Tuesday, December 15, 2009

Apathy Matters

This is part of an article I published on mcmanweb in 2005. Just because psychiatry doesn't care about apathy doesn't mean you shouldn't. Read on ...

You know what it’s like. Someone has seemingly pulled the plug and the power drains out. Your get up and go just got up and went. Life, the universe, everything – nothing matters as you shuffle through the clutter on the floor and flop into an unmade bed, your only refuge in a world you have given up on, that has seemingly given up on you.

Apathy is also used to describe indifference, such as to politics or NASCAR racing, but in a psychological context we are talking more like the opposite of motivation, the lack of will to go on and the inability to care about the consequences.

On my Website, Andrea describes it this way:

I am so lethargic and cannot find anyway out. ... I cannot seem to make myself do anything. All I want or seem to be able to do to get out of bed is get the newspaper and try and read it, smoke, or open a can of something or eat a box of ice cream, watch TV or surf the internet, and now a new addiction - buying things on E-Bay! Getting expensive!!! ...

I make jewelry and used to love it, but now can't complete anything and am in such a mess with my beads I don't think I'll ever get them straightened out. I've gained 40 pounds, don't care about my appearance, can't clean the house, etc etc. I feel I have all the symptoms of depression, plus I can't feel any excitement about seeing loved ones, can't think of anything, or anywhere I want to be but in my bedroom.

The Prize Patrol could probably show up on Andrea's door with a check for 25 million dollars, and she would still feel flat. Or even if she levitated to the ceiling in exultation, it wouldn't be long before she went back to her current life in a darkened room, even if that room happened to be part of a new mansion in the Hamptons.

So is apathy part of depression? The DSM is virtually silent on the topic, as is the depression literature. Depression is generally characterized by too much emotion, but the DSM implicitly acknowledges we can experience too little. One of the two major depression symptoms is loss of interest or pleasure, such as in a hobby. Basically, we stop caring.

What’s missing here is that lack of caring doesn’t necessarily stop at pleasure. We can also become desensitized to grief or to something bad happening, but we’re not likely to see psychiatry weigh in on this any time soon.

The people doing the actual talking are the neuropsychiatrists, and they’re not giving depression any respect. In a groundbreaking article in the Summer 1991 Journal of Neuropsychiatry and Clinical Neurosciences, Robert Marin MD of the University of Pittsburgh argued that it is illogical that depressed people, who experience emotional pain, can suffer from a state of mind that is characterized by a lack of emotion.

Martiin Levy MD of UCLA is even more blunt. "Apathy is Not Depression," he and his colleagues assert in bold in the title of an article in the Summer 1998 Journal of Clinical Neuropsychiatry.
Dr Marin and other neuropsychiatrists perceive apathy in the context of brain damage rather than as a sign of emotional distress or cognitive impairment. They see apathy as the result of neuropsychiatric illnesses such as Alzheimer’s, dementia, Parkinson's, or Huntington’s, or else an event such as a stroke, involving disruptions to frontal-subcortical pathways that are fueled by dopamine and acetylcholine

Dr Marin would like to see apathy regarded as a syndrome (sort of like an illness). He also views apathy as a symptom when it is associated with the likes of Alzheimer’s. There is already a precedent in sleep, which constitutes a number of DSM disorders, as well as being listed as a symptom for depression and mania.

Can Dr Marin’s views be reconciled to depression? Yes, when the lack of caring factor is taken into account. In this context, apathy would be a symptom of depression. As a separate entity, it could be that apathy co-occurs with depression, much like anxiety and depression hook up as the Bonnie and Clyde of the brain. One can even make a case for apathy-driven depression.

Obviously there’s much to discuss, but first psychiatry needs to join the conversation.


Loretta said...

Is this just semantics? Symptoms of depression can include amotivation and low energy. Those two together look a lot like apathy. Although I guess you could care a lot about something but just not have the energy or motivation to do anything about it.

John McManamy said...

Hey, Loretta. Very good point. In the apathy article on my website I link to a related article, "No Pleasure, No Reward."


My view is simply we need more discussion, so I very much appreciate your comments.

Michelle R said...

Apathy is SO much a part of depression. I remember Christmas of my 8th grade year I was super depressed and apathetic. I had wanted a computer forEVER. Low and behold down our pathway walks my mom's friend carrying a box with a computer in it. I didn't care. I knew it was something that would change my life, that I SHOULD be extremely excited about, but I had to fight really hard to be as excited as possible. I just wanted to curl up and die. I simply couldn't feel happy, couldn't care.

You're right. MUCH more discussion is needed.

Lori~ said...

My story goes like this...I was riding with my husband some years ago and we drove past a park. I remember thinking to myself, "Why would anyone want to go to a park?" It was a summer day, the park was filled with happy people. I on the other hand was depressed.

After I was diagnosed (at 41), messed around with several different med's, dosages, you know the routine, and woke up one day and said to my husband, "Oh my, is this how it feels to be normal, because I don't ever remember feeling this light and easy in my brain for years."

We drove past that park and I told him my thoughts from years ago. We now have an ongoing joke about parks..."Why would anyone want to go to a park?!"

I think this demonstrates that depression and apathy do go hand in hand. I am pretty in tune with my brain chemistry. I am a rapid cycler and I know the difference between situational depression and chemical depression. They ARE clearly different, but they require a huge personal awareness.

As for psychiatry and neuropsychiatry, yes it would be great to get them to join the conversation, but we will probably need more of them to be bi-polar first, otherwise they will probably just remain apathetic to the topic!

sharon said...


Once again it would be nice if the "experts" would consult with those who actually live with depression.

My experience with depression is that it runs along a continum. As the depression deepens there is a point where it crosses into apathy. Even though I want to care, I just do not have the energy to care. I dont have the desire to care, and last but not least I dont have even the memory of what caring feels like.

Apathy for me is tied directly to depression. When the depression abates, so does the apathy.