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teaching:apathy [on April 30, 2020]
teaching:apathy [on January 2, 2024] (current)
psychdb [Treatment]
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 ===== Primer ===== ===== Primer =====
-**Apathy** is a distinct neuropsychiatric syndrome that has various clinical definitions. Most commonly ​it is conceptualized ​as the "​simultaneous diminution in the cognitive ​and emotional ​concomitants of goal directed behaviour."[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16030444|Marin,​ R. S., & Wilkosz, P. A. (2005). Disorders of diminished motivation. The Journal of head trauma rehabilitation,​ 20(4), 377-388.]])] ​It is not the same as depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​9706539|Levy,​ M. L., Cummings, J. L., Fairbanks, L. A., Masterman, D., Miller, B. L., Craig, A. H., ... & Litvan, I. (1998). Apathy is not depression. The Journal of neuropsychiatry and clinical neurosciences,​ 10(3), 314-319.]])]+**Apathy** is a distinct neuropsychiatric syndrome that has various clinical definitions, which makes it difficult to study and examine clinically. It can be thought of as diminished ​cognitive ​plus emotional goal-directed behaviour.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​16030444|Marin,​ R. S., & Wilkosz, P. A. (2005). Disorders of diminished motivation. The Journal of head trauma rehabilitation,​ 20(4), 377-388.]])] ​Apathy ​is not the same as depression.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​9706539|Levy,​ M. L., Cummings, J. L., Fairbanks, L. A., Masterman, D., Miller, B. L., Craig, A. H., ... & Litvan, I. (1998). Apathy is not depression. The Journal of neuropsychiatry and clinical neurosciences,​ 10(3), 314-319.]])]
  
-===== Etiologies ​===== +===== Pathophysiology ​===== 
-Apathy ​is common in patients with [[geri:​stroke|stroke]],​ [[geri:​parkinsons|Parkinson’s disease]], [[geri:​dementia:​alzheimers|Alzheimer’s ​disease]], and [[cl:​tbi|traumatic brain injuries]].+  ​* ​Apathy ​can be common in patients with [[geri:​stroke|stroke]],​ [[geri:​parkinsons|Parkinson’s disease]], [[geri:​dementia:​alzheimers|Alzheimer’s ​dementia]], and [[cl:​tbi|traumatic brain injuries]]
 +  * Apathy is thought to related to the medial aspect of the frontal lobe (medial prefrontal cortex).[([[https://​jnnp.bmj.com/​content/​90/​3/​302|Le Heron, C., Holroyd, C. B., Salamone, J., & Husain, M. (2019). Brain mechanisms underlying apathy. Journal of Neurology, Neurosurgery & Psychiatry, 90(3), 302-312.]])] 
 + 
 +===== Abulia ===== 
 +**Abulia** (from Greek, meaning "​non-will"​) is considered a more severe type of apathy, but its definition varies across providers and clinical utility remains unclear.[([[https://​pubmed.ncbi.nlm.nih.gov/​18187477/​|Starkstein,​ S. E., & Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. Journal of Neurology, Neurosurgery & Psychiatry, 79(10), 1088-1092.]])] It is characterized by a lack of drive and initiative, no spontaneity,​ apathy, slowness of thought, blunted emotional responses and lack of response to external stimuli.
  
 ===== Diagnostic Criteria ===== ===== Diagnostic Criteria =====
 There is no consensus diagnostic criteria for apathy as a syndrome. Apathy is mostly defined as a disorder of motivation, and where there is diminished goal-oriented behaviour and cognition.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​18187477|Starkstein,​ S. E., Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. Journal of Neurology, Neurosurgery Psychiatry, 79(10), 1088-1092.]])] There is no consensus diagnostic criteria for apathy as a syndrome. Apathy is mostly defined as a disorder of motivation, and where there is diminished goal-oriented behaviour and cognition.[([[https://​www.ncbi.nlm.nih.gov/​pubmed/​18187477|Starkstein,​ S. E., Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. Journal of Neurology, Neurosurgery Psychiatry, 79(10), 1088-1092.]])]
  
-<panel type="​info"​ title="​Proposed Diagnostic Criteria for Apathy"​ subtitle="​Starkstein,​ S., and Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. JNNP. 79(10), 1088-1092"​ no-body="​true">​+<panel type="​info"​ title="​Proposed Diagnostic Criteria for Apathy"​ subtitle="​Adapted from: Starkstein, S., and Leentjens, A. F. (2008). The nosological position of apathy in clinical practice. JNNP. 79(10), 1088-1092"​ no-body="​true">​
  
-(A) Lack of motivation relative to the patient’s previous level of functioning or the standards of his or her age and culture as indicated either by subjective account or observation by others. ​                                                                                                                                                                                                                                                                                                              ^ +| **(A)** Lack of motivation relative to the patient’s previous level of functioning or the standards of his or her age and culture as indicated either by subjective account or observation by others. ​                                                                                                                                                                                                                                                                                                          | 
-(B) Presence for at least ''​4''​ weeks during most of the day, of at least ''​1''​ symptom belonging to each of the following ''​3''​ domains: ​                                                                                                                                                                                                                                                                                                                                                                      ^+| **(B)** Presence for at least ''​4''​ weeks during most of the day, of at least ''​1''​ symptom belonging to each of the following ''​3''​ domains: ​                                                                                                                                                                                                                                                                                                                                                                  |
 | **1. Diminished goal directed behaviour**\\ • Lack of effort or energy to perform everyday activities.\\ • Dependency on prompts from others to structure everyday activities.\\ **2. Diminished goal directed cognition**\\ • Lack of interest in learning new things, or in new experiences.\\ • Lack of concern about one’s personal problems.\\ **3. Diminished concomitants of goal directed behaviour**\\ • Unchanging or flat affect\\ • Lack of emotional responsivity to positive or negative events. ​ | | **1. Diminished goal directed behaviour**\\ • Lack of effort or energy to perform everyday activities.\\ • Dependency on prompts from others to structure everyday activities.\\ **2. Diminished goal directed cognition**\\ • Lack of interest in learning new things, or in new experiences.\\ • Lack of concern about one’s personal problems.\\ **3. Diminished concomitants of goal directed behaviour**\\ • Unchanging or flat affect\\ • Lack of emotional responsivity to positive or negative events. ​ |
-(C) The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. ​                                                                                                                                                                                                                                                                                                                                                                          ^ +| **(C)** The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. ​                                                                                                                                                                                                                                                                                                                                                                      | 
-(D) The symptoms are not due to diminished level of consciousness or the direct physiological effects of a substance. ​                                                                                                                                                                                                                                                                                                                                                                                          ^+| **(D)** The symptoms are not due to diminished level of consciousness or the direct physiological effects of a substance. ​                                                                                                                                                                                                                                                                                                                                                                                      |
 </​panel>​ </​panel>​
  
-===== Abulia ​===== +===== Treatment ​===== 
-Abulia is considered a more severe type of apathy, ​but its nosological position is still unclear+  * [[meds:​stimulants:​2-methylphenidate:​home|Methylphenidate]] has been shown to be useful in the treatment ​of apathy ​specifically in Alzheimer'​s disease.[([[https://​pubmed.ncbi.nlm.nih.gov/​34570180/​|Mintzer,​ J., Lanctôt, K. L., Scherer, R. W., Rosenberg, P. B., Herrmann, N., Van Dyck, C. H., ... & ADMET 2 Research Group. (2021). Effect of Methylphenidate on Apathy in Patients With Alzheimer Disease: The ADMET 2 Randomized Clinical Trial. JAMA neurology.]])] 
 +    * Individuals who are not anxious or agitated, younger, already on an acetylcholinesterase inhibitor, have optimal diastolic blood pressure control (73-80 mm Hg), or more impaired function are more likely to benefit from treatment. [([[https://​pubmed.ncbi.nlm.nih.gov/​37385898/​|Lanctôt,​ K. L., Rivet, L., Tumati, S., Perin, J., Sankhe, K., Vieira, D., ... & Herrmann, N. (2023). Heterogeneity of response to methylphenidate in apathetic patients in the ADMET 2 Trial. The American Journal of Geriatric Psychiatry.]])] 
 + 
 +===== Resources ===== 
 +== For Providers == 
 +  * [[https://​www.mdedge.com/​psychiatry/​article/​155167/​depression/​disorders-diminished-motivation-what-they-are-and-how-treat|Spiegel,​ D. R., Warren, A., Takakura, W., Servidio, L., & Leu, N. (2018). Disorders of diminished motivation: what they are, and how to treat them. Curr Psychiatry, 1710-18.]]
  
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