Mind-wandering in Parkinson's disease hallucinations reflects primary visual and default network coupling

Visual hallucinations in Parkinson's disease: spotlight on central cholinergic dysfunction

Visual hallucinations are a common non-motor feature of Parkinson's disease and have been associated with accelerated cognitive decline, increased mortality and early institutionalization. Despite their prevalence and negative impact on patient outcomes, the repertoire of treatments aimed at addressing this troubling symptom is limited. Over the past two decades, significant contributions have been made in uncovering the pathological and functional mechanisms of visual hallucinations, bringing us closer to the development of a comprehensive neurobiological framework. Convergent evidence now suggests that degeneration within the central cholinergic system may play a significant role in the genesis and progression of visual hallucinations. Here, we outline how cholinergic dysfunction may serve as a potential unifying neurobiological substrate underlying the multifactorial and dynamic nature of visual hallucinations. Drawing upon previous theoretical models, we explore the impact that alterations in cholinergic neurotransmission has on the core cognitive processes pertinent to abnormal perceptual experiences. We conclude by highlighting that a deeper understanding of cholinergic neurobiology and individual pathophysiology may help to improve established and emerging treatment strategies for the management of visual hallucinations and psychotic symptoms in Parkinson's disease.

Functional and connectivity correlates associated with Parkinson's disease psychosis: a systematic review

Neural underpinnings of Parkinson's disease psychosis remain unclear to this day with relatively few studies and reviews available. Using a systematic review approach, here, we aimed to qualitatively synthesize evidence from studies investigating Parkinson's psychosis-specific alterations in brain structure, function or chemistry using different neuroimaging modalities. PubMed, Web of Science and Embase databases were searched for functional MRI (task-based and resting state), diffusion tensor imaging, PET and single-photon emission computed tomography studies comparing Parkinson's disease psychosis patients with Parkinson's patients without psychosis. We report findings from 29 studies (514 Parkinson's psychosis patients, mean age ± SD = 67.92 ± 4.37 years; 51.36% males; 853 Parkinson's patients, mean age ± SD = 66.75 ± 4.19 years; 55.81% males). Qualitative synthesis revealed widespread patterns of altered brain function across task-based and resting-state functional MRI studies in Parkinson's psychosis patients compared with Parkinson's patients without psychosis. Similarly, white matter abnormalities were reported in parietal, temporal and occipital regions. Hypo-metabolism and reduced dopamine transporter binding were also reported whole brain and in sub-cortical areas. This suggests extensive alterations affecting regions involved in high-order visual processing and attentional networks.

Parkinson disease psychosis: from phenomenology to neurobiological mechanisms

Parkinson disease (PD) psychosis (PDP) is a spectrum of illusions, hallucinations and delusions that are associated with PD throughout its disease course. Psychotic phenomena can manifest from the earliest stages of PD and might follow a continuum from minor hallucinations to structured hallucinations and delusions. Initially, PDP was considered to be a complication associated with dopaminergic drug use. However, subsequent research has provided evidence that PDP arises from the progression of brain alterations caused by PD itself, coupled with the use of dopaminergic drugs. The combined dysfunction of attentional control systems, sensory processing, limbic structures, the default mode network and thalamocortical connections provides a conceptual framework to explain how new incoming stimuli are incorrectly categorized, and how aberrant hierarchical predictive processing can produce false percepts that intrude into the stream of consciousness. The past decade has seen the publication of new data on the phenomenology and neurobiological basis of PDP from the initial stages of the disease, as well as the neurotransmitter systems involved in PDP initiation and progression. In this Review, we discuss the latest clinical, neuroimaging and neurochemical evidence that could aid early identification of psychotic phenomena in PD and inform the discovery of new therapeutic targets and strategies.

Abnormal higher-order network interactions in Parkinson's disease visual hallucinations

Visual hallucinations in Parkinson's disease can be viewed from a systems-level perspective, whereby dysfunctional communication between brain networks responsible for perception predisposes a person to hallucinate. To this end, abnormal functional interactions between higher-order and primary sensory networks have been implicated in the pathophysiology of visual hallucinations in Parkinson's disease, however the precise signatures remain to be determined. Dimensionality reduction techniques offer a novel means for simplifying the interpretation of multidimensional brain imaging data, identifying hierarchical patterns in the data that are driven by both within- and between-functional network changes. Here, we applied two complementary non-linear dimensionality reduction techniques-diffusion-map embedding and t-distributed stochastic neighbour embedding (t-SNE)-to resting state functional MRI data, in order to characterize the altered functional hierarchy associated with susceptibility to visual hallucinations. Our study involved 77 people with Parkinson's disease (31 with hallucinations; 46 without hallucinations) and 19 age-matched healthy control subjects. In patients with visual hallucinations, we found compression of the unimodal-heteromodal gradient consistent with increased functional integration between sensory and higher order networks. This was mirrored in a traditional functional connectivity analysis, which showed increased connectivity between the visual and default mode networks in the hallucinating group. Together, these results suggest a route by which higher-order regions may have excessive influence over earlier sensory processes, as proposed by theoretical models of hallucinations across disorders. By contrast, the t-SNE analysis identified distinct alterations in prefrontal regions, suggesting an additional layer of complexity in the functional brain network abnormalities implicated in hallucinations, which was not apparent in traditional functional connectivity analyses. Together, the results confirm abnormal brain organization associated with the hallucinating phenotype in Parkinson's disease and highlight the utility of applying convergent dimensionality reduction techniques to investigate complex clinical symptoms. In addition, the patterns we describe in Parkinson's disease converge with those seen in other conditions, suggesting that reduced hierarchical differentiation across sensory-perceptual systems may be a common transdiagnostic vulnerability in neuropsychiatric disorders with perceptual disturbances.

Functional Brain Networks of Minor and Well-Structured Major Hallucinations in Parkinson's Disease

BACKGROUND

Minor hallucinations (mHs) and well-structured major hallucinations (MHs) are common symptoms of Parkinson's disease (PD) psychosis.

OBJECTIVES

To investigate the resting-state networks (RSNs) in patients with PD without hallucinations (PD-nH), with mH (PD-mH), and with MH (PD-MH).

METHODS

A total of 73 patients with PD were enrolled (27 PD-nH, 23 PD-mH, and 23 PD-MH). Using seed-based functional connectivity analyses, we investigated the RSNs supposedly related to hallucinations in PD: the default mode network (DMN), executive control network (ECN), dorsal attention network (DAN), ventral attention network (VAN), and visual network (VN). We compared the cognitive function and RSN connectivity among the three groups. In addition, we performed a seed-to-seed analysis to examine the inter-network connectivity within each group using the corresponding RSN seeds.

RESULTS

PD-MH group had lower test scores for attention and visuospatial functions compared with those in the other groups. The connectivity of the right intracalcarine cortex within the DAN was lower in the PD-MH group than in the others. The PD-mH and PD-MH groups showed higher connectivity in the left orbitofrontal cortex within DMN compared with the PD-nH group, whereas the connectivity was lower in the right middle frontal gyrus (MFG) within ECN, precuneus cortex within VAN, right middle temporal gyrus and precuneus cortex within DAN, and left MFG within VN. The PD-mH and PD-MH groups showed different inter-network connectivity between the five RSNs, especially regarding DAN connectivity.

CONCLUSIONS

DAN dysfunction may be a key factor in the progression from mH to MH in patients with PD. © 2023 International Parkinson and Movement Disorder Society.

Functional connectivity in Lewy body disease with visual hallucinations

BACKGROUND AND PURPOSE

Visual hallucinations are a common, potentially distressing experience of people with Lewy body disease (LBD). The underlying brain changes giving rise to visual hallucinations are not fully understood, although previous models have posited that alterations in the connectivity between brain regions involved in attention and visual processing are critical.

METHODS

Data from 41 people with LBD and visual hallucinations, 48 with LBD without visual hallucinations and 60 similarly aged healthy comparator participants were used. Connections were investigated between regions in the visual cortex and ventral attention, dorsal attention and default mode networks.

RESULTS

Participants with visual hallucinations had worse cognition and motor function than those without visual hallucinations. In those with visual hallucinations, reduced functional connectivity within the ventral attention network and from the visual to default mode network was found. Connectivity strength between the visual and default mode network correlated with the number of correct responses on a pareidolia task, and connectivity within the ventral attention network with visuospatial performance.

CONCLUSIONS

Our results add to evidence of dysfunctional connectivity in the visual and attentional networks in those with LBD and visual hallucinations.

Modelling perception as a hierarchical competition differentiates imagined, veridical, and hallucinated percepts

Mental imagery is a process by which thoughts become experienced with sensory characteristics. Yet, it is not clear why mental images appear diminished compared to veridical images, nor how mental images are phenomenologically distinct from hallucinations, another type of non-veridical sensory experience. Current evidence suggests that imagination and veridical perception share neural resources. If so, we argue that considering how neural representations of externally generated stimuli (i.e. sensory input) and internally generated stimuli (i.e. thoughts) might interfere with one another can sufficiently differentiate between veridical, imaginary, and hallucinatory perception. We here use a simple computational model of a serially connected, hierarchical network with bidirectional information flow to emulate the primate visual system. We show that modelling even first approximations of neural competition can more coherently explain imagery phenomenology than non-competitive models. Our simulations predict that, without competing sensory input, imagined stimuli should ubiquitously dominate hierarchical representations. However, with competition, imagination should dominate high-level representations but largely fail to outcompete sensory inputs at lower processing levels. To interpret our findings, we assume that low-level stimulus information (e.g. in early visual cortices) contributes most to the sensory aspects of perceptual experience, while high-level stimulus information (e.g. towards temporal regions) contributes most to its abstract aspects. Our findings therefore suggest that ongoing bottom-up inputs during waking life may prevent imagination from overriding veridical sensory experience. In contrast, internally generated stimuli may be hallucinated when sensory input is dampened or eradicated. Our approach can explain individual differences in imagery, along with aspects of daydreaming, hallucinations, and non-visual mental imagery.

Structural and Functional Imaging Correlates of Visual Hallucinations in Parkinson's Disease

PURPOSE OF REVIEW

To review recent structural and functional MRI studies of visual hallucinations in Parkinson's disease.

RECENT FINDINGS

Previously, neuroimaging had shown inconsistent findings in patients with Parkinson's hallucinations, especially in studies examining grey matter volume. However, recent advances in structural and functional MRI techniques allow better estimates of structural connections, as well as the direction of connectivity in functional MRI. These provide more sensitive measures of changes in structural connectivity and allow models of the changes in directional functional connectivity to be tested. We identified 27 relevant studies and found that grey matter imaging continues to show heterogeneous findings in Parkinson's patients with visual hallucinations. Newer approaches in diffusion imaging and functional MRI are consistent with emerging models of Parkinson's hallucinations, suggesting shifts in attentional networks. In particular, reduced bottom-up, incoming sensory information, and over-weighting of top-down signals appear to be important drivers of visual hallucinations in Parkinson's disease.

Noradrenergic and cholinergic systems take centre stage in neuropsychiatric diseases of ageing

Noradrenergic and cholinergic systems are among the most vulnerable brain systems in neuropsychiatric diseases of ageing, including Alzheimer's disease, Parkinson's disease, Lewy body dementia, and progressive supranuclear palsy. As these systems fail, they contribute directly to many of the characteristic cognitive and psychiatric symptoms. However, their contribution to symptoms is not sufficiently understood, and pharmacological interventions targeting noradrenergic and cholinergic systems have met with mixed success. Part of the challenge is the complex neurobiology of these systems, operating across multiple timescales, and with non-linear changes across the adult lifespan and disease course. We address these challenges in a detailed review of the noradrenergic and cholinergic systems, outlining their roles in cognition and behaviour, and how they influence neuropsychiatric symptoms in disease. By bridging across levels of analysis, we highlight opportunities for improving drug therapies and for pursuing personalised medicine strategies.

Mental imagery content is associated with disease severity and specific brain functional connectivity changes in patients with Parkinson's disease

Mental imagery is the mental re-creation of perceptual experiences, events and scenarios, and motor acts. In our previous study, we assessed whether motor imagery (MI) training combined with functional magnetic resonance imaging-based neurofeedback could improve the motor function of nondemented subjects with mild Parkinson's disease (PD) (N = 22). We used visual imagery (VI) (e.g., of scenes or events, but not of self-movements) training without neurofeedback for the control group (N = 22). Notably, both groups showed significant and comparable improvement in motor function after four weeks of daily imagery practice. In this study, we further examined the neural correlates of the motor enhancement as a result of the VI training by analyzing the self-reported VI content during daily practice and relating its quality to the functional connectivity characteristics of the same subjects. We demonstrated that the VI practice encompassed multisensory, spatial, affective, and executive processes all of which are also important for motor function in real life. Subjects with worse global disease severity also showed poorer quality of the VI content. Finally, the quality of the VI content showed significant positive correlations with the functional connectivity changes during the VI tasks in brain areas supporting visuospatial and sensorimotor processes. Our findings suggest that mental imagery training combining VI and MI may enhance motor function in patients with mild PD, and more broadly, underline the importance of incorporating self-reports of thoughts and experiences in neuroimaging studies that examine the brain mechanisms of complex cognitive processes especially in neuropsychiatric patient populations.

Reconceptualizing mind wandering from a switching perspective

Mind wandering is a universal phenomenon in which our attention shifts away from the task at hand toward task-unrelated thoughts. Despite it inherently involving a shift in mental set, little is known about the role of cognitive flexibility in mind wandering. In this article we consider the potential of cognitive flexibility as a mechanism for mediating and/or regulating the occurrence of mind wandering. Our review begins with a brief introduction to the prominent theories of mind wandering-the executive failure hypothesis, the decoupling hypothesis, the process-occurrence framework, and the resource-control account of sustained attention. Then, after discussing their respective merits and weaknesses, we put forward a new perspective of mind wandering focused on cognitive flexibility, which provides an account more in line with the data to date, including why older populations experience a reduction in mind wandering. After summarizing initial evidence prompting this new perspective, drawn from several mind-wandering and task-switching studies, we recommend avenues for future research aimed at further understanding the importance of cognitive flexibility in mind wandering.

Changes in both top-down and bottom-up effective connectivity drive visual hallucinations in Parkinson's disease

Visual hallucinations are common in Parkinson's disease and are associated with a poorer quality of life and a higher risk of dementia. An important and influential model that is widely accepted as an explanation for the mechanism of visual hallucinations in Parkinson's disease and other Lewy body diseases is that these arise due to aberrant hierarchical processing, with impaired bottom-up integration of sensory information and overweighting of top-down perceptual priors within the visual system. This hypothesis has been driven by behavioural data and supported indirectly by observations derived from regional activation and correlational measures using neuroimaging. However, until now, there was no evidence from neuroimaging for differences in causal influences between brain regions measured in patients with Parkinson's hallucinations. This is in part because previous resting-state studies focused on functional connectivity, which is inherently undirected in nature and cannot test hypotheses about the directionality of connectivity. Spectral dynamic causal modelling is a Bayesian framework that allows the inference of effective connectivity-defined as the directed (causal) influence that one region exerts on another region-from resting-state functional MRI data. In the current study, we utilize spectral dynamic causal modelling to estimate effective connectivity within the resting-state visual network in our cohort of 15 Parkinson's disease visual hallucinators and 75 Parkinson's disease non-visual hallucinators. We find that visual hallucinators display decreased bottom-up effective connectivity from the lateral geniculate nucleus to primary visual cortex and increased top-down effective connectivity from the left prefrontal cortex to primary visual cortex and the medial thalamus, as compared with non-visual hallucinators. Importantly, we find that the pattern of effective connectivity is predictive of the presence of visual hallucinations and associated with their severity within the hallucinating group. This is the first study to provide evidence, using resting-state effective connectivity, to support a model of aberrant hierarchical predictive processing as the mechanism for visual hallucinations in Parkinson's disease.

Believing is seeing: A Buddhist theory of creditions

The creditions model is incredibly powerful at explaining both how beliefs are formed and how they influence our perceptions. The model contains several cognitive loops, where beliefs not only influence conscious interpretations of perceptions downstream but are active in the subconscious construction of perceptions out of sensory information upstream. This paper shows how this model is mirrored in the epistemology of two central Buddhist figures, Dignāga (480–540 CE) and Dharmakı̄rti (c. 550–650 CE). In addition to showing these parallels, the paper also demonstrates that by drawing on Dignāga and Dharmakı̄rti's theory, we can extend the explanatory power of the creditions model. Namely, while creditions explain how beliefs influence both the conscious interpretation and subconscious construction of sensory information, Dignāga and Dharmakı̄rti suggest beliefs can even be generative of sensory-like information. I recruit ancient Buddhist texts in conjunction with contemporary cognitive science scholarship to offer a hypothesis for the cognitive mechanisms responsible for this.

A systematic review on resting state functional connectivity in patients with neurodegenerative disease and hallucinations

Hallucinations are a complex and multidimensional phenomenon which can differ based on the involved pathology, typology and sensory modality. Hallucinations are common in patients with neurodegenerative diseases. Recent sparse evidence from resting state functional magnetic resonance imaging (rs-fMRI) studies has identified altered functional connectivity in those patients within several brain networks, such as the default mode, attentional and sensory ones, without, however, providing an organized picture of the mechanisms involved. This systematic review, following PRISMA guidelines, aims at critically analyzing the current literature on the brain networks associated with the phenomenon of hallucinations in patients with neurodegenerative diseases. Ten rs-fMRI studies fulfilled our selection criteria. All these studies focused on synucleinopathies, and most of them focused on visual hallucinations and were characterized by a heterogeneous methodology. Thus, instead of offering a definite picture of the mechanisms underlying hallucinations in neurodegeneration, this systematic review encourages further research especially concerning tauopathies. Notwithstanding, the findings overall suggest a disruption in the top-down (associated with memory intrusion and difficulty of inhibition) and in the bottom-up processes (associated with the sensory areas involved in the hallucinations). Further investigations are needed in order to disentangle the brain mechanisms involved in hallucinations and to overcome possible limitations characterizing the current literature.

Large-scale network dysfunction in α-Synucleinopathy: A meta-analysis of resting-state functional connectivity

Background

Although dysfunction of large-scale brain networks has been frequently demonstrated in patients with α-Synucleinopathy (α-Syn, i.e., Parkinson's disease, dementia with Lewy bodies, and multiple system atrophy), a consistent pattern of dysfunction remains unclear. We aim to investigate network dysfunction in patients with α-Syn through a meta-analysis.

Methods

Whole-brain seed-based resting-state functional connectivity studies (published before September 1st, 2020 in English) comparing α-Syn patients with healthy controls (HC) were retrieved from electronic databases (PubMed, Web of Science, and EMBASE). Seeds from each study were categorized into networks by their location within a priori functional networks. Seed-based effect size mapping with Permutation of Subject Images analysis of between-group effects identified the network systems in which α-Syn was associated with hyperconnectivity (increased connectivity in α-Syn vs. HC) or hypoconnectivity (decreased connectivity in α-Syn vs. HC) within and between each seed-network. This study was registered on PROSPERO (CRD42020210133).

Findings

In total, 136 seed-based voxel-wise resting-state functional connectivity datasets from 72 publications (3093 α-Syn patients and 3331 HC) were included in the meta-analysis. We found that α-Syn patients demonstrated imbalanced connectivity among subcortical network, cerebellum, and frontal parietal networks that involved in motor functioning and executive control. The patient group was associated with hypoconnectivity in default mode network and ventral attention network that involved in cognition and attention. Additionally, the patient group exhibited hyperconnectivity between neural systems involved in top-down emotion regulation and hypoconnectivity between networks involved in bottom-up emotion processing.

Interpretation

These findings supported neurocognitive models in which network dysfunction is tightly linked to motor, cognitive and psychiatric symptoms observed in α-Syn patients.

[Causes of visual hallucinations in Parkinson's disease]

BACKGROUND

Visual hallucinations (VH) have mainly been considered as late symptoms of Parkinson's disease (PD); however, minor forms of VH also occur in early stages of the disease. Initially dopaminergic overstimulation was discussed as the cause and later on VH have been considered as an early red flag of dementia in PD.

OBJECTIVE

The present study analyzed whether the pathophysiological concept of VH has been enlarged in recent years.

MATERIAL AND METHODS

Clinical, pharmacological, neuropathological as well as functional magnetic resonance imaging studies dealing with VH were reviewed. A systematic classification in monomodal and multimodal models of VH is proposed. The applicability to various forms of VH and various triggering situations is critically examined.

RESULTS

Reduction of the visual information input, erroneous visual processing, attention deficits, and dysfunctional connectivity between various cerebral networks have been shown. There is partial overlapping with the Lhermitte syndrome and the Charles Bonnet syndrome. No model is able to fully explain all VH variants. Not all VH have the same pathogenesis and the same poor prognosis.

CONCLUSION

The chain of causes underlying VH is complex and can vary from patient to patient. So far the therapeutic applications are largely unexplored; however, there is preliminary evidence that beside adjustment of the medication, improvement of visual acuity, active involvement of the partner, and possibly, individually adaptable coping strategies could be successfully implemented.

Impaired sensory evidence accumulation and network function in Lewy body dementia

Deficits in attention underpin many of the cognitive and neuropsychiatric features of Lewy body dementia. These attention-related symptoms remain difficult to treat and there are many gaps in our understanding of their neurobiology. An improved understanding of attention-related impairments can be achieved via mathematical modelling approaches, which identify cognitive parameters to provide an intermediate level between observed behavioural data and its underlying neural correlate. Here, we apply this approach to identify the role of impaired sensory evidence accumulation in the attention deficits that characterize Lewy body dementia. In 31 people with Lewy body dementia (including 13 Parkinson's disease dementia and 18 dementia with Lewy bodies cases), 16 people with Alzheimer's disease, and 23 healthy controls, we administered an attention task whilst they underwent functional 3 T MRI. Using hierarchical Bayesian estimation of a drift-diffusion model, we decomposed task performance into drift rate and decision boundary parameters. We tested the hypothesis that the drift rate-a measure of the quality of sensory evidence accumulation-is specifically impaired in Lewy body dementia, compared to Alzheimer's disease. We further explored whether trial-by-trial variations in the drift rate related to activity within the default and dorsal attention networks, to determine whether altered activity in these networks was associated with slowed drift rates in Lewy body dementia. Our results revealed slower drift rates in the Lewy body dementia compared to the Alzheimer's disease group, whereas the patient groups were equivalent for their decision boundaries. The patient groups were reduced relative to controls for both parameters. This highlights sensory evidence accumulation deficits as a key feature that distinguishes attention impairments in Lewy body dementia, consistent with impaired ability to efficiently process information from the environment to guide behaviour. We also found that the drift rate was strongly related to activity in the dorsal attention network across all three groups, whereas the Lewy body dementia group showed a divergent relationship relative to the Alzheimer's disease and control groups for the default network, consistent with altered default network modulation being associated with impaired evidence accumulation. Together, our findings reveal impaired sensory evidence accumulation as a specific marker of attention problems in Lewy body dementia, which may relate to large-scale network abnormalities. By identifying impairments in a specific sub-process of attention, these findings will inform future exploratory and intervention studies that aim to understand and treat attention-related symptoms that are a key feature of Lewy body dementia.

Neuroanatomical and cognitive correlates of visual hallucinations in Parkinson's disease and dementia with Lewy bodies: Voxel-based morphometry and neuropsychological meta-analysis

Visual hallucinations (VH) are common in Parkinson's disease and dementia with Lewy bodies, two forms of Lewy body disease (LBD), but the neural substrates and mechanisms involved are still unclear. We conducted meta-analyses of voxel-based morphometry (VBM) and neuropsychological studies investigating the neuroanatomical and cognitive correlates of VH in LBD. For VBM (12 studies), we used Seed-based d Mapping with Permutation of Subject Images (SDM-PSI), including statistical parametric maps for 50% of the studies. For neuropsychology (35 studies), we used MetaNSUE to consider non-statistically significant unreported effects. VH were associated with smaller grey matter volume in occipital, frontal, occipitotemporal, and parietal areas (peak Hedges' g -0.34 to -0.49). In patients with Parkinson's disease without dementia, VH were associated with lower verbal immediate memory performance (Hedges' g -0.52). Both results survived correction for multiple comparisons. Abnormalities in these brain regions might reflect dysfunctions in brain networks sustaining visuoperceptive, attention, and executive abilities, with the latter also being at the basis of poor immediate memory performance.

Changes of Metabolic Connectivity in Dementia with Lewy Bodies with Visual Hallucinations: A 18F-Fluorodeoxyglucose Positron Emission Tomography/Magnetic Resonance Study

Background: Recurrent complex visual hallucinations (VHs) are common in dementia with Lewy bodies (DLB). Previous investigations suggest that VHs are associated with connectivity changes within and between large scale networks involved in visual processing and attention. Aim: To examine more directly whether VH in DLB reflects direct changes in neuronal activity between cortical regions assessing metabolic connectivity with ¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/magnetic resonance and graph theory. Methods: Twenty-six patients with probable DLB (13 VHs and 13 no-VHs; mean age: 72.9 ± 6.87 years vs. 70.2 ± 7.96 years) were enrolled. T1-weighted 3T-MR images and FDG-PET data were coacquired using an integrated PET/MR scanner. MR images defined cortical parcels of the Shaefer-Yeo atlas for multiple functional networks. We computed in each parcel the regional standardized-uptake-values (SUV) corrected for partial volume and normalized to the cerebellar cortex. Strength degree, clustering coefficient, characteristic path length, and hubs were analyzed with graph analysis. Results: The mean ¹⁸F-FDG-PET SUVr of parcels belonging to the visual and dorsal attention networks (DANs) were significantly lower in the VH group (p = 0.01). Metabolism in the right temporoparietal cortex correlated with VH severity (R = -0.58; p < 0.01). VH patients showed weaker metabolic connectivity in the parietal, temporal, and occipital cortex of the default mode network, DAN, and visual networks, but more robust connectivity in the right insula and orbitofrontal cortex. A lower global efficiency characterized the VH group, except for ventral attention network and limbic network. Conclusions: VHs in DLB correlate with lower glucose metabolism and weaker metabolic connectivity in the parietal-occipital cortex, but stronger connectivity in the limbic system. Impact statement This study shows that application of the graph theory to ¹⁸F-fluorodeoxyglucose-positron emission tomography data, commonly acquired during the diagnostic workflow in neurodegenerative diseases, could be used to obtain information of functional connectivity at a group level, with results that are consistent with other data commonly used in brain functional investigation (e.g., electroencephalography or functional magnetic resonance). New network-based methods of metabolic image analyses, such as graph analysis, are a recent area of research with a potential capacity to extract information on alterations of metabolic connectivity that may become pharmacological and neuromodulation targets of the physiopathology of recurrent complex visual hallucinations.

Behavioral and Neural Signatures of Visual Imagery Vividness Extremes: Aphantasia versus Hyperphantasia

Although Galton recognized in the 1880s that some individuals lack visual imagery, this phenomenon was mostly neglected over the following century. We recently coined the terms "aphantasia" and "hyperphantasia" to describe visual imagery vividness extremes, unlocking a sustained surge of public interest. Aphantasia is associated with subjective impairment of face recognition and autobiographical memory. Here we report the first systematic, wide-ranging neuropsychological and brain imaging study of people with aphantasia (n = 24), hyperphantasia (n = 25), and midrange imagery vividness (n = 20). Despite equivalent performance on standard memory tests, marked group differences were measured in autobiographical memory and imagination, participants with hyperphantasia outperforming controls who outperformed participants with aphantasia. Face recognition difficulties and autistic spectrum traits were reported more commonly in aphantasia. The Revised NEO Personality Inventory highlighted reduced extraversion in the aphantasia group and increased openness in the hyperphantasia group. Resting state fMRI revealed stronger connectivity between prefrontal cortices and the visual network among hyperphantasic than aphantasic participants. In an active fMRI paradigm, there was greater anterior parietal activation among hyperphantasic and control than aphantasic participants when comparing visualization of famous faces and places with perception. These behavioral and neural signatures of visual imagery vividness extremes validate and illuminate this significant but neglected dimension of individual difference.

Harnessing Visual Imagery and Oculomotor Behaviour to Understand Prospection

Much of the rich internal world constructed by humans is derived from, and experienced through, visual mental imagery. Despite growing appreciation of visual exploration in guiding episodic memory processes, extant theories of prospection have yet to accommodate the precise role of visual mental imagery in the service of future-oriented thinking. We propose that the construction of future events relies on the assimilation of perceptual details originally experienced, and subsequently reinstantiated, predominantly in the visual domain. Individual differences in the capacity to summon discrete aspects of visual imagery can therefore account for the diversity of content generated by humans during future simulation. Our integrative framework provides a novel testbed to query alterations in future thinking in health and disease.

Offline perception: an introduction

Experiences that are self-generated and independent of sensory stimulations permeate our whole life. This theme issue examines their similarities and differences, systematizes the literature from an integrative perspective, critically discusses state-of-the-art empirical findings and proposes new theoretical approaches. The aim of the theme issue is to foster interaction between the different disciplines and research directions involved and to explore the prospects of a unificatory account of offline perception in general. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Neuromodulation of the mind-wandering brain state: the interaction between neuromodulatory tone, sharp wave-ripples and spontaneous thought

Mind-wandering has become a captivating topic for cognitive neuroscientists. By now, it is reasonably well described in terms of its phenomenology and the large-scale neural networks that support it. However, we know very little about what neurobiological mechanisms trigger a mind-wandering episode and sustain the mind-wandering brain state. Here, we focus on the role of ascending neuromodulatory systems (i.e. acetylcholine, noradrenaline, serotonin and dopamine) in shaping mind-wandering. We advance the hypothesis that the hippocampal sharp wave-ripple (SWR) is a compelling candidate for a brain state that can trigger mind-wandering episodes. This hippocampal rhythm, which occurs spontaneously in quiescent behavioural states, is capable of propagating widespread activity in the default network and is functionally associated with recollective, associative, imagination and simulation processes. The occurrence of the SWR is heavily dependent on hippocampal neuromodulatory tone. We describe how the interplay of neuromodulators may promote the hippocampal SWR and trigger mind-wandering episodes. We then identify the global neuromodulatory signatures that shape the evolution of the mind-wandering brain state. Under our proposed framework, mind-wandering emerges due to the interplay between neuromodulatory systems that influence the transitions between brain states, which either facilitate, or impede, a wandering mind. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Hallucinations as intensified forms of mind-wandering

This paper argues for a novel way of thinking about hallucinations as intensified forms of mind-wandering. Starting from the observation that hallucinations are associated with hyperactive sensory areas underlying the content of hallucinatory experiences and a confusion with regard to the reality of the source of these experiences, the paper first reviews the different factors that might contribute to the impairment of reality monitoring. The paper then focuses on the sensory characteristics determining the vividness of an experience, reviews their relationship to the sensory hyperactivity observed in hallucinations, and investigates under what circumstances they can drive reality judgements. Finally, based on these considerations, the paper presents its main proposal according to which hallucinations are intensified forms of mind-wandering that are amplified along their sensory characteristics, and sketches a possible model of what factors might determine if an internally and involuntarily generated perceptual representation is experienced as a hallucination or as an instance of mind-wandering. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Perceptual Representations and the Vividness of Stimulus-Triggered and Stimulus-Independent Experiences

In recent years, researchers from independent subfields have begun to engage with the idea that the same cortical regions that contribute to on-line perception are recruited during and underlie off-line activities such as information maintenance in working memory, mental imagery, hallucinations, dreaming, and mind wandering. Accumulating evidence suggests that in all of these cases the activity of posterior brain regions provides the contents of experiences. This article is intended to move one step further by exploring specific links between the vividness of experiences, which is a characteristic feature of consciousness regardless of its actual content, and certain properties of the content-specific neural-activity patterns. Investigating the mechanisms that underlie mental imagery and its relation to working memory and the processes responsible for mind wandering and its similarities to dreaming form two clusters of research that are in the forefront of the recent scientific study of mental phenomena, yet communication between these two clusters has been surprisingly sparse. Here our aim is to foster such information exchange by articulating a hypothesis about the fine-grained phenomenological structure determining subjective vividness and its possible neural basis that allows us to shed new light on these mental phenomena by bringing them under a common framework.