BAL HARBOUR, FLA— The merits of including apathy as a stand-alone disorder in the DSM-V were debated at the 16th Annual Meeting of the American Neuropsychiatric Association. James D. Duffy, MD, Associate Professor of Psychiatry and Medicine at the University of Connecticut Health Center in Farmington, made a spirited case for why apathy should take its place in the rank and file of DSM-recognized entities. Michael B. First, MD, Professor of Clinical Psychiatry at Columbia University in New York City and Editor of the DSM-IV countered by elucidating some of the hurdles such a decision would involve.

APATHY ACROSS DISEASES

Apathy is nothing new, according to Dr. Duffy. In fact, the concept of apathy has been discussed for hundreds of years. “Freud began to remove the concept of amotivation from our psychiatric terminology when he described an unconscious predeterminism that he said drives many patients. The question is where to put disorders that fall between disorders of the mind and disorders of the brain,” he said, admitting that it is difficult to mesh concepts of motivation with a sociopolitical system that values autonomy above all else. Another problem is that people with apathy don’t present with distress and are almost forgotten by the health care system, he noted.

Nonetheless, apathy is common, Dr. Duffy said. It can occur alone and in conjunction with other disorders, in percentages that translate into millions of people with apathy. Consider the following statistics:

• One recent study found apathy alone occurred in approximately 22% of patients.

• In 2004, another study found that 27% of stroke patients developed apathy after suffering the stroke.

• Eighty percent of people with Alzheimer’s disease suffer from some form of apathy.

• Apathy is the most common symptom in patients with mild cognitive impairment, with 39% of these patients reporting apathy.

• Between 22% and 50% of patients with subcortical encephalomalacia have been reported to exhibit apathy.

• Twenty percent of patients with multiple sclerosis exhibit apathy.

• Eighty percent of patients with traumatic brain injury have apathy.

• About half of all patients with Huntington’s disease will experience apathy, and they will typically experience it later in the disease. “Unfortunately, as clinicians, we often hope that [these] patients do become apathetic because they will become less violent and explosive,” Dr. Duffy said.

• Apathy is also common in Parkinson’s disease with 38% to 45% of these patients exhibiting apathy according to the Neuropsychiatric Inventory.

• Eighty percent of patients with anoxic encephalopathy experience apathy. These are patients who attempted suicide using carbon monoxide or patients who experienced cardiac arrests from arrhythmias, Dr. Duffy said.

• Two studies have found that at least half of all patients with HIV infection experience apathy. Interestingly, the incidence of apathy does not seem to correlate with CD4 counts. “In the late 1980s, when the HIV epidemic was just beginning, you could recognize patients with HIV by their apathy. That seems to have changed,” remarked Dr. Duffy.

• A study that examined all of the data in patients with neurologic disease found that 40% of patients with cortical pathology and 60% of patients with subcortical pathology will exhibit an apathy syndrome as measured by the Neuropsychiatric Inventory.

• Patients with thyroid disease are typically apathetic, and apathy is often a significant feature in patients with chronic fatigue syndrome, as well as in some patients with mental retardation.

• Psychotropics are a very potent cause of apathy, and apathy is the hallmark of using marijuana.

• Apathy is also common in nursing home residents. In fact, apathy is the most common disorder found when the Neuropsychiatric Inventory is given to patients in nursing homes, with 15% of these patients suffering from apathy. “This is twice the prevalence of depression,” Dr. Duffy said, adding that he believes that a distinct subtype of depression involves apathy.

MORBIDITY AND MORTALITY

Beyond the prevalence of apathy—both alone and as a comorbidity—there are other justifications for including the disease prominently in the DSM-V, Dr. Duffy said. “It is important for clinicians to recognize patients with apathy because it can result in significant morbidity and mortality. Patients who are apathetic do not take care of themselves as well as patients who are not apathetic. I think about the patient with diabetes who just doesn’t bother to trim his or her toenails. The toenails then get infected, and the patient ends up in the emergency room.”

Apathy can also affect patients’ compliance with medical regimens, and it has been associated with increased mortality, Dr. Duffy remarked. Additionally, apathy is probably the most significant stressor for caregivers, and it also results in significant financial burden, he noted.

Another justification for including apathy in the DSM-V is that treatments—including pharmacologic and environmental manipulations—are available, Dr. Duffy said. However, while these treatments are effective, they could be better, he noted.

GET EXCITED ABOUT APATHY

Dr. Duffy encouraged his colleagues to take apathy seriously and to “get excited” about it. “We can actually develop a physical model to support apathy. We have talked about clinical associations, and we now have a sophisticated understanding of the motivational system to the brain. Using this model, we can describe apathy,” he said.

He also encouraged future research. “Funding research is vital if we are actually going to move forward in advancing our understanding of the development and treatment of this disorder.”

COUNTERPOINT—APATHY IN THE DSM-V

Dr. First allowed that there are some convincing arguments for including apathy in the DSM-V. Before determining how apathy should be addressed in the DSM-V, however, it is important to review how apathy is addressed in DSM-IV and to decide whether changes are necessary, he said. “We should look at DSM-IV and see if it is broken and if it needs to be fixed.”

To begin, the importance of apathy is not apparent in the DSM-IV, Dr. First noted. In fact, he elaborated, it is only mentioned specifically in four disorders, and it is only mentioned 15 times in 943 pages. “This might suggest that apathy is regarded as a nonspecific symptom, and one reason for this is that there is a lack of conceptual operational definitions. In the back of the DSM-IV, there is a glossary of terms, and apathy is not included as one of the terms in the glossary,” he said.

While there is a lack of focus on apathy as a presenting symptom, Dr. First noted that there are clearly disorders in the DSM that appear to have apathy as part of their symptomatology. Symptoms such as lack of feeling, lack of interest, lack of concern, indifference, flat affect, or emotional unresponsiveness are almost certainly related to apathy, he said.

Though apathy is mentioned only 15 times in DSM-IV, these other related terms appear much more frequently. For example, the definition of major depression includes diminished interest or pleasure in activities, and the diagnosis of posttraumatic stress disorder has criteria for loss of interest in activities. Additionally, the section on schizophrenia mentions catatonic behavior or decreasing reactivity to the environment and symptoms such as affective flattening and avolition. One of the criteria for the diagnosis of autism and Asperger’s disorder is lack of spontaneous seeking to share enjoyment with other people, and the section on schizoid personality disorders has items about constricted affect. “Clearly, if we look at a broader definition, the concept of apathy is already embedded in the DSM-IV. The question is not really whether apathy should be included in the DSM-V, but how to get it in there in a more effective way or how its status can be improved,” Dr. First said.

The problem needs to be articulated, and then solutions to the problem need to be proposed. The first difficulty is that there is no definition of apathy in the DSM-IV. Rather, there is a hodge-podge of terms throughout the book, he said. This can occur because various work groups are in charge of different sections of the DSM, and while they communicate with each other, the chapters are written in relative isolation. “You can have a concept like apathy seen by different groups through different prisms, and it will come out differently. There is really some diagnostic confusion.”

APATHY IN THE DSM-V

One way to improve the status of apathy in DSM-V is to clarify the definition of apathy and use it consistently throughout the DSM by adding apathy and its definition to the glossary. “Another issue is the concept of differential diagnosis. Apathy is an important presenting symptom. When a patient comes in with apathy, it would be helpful to direct the clinician to the range of disorders that are associated with apathy.”

Another proposal is to include some specific apathy subtypes, Dr. First said, but the most radical way to include apathy in the DSM-V is to reorganize the DSM and have a chapter called “Disorders of Diminished Motivation.” “The problem with this solution is the skimming off of the apathetic subtypes of other disorders that are already listed in other categories. I’m not sure it makes sense to take the apathetic form of depression and the apathetic form of schizophrenia and remove them from their respective chapters,” he explained.

A less radical solution would be to add a new decision tree to Appendix A of the DSM-V. “There is no precedent for that, but it could happen. Another proposal is the actual setting up of an apathy syndrome with specific diagnostic criteria,” he said, noting that Robert Marin, MD, of the University of Pittsburgh, has published some proposed diagnostic criteria that could be used.

However, the clinical utility of this proposal is not clear. “What’s the benefit of having a criteria set over just having a better definition? Also, there is little precedent in DSM-IV for having a syndrome independent of cause,” Dr. First said.

—Michelle Stephenson

Suggested Reading
Lampe IK, Heeren TJ. Is apathy in late-life depressive illness related to age-at-onset, cognitive function, or vascular risk? Int Psychogeriatr. 2004;16:481-486.
Marin RS. Apathy: a neuropsychiatric syndrome. J Neuropsychiatry Clin Neurosci. 1991;3:243-254.
van Reekum R, Stuss DT, Ostrander L. Apathy: why care? J Neuropsychiatry Clin Neurosci. 2005;17:7-19.

Return to table of contents