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Chapter 18. Disorders of Diminished Motivation

Robert S. Marin, M.D.; Patricia A. Wilkosz, M.D., Ph.D.
DOI: 10.1176/appi.books.9781585624201.679203

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Excerpt

Motivation is essential to adaptive functioning and quality of life. This is as much true for individuals with traumatic brain injury (TBI) as it is for those with stroke, dementia, or any other neuropsychiatric illness. Clinicians understand intuitively the importance of motivation. They know that without motivation, individuals with TBI will fail to keep appointments, stay on their medications, devote themselves to friends and family, or return to their jobs. Motivational loss handicaps physical rehabilitation and coping skills and is an important source of burden for families of individuals with TBI.

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Figure 18–1. Motivational circuitry.The core circuit that mediates the activation of behavior consists of the prefrontal cortex (PFC), basolateral and extended amygdala, and nucleus accumbens (NA). This circuit consists of glutamatergic interconnections among the amygdala, NA, and PFC and dopaminergic afferents from the ventral tegmental area. Three additional components include the -aminobutyric acid (GABA) and neuropeptide projections from the accumbens to the ventral pallidum, and the GABA/neuropeptide projections from the extended amygdala, a cluster of nuclei including the central amygdala nucleus, bed nucleus of the stria terminalis, and shell of the nucleus accumbens. The last component is a series subcircuit composed of GABAergic projections from the ventral pallidum to the mediodorsal thalamus and a reciprocal glutamatergic projection between the thalamus and PFC. This component serves to recapture information exiting the circuit back to the PFC. Output is via the motor cortex, basal ganglia, reticulospinal tract, and pedunculopontine nucleus. The flow of information within and through the circuits permits the translation of motivation into action.Source. Adapted from Kalivas PW, Churchill L, Klitenick MA: "The Circuitry Mediating the Translation of Motivational Stimuli Into Adaptive Motor Responses" in Limbic Motor Circuits and Neuropsychiatry. Edited by Kalivas PW, Barnes CD. Boca Raton, FL, CRC Press, 1993, pp. 237–288. Modified with permission from CRC Press, LLC, and Taylor & Francis.

Figure 18–2. Apathy Evaluation Scale (Clinician Version).Note. The Apathy Evaluation Scale was developed by Robert S. Marin. Development and validation studies are described in Marin et al. 1991. Administration instructions may be obtained from Dr. Marin (marinr@upmc.com) or from "The Apathy Evaluation Scale" in Handbook of Psychiatric Measures (Washington, DC, American Psychiatric Publishing, 2000).Source. Reprinted from Marin RS, Biedrzycki RC, Firinciogullari S: "Reliability and Validity of the Apathy Evaluation Scale." Psychiatry Research 38:143–162, 1991. Used with permission.
Table Reference Number
Table 18–1. Conditions associated with apathy, abulia, and akinetic mutism
Table Reference Number
Table 18–2. Drugs used in the treatment of apathy, abulia, and akinetic mutism

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