BRAIN INJURY,

1998,

VOL.

12,

NO .

1, 87 92

Prevalence of apathy following head injury

R. KANT , J. D. DUFFY and
A. PIVOVARNIK

Head Injury Clinic, Pittsburgh, PA 15224, USA

Department of Psychiatry, University of Connecticut Health Centre, University of
Connecticut, Farmington, Connecticut, USA
Department of Social Work, Western Psychiatric Institute and Clinic, Pittsburgh, PA,
USA

(Received 6 June 1997; accepted 17 July 1997)

Although several studies have examined the demographics of mood disorders and personality changes
following closed head injury (CHI), there are no studies that address the prevalence of apathy after
CHI. Utilizing standardized evaluation tools, this study examines the prevalence of apathy in 83
consecutive patients seen in a neuropsychiatric clinic. A total of 10.84% had apathy without depression
while an equal number were depressed without apathy; another 60% of patients exhibited both apathy
and depression. Younger patients were more likely to be apathetic than older patients who were more
likely to be depressed and apathetic. Patients with severe injury were more likely to exhibit apathy
alone. Family members rated the patients higher on apathy scale. These findings suggest that apathy is a
frequent symptom after head injury and may occur either alone or in association with depression.

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

1998 Taylor & Francis Ltd.

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R. Kant et al.

to successful employment. Despite its negative impact upon long-term outcome, no

studies have addressed the prevalence of apathy following CHI.
The theoretical construct that apathy is a specific neurobehavioural disorder
distinct from depression has recently received increasing attention and support
[9]. The development of a validated clinical scale, the Apathy Evaluation Scale
(AES), has provided a valuable tool for reliably assessing the presence of apathy in
various neurological conditions. AES is an18-item scale which has good excellent
reliability, and is able to differentiate depression and anxiety from apathy
(discriminant validity; p < 0. 01 and p = 0.03 respectively). Similarly, it is able to
distinguish patient groups according to their severity of apathy [10]. AES has three
versions self rated (AES-S), informant version (AES-I) and clinician version (AESC). Starkstein et al. have recently reported that apathy occurs in 11.25% of patients
following stroke [11] and 12% of patients with Parkinsons disease [12]. In these
studies, the presence of apathy was reported to be associated with greater cognitive
deficits and more functional impairments. This report describes the prevalence of
apathy, utilizing the AES-S, in a cohort of patients who presented to a neuropsychiatric clinic for treatment of emotional, behavioural and/or cognitive problems
following a CHI.
Methods
The subjects consisted of 83 consecutive patients (73.5% male; age range 14-65
years, mean 6 sd: 38 6 12.27; education mean 6 sd:12.4 6 2.37) who were evaluated at a neuropsychiatric clinic. Common presenting complaints included depression, change in personality, cognitive deficits and other physical symptoms of postconcussive syndrome. Eight patients (9.6%) had a history of multiple head injuries
and 10 patients (12%) had a history of psychiatric treatment prior to the head injury.
Based on the subjects history of duration of loss of consciousness and/or
Glasgow Coma Score (GCS) [13], their CHI was classified as severe/moderate
(20.48%) or mild (74.69%). Injury severity was unknown in 4 (4 .81%) patients.
This information was obtained from the patients, family members and/or medical
records from the trauma centre. CHI was classified according to GCS scores and/or
duration of loss of consciousness: mild-GCS 13 15 and/or loss of consciousness
<20 min, moderate- GCS 9 12 and/or loss of consciousness >20 min but <24 h,
and severe if GCS was < 8 and/or loss of consciousness >24 h.
Method of assessment
All patients were evaluated by a neuropsychiatrist (R.K./J.D.D.). In addition to a
comprehensive clinical neuropsychiatric assessment all subjects completed: 1) the
Self-Rated Version of the AES (AES-S) 2) the Beck Depression Inventory (BDI)
[14], and 3) a family member (when available) completed the Informant Version of
the AES (AES-I). All patients were given the clinical diagnoses based on DSM III-R
criteria and the diagnosis of depressive disorder was clinical and not just based on
BDI scores.
Because the original cut-off score on the AES-S for a diagnosis of apathy was
determined in an older population (age range 53-85 years) [10] than that studied in
this report, the AES-S was standardized in a cohort of 108 healthy, young subjects
(age range 20 65 years; 94.5% of the sample were in the age range 20 49 years; 49%

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)

Patients with apathy

(Group 1)
Patients with
depression (Group 2)
Patients with
depression and apathy
(Group 3)
Patients with neither
depression nor apathy
(Group 4)

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)

* Injury severity not known in 4 patients. sd = standard deviation; M = male; F = female

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-

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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 high prevalence of an apathy syndrome and/or a depressive disorder

following CHI reported in this study highlights the importance of evaluating motivational status as part of a thorough neuropsychiatric evaluation in patients with a
history of CHI. In particular, the patients family is often a more valuable resource
when attempting to identify an apathy syndrome.
Since this study addresses the prevalence of apathy following CHI in patients
seeking treatment, these findings cannot be generalized to all patients who suffer
CHI. Although depression was a frequent presenting complaint, the role it played in
the overall prevalence of apathy in this group cannot be assessed. Although, AES has
been shown to discriminate between apathy and depression, there are many other
important questions which demand attention.These include:
1)
2)
3)
4)

The
The
The
The

impact of apathy on the patients functional and cognitive capacity.

assessment of various therapeutic interventions for apathy.
longitudinal course of apathy and its implications for long-term outcome.
relationship of apathy and depression.

A clarification of the pathophysiological basis of apathy is likely to provide

important insights into the heterogenous disorders subsumed under the term
`depression.

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