COMMENTARY

Apathy, Explained

Derick E. Vergne, MD

Disclosures

March 16, 2016

In This Article

Treating Apathy

Dopamine is a key neurotransmitter involved in cognition. The current conceptualization of how cognition is disrupted in such disorders as schizophrenia; attention-deficit disorder; and, to some extent, major depression involves disrupted dopamine neurotransmission, which is needed to fuel the efficient flow of information through the basal ganglia and the efficient interpretation of information arriving at frontal cortical areas.

A detailed characterization of the way in which dopamine interacts with other neurotransmitter systems and with different dopamine receptors to filter, organize, and increase the signal-to-noise ratio of information reaching the prefrontal cortex is beyond the scope of this article. In apathetic states, hypofrontality (decrease in prefrontal lobe activity) appears to be related, at least in part, to dopamine deficiency, albeit in some but not all brain regions.

As we have discussed, goal direction devoid of emotional context does not translate into goal-directed behavior, which is a precursor for apathy. In addition, organizing one's thoughts to execute tasks is necessary for goal direction. Dopamine is critical for the efficiency of both processes. On the basis of the role of dopamine in information processing and apathetic states, it would make sense that dopamine agonists (stimulators of the dopamine system) could influence, at least to some degree, apathetic states. Dopamine agonists are precisely the treatment of choice[11] for improvement of information processing in apathetic states.

Conclusions

Apathy is a neuropsychiatric syndrome that is qualitatively different from major depression, but may nevertheless be a symptom of severe depression. It can be the result of localized cerebrovascular events; certain types of dementia, such as frontotemporal dementia; or traumatic brain injury. Disorders that do not involve structural brain damage, but rather neurochemical abnormalities in dopamine transmission, can cause a similar presentation.

It is critical to differentiate apathy from other, similar presentations, because treatment tends to be different. The repercussions of misdiagnosing apathy for major depression can include choosing the wrong therapy—for example, SSRIs, which are the treatment of choice for major depression but the incorrect therapy for apathy due to stroke.[12] It is therefore of utmost importance to begin by obtaining a complete history of present illness; the history may have to be augmented with collateral information; neuropsychological testing; neuroimaging; and, in some instances, second opinions from neuropsychiatrists, neuropsychologists, and behavioral neurologists.

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