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Apathy

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Apathy is a curious thing. It has various definitions, most of which have two components – one to do with lack of interest, concern, enthusiasm, and the other to do with lack of emotion.

Is it a mental state, that is, is it something that we feel inside? Yes, I think we all describe ourselves as feeling apathetic at times. But isn’t it also a behaviour? We can see people with blank expressions on their faces, not reacting to the environment, clearly not concerned to be doing anything much. Shrugging the shoulders is one way of showing we don’t give a monkey’s about it really. Then there are social forms of apathy, e.g. if voters don’t show up on polling day, that’s political apathy.

Apathy is associated with several mental disorders. The obvious association is with depression, where the person may certainly feel apathetic and unmotivated to do anything. They may also look apathetic and indifferent. Sometimes the feeling of apathy is greater than the sense of low mood or sadness. Apathy is also a common feature in schizophrenia especially when the condition has been present for some years.  It often goes with a lack of emotion and a tendency to become withdrawn and lacking in spontaneity.

You might ask what sort of disorder apathy is. Is it a mood problem? Is it a motor problem (i.e. is the core of it about decreased movement)? Or maybe it is a disorder of the will? Which raises the question as to what is meant by the will anyway. Modern neuroscience largely sidesteps this nasty question by talking about executive functioning, which is seen as a function of the frontal lobes of the brain and the underlying neural circuits.

Apathy can also be a feature of dementia. Indeed, it is one of the so-called Behavioural and Psychological Symptoms of Dementia (BPSD) and it is one of the items of the Neuropsychiatric Inventory (NPI), which is the main instrument used worldwide to measure BPSD. In the NPI, it is defined as diminished motivation not attributable to decreased level of consciousness, cognitive impairment, or emotional distress. So the NPI appears to see it as a disorder of the will.

What does apathy look like in dementia? Often folk just stop doing what they used to do, be it growing vegetables, painting pictures or going out to the pub. This can be perplexing to those around them – there is no obvious reason why they’ve stopped, they just don’t do it any more. If cajoled, they may start again, but only for a while and then they grind to a halt. If things get worse, they may simply sit in a chair all day, doing and saying nothing. You might think that, compared to be agitated and restless, this would be relatively easy to deal with but not so. It drives carers nuts. ‘He could do jigsaws/play the piano/read a book, but he just won’t!’ Often the carers blame themselves for this state arising, and certainly they can get very frustrated. So the nature of apathy needs to be explained to prevent this cycle of frustration and recrimination.

However, apathy is interesting for research too. Some of the work that Rianne van der Linde, a PhD student, has been doing has shown how apathy is an important symptom and also a strange entity. Some of our findings are yet to be published, but it’s already been shown by other researchers that it isn’t the same thing as depression and it seems to be related with worse cognitive impairment. You can measure it using the Lille Apathy Rating Scale, which has 33 items with 9 headings. These reduce to 4 factors: intellectual curiosity, emotion, action initiation, and self-awareness. Maybe apathy is a marker for global decline, for physical illness, or for something else. Any thoughts out there? Wake up, Apathy merits more attention!

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