Prevalence of Apathy Following Head Injury: R.Kant, J.D.Duffy and A.Pivovarnik
Prevalence of Apathy Following Head Injury: R.Kant, J.D.Duffy and A.Pivovarnik
Prevalence of Apathy Following Head Injury: R.Kant, J.D.Duffy and A.Pivovarnik
1998,
VOL.
12,
NO .
1, 87 92
Introduction
More than two million people sustain a closed head injury (CHI) in the United
States each year [1]. Approximately one-quarter of these patients require hospitalization and 70 000 90 000 experience a significant permanent disability [2]. These
statistics translate into a major cause of personal suffering for patients and their
families, and a loss of productivity for society.
In addition to cognitive sequelae, a wide range of behavioural disturbances have
been reported following CHI.These include mood disorders [3], anxiety disorders
[4], personality changes [5], thought disorders [6] and aggressive behaviours [7]. In
the largest retrospective study reported in the literature, Hillbom found that almost
one-third of Finnish soldiers who had sustained head injuries during World War II
developed psychiatric disorders [8].
Personality changes following CHI include irritability, impulsiveness, emotional
lability, amotivation, passivity, insensitivity and aggression. Although aggression is a
prominent presenting complaint, family, friends, and rehabilitation personnel will
frequently admit that the patients apathy is also a profoundly disabling (albeit less
destructive) symptom. Amotivation is likely to have a negative impact on the
patients participation in rehabilitation and the likelihood of their eventual return
This work was presented in part at 7th Annual Meeting of the American Neuropsychiatric
Association, Pittsburgh, PA 12 15 October, 1995.
Correspondence to: Ravi Kant, Head Injury Clinic, 4608 Penn Avenue, Pittsburgh, PA 15224, USA.
0269 9052/98 $12 00
88
R. Kant et al.
Apathy in CHI
Table 1.
89
AES and BDI scores of different patient groups with demographics
Group
N (%)
Sex
Age
mean
(sd)
All patients
83
(100%)
M-61
F-22
38.25
(12.27)
9
(10.84%)
9
(10.84%)
50
(60.24%)
M-8
F-1
M-6
F-3
M-35
F-15
29.00
(11.88)
41.77
(12.94)
38.12
(11.46)
15
(18.07%)
M-12
F-3
42.13
(12.93)
Injury
severity*
Mild
62
Moderate 8
Severe 9
Mild
6
Severe 3
Mild
8
Severe 1
Mild
40
Moderate 6
Severe 1
Mild
8
Moderate 2
Severe 4
AES
score
(sd)
BDI
score
(sd)
38.84
(9.81)
18.03
(10.24)
40.55
(6.26)
26.55
(5.05)
43.92
(7.56)
7.33
(2.5)
18.00
(5.26)
23.52
(8.58)
28.26
(3.97)
6.2
(2.42)
male). Subjects with a history of substance abuse, current or past psychiatric history,
acute or chronic medical or neurological conditions, or currently using medication,
were excluded from the initial sample of 127 volunteers. The healthy subjects were
not matched with the clinical sample because the healthy group was intended to be
reflective of the general adult population. Utilizing this control group, the mean
score on the AES-S was 24.4 (sd 4.5). The criterion for making a diagnosis of apathy
was a score of 34 or higher on the AES-S (representing greater than 2 SD from
normal). The same cut-off score was used for informant version of AES. Patients
who scored higher than 11 on the BDI were considered to be depressed.
Results
Fifty-nine patients (71.08%) met AES-S criteria for a diagnosis of apathy with or
without concomitant depression. Nine patients (10.84%) met AES-S criteria for
apathy alone and were not depressed; AES-S score (mean 6 sd) 40.5 6 6.26
(Group 1). Nine patients (10.84%) met BDI criteria for depression alone without
concomitant apathy; BDI score (mean 6 SD) 18 6 5.26 (Group 2). The AES-S
score for patients (60.24%) who were both depressed and apathetic was
(mean 6 SD) 43.92 6 7.56 and BDI score (mean 6 SD) 23.52 6 8.58 (Group 3).
Fifteen patients (18.07%) were neither depressed nor apathetic using the above
criteria (Group 4) (see Table 1). Self-report measures for both depression and apathy
(AES-S and BDI) were utilized for the data analysis.
There was a statistically significant between-group difference in age between
Groups 1 and 2 (t = - 2.18, df = 16, p < 0.04) and Groups 1 and 3 (t = - 2.18,
df = 57, p < 0.03). Younger patients were more likely to exhibit apathy in contrast
to the older patients who were more likely to exhibit depression or both depression
and apathy. There were no statistically significant differences noted in sex or injury
severity between apathetic and depressed only patients (Groups 1 and 2; p > 0.28
for both) or between depressed only and depressed with apathy patients (Groups 2
and 3; p > 0.83 and p > 0.69 respectively). Patients with severe injury were statis-
90
R. Kant et al.
tically more likely to exhibit apathy alone rather than apathy and depression combined (t = 2.53, df = 52, p < 0.01).
There was no statistically significant between-group difference on AES-S scores
in patients who were depressed (Group 2) or who were rated normal on both BDI
and AES-S (Group 4; t = - 0. 9; p > 0. 365). No between-group differences were
noted for age and injury severity in these two groups ( p > 0. 94 and p > 0. 14
respectively).
Family members were more likely to rate the patient higher on the AES-I than
the patients self-report on the AES-S (p < 0.000001). Twenty-two of the 28
available family members (78.5%) reported higher apathy scores; families AES-I
score (mean 6 sd) 50.5 6 6.6; patients AES-S score (mean 6 sd) 38.1 6 7.9. Five
patients (17.8%) reported higher apathy scores than their family members.
Discussion
The results of this study suggest that a significant percentage of patients with CHI
are suffering from an apathy syndrome. It is interesting to note that, although an
apathy syndrome may occur in isolation following CHI, it most frequently occurs in
association with a depressive disorder. Whether this association represents the comorbidity of two separate behavioural disorders with different clinical characteristics
or a single pathophysiological process leading to both a depressed mood and diminished motivation requires further evaluation. Our finding that apathy may occur
independently from depression does suggest, however, that its pathophysiology is
distinct from that of depression. The co-morbidity of apathy in some, but not all,
depressed CHI patients indicates some clinical heterogeneity within depressed CHI
patients.
This concept of heterogeneity within mood disorders following CHI is supported by the findings of Jorge et al. in their 1-year longitudinal follow-up of 66
patients who had sustained a CHI [3]. They reported that the symptom characteristics of patients with a major depressive disorder differed depending on the interval
since their head injury. Patients with early depression (i.e. 3 months post-CHI)
exhibited mostly autonomic symptoms (e.g. decreased appetite, insomnia, weight
loss) and were likely to be anxious. Patients with late depression (i.e. 1 year postCHI) were likely to exhibit early morning awakening, decreased concentration and
inefficient thinking as the core symptoms of their depression. Anergia remained a
consistent symptom in depressed patients regardless of the interval since CHI.
As regards symptoms referable to apathy, Jorge et al. reported that 11% and 45%
of their patient sample reported loss of interest and anhedonia at initial follow-up
and at 1 year respectively [3]. The latter sub-group may represent the apathetic
group reported in our study (who were also evaluated several months following
their index CHI) and suggests that distinct, temporally related pathophysiological
changes may underlie the generation of heterogenous depressive disorders following
head injury.
Our finding that family members were more likely to identify an apathy syndrome than the patient suggests that many patients experience diminished selfawareness following CHI. This is consistent with the high incidence of frontal
lobe injury [15] and subsequent diminished self-awareness due to frontal lobe injury
[16].
Apathy in CHI
91
The
The
The
The
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