Apathy Syndrome

We will find that nearly all psychiatric drugs can produce some degree of deactivation. Even stimulants, such as Ritalin, can cause sufficient apathy or indifference in a child to enable adults to more easily control or direct the child (see chapter 11). The SSRIs, such as Prozac and Paxil, can also produce an apathy syndrome (chapter 7). However, deactivation appears in its purest form in neuroleptic treatment. 

Apathy syndromes We and others have noted an apathy syndrome in some patients after months or years of successful treatment with SSRIs. Patients often confuse this syndrome with a recurrence of depression, but the two conditions are quite distinct. The syndrome is characterized by a loss of motivation, increased passivity, and often feelings of lethargy and flatness. ... Mistakenly interpreting the apathy and lethargy for a relapse of depression, and hence increasing the dose of medication, will worsen the symptoms. 

Note that the apathy syndrome is so spellbinding that patients often confuse this syndrome with a recurrence of depression. As the textbook indicates, doctors can make the same mistake of failing to identify the drug as causal. 

Barnhart et al. (2004) reviewed the literature on apathy syndrome and found 12 relevant case reports and one open-label treatment trial. They pointed out the difficulty in distinguishing apathy from clinical depression but noted that patients can often tell the difference. In my experience, patients suffering from SSRI-induced apathy experience an indifference or lack of interest, even when their own rational assessment tells them that they do not feel sad or depressed, when in fact they would like to feel more involved in life. Whereas depressed patients typically lapse into feeling helpless and withdrawn, these individuals want to become more interested in their loved ones, friends, work, or hobbies but find themselves unaccountably stifled in their capacity to do so. They often feel frustrated rather than depressed. Or if spellbound, they may actually claim to feel fine, even while they display indifference to their surroundings. 

Healy et al. (2006) posited a variety of possible mechanisms for SSRI-induced violence, including akathisia, emotional blunting (a lobotomy-like apathy syndrome), and manic or psychotic reactions. 

Barnhart, W., Makela, E., Latocha, M. (2004). SSRI-induced apathy syndrome A clinical review. Journal of Psychiatric Practice, 10, 196—199. 

Psychiatric Scale (IMPS) is used to measure psychotic syndromes in hospitalized adults capable of being interviewed. The 89 items are rated on the basis of a psychiatric interview. This test has been well validated and requires 10 to 15 minutes following a 35- to 45-minute interview. There are ten scores excitement, hostile belligerence, paranoid projection, grandiose expansiveness, perceptual distortions, anxious intropunitiveness, retardation and apathy, disorientation, motor disturbances, and conceptual disorganization. 

Chronic cocaine use can cause a syndrome of insomnia, hallucinations, delusions, and apathy. This syndrome develops around the time when the euphoria turns to a paranoid psychosis, which resembles paranoid schizophrenia. Further, after cessation of cocaine use, the hallucinations may stop, but the delusions can persist. Still, the incidence of a persistent cocaine-induced psychosis appears to be rare. One study found only 4 out of 298 chronic cocaine users receiving a diagnosis of psychotic disorder (Rounsaville et al. 1991). This incidence is approximately the... 

Benign Not evident while sole nutrition is breast milk Severe hypoglycemia and lactic acidosis after fructose ingestion Vomiting, apathy, diarrhea Liver damage and jaundice Proximal renal tubule disorder resembling Fanconi syndrome Treatment eliminate sources of fructose from diet... 

Injury to certain areas within the brain s frontal lobes may produce a syndrome that resembles depression but without depressed mood or a sad affect. Instead, this apathetic syndrome is marked by a lack of motivation, little emotional response, profound psychomotor slowing, and disengagement from social interaction. Antidepressants, stimulants, and medicines that specihcally boost dopamine activity have been tried when treating apathy after TBI (see Table 12.1). 

In chronic alcoholics, thiamine deficiency may manifest as Wernicke-Korsakoff syndrome, which Is characterized by a constellation of unusual neurologic disturbances. Including amnesia, apathy, and nystagmus. 

Acute administration of opioids, particularly in non-tolerant individuals, produces a syndrome of intoxication characterized by pupillary dilation and initial euphoria, followed by apathy, psychomotor retardation, slurred speech, and impaired attention and memory. Opioid overdose can produce fatal respiratory depression and thus is a medical emergency. 

Apathy and frontal lobe-like syndromes. A reversible, dose-related frontal lobe-like syndrome characterized by apathy, indifference, loss of initiative, and/or disinhibition has been reported in adults on SSRI therapy (Hoehn-Saric et al.l990, 1991). Recently, five cases of amotivational syndrome in youths, 10 to 17 years of age, were reported (Garland Baerg, 2001). Symptoms had a delayed onset, were dose related, and were reversible. The authors caution that such presentation may go underrecognized or may be mistakenly attributed to residual depression or to avoidance rather than to a medication side effect. 

There is a clinical impression that psychostimulants may be helpful in HIV- or AIDS-related affective syndromes (487, 488). Thus, methylphenidate 10 to 20 mg per day (up to 40 mg per day) or dextroamphetamine 5 to 15 mg per day (up to 60 mg per day) has been helpful in patients with mild depression who also show symptoms of social withdrawal, fatigue, and apathy, as well as mild cognitive impairment. At times, the combination of low-dose antidepressant and psychostimulant may be more effective and less likely to induce adverse CNS effects. 

Beriberi Wernicke-Korsakoff syndrome (most common in alcoholics) Tachycardia, vomiting, convulsions Apathy, loss of memory, eye movements None ... 

Another controversial issue has been the amotivational syndrome supposedly caused by heavy, chronic marijuana use. This syndrome has been characterized by feelings of lethargy and apathy and an absence of goal-directed behavior.226,227 However, studies conducted in countries where segments of the population use marijuana heavily228-230 and laboratory-based studies in the U.S.231,232 have not found empirical support for an amotivational syndrome. 

Severe organic brain syndrome has been seen in six patients taking long-term glucocorticoids (SEDA-3, 304). The manifestations included confusion, disorientation, apathy, confabulation, irrelevant speech, and slow thinking the symptoms occurred abruptly. 

Schizophrenia is a complex neuropsychiatric disorder with a prevalence of nearly 1% of the world population. Clinically, schizophrenia is characterized by chronic psychotic symptoms and psychosocial impairment. At least two core syndromes of schizophrenia, the positive and the negative, are recognized (Liddle, 1987). Those in whom positive symptoms predominate have hallucinations, delusions, and paranoid ideation. Those with negative symptoms have apathy and anledonia. Besides impairment in the cognitive domain, individuals with schizophrenia show a deficit in emotion processing, as indicated by a markedly reduced ability to perceive, process, and express facial emotions (Aleman et al., 1999). 

Neuroleptic A term frequently used to describe antipsychotic drugs, referring to the tendency of these drugs to produce a behavioral syndrome of apathy, sedation, decreased initiative, and decreased responsiveness (SYN antipsychotic). 

Chronic cannabis users frequently exhibit the amotivational syndrome", characterized by apathy, impaired judgement, memory defects and loss of interest in normal social pursuits. Whether chronic cannabis abuse leads to more permanent changes in brain function is uncertain, but it is known that chronic administration to animals results in permanent damage to the hippocampus. Regular use of cannabis by adolescents frequently predisposes them to other types of drug abuse later. This may reflect the social pressures placed upon them rather than the pharmacological consequences of abusing cannabis. 

Alzheimer s disease (AD) is the most common neurodegenerative disease in the elderly. Prevalence increases with age and by the year 2050 it has been estimated that world-wide 1 out of 85 persons will suffer from AD (Brookmeyer et ah, 2007). AD is clinically characterized by progressive memory deficits, speech problems, and visuospatial orientation. As the disease advances, the patient my develop apraxia (loss of the ability to execute or cany out learned purposeful movements), and requires help in performing activities of daily living. In moderate and severe stages of the disease, AD patients may show signs of neuropsychiatric syndromes like labile affect, aggression, hallucinations, sleep disturbances, and apathy. 

Panthenol is absorbed via passive diffusion after topical or oral application and then enzymatically oxidized to pantothenic acid. This is a component of coenzyme A and acyl carrier protein, and as such of great importance in fatty acid, carbohydrate, and amino acid metabolism. Deficiency leads to uncharacteristic symptoms such as headaches, apathy, gastrointestinal disturbances, palpitations, and paraesthesia typically in the feet, also known as burning feet syndrome. Wound healing is impaired. The recommended daily allowance is 5 to 7 mg.112... 

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