The year is 2006 and Deep Brain Stimulation (DBS) is commonly employed in the treatment of patients with Parkinson disease (PD) in the United States. DBS has been found to improve the motor symptoms of PD (tremor, rigidity and gait disturbance) in many patients and interest developed in using DBS to treat some of the psychiatric complications of PD.

With further refinement in technique it was discovered that by placing a fairly large number of electrodes very deep into the brain, improvement in severe apathy could sometimes be achieved. The only drawback is that in contrast to traditional DBS, in which the treatment was reversible, this modified DBS technique is not.

Mr. G. is a 61-year-old man with moderately advanced PD who was referred for DBS treatment. Prior to developing PD Mr. G. was a successful engineer for a military research firm. He rose through the ranks to become the director of aeronautics research, earning a reputation for diligence and conscientiousness. He was quiet, matter-of-fact and somewhat shy, but always very energetic and enthusiastic about new ideas at work. He worked 6 days a week and had few friends. He was married with 3 children and spent all of his free time with his family who shared his enthusiasm for ideas and experimentation.

After being afflicted with PD, Mr. G. initially continued to work. His company was very accommodating of his need for a flexible schedule, frequent absences, and modified workspace. As the disease progressed Mr. G. developed a fairly severe apathy syndrome that impaired his job performance. He no longer initiated new projects, began to miss deadlines, and often did not show up for work at all. At home his family described him as "a changed man," no longer showing interest in his children, skipping their school performances and responding to their stories with minimal emotion. He no longer "tinkered" in his shop and stopped reading the newspaper. He denied feeling sad and did not express feelings of hopelessness or guilt. His sleep and appetite were normal. His neurologist diagnosed him with an apathy syndrome related to the PD, and a psychiatric consultation concurred, finding no evidence of depression or cognitive impairment. Mr. G. was offered the newer technique of DBS as a potential treatment for the motor symptoms of PD as well as the severe apathy. After deliberation about the risks and benefits and after obtaining a second opinion, they decided to proceed with the DBS. Although they were concerned about the irreversibility of the modified DBS technique, they felt that the potential benefits of reversing the severe apathy outweighed the risks.

Following implantation of the DBS, Mr. G. had significant improvement in his motor symptoms. More dramatic, however, was the change in his personality and demeanor. Previously shy and introverted, Mr. G. now became extremely outgoing and gregarious. He would seek out crowds of people to speak to and frequently became the center of attention. He would spend hours at work telling stories instead of working on his projects. At home during meals he would re-direct the topic of conversation to something he could dominate. Although he demonstrated an apparent renewed interest in the happenings of his family, in fact the interest went only so far as he was able to attract the attention of the group onto himself.

Mr. G. went on to develop not only a new demeanor but also a new outlook on the world. Previously a loyal Republican, he switched his affiliation to the Democratic Party. He became an ardent environmentalist, travelling to numerous conferences and insisting (over his wife's objection) on giving all of their charity donations to environmental causes. Over time his interests shifted to a variety of other social, political and charitable causes, throwing himself passionately into each one in turn. He decided (without consulting with his wife or children) to quit his job in engineering in order to devote more of his time and energy to these various causes.

Apathy Fact Sheet

The core feature of the apathy syndrome is impairment in motivation and interest. This can encompass all or most aspects of life including work, family, social and religious life, etc. Interest in food often remains intact. Some patients retain an interest in activities or people yet have no apparent motivation to act on this interest. Some patients are cognizant of this discrepancy and baffled by it. They say that they do not know why they are unable to do a task, they just are unable to do it. Apathy can be severe, with some patients essentially remaining in bed all day without getting out even to use the bathroom. Others lose complete interest in family members and may react without any emotion upon learning that a close relative has just been diagnosed with a fatal disease.

The apathy syndrome is prevalent in many neuropsychiatric diseases including Alzheimer disease, stroke, Parkinson disease, frontotemporal dementia, traumatic brain injury, and normal pressure hydrocephalus. The apathy syndrome may improve modestly after treatment with medications that increase dopamine in the brain and may also improve with structured behavior modification plans. This syndrome can be among the most troubling for family members caring for patients with these disorders.