Apathy: Is it a mental disorder?

What is apathy?

Apathy refers to an absence of interest, emotion, and motivation. Apathy may apply to specific areas of life, such as at work or within relationships. In some cases, it may be resolved within a short time or managed with certain life changes or adjustments. Alternatively, apathy could be a persistent feeling that doesn’t go away, possibly signaling that apathy is a symptom of a clinical disorder ^[1][2].

Apathy can cause significant impairments in various areas, such as daily, social, or professional functioning, and can cause a severe decline in quality of life. If apathy is prolonged and affects several aspects of life, it may be a sign of a mental health condition ^[3].

Signs and symptoms of apathy

Apathy can cause signs and symptoms such as ^[1][4][5]:

• Indifference to positive or negative news
• Blunted emotional expression or a lack of emotional response
• Poor self-care and difficulties looking after basic needs such as eating, sleeping, and washing
• Decline in functioning or engagement at work or school
• Lack of motivation to start or finish tasks
• Social withdrawal, such as not wanting to spend time with friends
• Decline in communication with loved ones
• Reduced energy and feeling very tired
• No interest in engaging in hobbies or activities that were previously enjoyable
• Difficulties making decisions or choosing between options due to a lack of preference
• Reduced empathy for others

Do mental health conditions cause apathy?

Apathy can be caused by or be a sign of several situations or conditions.

Situational

Apathy may be situational and caused by stressful or overwhelming life changes and occurrences. Becoming burned out by responsibilities at work, school, or within the family can result in feeling overwhelmed, exhausted, and withdrawn, thus creating symptoms of apathy ^[1][6].

Personality traits or attitudes

Personality traits such as negative thinking or defeatism can also contribute to apathy. For instance, someone with very low self-esteem or a negative self-view may believe they will fail when attempting anything challenging or new. Their anticipated failure keeps them from even attempting to seek new interests or activities ^[7].

Traumatic experiences

A traumatic event or experience can also cause apathy. People respond to trauma in different ways. Some may develop PTSD or anxiety, while others may experience psychological symptoms of apathy, such as a loss of emotion, reduced interest in socializing, or being very fatigued and withdrawn ^[1].

Mental health and neurological conditions

In some instances, symptoms of apathy might alleviate after a short time or when circumstances change. However, if apathy persists for an extended period, it is likely due to a psychiatric or neurological condition. Conditions signaling persistent apathetic mood may include, but aren’t limited to ^[3][8]:

• Major depressive disorder
• Persistent depressive disorder
• Schizotypal personality disorder
• Schizophrenia
• Different types of dementias
• Mild cognitive impairment
• Parkinson’s disease
• Traumatic brain injury (TBI)

Depression

Apathy can occur in the context of depression, causing symptoms such as ^[9]:

• A lack of interest in previously enjoyable hobbies
• Social withdrawal
• Low energy
• Lack of motivation

Schizophrenia

Apathy is a common symptom of schizophrenia and may contribute to the negative subtype of sypmtoms seen in schizophrenia, such as ^[7][8]:

• Blunted expressions
• Lack of emotional response
• Decline in motivation and functioning
• Reduced interest and enjoyment
• Decline in social abilities and engagement
• Social withdrawal and isolation

Neurological conditions

Apathy has been found to be a common symptom of various conditions that affect the brain. These conditions may include several types of dementia, such as Alzheimer’s disease and frontotemporal dementia, traumatic brain injury, and Parkinson’s disease. Within these conditions, apathy is associated with significant cognitive and functional impairments ^[2][3].

Symptoms of apathy that may occur in individuals with neurological conditions can include ^[3][8]:

• Loss of interest in new activities
• Lack of motivation
• Reduced emotional expression
• Fewer spontaneous actions

Diagnosis of apathy

There are no specific diagnostic criteria for apathy in the DSM-5, as it is not listed as a condition ^[10]. However, apathy can occur in the context of several other conditions, so it may be recognized as a symptom of a diagnosable condition. Additionally, researchers have developed assessment tools to help determine the severity of apathy and the areas of functioning it affects ^[5].

If an individual seeks professional help for persistent and problematic symptoms of apathy, it’s necessary to first determine the cause. Since apathy is typically related to mental disorders, such as major depression and schizophrenia, or neurocognitive conditions, such as dementia, a doctor may assess an individual for these conditions.

Diagnosing cognitive impairment may include the use of diagnostic tools such as the Montreal Cognitive Assessment (MoCA) or the Mini-Mental State Exam (MMSE), which test various aspects of cognitive function ^[11].

It is also likely that the individual will be assessed for symptoms of depression, as apathy is a common symptom of depression ^[12].

Symptoms of apathy could be measured using tools such as the Apathy Evaluation Scale or the Apathy-Motivation Index, which assess the prevalence of various symptoms relating to emotion, cognition, and behavior, regardless of other diagnoses ^[11][13].

In 2018, an expert panel devised diagnostic criteria for apathy that states the individual must have experienced symptoms that have occurred for at least four weeks, caused a significant reduction in functioning, and are not due to substances, environmental changes, or disabilities ^[5].

The panel’s diagnostic criteria includes a significant decline in functioning or goal-directed activity in areas related to behavior, cognition, social abilities, and emotion, such as ^[5][11]:

• Reduced activity and ability to complete tasks
• Reduced level of self-care and hygiene
• Loss of interest in news or engaging in activities
• Reduced empathy or concern for others
• Reduced spontaneous and reactive emotions
• Preference to remain at home and not communicate or socialize with others

Treatment for apathy

Treatment for apathy may vary depending on the cause, type, and severity of the presenting symptoms. Various kinds of medications can be used to treat symptoms of apathy if it is related to a clinical condition. Additionally, it may be beneficial to engage in therapy and utilize self-care techniques to help manage symptoms.

Depression medication

If apathy occurs as a symptom of depression, treatment may include the use of antidepressant medication and therapy. Commonly, selective serotonin reuptake inhibitors (SSRIs) are the first choice of medication for depression and may help to reduce apathy for some individuals ^[9].

However, some research suggests that SSRIs may actually worsen or cause apathy, so alternative antidepressants may be preferable, such as bupropion ^[3][14].

Non-SSRI antidepressants may also be prescribed to treat apathy in the context of other conditions, including schizophrenia and dementia ^[8][11].

Schizophrenia medication

Schizophrenia is often treated with antipsychotic medications. This medication effectively manages the positive symptoms of schizophrenia, such as hallucinations and delusions.

Some research suggests that antipsychotic medication, particularly high doses, can increase the negative effect of schizophrenia, such as loss of emotion and motivation, thus contributing to apathy. However, other studies indicate that this is not the case and that atypical antipsychotics, such as risperidone and olanzapine, can help to improve negative symptoms ^[8][15].

Medication for neurodegenerative disorders

Acetylcholinesterase inhibitors, such as donepezil, are commonly used to treat dementia. Studies have found that these medications can significantly reduce symptoms of apathy in patients with neurological conditions such as Alzheimer’s and Parkinson’s disease ^[3][8].

Dopamine receptor agonists, such as bromocriptine, are medications commonly used to treat Parkinson’s disease. Recent research suggests that this type of medication is effective at improving symptoms of apathy in individuals with neurological conditions, including Parkinson’s, dementia, stroke, and TBI ^[8][11].

Amphetamines, such as methylphenidate, have been shown to improve apathy in various neurological conditions, such as Alzheimer’s disease, vascular dementia, and stroke ^[8][11].

Therapy

Therapy may be a helpful intervention to reduce symptoms of apathy within various conditions by helping the individual to develop more positive thought patterns. This could contribute to an increase in motivation, interest, and enthusiasm in multiple aspects of life, along with helping to reduce emotional distress ^[7][8][9].

Self-care

Symptoms of apathy and underlying conditions could be reduced or managed with the use of various self-help techniques, such as ^[1][6]:

• Recognizing your triggers: Keeping a diary or a record of changes in mood or symptoms can be helpful. This can help recognize specific situations that cause worsening symptoms and learn how to avoid or cope with these circumstances.
• Talking to others: It can be beneficial to talk to others about your feelings and concerns, as this can help reduce negative emotions as well as help youreceive support and advice. This may include talking with friends and family, attending a support group, or utilizing professional services.
• Exploring new interests: As apathy can cause a loss of interest, exploring new activities and finding new ways to experience enjoyment may be helpful.
• Taking care of your general well-being: Looking after your general well-being can help to improve your physical and mental health and reduce symptoms of apathy and other conditions such as depression. This includes eating a healthy diet, sleeping well, and exercising regularly.

Apathy vs depression: What's the difference?

In some instances, apathy can be a symptom of depression as it is common for people with depression to experience a loss of interest and motivation ^[9].

However, not all individuals with depression will experience apathy; conversely, not all individuals who experience apathy have depression. It is important to remember that apathy and depression are two different conditions ^[12][16].

Many researchers consider apathy a primary condition if it does not occur due to another circumstance or condition. Therefore, apathy in the context of depression may be regarded as secondary apathy ^[2].

Furthermore, apathy is defined as an absence of emotion and expression or an indifference to people, situations, and occurrences. While some with depression experience blunted emotions, it is common for depression to cause high levels of negative emotions, such as hopelessness, worthlessness, and helplessness. As this is not an absence of emotion, ‘true’ apathy is not present ^[9][12].

Similarly, someone with apathy may experience a total loss of interest in maintaining interpersonal relationships, no longer considering friends or family relationships to be essential or valuable. In contrast, someone with depression may still acknowledge the importance of these relationships, but struggle with socializing due to their symptoms ^[7][11].

As such, despite similarities between the symptoms of apathy and depression, it is widely considered that the two can occur independently ^[12].