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Author: Chen Xiaohui This article is published by Yimaitong authorized by the author, please do not reprint without authorization.
Note: The pictures in the text can be clicked to view a clear large picture.
All academic discussions must give a clear definition of what is being discussed, but different disciplines have different views on the same thing.
According to the neurology guidelines/expert consensus, apathy refers to a state of reduced motivation, which is clinically manifested as a decrease in goal-oriented behavior and a decrease in different degrees of interest and emotion, and it is not due to a decline in consciousness, nor is it a cognitive impairment or Caused by mood disorders [1].
The incidence of PD apathy is 17% to 60% [2, 3].
According to the research of Martin, a dyskinesia specialist 20 years ago, indifference can be expressed in three aspects: cognitive, emotion and behavior (Figure 1).
Later, there were also different forms of content classification.
For example, a good review published on Lancet Neurol 6 years ago had a similar but different classification (reward disorder syndrome, depression, executive dysfunction, and decreased spontaneous mental activity [ Mental blank]) [2].
The Chinese have a more concise description-"Essence, Qi, God", which is not exactly the same; the one that is more consistent with the motive should be "heart", whether it is conscience, desire, good or evil.
.
The definition of indifference in the old Chinese proverb probably means that there is no "heart" and "essence, energy, and spirit".
It is simple and does not lose its connotation.
Indifferent psychology, philosophy, and brain psychology and philosophy are much more metaphysical to the study of indifferent, which can be "free will".
A few years ago, I saw an article titled "lesion network localization of free will" on PNAS.
The content was roughly that the researcher described the lesions that caused inactivity and alien hand syndrome, and then calculated a "lesion "Brain Network", the article is impressive, but in fact the content is very simple, I just lament the author's ability to tell stories-if I remember correctly, the introduction introduces the free will of "what makes people a person" from the introduction.
The conclusion of the study is also worth looking at, because these brain areas are the basis of the lesions that cause apathy (anterior cingulate gyrus, medial prefrontal lobe, ventral striatum, basal ganglia, nucleus accumbens, ventral midbrain tegmental area) [4].
Figure 1 The brain network of the lesion with inactivity and silence [4].
(A) Delineated lesion; (B) Corresponding brain connection of the lesion; (C) Lesion-brain connection difference that causes inactivity vs.
hemiplegia; (D) Anterior cingulate area of interest; (E) Front The brain network map of the area of interest of the cingulate gyrus and its overlapping area with the A map.
Inactive silence can be understood as a serious, complete form of indifference, manifested as reward disorder syndrome, depression, executive dysfunction, and severe reduction in spontaneous mental activity.
In psychology (and neuroscience) research, an effort-based decision making for reward is commonly used.
The simple and most classic case is Pavlov’s dog.
When a specific behavior is given repeated food rewards, the behavior will cause "Motivation appears", or "wanting" (want, desire).
Therefore, a person who has experienced painful feelings will adjust their cost-benefit decisions when the final outcome is a high-intensity negative feedback.
And the so-called "beginning with appearance and ending with character" can also be understood as forming a good cycle between selection and result feedback.
To get back to the subject, the regulatory factor barriers in this loop can cause apathy, and apathy can also be manifested as barriers to various links in this loop, such as the loss of internal motivation, the imbalance of cost-benefit decisions, planning and execution dysfunction, and loss of feedback— -This is the same as the definition of indifference mentioned earlier.
Indifference related circuits in neuroscience and neurotransmitter neuroscience, indifference mainly involves two circuits: the ventral tegmental area of the midbrain-limbic system dopaminergic circuit and the ventral tegmental area of the midbrain-prefrontal dopamine Energy loop, the main neurotransmitter is dopamine.
These two loops are mainly related to motivation.
Although Parkinson's disease was originally proposed to be related to the apoptosis of substantia nigra-striatal dopaminergic neurons, it is actually a widespread failure of dopaminergic neurotransmitter and non-dopaminergic neurotransmitter disorders in the whole brain.
Therefore, it is well understood that PD dopamine deficiency causes apathy.
Figure 2 [5] ACC (anterior cingulate cortex) anterior cingulate gyrus; dmPFC (dorsomedial prefrontal cortex) dorsal medial prefrontal lobe; NAc (nucleus accumbens) nucleus accumbens; vmPFC (ventromedial prefrontal cortex) ventromedial prefrontal frontal lobe; VP (ventral pallidum) ventral globus pallidum; vStr (ventral striatum) ventral striatum; VTA (ventral tegmental area) midbrain ventral tegmental area.
The cognitive inertia and executive dysfunction in apathy are also related to other brain areas of the basal ganglia (such as the caudate nucleus) and the dorsolateral prefrontal cortex.
Diagnosis and evaluation of PD indifference The diagnostic criteria for PD indifference are not recognized, there are about 3-4 diagnostic criteria, here is only one standard of teacher SE Starkstein, which is relatively simple and easy to operate [6], and the translation may be inaccurate.
Can refer to the original text.
The International Dyskinesia Association recommends two evaluation scales-Starkstein Apathy Scale (SAS)[7] and Lille Apathy Rating Scale (LARS)[8]; the scale in MDS-UPDRS I can only be used as a screening test and is not recommendedassessment.
Table 1 The diagnostic criteria proposed by Starkstein [6] The recognized risk factors or related factors for PD apathy include advanced age, cognitive impairment, depression, long course of disease, severity of movement disorders, impulse control disorders, end-of-dose phenomena, and dopaminergic reduction drug.
DBS may aggravate or cause PD apathy, but some patients may be transient and may be related to postoperative drug reduction.
Therefore, the relationship between DBS and PD apathy is controversial.
Distinguishing needs of indifference and depression: both have lack of motivation, and both can show the lack of "essence, qi, and spirit", but the latter emphasizes "low mood" and accompanied by "sadness, helplessness, and self-confidence".
Negative emotions and behaviors such as guilt, hopelessness, and suicidal emotions, while the former are lack of motivation, emotions, and behaviors (without "heart").
Apathy can be comorbid with depression, but there are also cases of simple apathy without depression.
In 2015, the Lancet Neurol diagnostic criteria proposed a diagnostic system of simple apathy, apathy with depression, and apathy with cognitive impairment, which can also be referred to [2].
Treatment of PD with apathy Domestic PD treatment guidelines suggest that the treatment of PD with apathy lacks well-documented drugs.
The DAs drug piribedil and the cholinesterase inhibitor rivastigmine may be useful.
These two drugs are confirmed by small clinical studies.
In theory, dopa receptor agonists and levodopa drugs may improve apathy; the drug reduction process after DBS may cause apathy or aggravation.
Dopa receptor agonists and levodopa drugs can be added.
Apathy often has cognitive impairment, especially executive dysfunction.
Cognitive improvement drugs can also be used, but the effect is not accurate.
For depression combined with apathy, in the 2015 Lancet Neurol review, it was mentioned that SSRI or SRNI drugs can be used, but increasing 5-HT in the brain may aggravate the risk of apathy.
Bupropion, which is not a 5-HT target in antidepressants, can be tried without personal experience.
Individual patients with muted delirium after subarachnoid hemorrhage, the muting symptoms of a week after the addition of SSRI are significantly improved, completely changed like a person, the case experience is for reference only.
The central agonist methylphenidate hydrochloride tablets can be tried, but the effect is uncertain.
Exercise can significantly improve the depression, fatigue, etc.
of PD patients.
Whether it can improve apathy is also worth trying-after all, it can produce endogenous dopamine. In order to understand the knowledge needs of teachers in Parkinson's disease, and to provide better professional services, I hope you can take 1 minute to complete the following questionnaire, thank you! References: 1.
Levy R.
Apathy: a pathology of goal-directed behaviour: a new concept of the clinic and pathophysiology of apathy[J].
Rev Neurol (Paris).
2012,168(8-9):585-97.
2 .
Pagonabarraga J, Kulisevsky J, Strafella AP, Krack P.
Apathy in Parkinson's disease: clinical features, neural substrates, diagnosis, and treatment[J].
Lancet Neurol.
2015,14(5):518-31.
3.
Szatmari S, Illigens BM, Siepmann T, Pinter A, Takats A, Bereczki D.
Neuropsychiatric symptoms in untreated Parkinson's disease[J].
Neuropsychiatr Dis Treat.
2017,13:815-26.
4.
Darby RR, Joutsa J, Burke MJ, Fox MD.
Lesion network localization of free will[J].
Proc Natl Acad Sci US A.
2018,115(42):10792-7.
5.
Husain M, Roiser JP.
Neuroscience of apathy and anhedonia: a transdiagnostic approach[J].
Nat Rev Neurosci.
2018 , 19(8):470-84.
6.
Note: The pictures in the text can be clicked to view a clear large picture.
All academic discussions must give a clear definition of what is being discussed, but different disciplines have different views on the same thing.
According to the neurology guidelines/expert consensus, apathy refers to a state of reduced motivation, which is clinically manifested as a decrease in goal-oriented behavior and a decrease in different degrees of interest and emotion, and it is not due to a decline in consciousness, nor is it a cognitive impairment or Caused by mood disorders [1].
The incidence of PD apathy is 17% to 60% [2, 3].
According to the research of Martin, a dyskinesia specialist 20 years ago, indifference can be expressed in three aspects: cognitive, emotion and behavior (Figure 1).
Later, there were also different forms of content classification.
For example, a good review published on Lancet Neurol 6 years ago had a similar but different classification (reward disorder syndrome, depression, executive dysfunction, and decreased spontaneous mental activity [ Mental blank]) [2].
The Chinese have a more concise description-"Essence, Qi, God", which is not exactly the same; the one that is more consistent with the motive should be "heart", whether it is conscience, desire, good or evil.
.
The definition of indifference in the old Chinese proverb probably means that there is no "heart" and "essence, energy, and spirit".
It is simple and does not lose its connotation.
Indifferent psychology, philosophy, and brain psychology and philosophy are much more metaphysical to the study of indifferent, which can be "free will".
A few years ago, I saw an article titled "lesion network localization of free will" on PNAS.
The content was roughly that the researcher described the lesions that caused inactivity and alien hand syndrome, and then calculated a "lesion "Brain Network", the article is impressive, but in fact the content is very simple, I just lament the author's ability to tell stories-if I remember correctly, the introduction introduces the free will of "what makes people a person" from the introduction.
The conclusion of the study is also worth looking at, because these brain areas are the basis of the lesions that cause apathy (anterior cingulate gyrus, medial prefrontal lobe, ventral striatum, basal ganglia, nucleus accumbens, ventral midbrain tegmental area) [4].
Figure 1 The brain network of the lesion with inactivity and silence [4].
(A) Delineated lesion; (B) Corresponding brain connection of the lesion; (C) Lesion-brain connection difference that causes inactivity vs.
hemiplegia; (D) Anterior cingulate area of interest; (E) Front The brain network map of the area of interest of the cingulate gyrus and its overlapping area with the A map.
Inactive silence can be understood as a serious, complete form of indifference, manifested as reward disorder syndrome, depression, executive dysfunction, and severe reduction in spontaneous mental activity.
In psychology (and neuroscience) research, an effort-based decision making for reward is commonly used.
The simple and most classic case is Pavlov’s dog.
When a specific behavior is given repeated food rewards, the behavior will cause "Motivation appears", or "wanting" (want, desire).
Therefore, a person who has experienced painful feelings will adjust their cost-benefit decisions when the final outcome is a high-intensity negative feedback.
And the so-called "beginning with appearance and ending with character" can also be understood as forming a good cycle between selection and result feedback.
To get back to the subject, the regulatory factor barriers in this loop can cause apathy, and apathy can also be manifested as barriers to various links in this loop, such as the loss of internal motivation, the imbalance of cost-benefit decisions, planning and execution dysfunction, and loss of feedback— -This is the same as the definition of indifference mentioned earlier.
Indifference related circuits in neuroscience and neurotransmitter neuroscience, indifference mainly involves two circuits: the ventral tegmental area of the midbrain-limbic system dopaminergic circuit and the ventral tegmental area of the midbrain-prefrontal dopamine Energy loop, the main neurotransmitter is dopamine.
These two loops are mainly related to motivation.
Although Parkinson's disease was originally proposed to be related to the apoptosis of substantia nigra-striatal dopaminergic neurons, it is actually a widespread failure of dopaminergic neurotransmitter and non-dopaminergic neurotransmitter disorders in the whole brain.
Therefore, it is well understood that PD dopamine deficiency causes apathy.
Figure 2 [5] ACC (anterior cingulate cortex) anterior cingulate gyrus; dmPFC (dorsomedial prefrontal cortex) dorsal medial prefrontal lobe; NAc (nucleus accumbens) nucleus accumbens; vmPFC (ventromedial prefrontal cortex) ventromedial prefrontal frontal lobe; VP (ventral pallidum) ventral globus pallidum; vStr (ventral striatum) ventral striatum; VTA (ventral tegmental area) midbrain ventral tegmental area.
The cognitive inertia and executive dysfunction in apathy are also related to other brain areas of the basal ganglia (such as the caudate nucleus) and the dorsolateral prefrontal cortex.
Diagnosis and evaluation of PD indifference The diagnostic criteria for PD indifference are not recognized, there are about 3-4 diagnostic criteria, here is only one standard of teacher SE Starkstein, which is relatively simple and easy to operate [6], and the translation may be inaccurate.
Can refer to the original text.
The International Dyskinesia Association recommends two evaluation scales-Starkstein Apathy Scale (SAS)[7] and Lille Apathy Rating Scale (LARS)[8]; the scale in MDS-UPDRS I can only be used as a screening test and is not recommendedassessment.
Table 1 The diagnostic criteria proposed by Starkstein [6] The recognized risk factors or related factors for PD apathy include advanced age, cognitive impairment, depression, long course of disease, severity of movement disorders, impulse control disorders, end-of-dose phenomena, and dopaminergic reduction drug.
DBS may aggravate or cause PD apathy, but some patients may be transient and may be related to postoperative drug reduction.
Therefore, the relationship between DBS and PD apathy is controversial.
Distinguishing needs of indifference and depression: both have lack of motivation, and both can show the lack of "essence, qi, and spirit", but the latter emphasizes "low mood" and accompanied by "sadness, helplessness, and self-confidence".
Negative emotions and behaviors such as guilt, hopelessness, and suicidal emotions, while the former are lack of motivation, emotions, and behaviors (without "heart").
Apathy can be comorbid with depression, but there are also cases of simple apathy without depression.
In 2015, the Lancet Neurol diagnostic criteria proposed a diagnostic system of simple apathy, apathy with depression, and apathy with cognitive impairment, which can also be referred to [2].
Treatment of PD with apathy Domestic PD treatment guidelines suggest that the treatment of PD with apathy lacks well-documented drugs.
The DAs drug piribedil and the cholinesterase inhibitor rivastigmine may be useful.
These two drugs are confirmed by small clinical studies.
In theory, dopa receptor agonists and levodopa drugs may improve apathy; the drug reduction process after DBS may cause apathy or aggravation.
Dopa receptor agonists and levodopa drugs can be added.
Apathy often has cognitive impairment, especially executive dysfunction.
Cognitive improvement drugs can also be used, but the effect is not accurate.
For depression combined with apathy, in the 2015 Lancet Neurol review, it was mentioned that SSRI or SRNI drugs can be used, but increasing 5-HT in the brain may aggravate the risk of apathy.
Bupropion, which is not a 5-HT target in antidepressants, can be tried without personal experience.
Individual patients with muted delirium after subarachnoid hemorrhage, the muting symptoms of a week after the addition of SSRI are significantly improved, completely changed like a person, the case experience is for reference only.
The central agonist methylphenidate hydrochloride tablets can be tried, but the effect is uncertain.
Exercise can significantly improve the depression, fatigue, etc.
of PD patients.
Whether it can improve apathy is also worth trying-after all, it can produce endogenous dopamine. In order to understand the knowledge needs of teachers in Parkinson's disease, and to provide better professional services, I hope you can take 1 minute to complete the following questionnaire, thank you! References: 1.
Levy R.
Apathy: a pathology of goal-directed behaviour: a new concept of the clinic and pathophysiology of apathy[J].
Rev Neurol (Paris).
2012,168(8-9):585-97.
2 .
Pagonabarraga J, Kulisevsky J, Strafella AP, Krack P.
Apathy in Parkinson's disease: clinical features, neural substrates, diagnosis, and treatment[J].
Lancet Neurol.
2015,14(5):518-31.
3.
Szatmari S, Illigens BM, Siepmann T, Pinter A, Takats A, Bereczki D.
Neuropsychiatric symptoms in untreated Parkinson's disease[J].
Neuropsychiatr Dis Treat.
2017,13:815-26.
4.
Darby RR, Joutsa J, Burke MJ, Fox MD.
Lesion network localization of free will[J].
Proc Natl Acad Sci US A.
2018,115(42):10792-7.
5.
Husain M, Roiser JP.
Neuroscience of apathy and anhedonia: a transdiagnostic approach[J].
Nat Rev Neurosci.
2018 , 19(8):470-84.
6.
