some syndromes in DSM-III-R

are

for example,

nosis,

actually

organic

or simple

Definition

2:

monosymptomatic amnestic

syndromes,

disorder,

organic

halluci-

phobias. A syndrome

toms and, therefore, to each other would

is a group

of heterogeneous

a group of symptoms whose not otherwise be considered.

symp-

relationship

The requirement for heterogeneity means that the symptoms defining the syndrome will not be categorically or logically related to each other. Certainly, they should not be synonyms for each other. For example, if anxiety is defined by the symptoms of nervousness, tension, and jitteriness, the attributes of an anxiety syndrome are relatively homogeneous, and, one might argue, synonymous. They would, therefore, suffice for definition 1, but not for definition 2. In fact, since these symptoms are synonymous, it could be argued that they serve only as different labels for the same phenomenon and, therefore, that anxiety is a monosymptomatic syndrome or, simply, a single symptom. By contrast, the diagnosis of delirium conforms question memory

to definition 2 because entails such categorically failure, impaired attention,

and visual depression

hallucinations. Similarly, embody considerable

pressed

mood,

considering stomach

anxiety as a syndrome, pains, urinary frequency,

are added symptom

to the profile of anxiety, cluster is obtained such

be regarded of definition gent test syndrome. symptomatic

anxiety,

weight

as a syndrome for

2. Definition establishing

homogeneous

group

the criteria heterogeneity, loss,

and

for major e.g., de-

insomnia.

Re-

if depressed

and sleep

mood,

disturbance

a more heterogeneous that anxiety might

been

now

to the requirements

2 thus provides a more a group of symptoms

It has the disadvantage states that have

are multiple synonyms enon and from defining

the clinical state in varied symptoms as emotional lability,

according

tionally as syndromes, e.g., However, it has the corollary from mistaking a symptom

many

power

and

‘Syndrome’

‘disease.’

be associated with processes [p. 291.

is equivalent a syndrome

together

condition.

may

of excluding regarded

strinas a monoconven-

organic amnestic disorder. advantage of preventing us for a syndrome when there

used to label the same phenoma syndrome on the basis of every

of symptoms.

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Definition shared found,

3:

A syndrome

is a group

pathological mechanism. for example, in the

volved.”7

Thus,

hemiparesis

a stroke

and

the anterior be pointed

infarction

ognized that the

pathological

presence

of organic

specific implied.2’

location Thus,

implied.

nism atively the

brain

dysfunction”)

nonspecific

specificity

regarding if compared,

of information

syndrome

of congestive

current state 3 for a shared

heart

of knowledge, mechanism

prerequisite

in most,

In summary,

definitions

is not heuristic

apathy.

other, pattern

value

but

rel-

picture

to

the

be

implied

by

in our

of definition rather than

tomatic

thus,

it admits

syndromes,

tween

a symptom

patient

care,

heuristic

value

whose would

and

as do the

blurring

a syndrome.

other

because

it attaches

but meaning

interrelationship as part otherwise be overlooked.

some symptom clusters (monosymptomatic usually thought of as having syndromic meet the heterogeneity criterion, e.g.,

disorder. prising nism.

Definition a syndrome Its virtue

mechanism.

JOURNAL

for,

OF

that

reflect a shared is the emphasis

Yet,

weakness,

3 requires

its

strength

if strictly

NEUROPSYCHIATRY

applied,

in

specific

is that

syndromes) status would not organic amnestic

the symptoms

com-

pathological mechaon the elucidation of this

regard

definition

any

to require of iden-

is also

its

with

like

sign

A variety

as

be used

to

describing

by a group

of symptoms

apathy

..

of

(Table

that 2).

can

A vivid

of the loss of affectivity

sit about

They to the

the

expressionless

of satisfaction to injuries

hunched

themselves and

back

or dissatisfaction. on them

inflicted

of terms

have

including Psychological and apathy syndromes

been

flat

their again

the

and

customary without

they image un-

place

of

expressing

They do not even seem by other patients (p. 40].

used

affect,Z

clinical

up,

to be dressed

to be led from

messhall,

to which

institutions

faces,

permit

automatons,

phenomena, 2.

now

literature

defined

description

schizophrenics.

to react

TABLE

to attributes pattern

of a recurring Its limitation

Thus,

schizophrenia:

confined

inactivity

be2 aids

it has

place.

But

will

of the

as a group

overall

in chronic

dressed

The to

boundary

be specified

of indifference.

I

instances in for the same

Definition

definitions,

first

There are a number of disorders that in such a way that the overall clinical

is Bleuler’s

Many

a

of monosympthe

of

etc.

is a syndrome

characterized

example

a

to defining

the presence

thereby

in

the purpose

the purpose

of a syndrome

described

may

are

against labels

be described

IS A

aspects

symptoms.

been

seen

constitute a recognizfor patient care. Its

weakness is that it does not guard which the symptoms are synonymous

APATHY

1: Apathy

related

is important

approaches

but may nevertheless that has heuristic

phenomenon;

Definition

the

all, instances.

of these

THAT

pertinent

Thus,

then

as a syndrome is lead to new knowl-

treatment, defeats

would

syndromes.

organize

example,

in the cluster it may

in advance

The three

have

failure.

mechanism,

the

syndrome has strengths and weaknesses. Definition helps us to identify distinctive groups of symptoms. symptoms may or may not be categorically related each able

tifying

mecha-

the requirement represents a goal

if not

each

about information

pathological

mechanism

of symptoms

the

Furthermore,

for

about

patterns

EVIDENCE

but is not to be equated entity.

we

has

However,

of this dysfunction of delirium has

situations,

SYNDROME

implies

dysfunction.

and nature the syndrome

(“organic

delirium

In such

in syndromic to specify path-

the

it is understood the syndrome

mechanism:

it provides

example,

thrombosis, hemwhich is a well-rec-

syndrome, that defines

brain

infarction

For

be embolism, of delirium,

a patient knowledge

the recognition of a symptom often useful precisely because such

is not

mechanism.

defining

may in-

of right

suggests

from characterizing until there is sufficient

face the problem that patients could only terms of symptoms, which would defeat

edge

value for diagnosing etiology, with the diagnosis of a disease information

terms ogenetic

of

neuropsychiatric symptom cluster

a common

if “charac(syndromes)

consisting

aphasia

may case

that

is of

clinicians

hemisphere, although it should etiology of such a syndrome of

nonfluent

cause of the stroke orrhage, etc. In the

a

which chapter

location of the cause or tissue or system

syndrome

left cerebral out that the

hemispheric

states symptoms

the anatomical or the organ

...

that have

This definition, introductory

MacBryde’s textbook of medicine, teristic groupings of signs and are recognized, be suggested

of symptoms

states

to describe

the

amotivational that

may

same syn-

produce

Schizophrenia (type II or negative symptoms) Frontal lobe injury Postpsychotic depression Frontoparietal right hemisphere infarction Cingulate gyrus/supplementary motor area infarction Amphetamine or cocaine withdrawal Parkinson’s disease and other states of catecholamine hypoactivity, especially dopaminergic hypoactivity (e.g., neuroleptic-induced akinesia) Lack

of environmental

incentive

or reward,

as in role

institutionalization, and other states of environmental Loss of elementary sensory or motor capacity, including vision “Apathetic” hyperthyroidism Serotonergic hyperactivity, possible

loss,

deficiency hearing

and

3 prevents

247

APATHY

drome,24 emotional blunting,n negative symptoms,26 and type II schizophrenia.27 Regardless of the term used, the “signs and symptoms” of the state described are similar:

ior-may

the

patient

rected ity

shows

a diminution

behavior

and

to events

that

an absence are

related

be seen

other clinical progressive

in initiative

or goal-di-

Wilson’s

of emotional

responsiv-

ism. vation,

to the

patient’s

needs

or

goals. and

thy, therefore, one initiative; inactivity; lack

of goals

and

sponsiveness sponse

other

plans;

behavioral

to success lack

cern about range, and

failure

(i.e.,

of persistence;

anergy;

decreased effort; of emotional affect;

and

suggested

by descriptions

depression. depression

According is “seldom

as lack of interests;

disease,

of patients

re-

diminished

diminished reactions;

con-

frontal

lobe

apathetic

with

On

psychomotor or

retardation

for making

this

last section author has

occur sources normal

differential

of the pointed

roe3#{176} highlighted

rasthenic”

features,

cause lack neurasthenic

of

their

noted

energy as well

by

vations better thermore,

rating

suggest characterized

of initiative.

Kayton,3’

are

on the paucity Undoubtedly, may show

scales.33

that

consideration

raises the possibility ings in postpsychotic

of

this

features

rather

evaluated

in depression

than rating

of

these

such than

differential

may

as apathetic such

because

of concern

tive,

by clinical about

motivation

can

Akinetic

be Fur-

diagnosis ratto the

mutism

syndromes. ized as mute,

occur if they improve trated by a patient was recovering from

to the

dysphoric

features

gyms,

scales.

To test this

hypoth-

area.

supplementary

In

motor

addition

‘will’

to reply

of as

charge relative

by depressed

culty falling asleep, While psychomotor a feature the

248

of depressive

syndrome-slowing

states

mood, and

guilt,

major

would

depression

suicidal

anxiety. retardation

is often

disorders,

the defining

of mental

or

be characterized

processes

ideation, thought features and

behav-

of

glect

“a state

to

diffi-

more

whereas

Occasionally, for

treatment

of interests

or initia-

when, levels,

in fact,

such

of most

an unusual

sufficiently. of Damasio unilateral

perhaps,

affective

may

their usual In otherwise in response to

loss of reward

While such patients akinetic, and abulic,

She apparently even during the

of insight,

lack

clinical

presents

tered.’ tions

lack

apathy

of

present

hand,

reach

showed

dysphoric

that

depressed

On the other

esis using the Hamilton Rating Scale, for example, one would hypothesize that the elevated total scores in postpsychotic depression would be more due to lack of interests, lack of energy, psychomotor retardation, and,

other

are

howapathy Strat-

are discussed

standards.

their

syn-

or other phase-of-life otherwise functioning they should be char-

will

if they

are apathetic.

the

be regarded

diagnosis

individuals

wondering

emo-

they

or incenas in insti-

tutionalism or in sensory loss in the elderly. When this occurs in the absence of depressive features, the appropriate diagnosis may be apathy rather than depression.35

obser-

patients depressed.

hand,

then also

when individuals are deprived of incentive or reward motivation. individuals, such apathy occurs

however,

tive

of spontaneous patients with elevated ratings

that such elevated depression “depression” may be due

apathetic

be-

a feature McGlashan

Nevertheless,

at least some as apathetic

“Neu-

relevant

is often considered as of apathetic patients.

and Carpenter32 remarked speech seen in such patients. postpsychotic “depression”

on depression

lack

other

reports

paper. out elsewhere’

acterized

Wild

mut-

If the mood is dysphoric, to determine whether symptom or a syndrome.

that contain postpsychotic while

the

may

role changes, such as retirement transitions. Since such people are normally, it is questionable whether

ideas. Steinberg et al.29 described as having a “wooden” demeanor,

akinetic

indifference,

ancholy or depressive contents but frequently by apathy.” They use the terms, “lack of vital impulse” and “lack of desire,” citing a number of German publications related patients

disease, disease,

retardation

of psychomotor

by

postpsychotic

and

of

not imply loss of motidoes not necessarily

syndrome.

unresponsiveness

in the The

et al.,28 postpsychotic by genuine deep mel-

injury,

tional

egies is

as a variety

Parkinson’s Huntington’s

per se does retardation

drome

spontaneous Bleuler

including palsy,

as an apathy syndrome. ever, it may be difficult represents an associated

intensity, flat or inap-

with

an

as well

many of the associated features of psychomotor retardation are consistent with apathy, including diminished initiative, loss of interest, lack of energy, and flat affect. If the patient

unre-

behavioral

described

to Floru expressed

of

diminished

diminished

or movement. similar to that

apa-

emotional

reinforcement);

cheerful

speech, gesture, A syndrome

or

and

or negative

others; duration

propriately

producing

may find such symptoms social withdrawal; lack

to positive

compliance;

disorders

aging

disorders, supranuclear

Since slowing psychomotor

represent

In schizophrenia

in normal

cause

are usually an apathetic

area,

and

contralateral she

mesial

to our

regained

questions.

states have

VOLUME

ne-

her

ability

she

had

‘Nothing

to

had mat-

able to follow our conversaperiod of illness, but felt no

In the

she continued to note lack of concern.”

Similar apathetic sphere stroke who

she

nonlateralized

speak, she reported that prior to recovery “nothing to say.’ Her mind was ‘empty.’ was early

motor

hemiparesis, and

When

characterstate may

This possibility is illusand VanHoesen who infarction of the cingulate

of aspontaneity

stimuli.”

of apathy

a feeling

period

after

of tranquility

disand

occur in victims of right hemibeen described37”#{176} as showing

3

NUMBER

#{149}

3

SUMMER

#{149}

1991

MARIN

lack

of emotional

and

inappropriate

concern,

lack

diagnosis of such affective dias, which are impairments understand

affective

aspects the

Since

expression

patients

should

not

and not

thy. A last

example

syndrome

show

affect,

deficits

and,

syndrome

of apa-

is exemplified

and

pet-like the

and as

compli-

to show

events occur. are compatible

monkeys.

evidence

type

that

the

or concern

patient

when

unto-

irritability, agitation, or sadapathy if their intensity and On the other

dominate

of abulia and be appropriate

from shallow,

dissame

complement-

imply

of distress

emotions

“background will no longer

requires

state,

Anger, with

are diminished.

such

the

of the symptoms with clinical euphoric affect are both consisboth, when used to characterize

affective

ward ness

Huntington’s palsy,46

contradictions

analysis Flat and because

fails

that

disease,45

supranuclear

usual

apathetic that flat,

Kiuver-Bucy

Alzheimer’s

ing the logical considerations. tent with apathy

duration

amygdala described4’

to resemble

lobectomized

therefore,

syndrome

with

a patient’s

in goal-directed

the

apathy,

in

information,

lesions of the who have been

thought

in temporal

impairments

cognitions

bilateral lobes,

a syndrome

nonlinguistic

are

as having

“blunted

ance,”

includes aprosoability to express or

through

of an apathy

by patients with anterior temporal

affect.

of affective

goal-related

be regarded

showing

ease,4 or progressive of problem arises. Resolving these

aprosodias

and

would

example,

Differential

information

of speech.’5

behavior

expression,

or flat symptoms in the

processing

such

of emotional

cheerfulness

the

hand,

to the extent

clinical

picture,

the

apathy” will be absent and it to characterize a patient as

a syndromic or euphoric

standpoint. affect are

To the extent present, apathy

is suggested. Definition 2: Apathy is a syndrome composed of a heterogeneous group of symptoms. The so-cailed frontal lobe syn-

dromes

are

arising

perhaps

from

patients

the

best-known

neurological

in

global

undoubtedly

an

cause

damage.

of apathy

Characterizing

behavioral terms oversimplification.42

of

such

any

sort

is

it fre-

However,

To summarize, normal emotional responses are integrated into goal-directed behavior and show amplitude and persistence that is in keeping with the goals (purposes, values, concerns, interests, etc.) embodied in thought and overt behavior. To the extent that emotion is superficial,

lacking

in intensity,

unsustained,

or unre-

quently has been noted that such patients show impairment in initiative and perseverance. Similarly, they seem unconcerned and unengaged with their social and inter-

sponsive to negative or positive events, state in question is consistent with apathy.

the behavioral For example,

if a patient

or Alzheimer’s

personal

environment.

damaged

patients

disease ize this

For are said

these

reasons,

to show

“an

frontal

underlying

lobe back-

ground of abulia and apathy,”43 which is consistent with definition I. Inclusion of frontal lobe syndromes with definition 2 is suggested by descriptions of such patients’ affective states. Some frontal lobe patients show flat affect,

while

patients sometimes drome that

others

show

also may rage. that

these

meets

silly

show From the

or

impulsivity, the vantage

criterion

symptoms

euphoric

affect.

Such

irritability, of an apathy

and syn-

of definition

introduce

categorical

into the features defining a frontal lobe example, it is paradoxical to consider euphoric affect parts of the same syndrome suggest

categorically

implying capacity emotional

elevation for pleasure, expression

being

apathetic

and,

contradictory, since concern, objection, or issue, concern, ilar

contrasts

with

differences

cability

states,

For and they

euphoria

at the

same

time,

angry

implies behavioral apathy

NEUROPSYCHIATRY

the

apply and occurs

opposite compliance, to

are

logically

implies intense to some event (i.e., lack of etc.). Sim-

the

symptoms

of

agitation. in other

When disorders,

this for

a frontal

lobe

sad, it may as depressed

sadness

syndrome

be misleading to characterfrom a syndromic stand-

is superficial

If it is persistent Similar analyses

or transient,

and apply

sexual behavior, anger, and other considered features of apathy. Definition of symptoms

syndrome. flat affect because

anger by convention or protest in response

demandingness, of behaviors

OF

affective

If the

suggested. pression.

2, it is clear

of mood and the preservation of the flat affect suggesting an absence of and hedonic capacity. Similarly,

while apathy complacency,

irritability, combination

JOURNAL

different

point.

with becomes patient

the

of this

mechanisms

of apathy only

3: Apathy having

has

suggestive

lates of apathy ropsychological

intense, to the

apathy

behaviors

not

is a syndrome characterized a shared pathological basis.

definition

of apathy. been

reported

information

depends

Since only about

on

deof usually

by a group The appli-

knowledge

reliable

about

measurement

recently,25 the

is

it suggests interpretation

biological

per Se. Clearly, neurobehavioral analyses of frontal lobe function

we

have corre-

and neuprovide

a fertile source for interpretating apathy, based on the frontal lobe effect on drive, sequencing, and the so-called executive functions, such as anticipation, goal-setting, planning, and monitoring.42 From a neurochemical standpoint, it may be noteworthy that functional deficiency of dopaminergic systems has been postulated to underlie a number of disorders causing apathy, including neuroleptic-induced akinesia,47 negative symptoms in schizophrenia,26’27 postpsychotic depression,232 subcortical dementing diseases

249

APATHY

such as dromes.49

Parkinson’s Flat affect,

disease, lack of

and frontal lobe syninitiative, psychomotor

slowing, and other features associated with apathy have noted in these disorders as well as in depression.50’5’ Such clinical and neurochemical parallels may apply to akinetic mutism52 and to other stroke syndromes involving more delimited midline diencephalic structures.53

been

Given that are as

the now

simple

as

multiplicity recognized, this

will

of neurotransmitter it is doubtful that prove

sufficient.

systems a hypothesis However,

for

influencing

motor

and

autonomic

MesuIam’59

cate

that

systems,

environmental

250

as an illustration.

of the connectivity

specifically it receives

and

expectancy.” reciprocal

other

highly

According

parietal

processed

cortex

This region of the connections with the

thought

structures

to

with

and,

sensory

by con-

level “motiinterest and lobe also eye fields

to be important comprising

indi-

the limbic are with the

therefore,

parietal frontal

lobe

lobule,

multimodal

connections interconnections

retrosplenial

have of

of the parietal

the inferior

eye-orienting responses This connectivity has

for

has and

head-

directed

and

attention.

been interpreted as providing a functional anatomical basis for the prominent role of the parietal lobe and the interconnected structures (frontal lobe and cingulum) in the control of attention to extrapersonal space.50 The apathy of right hemisphere damaged of these

patients anatomical

amygdala,

may also be understandable relationships. As in the

destruction

cortical

regions

of the parietal,

involved

in this

case

frontal,

system

in terms of the

or limbic

would

disrupt

the organism’s capacity to respond adaptively to potential sources of reward because the organism’s motivational state would not be integrated with sensory and motor systems. Predictably, these considerations indicate that there is not a single pathogenic mechanism for apathy. On the other ristic

hand, value

of neural

they do suggest that apathy may have heuin leading us to consider a delimited group

systems.

multiple

levels

Studying

the correlates

of behavioral

analysis

may

of apathy

at

also

to

help

subtypes of apathy whose distinguishing features in behavioral or neuropsychological terms will be predictive of these different mechanisms. Thus, multiple causes of apathy are associated with flat affect. These disorders may be associated with functional hypoactivity of dopamine systems, e.g., type II schizophrenia,

sponses

important

here

attention formulation

trast to the amygdala, provide a higher vational map for the distribution of

occurs

events would present as a deficit in goal-directed behavior occurring in the absence of intellectual deficits, emotional distress, or diminished level of consciousness, i.e., apathy. The right cerebral hemisphere lesions responsible for neglect and for the indifference reaction37#{176}’5’59 may point to a mechanism for apathy that in some ways is analogous to the mechanisms hypothesized with respect to the amygdala. Functional anatomic interpretaUons of

role in directed authors.2 The

input and has reciprocal system, although these

identify

motivationally

studies

in monkeys,

as well as limbic structures influencing memory50 and cerebral cortex.’59 In functional anatomical terms, the failure to associate environmental events with previous sources of reinforcement would, in part, reflect the disruption of a neural system that permits sensory information to influence and to be integrated with the organism’s drive states as represented in and organized by midline limbic system structures. Fron a clinical standpoint, such failure to make appropriate motor and emotional reto

is used

Mesulam,

cingulate the

clinical similarity among these disorders with respect to the symptoms and signs that comprise apathy does suggest that this symptom cluster may have heuristic value for identifying a common biological basis for the motivational loss seen in these disorders. Other mechanisms of apathy may be pertinent to other disorders. For example, Alzheimer’s disease is associated with damage, not only to the hippocampus, but also to the amygdala and contiguous structures.5 The role of the amygdala and closely interconnected temporal-diencephalic subsystems in producing apathy4’ is suggested by the Kluver-Bucy syndrome in monkeys and by the taming observed in other species of animals with anterior temporal damage.50 The tameness, hypoemotionality, and altered responses to food seen with bilateral removal of the amygdala in monkeys may reflect an inability to associate sensory events with positive or negative reinforcement.50’57 Experimental evidence that such amygdalectomized animals are unable to associate environmental stimuli with reward or punishment may be understandable in terms of the amygdala’s connectivity.50 Input to the amygdala includes multiple sources of highly processed cortical input, while its output provides a means

the right hemisphere’s been offered by many

postpsychotic depression, Parkinson’s motor retardation, and neuroleptic-induced

the other

hand,

in some

disease,

frontal

euphoria patients lobe

disease, psychoakinesia. On

or inappropriate with

injury,

cheerfulness

Alzheimer’s or right

disease, hemisphere

Pick’s stroke.

In these instances, there may be impairment of neurological structures (amygdala, prefrontal cortex, temporo-parietal cortex) critical for the integration of the organism’s motivational

status

with

sensory

and

motor

systems.

In

the presence of intact dopaminergic innervation, emotional reactivity is present (i.e., affect is not flat), but its intensity and duration are not regulated by the reinforcement value of socioenvironmental events.

VOLUME

3 #{149} NUMBER

3

SUMMER

#{149}

1991

MARIN

CLASSIFICATION ASSOCIATION SYNDROMES

OF APATHY OTHER

IN

sive

WITH

symptoms

judgment though

requires

does so more dromes, such

what

about

accurately as depression,

the

than

instances

other delirium,

more familiar or dementia.

in which

occurs cally,

in association with in such circumstances treated apathy as a symptom

loss

synBut

of motivation

other syndromes? clinicians have

it might

a symptom such

The

variation

term

seem

confusing

or a syndrome in the

use

“depression”

sometimes

used

times a syndrome. should be regarded syndrome,

of clinical

is a good

to

describe

terms

is quite

when

the

usual.

motivational

This distinction question posed apathy

occurs

loss

provides above. For in associa-

tion with other disorders, as a symptom and apathy clinician’s a patient’s

the distinction between apathy as a syndrome depends on the of its cause. If the apathy is due to

assessment emotional

distress,

intellectual

deficits,

or lev-

el of consciousness, then it represents a symptom. If not, it represents an apathy syndrome co-occurring with another syndrome and, therefore, requires an additional diagnosis.

For

example,

one

might

diagnose

dementia

and apathy in a patient with Parkinson’s disease or Huntington’s disease. This approach may seem simple in principle, but its application is undoubtedly difficult. How is a clinician to determine able

whether

to a patient’s

loss

of motivation

cognitive

deficits,

is in fact emotional

attributdistress,

or diminished level of consciousness. Two answers should be considered. The first, a conventional clinical approach, is that this problem is not unique to the differential diagnosis of apathy and that, as clinicians, we make such evaluations frequently. The differential diagnosis

of dementia

is a case

in point.

DSM-III-R

states

that

in the diagnosis of dementia an etiological factor must be demonstrable or, if not, “an etiological factor can be presumed if the disturbance cannot be accounted for by any nonorganic mental disorder, e.g., Major Depression accounting for cognitive impairment” (p. 107). In other words,

JOURNAL

diagnosing

OF

dementia

NEUROPSYCHIATRY

in the

presence

the

the uncertainty

that

surrounds

this

differentiation.

to the problem of deciding the cause of a patient’s apathy, the conventional clinical approach entails asking clinicians to make a similar clinical judgment. A delirious patient would not be given the diagnosis of apathy if the loss of motivation was clearly related to the fact that the patient was too drowsy or inattentive to organize would

Depression is and at other therefore, that apathy as a symptom or as a

on whether

purposes,

as

example.

It is proposed, nosologically

depending

apathy

circumstances,

a symptom

is due to some other syndrome. assistance in answering the classificatory

to regard

in different

from

Returning

delirium.

Although

the same

to apathy. Alwhether major

accounts

parent

speak

Nosologitraditionally

rather than as a syndrome. In other words, the loss of motivation seen in such patients is attributed to the other diagnosable syndrome, e.g.,

to exercise

with respect to decide

for cognitive impairment, it is apattention given to this topicM that, while important, it is not easily accomplished. Ongoing attempts to validate clinical,63 neuropsychological,65’50 or sleep electroencephalographic67 approaches to understanding mixed states of depression and dementia bedepression

The rationale for describing a patient as showing an apathy syndrome is apparent when loss of motivation characterizes a patient’s overall behavioral state and

the clinician

as that discussed it may seem simple

of depres-

behavior not

effectively.

be diagnosed

A

with

the

demented

patient

syndrome

of apathy

if

he or she lacked the problem-solving capacities to devise a plan for obtaining some goal, such as how to prepare a meal or balance a checkbook. Analogously, a depressed patient who professed a disinterest in socializing or working because he or she was “just too depressed to do anything” would not be said to present with the syndrome of apathy. On the other hand, to the extent that major not

depression attributed

is associated to dysphoria

of consideration if one tion a state of diminished the role

of dopaminergic

take

between

a dimension fiable variable and

valid

considers

psychomotor motivation or if one

and

approach.

of behavior, that that is measured

means

experimental

of motivation worthy retardaconsiders

in depression5’),

then

syndromic descriptor. to evaluating the causative

apathy

an investigative

loss

se (a possibility

systems

apathy may be a valid The second approach tionship

with per

for

measuring

methods

could

associated Here

disorders apathy

apathy, used

is to

is treated

is, as a continuous, reliably. Given be

as

quantia reliable

correlational to

rela-

examine

or the

relationship between apathy and other variables of interest.’2 Thus, one would measure or experimentally manipulate apathy in a population of interest and then show that the variance in apathy occurs independently of the potential covariates, e.g., depression, cognitive impairment, or attentional disturbance.

CONCLUSIONS The value of terms used to describe or classify clinical phenomena derives from their use in facilitating communication about patients, in predicting pathological mechanism, etiology, prognosis, or treatment response, and in generating new knowledge.’6 The starting point

251

APATHY

for proposing that apathy has validity as a syndrome is that it helps clinicians recognize that some patients are better characterized as apathetic than by some other recognized syndrome. In other words, characterizing such patients as apathetic is immediately useful in a clinical setting such individuals useful

because into

it facilitates recognizable

in assessment

and

the classification groups that may

of be

treatment.

If we reconsider the three definitions of a syndrome discussed in this paper, these benefits suggest that the concept of an apathy syndrome at least meets the requirements of definition 1. The clinical characteristics of apathetic patients described here provide numerous symptoms

that

appropriately

the syndrome assembled into

are considered

of apathy. an assessment

Such

to comprise

symptoms are device for evaluating

readily apa-

thy.2

In the author’s view, apathy does fulfill the neity requirement of definition 2. Not only is erogeneity among the symptoms referred to (i.e., apathetic patients may be affectively flat, or irritable), but interpreting apathy in terms ished

motivation

terize

patients

explains as

nonapathetic

sity ple,

or duration

apathetic At

the helps

the

from

can

face

Specifically,

intensity

distinguishes

clinicians

in

symptoms.

diminished sponses. syndrome

how

apathetic

of

the

charac-

seemingly

it is proposed

of emotional

nonapathetic

same time, us understand

heterogethere hetby apathy euphoric, of dimin-

that

responses emotional

re-

definition of an why diminished

apathy inten-

and duration of emotional responses, as in, for examflattened affect, are not sufficient to diagnose apathy.

A person sion

may

without

manifest

diminished

necessarily

losing

emotional interest

expres-

or involvement

in usual tivation. pression

sources of gratification, i.e., without losing moFor example, aprosodias impair emotional exwithout deficits in goal-directed behavior.’5

Further,

not

Parkinson’s

all patients disease

are

showing

masked

apathetic;

thus,

term “masked.” Similarly, an obsessional overvalues emotional control but who achievement-oriented may be emotionally but highly productive.

facies the

due

The applicability athy

but

of definition

probably

syndromes. depression,

not

more

so than

Multiple possible and delirium-each

chiatric

syndrome-are

psychiatric mechanisms

does

dromic

concepts.

not

symptom

gleaned

psychiatric

from

the usefulness contrary, the

the

clusters

contributes to our Brief consideration variety of pathological

for other

the

neuro-

in general, the validity of these at this time. This uncertainty,

diminish

On

for ap-

mechanisms for dementia, a well-recognized psy-

readily

literature, but, is uncertain

however, define

3 is problematic

that

are

of these fact that

readily

synthey

investigated

assessment of their heuristic value. of the etiologies of apathy suggests a mechanisms at multiple levels of

behavioral organization. Defining apathy as lack of motivation suggests that multiple socioenvironmental influences on apathy deserve investigation, as, for example, the influence of residence in nursing homes or in other institutions.35 It also suggests that the mechanisms of apathy may be illuminated by the vast literature of experimental psychology dealing with theories of motivation.’2 Further, from a biological standpoint, anatomical, physiological, and biochemical approaches warrant consideration. Neurobehavioral interpretations of the structures whose dysfunction produces apathyright cerebral hemisphere, frontal lobes, amygdala, midline diencephalic regions-suggest explanations of apathy based on such concepts as reinforcement value of sensory information, integration of motivational state with sensory and motor representations of extrapersonal space, and executive functions of the frontal lobe. Correlations with neurotransmitter function, particularly dopaminergic systems, is also suggested by the neuropsychiatric disorders that cause apathy. To the extent that apathy has validity at multiple levels of behavioral organization, diverse treatments can be envisioned.

to

suggestive

This

patient who remains highly unexpressive

study

demic

was

Award

supported

in part

AG-00235)

and

thor thanks Horacio Fabrega, for contributing many helpful ment of this paper.

by grants

NJMH

from

NIA

(MH-41930).

Jr., M.D., suggestions

(AcaThe

au-

and Rolf Jacob, M.D., during the develop-

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of

3

and

#{149} NUMBER

Clinical

3

Interpretation,

#{149} SUMMER

1991

MARIN

5th

edition.

Philadelphia,

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JG:

ner/Mazel, Van

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