Chapter 5-Physician's Guide to Management of HD~Psychiatric Disorder
Apathy is common in HD and is probably related to frontal lobe dysfunction. Apathetic patients become unmotivated and uninterested in their surroundings. They lose enthusiasm and spontaneity. Performance at work or school becomes sluggish.
The symptom of apathy can be very troubling to families, if they see the active person they knew slipping away. It can be a source of conflict for caregivers, who know the person is physically capable of activities but "won't" do them.
Families need much education and support in this regard and should learn to practice a combination of exhortation and accommodation.
While apathetic patients have trouble initiating actions, they will often participate if someone else suggests an activity and works along with them to sustain energy and attention. For example, a man with HD had always loved fishing, but when his brother came to take him fishing for his birthday he wanted to stay home in front of the television. The brother insisted, and when they left the house, he had a good time fishing all day. When he returned, he immediately turned the television back on.
Apathy can be hard to distinguish from depression. Apathetic patients, like those with depression, may be sluggish, quiet, and disengaged. They may
talk slowly, or not at all.
By and large apathetic patients will deny being sad, but in distinguishing the two it is important to ask not only about the patient's mood, but about other depressive symptoms as well, such as a change in sleeping or eating patterns, feelings of guilt, or suicidal thoughts.
Neuroleptics and benzodiazepines can cause or worsen apathy. The need for these medications should be reexamined if the patient is apathetic.
TABLE 17: COPING STRATEGIES FOR APATHY
- Use calendars, schedules and routines to keep the person busy.
- Do not interpret lack of activity as "laziness."
- Patients may not be able to initiate activities, but may participate if encouraged by others.
- Gently guide behaviors, but accept "no."
Depressed patients with apathy should be treated aggressively for their depression, which may cause the other symptoms to remit. It can be very difficult to distinguish depression from primary apathy, but patients with primary apathy sometimes respond to psychostimulants such as methylphenidate (Ritalin), pemoline (Cylert) or dextroamphetamine (Dexedrine).
These medicines are highly abusable and may exacerbate irritability. They should be used with caution. It may be more prudent to make a trial of a non-sedating antidepressant, such as an SSRI, first even if the patient does not seem to meet the criteria for depression, as these agents have also occasionally been helpful.