1
|
Chung RS, Martin del Campo Vera R, Sundaram S, Cavaleri J, Gilbert ZD, Leonor A, Shao X, Zhang S, Kammen A, Mason X, Heck C, Liu CY, Kellis SS, Lee B. Beta-band power modulation in the human amygdala differentiates between go/no-go responses in an arm-reaching task. J Neural Eng 2024; 21:046019. [PMID: 38959877 PMCID: PMC11369913 DOI: 10.1088/1741-2552/ad5ebe] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/22/2024] [Accepted: 07/03/2024] [Indexed: 07/05/2024]
Abstract
Objective. Traditionally known for its involvement in emotional processing, the amygdala's involvement in motor control remains relatively unexplored, with sparse investigations into the neural mechanisms governing amygdaloid motor movement and inhibition. This study aimed to characterize the amygdaloid beta-band (13-30 Hz) power between 'Go' and 'No-go' trials of an arm-reaching task.Approach. Ten participants with drug-resistant epilepsy implanted with stereoelectroencephalographic (SEEG) electrodes in the amygdala were enrolled in this study. SEEG data was recorded throughout discrete phases of a direct reach Go/No-go task, during which participants reached a touchscreen monitor or withheld movement based on a colored cue. Multitaper power analysis along with Wilcoxon signed-rank and Yates-correctedZtests were used to assess significant modulations of beta power between the Response and fixation (baseline) phases in the 'Go' and 'No-go' conditions.Main results. In the 'Go' condition, nine out of the ten participants showed a significant decrease in relative beta-band power during the Response phase (p⩽ 0.0499). In the 'No-go' condition, eight out of the ten participants presented a statistically significant increase in relative beta-band power during the response phase (p⩽ 0.0494). Four out of the eight participants with electrodes in the contralateral hemisphere and seven out of the eight participants with electrodes in the ipsilateral hemisphere presented significant modulation in beta-band power in both the 'Go' and 'No-go' conditions. At the group level, no significant differences were found between the contralateral and ipsilateral sides or between genders.Significance.This study reports beta-band power modulation in the human amygdala during voluntary movement in the setting of motor execution and inhibition. This finding supplements prior research in various brain regions associating beta-band power with motor control. The distinct beta-power modulation observed between these response conditions suggests involvement of amygdaloid oscillations in differentiating between motor inhibition and execution.
Collapse
Affiliation(s)
- Ryan S Chung
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Roberto Martin del Campo Vera
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Shivani Sundaram
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Jonathon Cavaleri
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Zachary D Gilbert
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Andrea Leonor
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Xiecheng Shao
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, United States of America
| | - Selena Zhang
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, United States of America
| | - Alexandra Kammen
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Xenos Mason
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States of America
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Christi Heck
- USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States of America
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Charles Y Liu
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States of America
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, United States of America
| | - Spencer S Kellis
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States of America
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
| | - Brian Lee
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States of America
- Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States of America
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA, United States of America
| |
Collapse
|
2
|
Schneider A, Weber S, Wyss A, Loukas S, Aybek S. BOLD signal variability as potential new biomarker of functional neurological disorders. Neuroimage Clin 2024; 43:103625. [PMID: 38833899 PMCID: PMC11179625 DOI: 10.1016/j.nicl.2024.103625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/16/2024] [Accepted: 05/29/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Functional neurological disorder (FND) is a common neuropsychiatric condition with established diagnostic criteria and effective treatments but for which the underlying neuropathophysiological mechanisms remain incompletely understood. Recent neuroimaging studies have revealed FND as a multi-network brain disorder, unveiling alterations across limbic, self-agency, attentional/salience, and sensorimotor networks. However, the relationship between identified brain alterations and disease progression or improvement is less explored. METHODS This study included resting-state functional magnetic resonance imaging (fMRI) data from 79 patients with FND and 74 age and sex-matched healthy controls (HC). First, voxel-wise BOLD signal variability was computed for each participant and the group-wise difference was calculated. Second, we investigated the potential of BOLD signal variability to serve as a prognostic biomarker for clinical outcome in 47 patients who attended a follow-up measurement after eight months. RESULTS The results demonstrated higher BOLD signal variability in key networks, including the somatomotor, salience, limbic, and dorsal attention networks, in patients compared to controls. Longitudinal analysis revealed an increase in BOLD signal variability in the supplementary motor area (SMA) in FND patients who had an improved clinical outcome, suggesting SMA variability as a potential state biomarker. Additionally, higher BOLD signal variability in the left insula at baseline predicted a worse clinical outcome. CONCLUSION This study contributes to the understanding of FND pathophysiology, emphasizing the dynamic nature of neural activity and highlighting the potential of BOLD signal variability as a valuable research tool. The insula and SMA emerge as promising regions for further investigation as prognostic and state markers.
Collapse
Affiliation(s)
- Ayla Schneider
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Samantha Weber
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland; University of Zurich, Psychiatric University Hospital Zurich, Department of Psychiatry, Psychotherapy and Psychosomatics, 8032 Zurich, Switzerland
| | - Anna Wyss
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Graduate School for Health Sciences (GHS), University of Bern, 3006 Bern, Switzerland
| | - Serafeim Loukas
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland
| | - Selma Aybek
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland.
| |
Collapse
|
3
|
Weber S, Bühler J, Loukas S, Bolton TAW, Vanini G, Bruckmaier R, Aybek S. Transient resting-state salience-limbic co-activation patterns in functional neurological disorders. Neuroimage Clin 2024; 41:103583. [PMID: 38422831 PMCID: PMC10944183 DOI: 10.1016/j.nicl.2024.103583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/09/2024] [Accepted: 02/25/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND Functional neurological disorders were historically regarded as the manifestation of a dynamic brain lesion which might be linked to trauma or stress, although this association has not yet been directly tested yet. Analysing large-scale brain network dynamics at rest in relation to stress biomarkers assessed by salivary cortisol and amylase could provide new insights into the pathophysiology of functional neurological symptoms. METHODS Case-control resting-state functional magnetic resonance imaging study of 79 patients with mixed functional neurological disorders (i.e., functional movement disorders, functional seizures, persistent perceptual-postural dizziness) and 74 age- and sex-matched healthy controls. Using a two-step hierarchical data-driven neuroimaging approach, static functional connectivity was first computed between 17 resting-state networks. Second, dynamic alterations in these networks were examined using co-activation pattern analysis. Using a partial least squares correlation analysis, the multivariate pattern of correlation between altered temporal characteristics and stress biomarkers as well as clinical scores were evaluated. RESULTS Compared to healthy controls, patients presented with functional aberrancies of the salience-limbic network connectivity. Thus, the insula and amygdala were selected as seed-regions for the subsequent analyses. Insular co-(de)activation patterns related to the salience network, the somatomotor network and the default mode network were detected, which patients entered more frequently than controls. Moreover, an insular co-(de)activation pattern with subcortical regions together with a wide-spread co-(de)activation with diverse cortical networks was detected, which patients entered less frequently than controls. In patients, dynamic alterations conjointly correlated with amylase measures and duration of symptoms. CONCLUSION The relationship between alterations in insular co-activation patterns, stress biomarkers and clinical data proposes inter-related mechanisms involved in stress regulation and functional (network) integration. In summary, altered functional brain network dynamics were identified in patients with functional neurological disorder supporting previously raised concepts of impaired attentional and interoceptive processing.
Collapse
Affiliation(s)
- Samantha Weber
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; University of Zurich, Psychiatric University Hospital Zurich, Department of Psychiatry, Psychotherapy and Psychosomatics, 8032 Zurich, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland; Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland.
| | - Janine Bühler
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Translational Imaging Center (TIC), Swiss Institute for Translational and Entrepreneurial Medicine, 3010 Bern, Switzerland
| | - Serafeim Loukas
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), 1015 Lausanne, Switzerland; Division of Development and Growth, Department of Pediatrics, University of Geneva, 1211 Geneva, Switzerland
| | - Thomas A W Bolton
- Department of Clinical Neurosciences, Neurosurgery Service and Gamma Knife Center, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland; Department of Radiology, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
| | - Giorgio Vanini
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Rupert Bruckmaier
- Veterinary Physiology, Vetsuisse Faculty, University of Bern, 3012 Bern, Switzerland
| | - Selma Aybek
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University Hospital, University of Bern, 3012 Bern, Switzerland; Faculty of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland
| |
Collapse
|
4
|
Onofrj M, Russo M, Delli Pizzi S, De Gregorio D, Inserra A, Gobbi G, Sensi SL. The central role of the Thalamus in psychosis, lessons from neurodegenerative diseases and psychedelics. Transl Psychiatry 2023; 13:384. [PMID: 38092757 PMCID: PMC10719401 DOI: 10.1038/s41398-023-02691-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/06/2023] [Accepted: 11/27/2023] [Indexed: 12/17/2023] Open
Abstract
The PD-DLB psychosis complex found in Parkinson's disease (PD) and Dementia with Lewy Bodies (DLB) includes hallucinations, Somatic Symptom/Functional Disorders, and delusions. These disorders exhibit similar presentation patterns and progression. Mechanisms at the root of these symptoms also share similarities with processes promoting altered states of consciousness found in Rapid Eye Movement sleep, psychiatric disorders, or the intake of psychedelic compounds. We propose that these mechanisms find a crucial driver and trigger in the dysregulated activity of high-order thalamic nuclei set in motion by ThalamoCortical Dysrhythmia (TCD). TCD generates the loss of finely tuned cortico-cortical modulations promoted by the thalamus and unleashes the aberrant activity of the Default Mode Network (DMN). TCD moves in parallel with altered thalamic filtering of external and internal information. The process produces an input overload to the cortex, thereby exacerbating DMN decoupling from task-positive networks. These phenomena alter the brain metastability, creating dreamlike, dissociative, or altered states of consciousness. In support of this hypothesis, mind-altering psychedelic drugs also modulate thalamic-cortical pathways. Understanding the pathophysiological background of these conditions provides a conceptual bridge between neurology and psychiatry, thereby helping to generate a promising and converging area of investigation and therapeutic efforts.
Collapse
Affiliation(s)
- Marco Onofrj
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology - CAST, Institute for Advanced Biomedical Technology-ITAB University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
| | - Mirella Russo
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology - CAST, Institute for Advanced Biomedical Technology-ITAB University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Stefano Delli Pizzi
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology - CAST, Institute for Advanced Biomedical Technology-ITAB University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Danilo De Gregorio
- Division of Neuroscience, Vita-Salute San Raffaele University, Milan, Italy
| | - Antonio Inserra
- Neurobiological Psychiatry Unit, McGill University, Montreal, QC, Canada
| | - Gabriella Gobbi
- Neurobiological Psychiatry Unit, McGill University, Montreal, QC, Canada
| | - Stefano L Sensi
- Behavioral Neurology and Molecular Neurology Units, Center for Advanced Studies and Technology - CAST, Institute for Advanced Biomedical Technology-ITAB University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
- Department of Neuroscience, Imaging, and Clinical Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy.
| |
Collapse
|
5
|
Waugh RE, Parker JA, Hallett M, Horovitz SG. Classification of Functional Movement Disorders with Resting-State Functional Magnetic Resonance Imaging. Brain Connect 2023; 13:4-14. [PMID: 35570651 PMCID: PMC9942186 DOI: 10.1089/brain.2022.0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Functional movement disorder (FMD) is a type of functional neurological disorder characterized by abnormal movements that patients do not perceive as self-generated. Prior imaging studies show a complex pattern of altered activity, linking regions of the brain involved in emotional responses, motor control, and agency. This study aimed to better characterize these relationships by building a classifier using a support vector machine to accurately distinguish between 61 FMD patients and 59 healthy controls using features derived from resting-state functional magnetic resonance imaging. Materials and Methods: First, we selected 66 seed regions based on prior related studies, then we calculated the full correlation matrix between them before performing recursive feature elimination to winnow the feature set to the most predictive features and building the classifier. Results: We identified 29 features of interest that were highly predictive of the FMD condition, classifying patients and controls with 80% accuracy. Several key features included regions in the right sensorimotor cortex, left dorsolateral prefrontal cortex, left cerebellum, and left posterior insula. Conclusions: The features selected by the model highlight the importance of the interconnected relationship between areas associated with emotion, reward, and sensorimotor integration, potentially mediating communication between regions associated with motor function, attention, and executive function. Exploratory machine learning was able to identify this distinctive abnormal pattern, suggesting that alterations in functional linkages between these regions may be a consistent feature of the condition in many FMD patients. Clinical-Trials.gov ID: NCT00500994 Impact statement Our research presents novel results that further elucidate the pathophysiology of functional movement disorder (FMD) with a machine learning model that classifies FMD and healthy controls correctly 80% of the time. Herein, we demonstrate how known differences in resting-state functional magnetic resonance imaging connectivity in FMD patients can be leveraged to better understand the complex pattern of neural changes in these patients. Knowing that there are measurable predictable differences in brain activity in patients with FMD may help both clinicians and patients conceptualize and better understand the illness at the point of diagnosis and during treatment. Our methods demonstrate how an effective combination of machine learning and qualitative approaches to analyzing functional brain connectivity can enhance our understanding of abnormal patterns of brain activity in FMD patients.
Collapse
Affiliation(s)
- Rebecca E. Waugh
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Jacob A. Parker
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark Hallett
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Silvina G. Horovitz
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| |
Collapse
|
6
|
Baykara M, Baykara S, Atmaca M. Magnetic resonance imaging histogram analysis of amygdala in functional neurological disorder: Histogram Analysis of Amygdala in Functional Neurological Disorder. Psychiatry Res Neuroimaging 2022; 323:111487. [PMID: 35523011 DOI: 10.1016/j.pscychresns.2022.111487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/27/2022] [Accepted: 04/23/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Murat Baykara
- Fırat University, Faculty of Medicine, Department of Radiology, Elazig, Turkey
| | - Sema Baykara
- Fırat University, Faculty of Medicine, Department of Psychiatry, Elazig, Turkey.
| | - Murad Atmaca
- Fırat University, Faculty of Medicine, Department of Psychiatry, Elazig, Turkey
| |
Collapse
|
7
|
Cheng Y, Liu S, Zhang L, Jiang H. Identification of Prefrontal Cortex and Amygdala Expressed Genes Associated With Sevoflurane Anesthesia on Non-human Primate. Front Integr Neurosci 2022; 16:857349. [PMID: 35845920 PMCID: PMC9286018 DOI: 10.3389/fnint.2022.857349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 05/19/2022] [Indexed: 11/22/2022] Open
Abstract
Clinical trials and animal studies have indicated that long-term use or multiple administrations of anesthesia may lead to fine motor impairment in the developing brain. Most studies on anesthesia-induced neurotoxicity have focused on the hippocampus and prefrontal cortex (PFC); however, the role of other vital encephalic regions, such as the amygdala, is still unclear. Herein, we focused on sevoflurane, the most commonly used volatile anesthetic in infants, and performed a transcriptional analysis of the PFC and amygdala of macaques after multiple exposures to the anesthetic by RNA sequencing. The overall, overlapping, and encephalic region-specific transcriptional patterns were separately analyzed to reveal their functions and differentially expressed gene sets that were influenced by sevoflurane. Specifically, functional, protein–protein interaction, neighbor gene network, and gene set enrichment analyses were performed. Further, we built the basic molecular feature of the amygdala by comparing it to the PFC. In comparison with the amygdala’s changing pattern following sevoflurane exposure, functional annotations of the PFC were more enriched in glial cell-related biological functions than in neuron and synapsis development. Taken together, transcriptional studies and bioinformatics analyses allow for an improved understanding of the primate PFC and amygdala.
Collapse
|
8
|
Weber S, Heim S, Richiardi J, Van De Ville D, Serranová T, Jech R, Marapin RS, Tijssen MAJ, Aybek S. Multi-centre classification of functional neurological disorders based on resting-state functional connectivity. Neuroimage Clin 2022; 35:103090. [PMID: 35752061 PMCID: PMC9240866 DOI: 10.1016/j.nicl.2022.103090] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/28/2022] [Accepted: 06/16/2022] [Indexed: 11/28/2022]
Abstract
Using machine learning on multi-centre data, FND patients were successfully classified with an accuracy of 72%. The angular- and supramarginal gyri, cingular- and insular cortex, and the hippocampus were the most discriminant regions. To provide diagnostic utility, future studies must include patients with similar symptoms but different diagnoses.
Background Patients suffering from functional neurological disorder (FND) experience disabling neurological symptoms not caused by an underlying classical neurological disease (such as stroke or multiple sclerosis). The diagnosis is made based on reliable positive clinical signs, but clinicians often require additional time- and cost consuming medical tests and examinations. Resting-state functional connectivity (RS FC) showed its potential as an imaging-based adjunctive biomarker to help distinguish patients from healthy controls and could represent a “rule-in” procedure to assist in the diagnostic process. However, the use of RS FC depends on its applicability in a multi-centre setting, which is particularly susceptible to inter-scanner variability. The aim of this study was to test the robustness of a classification approach based on RS FC in a multi-centre setting. Methods This study aimed to distinguish 86 FND patients from 86 healthy controls acquired in four different centres using a multivariate machine learning approach based on whole-brain resting-state functional connectivity. First, previously published results were replicated in each centre individually (intra-centre cross-validation) and its robustness across inter-scanner variability was assessed by pooling all the data (pooled cross-validation). Second, we evaluated the generalizability of the method by using data from each centre once as a test set, and the data from the remaining centres as a training set (inter-centre cross-validation). Results FND patients were successfully distinguished from healthy controls in the replication step (accuracy of 74%) as well as in each individual additional centre (accuracies of 73%, 71% and 70%). The pooled cross validation confirmed that the classifier was robust with an accuracy of 72%. The results survived post-hoc adjustment for anxiety, depression, psychotropic medication intake, and symptom severity. The most discriminant features involved the angular- and supramarginal gyri, sensorimotor cortex, cingular- and insular cortex, and hippocampal regions. The inter-centre validation step did not exceed chance level (accuracy below 50%). Conclusions The results demonstrate the applicability of RS FC to correctly distinguish FND patients from healthy controls in different centres and its robustness against inter-scanner variability. In order to generalize its use across different centres and aim for clinical application, future studies should work towards optimization of acquisition parameters and include neurological and psychiatric control groups presenting with similar symptoms.
Collapse
Affiliation(s)
- Samantha Weber
- Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Salome Heim
- Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Jonas Richiardi
- Department of Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Dimitri Van De Ville
- Institute of Bioengineering, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Tereza Serranová
- Centre for Interventional Therapy of Movement Disorders, Department of Neurology, Charles University, 1(st) Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Robert Jech
- Centre for Interventional Therapy of Movement Disorders, Department of Neurology, Charles University, 1(st) Faculty of Medicine and General University Hospital in Prague, Czech Republic; Department of Neurology, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Ramesh S Marapin
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands; UMCG Expertise Center Movement Disorders Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ Groningen, the Netherlands; UMCG Expertise Center Movement Disorders Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
| | - Selma Aybek
- Psychosomatic Medicine, Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| |
Collapse
|
9
|
Jungilligens J, Paredes-Echeverri S, Popkirov S, Barrett LF, Perez DL. A new science of emotion: implications for functional neurological disorder. Brain 2022; 145:2648-2663. [PMID: 35653495 PMCID: PMC9905015 DOI: 10.1093/brain/awac204] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/28/2022] [Accepted: 05/20/2022] [Indexed: 01/11/2023] Open
Abstract
Functional neurological disorder reflects impairments in brain networks leading to distressing motor, sensory and/or cognitive symptoms that demonstrate positive clinical signs on examination incongruent with other conditions. A central issue in historical and contemporary formulations of functional neurological disorder has been the mechanistic and aetiological role of emotions. However, the debate has mostly omitted fundamental questions about the nature of emotions in the first place. In this perspective article, we first outline a set of relevant working principles of the brain (e.g. allostasis, predictive processing, interoception and affect), followed by a focused review of the theory of constructed emotion to introduce a new understanding of what emotions are. Building on this theoretical framework, we formulate how altered emotion category construction can be an integral component of the pathophysiology of functional neurological disorder and related functional somatic symptoms. In doing so, we address several themes for the functional neurological disorder field including: (i) how energy regulation and the process of emotion category construction relate to symptom generation, including revisiting alexithymia, 'panic attack without panic', dissociation, insecure attachment and the influential role of life experiences; (ii) re-interpret select neurobiological research findings in functional neurological disorder cohorts through the lens of the theory of constructed emotion to illustrate its potential mechanistic relevance; and (iii) discuss therapeutic implications. While we continue to support that functional neurological disorder is mechanistically and aetiologically heterogenous, consideration of how the theory of constructed emotion relates to the generation and maintenance of functional neurological and functional somatic symptoms offers an integrated viewpoint that cuts across neurology, psychiatry, psychology and cognitive-affective neuroscience.
Collapse
Affiliation(s)
- Johannes Jungilligens
- Correspondence to: Johannes Jungilligens University Hospital Knappschaftskrankenhaus Bochum Department of Neurology In der Schornau 23-25 44892 Bochum, Germany E-mail:
| | | | - Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | | | | |
Collapse
|
10
|
Mueller K, Růžička F, Slovák M, Forejtová Z, Dušek P, Dušek P, Jech R, Serranová T. Symptom-severity-related brain connectivity alterations in functional movement disorders. Neuroimage Clin 2022; 34:102981. [PMID: 35287089 PMCID: PMC8921488 DOI: 10.1016/j.nicl.2022.102981] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 01/21/2023]
Abstract
Brain connectivity alterations were found in functional movement disorders. Hyperconnectivity in temporoparietal junction and precuneus in functional weakness. Consistent brain connectivity differences with four different centrality measures. Motor symptom severity correlates positively with connectivity in functional weakness.
Background Functional movement disorders, a common cause of neurological disabilities, can occur with heterogeneous motor manifestations including functional weakness. However, the underlying mechanisms related to brain function and connectivity are unknown. Objective To identify brain connectivity alterations related to functional weakness we assessed network centrality changes in a group of patients with heterogeneous motor manifestations using task-free functional MRI in combination with different network centrality approaches. Methods Task-free functional MRI was performed in 48 patients with heterogeneous motor manifestations including 28 patients showing functional weakness and 65 age- and sex-matched healthy controls. Functional connectivity differences were assessed using different network centrality approaches, i.e. global correlation, eigenvector centrality, and intrinsic connectivity. Motor symptom severity was assessed using The Simplified Functional Movement Disorders Rating Scale and correlated with network centrality. Results Comparing patients with and without functional weakness showed significant network centrality differences in the left temporoparietal junction and precuneus. Patients with functional weakness showed increased centrality in the same anatomical regions when comparing functional weakness with healthy controls. Moreover, in the same regions, patients with functional weakness showed a positive correlation between motor symptom severity and network centrality. This correlation was shown to be specific to functional weakness with an interaction analysis, confirming a significant difference between patients with and without functional weakness. Conclusions We identified the temporoparietal junction and precuneus as key regions involved in brain connectivity alterations related to functional weakness. We propose that both regions may be promising targets for phenotype-specific non-invasive brain stimulation.
Collapse
Affiliation(s)
- Karsten Mueller
- Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
| | - Filip Růžička
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Matěj Slovák
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Zuzana Forejtová
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Petr Dušek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Pavel Dušek
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Robert Jech
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic
| | - Tereza Serranová
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, First Faculty of Medicine and General University Hospital in Prague, Czech Republic.
| |
Collapse
|
11
|
Functional seizures are associated with cerebrovascular disease and functional stroke is more common in patients with functional seizures than epileptic seizures. Epilepsy Behav 2022; 128:108582. [PMID: 35123242 PMCID: PMC8898282 DOI: 10.1016/j.yebeh.2022.108582] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/14/2022] [Accepted: 01/17/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE To characterize the relationship between functional seizures (FSe), cerebrovascular disease (CVD), and functional stroke. METHOD A retrospective case-control study of 189 patients at a single large tertiary medical center. We performed a manual chart review of medical records of patients with FSe or epileptic seizures (ES), who also had ICD code evidence of CVD. The clinical characteristics of FSe, ES, CVD, and functional stroke were recorded. Logistic regression and Welch's t-tests were used to evaluate the differences between the FSe and ES groups. RESULTS Cerebrovascular disease was confirmed in 58.7% and 87.6% of patients with FSe or ES through manual chart review. Stroke was significantly more common in patients with ES (76.29%) than FSe (43.48%) (p = 4.07 × 10-6). However, compared to nonepileptic controls FSe was associated with both CVD (p < 0.0019) and stroke (p < 6.62 × 10-10). Functional stroke was significantly more common in patients with FSe (39.13%) than patients with ES (4.12%) (p = 4.47 × 10-9). Compared to patients with ES, patients with FSe were younger (p = 0.00022), more likely to be female (p = 0.00040), and more likely to have comorbid mental health needs including anxiety (p = 1.06 × 10-6), PTSD or history of trauma (e.g., sexual abuse) (p = 1.06 × 10-13), and bipolar disorder (p = 0.0011). CONCLUSION Our results confirm the initial observation of increased CVD in patients with FSe and further suggest that patients with FSe may be predisposed to developing another functional neurological disorder (FND) (i.e., functional stroke). We speculate that this may be due to shared risk factors and pathophysiological processes that are common to various manifestations of FND.
Collapse
|
12
|
Feinstein A, Voon V. Understanding conversion disorder: How contemporary brain imaging is shedding light on an early Freudian concept. J Psychiatr Res 2021; 141:353-357. [PMID: 34304040 DOI: 10.1016/j.jpsychires.2021.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/30/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Conversion disorder, also called Functional Neurological Symptom Disorder is poorly understood by many in the medical profession and is associated with considerable health care costs. Sigmund Freud, in an early, pre-psychoanalytic period paper, suggested that hysterical motor paralyses arose from a "functional or dynamic lesion" which was no different from an organic one, but rather an altered expression of it. He linked this functional brain disturbance to an excess of affect, a faulty conceptualization on the part of the symptomatic individual of how the affected organ works, and elements of dissociation and dual consciousness. One hundred and thirty years later converging functional imaging studies provide support for the excess affect component of his hypothesis. A small but growing fMRI literature has revealed bottom-up hyperactive neural activity in limbic regions and a potential failure of top-down regulation from prefrontal regions. Aberrant functional connectivity of limbic-motor regions now provides a mechanistic model that sheds light on an early Freudian theory explaining, in part, how symptoms of Conversion Disorder arise.
Collapse
Affiliation(s)
- Anthony Feinstein
- Department of Psychiatry, University of Toronto and Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario, M4N 3M5, Canada.
| | - Valerie Voon
- University of Cambridge. Addenbrookes Hospital, Level E4, Box 189, Cambridge, CB20QQ, United Kingdom.
| |
Collapse
|
13
|
Effective connectivity between emotional and motor brain regions in people with psychogenic nonepileptic seizures (PNES). Epilepsy Behav 2021; 122:108085. [PMID: 34166951 DOI: 10.1016/j.yebeh.2021.108085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize the effective connectivity (EC) between the emotion and motor brain regions in patients with psychogenic nonepileptic seizures (PNES), based on resting-state spectral dynamic causal modeling (spDCM). METHODS Twenty-three patients with PNES and twenty-five healthy control (HC) subjects underwent resting-state fMRI scanning. The coupling parameters indicating the causal interactions between eight brain regions associated with emotion, executive control, and motion were estimated for both groups, using resting-state fMRI spDCM. RESULTS Compared to the HC subjects, in patients with PNES: (i) the left insula (INS) and left and right inferior frontal gyri (IFG) are more inhibited by the amygdala (AMYG), anterior cingulate cortex (ACC), and precentral gyrus (PCG); (ii) the left AMYG has greater inhibitory effects on the INS, IFG, dorsolateral prefrontal cortex (DLPFC), PCG, and supplementary motor area (SMA); (iii) the left ACC has more inhibitory effects on the INS and IFG; (iv) the right ACC is more inhibited by the INS and IFG, and has a less inhibitory effect on the SMA and PCG; and (v) the left caudate (CAU) had increased inhibitory effects on the AMYG and IFG and a more excitatory effect on the SMA. CONCLUSION Our results suggest that in patients with PNES, the emotion-processing regions have inhibitory effects on the executive control areas and motor regions. Our findings may provide further insight into the influence of emotional arousal on functional movements and the underlying mechanisms of involuntary movements during functional seizures. Furthermore, they may suggest that emotion regulation through cognitive behavioral psychotherapies can be a potentially effective treatment modality.
Collapse
|
14
|
Early-life trauma endophenotypes and brain circuit-gene expression relationships in functional neurological (conversion) disorder. Mol Psychiatry 2021; 26:3817-3828. [PMID: 32051548 PMCID: PMC7423688 DOI: 10.1038/s41380-020-0665-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 01/02/2020] [Accepted: 01/28/2020] [Indexed: 12/14/2022]
Abstract
Functional neurological (conversion) disorder (FND) is a neuropsychiatric condition whereby individuals present with sensorimotor symptoms incompatible with other neurological disorders. Early-life maltreatment (ELM) is a risk factor for developing FND, yet few studies have investigated brain network-trauma relationships in this population. In this neuroimaging-gene expression study, we used two graph theory approaches to elucidate ELM subtype effects on resting-state functional connectivity architecture in 30 patients with motor FND. Twenty-one individuals with comparable depression, anxiety, and ELM scores were used as psychiatric controls. Thereafter, we compared trauma endophenotypes in FND with regional differences in transcriptional gene expression as measured by the Allen Human Brain Atlas (AHBA). In FND patients only, we found that early-life physical abuse severity, and to a lesser extent physical neglect, correlated with corticolimbic weighted-degree functional connectivity. Connectivity profiles influenced by physical abuse occurred in limbic (amygdalar-hippocampal), paralimbic (cingulo-insular and ventromedial prefrontal), and cognitive control (ventrolateral prefrontal) areas, as well as in sensorimotor and visual cortices. These findings held adjusting for individual differences in depression/anxiety, PTSD, and motor phenotypes. In FND, physical abuse also correlated with amygdala and insula coupling to motor cortices. In exploratory analyses, physical abuse correlated connectivity maps overlapped with the AHBA spatial expression of three gene clusters: (i) neuronal morphogenesis and synaptic transmission genes in limbic/paralimbic areas; (ii) locomotory behavior and neuronal generation genes in left-lateralized structures; and (iii) nervous system development and cell motility genes in right-lateralized structures. These circuit-specific architectural profiles related to individual differences in childhood physical abuse burden advance our understanding of the pathophysiology of FND.
Collapse
|
15
|
Spagnolo PA, Garvey M, Hallett M. A dimensional approach to functional movement disorders: Heresy or opportunity. Neurosci Biobehav Rev 2021; 127:25-36. [PMID: 33848511 DOI: 10.1016/j.neubiorev.2021.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 03/10/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
Functional movement disorders (FMD) are a common and disabling neuropsychiatric condition, part of the spectrum of functional neurological/conversion disorder. FMD represent one of the most enigmatic disorders in the history of medicine. However, in the twenty years after the first report of distinctive abnormal brain activity associated with functional motor symptoms, there have been tremendous advances in the pathophysiologic understanding of these disorders. FMD can be characterized as a disorder of aberrant neurocircuitry interacting with environmental and genetic factors. These developments suggest that research on FMD could be better served by an integrative, neuroscience-based approach focused on functional domains and their neurobiological substrates. This approach has been developed in 'Research Domain Criteria' (RDoC) project, which promotes a dimensional approach to psychiatric disorders. Here, we use the RDoC conceptualization to review recent neuroscience research on FMD, focusing on the domains most relevant to these disorders. We discuss how the adoption of a similar integrative framework may facilitate the identification of the mechanisms underlying FMD and could also have potential clinical applicability.
Collapse
Affiliation(s)
- Primavera A Spagnolo
- Mary Horrigan Connors Center for Women's Health and Gender Biology, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| | - Marjorie Garvey
- Novel Strategies for Treatment of Developmental Psychopathology Program, Biomarker and Intervention Development for Childhood-Onset Mental Disorders Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA.
| |
Collapse
|
16
|
Perez DL, Nicholson TR, Asadi-Pooya AA, Bègue I, Butler M, Carson AJ, David AS, Deeley Q, Diez I, Edwards MJ, Espay AJ, Gelauff JM, Hallett M, Horovitz SG, Jungilligens J, Kanaan RAA, Tijssen MAJ, Kozlowska K, LaFaver K, LaFrance WC, Lidstone SC, Marapin RS, Maurer CW, Modirrousta M, Reinders AATS, Sojka P, Staab JP, Stone J, Szaflarski JP, Aybek S. Neuroimaging in Functional Neurological Disorder: State of the Field and Research Agenda. Neuroimage Clin 2021; 30:102623. [PMID: 34215138 PMCID: PMC8111317 DOI: 10.1016/j.nicl.2021.102623] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/03/2021] [Indexed: 02/06/2023]
Abstract
Functional neurological disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart - leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed using "rule-in" examination signs. The parallel use of scientific tools to bridge brain structure - function relationships has helped refine an integrated biopsychosocial framework through which to conceptualize FND. In particular, a growing number of quality neuroimaging studies using a variety of methodologies have shed light on the emerging pathophysiology of FND. This renewed scientific interest has occurred in parallel with enhanced interdisciplinary collaborations, as illustrated by new care models combining psychological and physical therapies and the creation of a new multidisciplinary FND society supporting knowledge dissemination in the field. Within this context, this article summarizes the output of the first International FND Neuroimaging Workgroup meeting, held virtually, on June 17th, 2020 to appraise the state of neuroimaging research in the field and to catalyze large-scale collaborations. We first briefly summarize neural circuit models of FND, and then detail the research approaches used to date in FND within core content areas: cohort characterization; control group considerations; task-based functional neuroimaging; resting-state networks; structural neuroimaging; biomarkers of symptom severity and risk of illness; and predictors of treatment response and prognosis. Lastly, we outline a neuroimaging-focused research agenda to elucidate the pathophysiology of FND and aid the development of novel biologically and psychologically-informed treatments.
Collapse
Affiliation(s)
- David L Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz Iran; Department of Neurology, Jefferson Comprehensive Epilepsy Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Indrit Bègue
- Division of Adult Psychiatry, Department of Psychiatry, University of Geneva, Geneva Switzerland; Service of Neurology Department of Clinical Neuroscience, University of Geneva, Geneva, Switzerland
| | - Matthew Butler
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Anthony S David
- Institute of Mental Health, University College London, London, UK
| | - Quinton Deeley
- South London and Maudsley NHS Foundation Trust, London UK Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Ibai Diez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mark J Edwards
- Neurosciences Research Centre, St George's University of London, London, UK
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Jeannette M Gelauff
- Department of Neurology, Amsterdam UMC, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, Netherlands
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Silvina G Horovitz
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Johannes Jungilligens
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Richard A A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health Heidelberg, Australia
| | - Marina A J Tijssen
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, The Netherlands
| | - Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead Institute of Medical Research, University of Sydney Medical School, Sydney, NSW, Australia
| | - Kathrin LaFaver
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - W Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, RI, USA
| | - Sarah C Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, University Health Network and the University of Toronto, Toronto, Ontario, Canada
| | - Ramesh S Marapin
- Expertise Center Movement Disorders Groningen, University Medical Center Groningen, Groningen, University of Groningen, The Netherlands
| | - Carine W Maurer
- Department of Neurology, Stony Brook University Renaissance School of Medicine, Stony Brook, NY, USA
| | - Mandana Modirrousta
- Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Petr Sojka
- Department of Psychiatry, University Hospital Brno, Czech Republic
| | - Jeffrey P Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic Rochester, MN, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, The University of Edinburgh, EH16 4SB, UK
| | - Jerzy P Szaflarski
- University of Alabama at Birmingham Epilepsy Center, Department of Neurology, University of Alabama at Birmingham Birmingham, AL, USA
| | - Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
| |
Collapse
|
17
|
BAYKARA S, BAYKARA M, MERMİ O, YILDIRIM H, ATMACA M. Magnetic resonance imaging histogram analysis of corpus callosum in a functional neurological disorder. Turk J Med Sci 2021; 51:140-147. [PMID: 32892546 PMCID: PMC7991863 DOI: 10.3906/sag-2004-252] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 08/29/2020] [Indexed: 02/02/2023] Open
Abstract
Background/aim The aim of the present study was to examine and compare the corpus callosum (CC) via histogram analysis (HA) on T1-weighted MR images of patients diagnosed with Functional Neurological Disorder (FND) and healthy controls. Materials and methods The study group included 19 female patients diagnosed with FND, and the control group included 20 healthy subjects. All participants were scanned with a 1.5 T MR scanner. A high-resolution structural image of the entire brain was obtained with sagittal 3D spiral fast spin echo T1-weighted images. Gray level intensity, standard deviation of the histogram, entropy, uniformity, skewness, and kurtosis values were determined with texture analysis. A student’s t-test was used to compare the group data. P < 0.05 was accepted as statistically significant. Results It was determined that the mean gray level intensity, standard deviation of the histogram, entropy calculated by the maximum, median and variance and size M percentage values were higher in patients with FND. Kurtosis and size U percentages values were lower in patients with FND. Conclusion In the present study, analysis of CC with T1-weighted MR image HA demonstrated significant differences between FND patients and healthy controls. The study findings indicated that HA is a beneficial technique for demonstrating textural variations between the CCs of patients with FND and healthy controls using MR images.
Collapse
Affiliation(s)
- Sema BAYKARA
- Department of Psychiatry, Faculty of Medicine, Fırat University, ElazığTurkey
| | - Murat BAYKARA
- Department of Radiology, Faculty of Medicine, Fırat University, ElazığTurkey
| | - Osman MERMİ
- Department of Psychiatry, Faculty of Medicine, Fırat University, ElazığTurkey
| | - Hanefi YILDIRIM
- Department of Radiology, Faculty of Medicine, Fırat University, ElazığTurkey
| | - Murad ATMACA
- Department of Psychiatry, Faculty of Medicine, Fırat University, ElazığTurkey
| |
Collapse
|
18
|
Abstract
This paper reviews the literature on functional neurological disorders (Dissociative (conversion disorders - F44). The authors present a change in views on the etiology and the main mechanisms of the pathogenesis of this pathology during the period of its study. The modern ideas about the types of cerebral dysfunction characteristic of functional neurological disorders are considered. The description of the most characteristic mental and somatic symptoms observed in dissociative disorders and the features of their clinical manifestations are given. The current approaches to the therapy of functional neurological disorders are considered.
Collapse
Affiliation(s)
- L S Chutko
- Institute of Human Brain Russian Academy of Sciences, St. Petersburg, Russia
| | - S Yu Surushkina
- Institute of Human Brain Russian Academy of Sciences, St. Petersburg, Russia
| |
Collapse
|
19
|
Diez I, Williams B, Kubicki MR, Makris N, Perez DL. Reduced limbic microstructural integrity in functional neurological disorder. Psychol Med 2021; 51:485-493. [PMID: 31769368 PMCID: PMC7247956 DOI: 10.1017/s0033291719003386] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry. Individuals with FND exhibit corticolimbic abnormalities, yet little is known about the role of white matter tracts in the pathophysiology of FND. This study characterized between-group differences in microstructural integrity, and correlated fiber bundle integrity with symptom severity, physical disability, and illness duration. METHODS A diffusion tensor imaging (DTI) study was performed in 32 patients with mixed FND compared to 36 healthy controls. Diffusion-weighted magnetic resonance images were collected along with patient-reported symptom severity, physical disability (Short Form Health Survey-36), and illness duration data. Weighted-degree and link-level graph theory and probabilistic tractography analyses characterized fractional anisotropy (FA) values across cortico-subcortical connections. Results were corrected for multiple comparisons. RESULTS Compared to controls, FND patients showed reduced FA in the stria terminalis/fornix, medial forebrain bundle, extreme capsule, uncinate fasciculus, cingulum bundle, corpus callosum, and striatal-postcentral gyrus projections. Except for the stria terminalis/fornix, these differences remained significant adjusting for depression and anxiety. In within-group analyses, physical disability inversely correlated with stria terminalis/fornix and medial forebrain bundle FA values; illness duration negatively correlated with stria terminalis/fornix white matter integrity. A FND symptom severity composite score did not correlate with FA in patients. CONCLUSIONS In this first DTI study of mixed FND, microstructural differences were observed in limbic and associative tracts implicated in salience, defensive behaviors, and emotion regulation. These findings advance our understanding of neurocircuit pathways in the pathophysiology of FND.
Collapse
Affiliation(s)
- Ibai Diez
- Department of Neurology, Functional Neurology Research Group, Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Gordon Center, Department of Nuclear Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Neurotechnology Laboratory, Tecnalia Health Department, Derio, Spain
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marek R. Kubicki
- Department of Psychiatry, Center for Morphometric Analysis, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikos Makris
- Department of Psychiatry, Center for Morphometric Analysis, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - David L. Perez
- Department of Neurology, Functional Neurology Research Group, Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
Hassa T, Spiteri S, Schmidt R, Merkel C, Schoenfeld MA. Increased Amygdala Activity Associated With Cognitive Reappraisal Strategy in Functional Neurologic Disorder. Front Psychiatry 2021; 12:613156. [PMID: 33841199 PMCID: PMC8032865 DOI: 10.3389/fpsyt.2021.613156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/18/2021] [Indexed: 01/12/2023] Open
Abstract
Cognitive reappraisal is an emotion regulation strategy to reduce the impact of affective stimuli. This regulation could be incomplete in patients with functional neurologic disorder (FND) resulting in an overflowing emotional stimulation perpetuating symptoms in FND patients. Here we employed functional MRI to study cognitive reappraisal in FND. A total of 24 FND patients and 24 healthy controls employed cognitive reappraisal while seeing emotional visual stimuli in the scanner. The Symptom Checklist-90-R (SCL-90-R) was used to evaluate concomitant psychopathologies of the patients. During cognitive reappraisal of negative IAPS images FND patients show an increased activation of the right amygdala compared to normal controls. We found no evidence of downregulation in the amygdala during reappraisal neither in the patients nor in the control group. The valence and arousal ratings of the IAPS images were similar across groups. However, a subgroup of patients showed a significant higher account of extreme low ratings for arousal for negative images. These low ratings correlated inversely with the item "anxiety" of the SCL-90-R. The increased activation of the amygdala during cognitive reappraisal suggests altered processing of emotional stimuli in this region in FND patients.
Collapse
Affiliation(s)
- Thomas Hassa
- Lurija Institute for Rehabilitation and Health Sciences, University of Konstanz, Konstanz, Germany.,Neurological Rehabilitation Center Kliniken Schmieder, Allensbach, Germany
| | - Stefan Spiteri
- Lurija Institute for Rehabilitation and Health Sciences, University of Konstanz, Konstanz, Germany.,Neurological Rehabilitation Center Kliniken Schmieder, Allensbach, Germany
| | - Roger Schmidt
- Department of Psychology, University of Konstanz, Konstanz, Germany.,Department of Psychotherapeutic Neurology, Neurological Rehabilitation Center Kliniken Schmieder, Konstanz, Germany
| | - Christian Merkel
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Mircea Ariel Schoenfeld
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Leibniz-Institute for Neurobiology, Magdeburg, Germany.,Neurological Rehabilitation Center Kliniken Schmieder, Heidelberg, Germany
| |
Collapse
|
21
|
Thomsen BLC, Teodoro T, Edwards MJ. Biomarkers in functional movement disorders: a systematic review. J Neurol Neurosurg Psychiatry 2020; 91:1261-1269. [PMID: 33087421 DOI: 10.1136/jnnp-2020-323141] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/11/2020] [Accepted: 09/23/2020] [Indexed: 11/04/2022]
Abstract
Functional movement disorders (FMD) are proposed to reflect a specific problem with voluntary control of movement, despite normal intent to move and an intact neural capacity for movement. In many cases, a positive diagnosis of FMD can be established on clinical grounds. However, the diagnosis remains challenging in certain scenarios, and there is a need for predictors of treatment response and long-term prognosis.In this context, we performed a systematic review of biomarkers in FMD. Eighty-six studies met our predefined criteria and were included.We found fairly reliable electroencephalography and electromyography-based diagnostic biomarkers for functional myoclonus and tremor. Promising biomarkers have also been described for functional paresis, gait and balance disorders. In contrast, there is still a lack of diagnostic biomarkers of functional dystonia and tics, where clinical diagnosis is often also more challenging. Importantly, many promising findings focus on pathophysiology and reflect group-level comparisons, but cannot differentiate on an individual basis. Some biomarkers also require access to time-consuming and resource-consuming techniques such as functional MRI.In conclusion, there are important gaps in diagnostic biomarkers in FMD in the areas of most clinical uncertainty. There is also is a lack of treatment response and prognostic biomarkers to aid in the selection of patients who would benefit from rehabilitation and other forms of treatment.
Collapse
Affiliation(s)
- Birgitte Liang Chen Thomsen
- Neurology, Bispebjerg Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tiago Teodoro
- Neurosciences Research Centre, St George's University of London, London, UK.,Instituto de Medicina Molecular, University of Lisbon, Lisboa, Portugal
| | - Mark J Edwards
- Neurosciences Research Centre, St George's University of London, London, UK
| |
Collapse
|
22
|
Roydeva MI, Reinders AATS. Biomarkers of Pathological Dissociation: A Systematic Review. Neurosci Biobehav Rev 2020; 123:120-202. [PMID: 33271160 DOI: 10.1016/j.neubiorev.2020.11.019] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 08/20/2020] [Accepted: 11/15/2020] [Indexed: 02/06/2023]
Abstract
Pathological dissociation is a severe, debilitating and transdiagnostic psychiatric symptom. This review identifies biomarkers of pathological dissociation in a transdiagnostic manner to recommend the most promising research and treatment pathways in support of the precision medicine framework. A total of 205 unique studies that met inclusion criteria were included. Studies were divided into four biomarker categories, namely neuroimaging, psychobiological, psychophysiological and genetic biomarkers. The dorsomedial and dorsolateral prefrontal cortex, bilateral superior frontal regions, (anterior) cingulate, posterior association areas and basal ganglia are identified as neurofunctional biomarkers of pathological dissociation and decreased hippocampal, basal ganglia and thalamic volumes as neurostructural biomarkers. Increased oxytocin and prolactin and decreased tumor necrosis factor alpha (TNF-α) are identified as psychobiological markers. Psychophysiological biomarkers, including blood pressure, heart rate and skin conductance, were inconclusive. For the genetic biomarker category studies related to dissociation were limited and no clear directionality of effect was found to warrant identification of a genetic biomarker. Recommendations for future research pathways and possible clinical applicability are provided.
Collapse
Affiliation(s)
- Monika I Roydeva
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Antje A T S Reinders
- Department of Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, United Kingdom.
| |
Collapse
|
23
|
Zhang Y, Ma K, Yang Y, Yin Y, Hou Z, Zhang D, Yuan Y. Predicting Response to Group Cognitive Behavioral Therapy in Asthma by a Small Number of Abnormal Resting-State Functional Connections. Front Neurosci 2020; 14:575771. [PMID: 33328851 PMCID: PMC7732460 DOI: 10.3389/fnins.2020.575771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/27/2020] [Indexed: 11/13/2022] Open
Abstract
Group cognitive behavioral therapy (GCBT) is a successful psychotherapy for asthma. However, response varies considerably among individuals, and identifying biomarkers of GCBT has been challenging. Thus, the aim of this study was to predict an individual's potential response by using machine learning algorithms and functional connectivity (FC) and to improve the personalized treatment of GCBT. We use the lasso method to make the feature selection in the functional connections between brain regions, and we utilize t-test method to test the significant difference of these selected features. The feature selections are performed between controls (size = 20) and pre-GCBT patients (size = 20), pre-GCBT patients (size = 10) and post-GCBT patients (size = 10), and post-GCBT patients (size = 10) and controls (size = 10). Depending on these features, support vector classification was used to classify controls and pre- and post-GCBT patients. Pearson correlation analysis was employed to analyze the associations between clinical symptoms and the selected discriminated FCs in post-GCBT patients. At last, linear support vector regression was applied to predict the therapeutic effect of GCBT. After feature selection and significant analysis, five discriminated FC regarding neuroimaging biomarkers of GCBT were discovered, which are also correlated with clinical symptoms. Using these discriminated functional connections, we could accurately classify the patients before and after GCBT (classification accuracy, 80%) and predict the therapeutic effect of GCBT in asthma (predicted accuracy, 67.8%). The findings in this study would provide a novel sight toward GCBT response prediction and further confirm neural underpinnings of asthma. Moreover, our findings had clinical implications for personalized treatment by identifying asthmatic patients who will be appropriate for GCBT. CLINICAL TRIAL REGISTRATION The brain mechanisms of group cognitive behavioral therapy to improve the symptoms of asthma (Registration number: Chi-CTR-15007442, http://www.chictr.org.cn/index.aspx).
Collapse
Affiliation(s)
- Yuqun Zhang
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, China
- Department of Psychosomatics and Psychiatry, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Kai Ma
- MIIT Key Laboratory of Pattern Analysis and Machine Intelligence, College of Computer Science and Technology, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Yuan Yang
- Department of Respiratory, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yingying Yin
- Department of Psychosomatics and Psychiatry, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhenghua Hou
- Department of Psychosomatics and Psychiatry, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Daoqiang Zhang
- MIIT Key Laboratory of Pattern Analysis and Machine Intelligence, College of Computer Science and Technology, Nanjing University of Aeronautics and Astronautics, Nanjing, China
| | - Yonggui Yuan
- Department of Psychosomatics and Psychiatry, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| |
Collapse
|
24
|
The pathophysiology of functional movement disorders. Neurosci Biobehav Rev 2020; 120:387-400. [PMID: 33159917 DOI: 10.1016/j.neubiorev.2020.10.019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/05/2020] [Accepted: 10/22/2020] [Indexed: 01/04/2023]
Abstract
Functional neurological disorder is characterized by neurological symptoms that cannot be explained by typical neurological diseases or other medical conditions. This review will critically discuss the literature on the pathophysiology of functional movement disorders (FMD), including functional neuroimaging studies, neurophysiological studies, studies on biomarkers and genetic studies. According to PRISMA guidelines for systematic reviews, we selected 39 studies. A complex scenario emerged, with the involvement of different areas of the brain in the pathophysiology of FMD. Our findings showed a hypoactivation of the contralateral primary motor cortex, a decreased activity in the parietal lobe, an aberrant activation of the amygdala, an increased temporo-parietal junction activity and a hyperactivation of insular regions in patients with FMD. Functional connectivity (FC) findings underlined aberrant connections between amygdala and motor areas, temporo-parietal junction and insula. We proposed amygdala hyperactivation as a possible biological marker for FMD and FC alterations between amygdala and other areas of the brain as consequent epiphenomena, accounting for the pathophysiological complexity of FMD. These conclusions might drive novel treatment hypotheses.
Collapse
|
25
|
Alciati A, Shiffer D, Dipaola F, Barbic F, Furlan R. Psychogenic Pseudosyncope: Clinical Features, Diagnosis and Management. J Atr Fibrillation 2020; 13:2399. [PMID: 33024500 DOI: 10.4022/jafib.2399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 02/15/2020] [Accepted: 03/18/2020] [Indexed: 12/25/2022]
Abstract
Psychogenic Pseudosyncope (PPS) is the appearance of Transient Loss of Consciousness (TLOC) in which movements are absent, but there are no hemodynamic and electroencephalographic modifications as are induced by gravitational challenges which characterize syncope and true loss of consciousness. For younger and adult populations, a detailed history is crucial for the diagnosis. Clinical clues that should raise the suspicion for PPS include prolonged duration of the LOC, eye closure during the episode, unusual triggers, no recognizable prodromes and the high frequency of attacks. The presence of an established diagnosis of syncope should not deter from the concomitant diagnosis of PPS. The gold standard for a proper diagnosis of PPS is the documentation by a tilt test of normal hemodynamic and electroencephalographic parameters, when recorded during an attack. Treatment of PPS, based on the clear and empathetic communication of the diagnosis, can lead to an immediate reduction of attack frequency and lower the need to call on emergency services. Pharmacological treatment of associated psychiatric disorders and psychological interventions may be beneficial in patients with PPS. Cognitive-behavioural therapy holds the most reliable evidence of efficacy. In the present review, we aimed to address PPS with historical aspects, main clinical features and diagnostic tests, current diagnostic classification, underlying neurobiological abnormalities, management and therapy.
Collapse
Affiliation(s)
- Alessandra Alciati
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.,Department of Clinical Neurosciences, Hermanas Hospitalarias, Villa S. Benedetto Menni Hospital, Albese con Cassano (CO), Italy
| | - Dana Shiffer
- Internal Medicine, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Franca Dipaola
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.,Internal Medicine, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Franca Barbic
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.,Internal Medicine, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Raffaello Furlan
- Department of Biomedical Sciences, Humanitas University, Rozzano, Milan, Italy.,Internal Medicine, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| |
Collapse
|
26
|
Faul L, Knight LK, Espay AJ, Depue BE, LaFaver K. Neural activity in functional movement disorders after inpatient rehabilitation. Psychiatry Res Neuroimaging 2020; 303:111125. [PMID: 32585576 DOI: 10.1016/j.pscychresns.2020.111125] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 11/18/2022]
Abstract
Functional movement disorders (FMD) are a common source of disability in neurology.While treatment of FMD can reduce motor severity and disability, the neural mechanisms implicated in such a response remain unclear. We aimed to investigate neural changes in patients with FMD after a one-week multidisciplinary motor retraining (MoRe) treatment program. Fourteen FMD patients completed an emotional Go/No-Go fMRI task before and after MoRe treatment. Standardized pre- and post-treatment videos were rated for motor severity by a blinded reviewer using the psychogenic movement disorder rating scale (PMDRS). PMDRS scores before and after treatment were used for whole-brain regression. PMDRS scores were significantly reduced after MoRe treatment. Worse severity prior to treatment was associated with greater primary motor cortex (M1) activation at baseline and a larger response to treatment. Globally, increased connectivity between bilateral amygdala and premotor regions was observed following treatment. Lower post-treatment PMDRS scores were associated with increased connectivity between amygdala and ventromedial prefrontal cortex, whereas higher post-treatment PMDRS scores (and poorer treatment response) were associated with increased connectivity between amygdala and M1. Motor retraining in FMD may reorganize activity and connectivity in emotion processing and motor planning networks, with shifts in amygdala connectivity from posterior to frontal/prefrontal regions.
Collapse
Affiliation(s)
- L Faul
- Center for Cognitive Neuroscience, Duke University, DurhamNC, United States
| | - L K Knight
- Interdisciplinary Program in Translational Neuroscience, University of Louisville, LouisvilleKY, United States; Department of Psychological and Brain Sciences, University of Louisville, LouisvilleKY, United States
| | - A J Espay
- Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
| | - B E Depue
- Department of Psychological and Brain Sciences, University of Louisville, LouisvilleKY, United States; Department of Anatomical Sciences and Neurobiology, University of Louisville, LouisvilleKY, United States.
| | - K LaFaver
- Department of Neurology, University of Louisville, Louisville, KY, United States; Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
| |
Collapse
|
27
|
Joos A, Halmer R, Leiprecht N, Schörner K, Lahmann C, Blahak C. [Functional neurological disorders: update and example of integrated inpatient treatment including mirror therapy]. DER NERVENARZT 2020; 91:252-256. [PMID: 31690969 DOI: 10.1007/s00115-019-00827-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- A Joos
- Zentrum für Psychische Erkrankungen, Klinik für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland.
- Psychotherapeutische Neurologie, Kliniken Schmieder, Gailingen, Deutschland.
| | - R Halmer
- Psychotherapeutische Neurologie, Kliniken Schmieder, Gailingen, Deutschland
| | - N Leiprecht
- Psychotherapeutische Neurologie, Kliniken Schmieder, Gailingen, Deutschland
| | - K Schörner
- Psychotherapeutische Neurologie, Kliniken Schmieder, Gailingen, Deutschland
| | - C Lahmann
- Zentrum für Psychische Erkrankungen, Klinik für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Freiburg, Medizinische Fakultät, Universität Freiburg, Freiburg, Deutschland
| | - C Blahak
- Klinik für Neurologie und Neurogeriatrie, Ortenau-Klinikum Lahr-Ettenheim, Lahr, Deutschland
- Neurologische Klinik, UniversitätsMedizin Mannheim, Universität Heidelberg, Mannheim, Deutschland
| |
Collapse
|
28
|
Reduced left amygdala volume in patients with dissociative seizures (psychogenic nonepileptic seizures). Seizure 2020; 75:43-48. [DOI: 10.1016/j.seizure.2019.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/09/2019] [Accepted: 12/17/2019] [Indexed: 01/20/2023] Open
|
29
|
Sojka P, Lošák J, Lamoš M, Bareš M, Kašpárek T, Brázdil M, Baláž M, Světlák M, Kočvarová J, Fialová J. Processing of Emotions in Functional Movement Disorder: An Exploratory fMRI Study. Front Neurol 2019; 10:861. [PMID: 31474926 PMCID: PMC6703143 DOI: 10.3389/fneur.2019.00861] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/25/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Affective dysregulation and impaired cognitive control are implicated in the pathology of functional neurological disorders (FNDs). However, voluntary regulation of emotions has seldom been researched in this group of patients. We hypothesized that patients with FNDs use inefficient voluntary emotion regulation strategies and regulate emotional reactions via increased motor activation. Methods: Fifteen patients with functional movement disorder (FMD) and fifteen healthy subjects matched by age, sex, and education underwent an emotion regulation task in fMRI. For stimuli, we used neutral and negative pictures from the International Affective Picture System. There was no restriction on their emotion regulation strategy. Both patients and healthy subjects were asked about the strategies they had used in a post-scanning interview. Participant levels of depression, trait anxiety, and alexithymia were assessed. Results: There were no significant differences in the emotion regulation strategies used by patients and healthy subjects, nor in levels of reported alexithymia and depression. However, patients showed increased activation in several brain areas when observing negative pictures, notably in the post-central gyrus, precuneus, posterior cingulate cortex (PCC) and cerebellar vermis, and also in their emotion regulation condition, particularly in the precuneus and post-central gyrus. Alexithymia was negatively associated with left insular activation during the observation of unpleasant stimuli only in the patient group. Conclusions: Our findings may implicate areas associated with self-referential processing in voluntary emotional regulation and lower emotional awareness as having a role in patients with functional movement disorders. However, our findings must be replicated with larger sample.
Collapse
Affiliation(s)
- Petr Sojka
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia.,Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Jan Lošák
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia.,Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Martin Lamoš
- Multimodal and Functional Neuroimaging, CEITEC, Masaryk University, Brno, Czechia
| | - Martin Bareš
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia.,Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Tomáš Kašpárek
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - M Brázdil
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia
| | - M Baláž
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia
| | - Miroslav Světlák
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - J Kočvarová
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia
| | - J Fialová
- Department of Public Health, Faculty of Medicine, Masaryk University, Brno, Czechia
| |
Collapse
|
30
|
FMRI response to acute psychological stress differentiates patients with psychogenic non-epileptic seizures from healthy controls - A biochemical and neuroimaging biomarker study. NEUROIMAGE-CLINICAL 2019; 24:101967. [PMID: 31446314 PMCID: PMC6718876 DOI: 10.1016/j.nicl.2019.101967] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/24/2019] [Accepted: 08/01/2019] [Indexed: 11/24/2022]
Abstract
We investigated psychological stress response in the brain regions involved in emotion-motor-executive control in psychogenic non-epileptic seizures (PNES). 12 PNES patients and 12 healthy controls (HCs) underwent stress task and resting state functional MRI (fMRI), mood and quality of life (QOL) assessments, and measurements of salivary cortisol, alpha-amylase, and heart rate. Group differences were assessed, and we correlated beta values from a priori selected brain regions showing stress task fMRI group differences with other stress response measures. We also used the regions showing stress task fMRI group differences as seeds for resting state functional connectivity (rs-FC) analysis. Mood and QOL were worse in PNES versus HCs. Physiological and assessment measures were similar except 'Planful Problem Solving' coping that was greater for HCs (p = .043). Perceived stress associated negatively with heart rate change (rs = -0.74, p = .0063). There was stress fMRI hyporeactivity in left/right amygdala and left hippocampus in PNES versus HCs (corrected p < .05). PNES exhibited a positive association between alpha-amylase change and right amygdala activation (rs = 0.71, p = .010). PNES versus HCs exhibited greater right amygdala rs-FC to left precentral and inferior/middle frontal gyri (corrected p < .05). Our findings of fMRI hyporeactivity to psychological stress, along with greater emotion-motor-executive control network rs-FC in PNES when compared to HCs suggest a dysregulation in stress response circuitry in PNES.
Collapse
|
31
|
Diez I, Ortiz-Terán L, Williams B, Jalilianhasanpour R, Ospina JP, Dickerson BC, Keshavan MS, LaFrance WC, Sepulcre J, Perez DL. Corticolimbic fast-tracking: enhanced multimodal integration in functional neurological disorder. J Neurol Neurosurg Psychiatry 2019; 90:929-938. [PMID: 30850473 PMCID: PMC6625895 DOI: 10.1136/jnnp-2018-319657] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 12/18/2018] [Accepted: 02/09/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Some individuals with functional neurological disorder (FND) exhibit motor and affective disturbances, along with limbic hyper-reactivity and enhanced motor-limbic connectivity. Given that the multimodal integration network (insula, dorsal cingulate, temporoparietal junction (TPJ)) is implicated in convergent sensorimotor, affective and interoceptive processing, we hypothesised that patients with FND would exhibit altered motor and amygdalar resting-state propagation to this network. Patient-reported symptom severity and clinical outcome were also hypothesised to map onto multimodal integration areas. METHODS Between-group differences in primary motor and amygdalar nuclei (laterobasal, centromedial) were examined using graph-theory stepwise functional connectivity (SFC) in 30 patients with motor FND compared with 30 healthy controls. Within-group analyses correlated functional propagation profiles with symptom severity and prospectively collected 6-month outcomes as measured by the Screening for Somatoform Symptoms Conversion Disorder subscale and Patient Health Questionnaire-15 composite score. Findings were clusterwise corrected for multiple comparisons. RESULTS Compared with controls, patients with FND exhibited increased SFC from motor regions to the bilateral posterior insula, TPJ, middle cingulate cortex and putamen. From the right laterobasal amygdala, the FND cohort showed enhanced connectivity to the left anterior insula, periaqueductal grey and hypothalamus among other areas. In within-group analyses, symptom severity correlated with enhanced SFC from the left anterior insula to the right anterior insula and TPJ; increased SFC from the left centromedial amygdala to the right anterior insula correlated with clinical improvement. Within-group associations held controlling for depression, anxiety and antidepressant use. CONCLUSIONS These neuroimaging findings suggest potential candidate neurocircuit pathways in the pathophysiology of FND.
Collapse
Affiliation(s)
- Ibai Diez
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Radiology, Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, USA.,Neurotechnology Laboratory, Tecnalia Health, Derio, Bizkai, Spain.,Radiology and Nuclear Medicine, Gordon Center for Medical Imaging, Harvard Medical School, Boston, Massachusetts, USA
| | - Laura Ortiz-Terán
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Radiology and Nuclear Medicine, Gordon Center for Medical Imaging, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Williams
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Juan Pablo Ospina
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bradford C Dickerson
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matcheri S Keshavan
- Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - W Curt LaFrance
- Psychiatry and Neurology, Rhode Island Hospital, Brown Medical School, Providence, Rhode Island, USA
| | - Jorge Sepulcre
- Radiology and Nuclear Medicine, Gordon Center for Medical Imaging, Harvard Medical School, Boston, Massachusetts, USA
| | - David L Perez
- Radiology, Athinoula A Martinos Center for Biomedical Imaging, Charlestown, Massachusetts, USA .,Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| |
Collapse
|
32
|
Pick S, Goldstein LH, Perez DL, Nicholson TR. Emotional processing in functional neurological disorder: a review, biopsychosocial model and research agenda. J Neurol Neurosurg Psychiatry 2019; 90:704-711. [PMID: 30455406 PMCID: PMC6525039 DOI: 10.1136/jnnp-2018-319201] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/20/2018] [Accepted: 10/29/2018] [Indexed: 12/13/2022]
Abstract
Functional neurological disorder (FND) is a common and highly disabling disorder, but its aetiology remains enigmatic. Conceptually, there has been reduced emphasis on the role of psychosocial stressors in recent years, with a corresponding increase in neurobiological explanations. However, a wealth of evidence supports the role of psychosocial adversities (eg, stressful life events, interpersonal difficulties) as important risk factors for FND. Therefore, there is a need to integrate psychosocial (environmental) and neurobiological factors (eg, sensorimotor and cognitive functions) in contemporary models of FND. Altered emotional processing may represent a key link between psychosocial risk factors and core features of FND. Here, we summarise and critically appraise experimental studies of emotional processing in FND using behavioural, psychophysiological and/or neuroimaging measures in conjunction with affective processing tasks. We propose that enhanced preconscious (implicit) processing of emotionally salient stimuli, associated with elevated limbic reactivity (eg, amygdala), may contribute to the initiation of basic affective/defensive responses via hypothalamic and brainstem pathways (eg, periaqueductal grey). In parallel, affect-related brain areas may simultaneously exert a disruptive influence on neurocircuits involved in voluntary motor control, awareness and emotional regulation (eg, sensorimotor, salience, central executive networks). Limbic-paralimbic disturbances in patients with FND may represent one of several neurobiological adaptations linked to early, severe and/or prolonged psychosocial adversity. This perspective integrates neurobiological and psychosocial factors in FND and proposes a research agenda, highlighting the need for replication of existing findings, multimodal sampling across emotional response domains and further examination of emotional influences on sensorimotor and cognitive functions in FND populations.
Collapse
Affiliation(s)
- Susannah Pick
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioural Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| |
Collapse
|
33
|
Bègue I, Adams C, Stone J, Perez DL. Structural alterations in functional neurological disorder and related conditions: a software and hardware problem? Neuroimage Clin 2019; 22:101798. [PMID: 31146322 PMCID: PMC6484222 DOI: 10.1016/j.nicl.2019.101798] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/20/2019] [Accepted: 03/26/2019] [Indexed: 01/01/2023]
Abstract
Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A "software" vs. "hardware" analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including "disease staging" discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a "software" and "hardware" problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder.
Collapse
Affiliation(s)
- Indrit Bègue
- Department of Psychiatry, University of Geneva, Switzerland; Service of Adult Psychiatry, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland; Laboratory for Behavioral Neurology and Imaging of Cognition, Geneva Neuroscience Center, University of Geneva, Switzerland
| | - Caitlin Adams
- Functional Neurology Research Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Inpatient Psychiatry Division, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - David L Perez
- Functional Neurology Research Group, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA.
| |
Collapse
|
34
|
Roy N, Dietrich M, Blomgren M, Heller A, Houtz DR, Lee J. Exploring the Neural Bases of Primary Muscle Tension Dysphonia: A Case Study Using Functional Magnetic Resonance Imaging. J Voice 2019; 33:183-194. [DOI: 10.1016/j.jvoice.2017.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 11/15/2017] [Accepted: 11/16/2017] [Indexed: 01/17/2023]
|
35
|
Baizabal-Carvallo JF, Hallett M, Jankovic J. Pathogenesis and pathophysiology of functional (psychogenic) movement disorders. Neurobiol Dis 2019; 127:32-44. [PMID: 30798005 DOI: 10.1016/j.nbd.2019.02.013] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/31/2019] [Accepted: 02/20/2019] [Indexed: 11/17/2022] Open
Abstract
Functional movement disorders (FMDs), known over time as "hysteria", "dissociative", "conversion", "somatoform", "non-organic" and "psychogenic" disorders, are characterized by having a voluntary quality, being modifiable by attention and distraction but perceived by the patient as involuntary. Although a high prevalence of depression and anxiety is observed in these patients, a definitive role of psychiatric disorders in FMDs has not been proven, and many patients do not endorse such manifestations. Stressful events, social influences and minor trauma may precede the onset of FMDs, but their pathogenic mechanisms are unclear. Patients with FMDs have several abnormalities in their neurobiology including strengthened connectivity between the limbic and motor networks. Additionally, there is altered top-down regulation of motor activities and increased activation of areas implicated in self-awareness, self-monitoring, and active motor inhibition such as the cingulate and insular cortex. Decreased activation of the supplementary motor area (SMA) and pre-SMA, implicated in motor control and preparation, is another finding. The sense of agency defined as the feeling of controlling external events through one's own action also seems to be impaired in individuals with FMDs. Correlating with this is a loss of intentional binding, a subjective time compression between intentional action and its sensory consequences. Organic and functional dystonia may be difficult to differentiate since they share diverse neurophysiological features including decreased cortical inhibition, and similar local field potentials in the globus pallidus and thalamus; although increased cortical plasticity is observed only in patients with organic dystonia. Advances in the pathogenesis and pathophysiology of FMDs may be helpful to understand the nature of these disorders and plan further treatment strategies.
Collapse
Affiliation(s)
- José Fidel Baizabal-Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA; University of Guanajuato, Mexico.
| | - Mark Hallett
- Human Motor Control Section, NINDS, National Institutes of Health, Bethesda, MD, USA
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
36
|
Leon-Sarmiento FE, Bayona-Prieto J, Leon-Ariza JS, Leon-Ariza DS, Jacob AE, LaFaver K, Doty RL. Smell status in functional movement disorders: New clues for diagnosis and underlying mechanisms. Clin Neurol Neurosurg 2019; 177:68-72. [DOI: 10.1016/j.clineuro.2018.12.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 12/24/2018] [Accepted: 12/25/2018] [Indexed: 01/11/2023]
|
37
|
Ospina JP, Jalilianhasanpour R, Perez DL. The role of the anterior and midcingulate cortex in the neurobiology of functional neurologic disorder. HANDBOOK OF CLINICAL NEUROLOGY 2019; 166:267-279. [PMID: 31731915 DOI: 10.1016/b978-0-444-64196-0.00014-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Functional neurologic disorder (FND)/conversion disorder is a prevalent and disabling condition at the intersection of neurology and psychiatry. Clinicians often report feeling ill-equipped treating patients with FND, perpetuated by a historically limited understanding of neurobiologic disease mechanisms. In this review, we summarize the neuroimaging literature across the spectrum of sensorimotor FND, including functional imaging studies during rest, sensorimotor performance, and emotional-processing tasks as well as structural magnetic resonance imaging findings. Particular attention is given to studies implicating the anterior and middle cingulate cortex and related salience network structures (insula, amygdala, and periaqueductal gray) in the neurobiology of FND. Neuroimaging studies identify cingulo-insular functional alterations during rest, motor performance, and emotion processing in FND populations. The literature also supports that patients with FND exhibit heightened amygdalar and periaqueductal gray reactivity to emotionally valenced stimuli, enhanced coupling between amygdalar and motor control areas, and increased amygdalar volumes. The structural neuroimaging literature also implicates cingulo-insular areas in the pathophysiology of FND, though these findings require replication and clarification. While more research is needed to fully elucidate the pathophysiology of FND, salience network alterations appear present in some FND populations and can be contextualized using biopsychosocial models for FND.
Collapse
Affiliation(s)
- Juan Pablo Ospina
- Department of Neurology, Cognitive Behavioral Neurology Unit, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Rozita Jalilianhasanpour
- Department of Neurology, Cognitive Behavioral Neurology Unit, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - David L Perez
- Departments of Neurology and Psychiatry, Cognitive Behavioral Neurology and Neuropsychiatry Units, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|
38
|
Maurer CW, LaFaver K, Limachia GS, Capitan G, Ameli R, Sinclair S, Epstein SA, Hallett M, Horovitz SG. Gray matter differences in patients with functional movement disorders. Neurology 2018; 91:e1870-e1879. [PMID: 30305450 DOI: 10.1212/wnl.0000000000006514] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 08/02/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explore alterations in gray matter volume in patients with functional movement disorders. METHODS We obtained T1-weighted MRI on 48 patients with clinically definite functional movement disorders, a subset of functional neurologic symptom disorder characterized by abnormal involuntary movements, and on 55 age- and sex-matched healthy controls. We compared between-group differences in gray matter volume using voxel-based morphometry across the whole brain. All participants in addition underwent a thorough neuropsychological battery, including the Hamilton Anxiety and Depression Scales and the Childhood Trauma Questionnaire. To determine whether confounding factors such as comorbid depression, anxiety, or childhood trauma exposure contributed to the observed structural changes, nonparametric correlation analysis was performed. RESULTS Patients with functional movement disorders exhibited increased volume of the left amygdala, left striatum, left cerebellum, left fusiform gyrus, and bilateral thalamus, and decreased volume of the left sensorimotor cortex (whole-brain corrected p ≤ 0.05). Volumetric differences did not correlate with measures of disease duration or patient-rated disease severity. CONCLUSION This study demonstrates that patients with functional movement disorders exhibit structural gray matter abnormalities in critical components of the limbic and sensorimotor circuitry. These abnormalities may represent a premorbid trait rendering patients more susceptible to disease, the disease itself, or a compensatory response to disease.
Collapse
Affiliation(s)
- Carine W Maurer
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC.
| | - Kathrin LaFaver
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Gaurang S Limachia
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Geanna Capitan
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Rezvan Ameli
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Stephen Sinclair
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Steven A Epstein
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Mark Hallett
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| | - Silvina G Horovitz
- From the Human Motor Control Section, Medical Neurology Branch (C.W.M., K.L., G.S.L., G.C., M.H., S.G.H.), National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD; Department of Neurology (C.W.M.), Stony Brook University School of Medicine, NY; Department of Neurology (K.L.), University of Louisville, KY; Experimental Therapeutics and Pathophysiology Branch (R.A.) and Office of the Clinical Director (S.S.), National Institute of Mental Health, NIH, Bethesda, MD; and Department of Psychiatry (S.A.E.), Georgetown University, Washington, DC
| |
Collapse
|
39
|
Sojka P, Bareš M, Kašpárek T, Světlák M. Processing of Emotion in Functional Neurological Disorder. Front Psychiatry 2018; 9:479. [PMID: 30344497 PMCID: PMC6182079 DOI: 10.3389/fpsyt.2018.00479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/13/2018] [Indexed: 01/25/2023] Open
Abstract
Emotions have traditionally been considered crucial in the development of functional neurological disorder, but the evidence underpinning this association is not clear. We aimed to summarize evidence for association between functional neurological disorder and emotions as formulated by Breuer and Freud in their conception of hysterical conversion. Based on a systematic literature search, we identified 34 controlled studies and categorized them into four groups: (i) autonomic arousal, (ii) emotion-motion interactions, (iii) social modulation of symptoms, and (iv) bodily awareness in FND. We found evidence for autonomic dysregulation in FND; convergent neuroimaging findings implicate abnormal limbic-motor interactions in response to emotional stimuli in FND. Our results do not provide enough empirical evidence for social modulation of the symptoms, but there is a clinical support for the role of suggestion and placebo in FND. Our results provide evidence for abnormal bodily awareness in FND. Based on these findings, we propose that functional neurological symptoms are forms of emotional reactions shaped into symptoms by previous experience with illness and possibly reinforced by actual social contexts. Additional research should investigate the effect of social context on the intensity of functional neurological symptoms and associated brain regions.
Collapse
Affiliation(s)
- Petr Sojka
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
| | - Martin Bareš
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Tomáš Kašpárek
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Miroslav Světlák
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| |
Collapse
|
40
|
Psychogenic Nonepileptic Seizures (PNES) as a Network Disorder - Evidence From Neuroimaging of Functional (Psychogenic) Neurological Disorders. Epilepsy Curr 2018; 18:211-216. [PMID: 30254510 DOI: 10.5698/1535-7597.18.4.211] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
41
|
Perez DL, Keshavan MS, Scharf JM, Boes AD, Price BH. Bridging the Great Divide: What Can Neurology Learn From Psychiatry? J Neuropsychiatry Clin Neurosci 2018; 30:271-278. [PMID: 29939105 PMCID: PMC6309772 DOI: 10.1176/appi.neuropsych.17100200] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Neurology and psychiatry share common historical origins and rely on similar tools to study brain disorders. Yet the practical integration of medical and scientific approaches across these clinical neurosciences remains elusive. Although much has been written about the need to incorporate emerging systems-level, cellular-molecular, and genetic-epigenetic advances into a science of mind for psychiatric disorders, less attention has been given to applying clinical neuroscience principles to conceptualize neurologic conditions with an integrated neurobio-psycho-social approach. In this perspective article, the authors briefly outline the historically interwoven and complicated relationship between neurology and psychiatry. Through a series of vignettes, the authors then illustrate how some traditional psychiatric conditions are being reconceptualized in part as disorders of neurodevelopment and awareness. They emphasize the intersection of neurology and psychiatry by highlighting conditions that cut across traditional diagnostic boundaries. The authors argue that the divide between neurology and psychiatry can be narrowed by moving from lesion-based toward circuit-based understandings of neuropsychiatric disorders, from unidirectional toward bidirectional models of brain-behavior relationships, from exclusive reliance on categorical diagnoses toward transdiagnostic dimensional perspectives, and from silo-based research and treatments toward interdisciplinary approaches. The time is ripe for neurologists and psychiatrists to implement an integrated clinical neuroscience approach to the assessment and management of brain disorders. The subspecialty of behavioral neurology & neuropsychiatry is poised to lead the next generation of clinicians to merge brain science with psychological and social-cultural factors. These efforts will catalyze translational research, revitalize training programs, and advance the development of impactful patient-centered treatments.
Collapse
Affiliation(s)
- David L. Perez
- Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Neuropsychiatry Unit, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Matcheri S. Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jeremiah M. Scharf
- Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women’s Hospital, Boston, MA
| | - Aaron D. Boes
- Departments of Pediatrics, Neurology and Psychiatry, University of Iowa Health Care, Carver College of Medicine, Iowa City, IA
| | - Bruce H. Price
- Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Neurology, McLean Hospital, Harvard Medical School, Belmont, MA
| |
Collapse
|
42
|
Perez DL, Williams B, Matin N, LaFrance WC, Costumero-Ramos V, Fricchione GL, Sepulcre J, Keshavan MS, Dickerson BC. Corticolimbic structural alterations linked to health status and trait anxiety in functional neurological disorder. J Neurol Neurosurg Psychiatry 2017; 88:1052-1059. [PMID: 28844071 DOI: 10.1136/jnnp-2017-316359] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/04/2017] [Accepted: 07/18/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Affective symptoms influence health status (health-related quality of life) in functional neurological disorder (FND), and the salience network is implicated in the pathophysiology of FND and mood/anxiety disorders. We hypothesised that self-reported health status and affective symptoms would map onto salience network regions and that patients with FND would show decreased insular volumes compared with controls. METHODS This voxel-based morphometry study investigated volumetric differences in 26 patients with FND (21 women, 5 men; mean age=40.3±11.5) compared with 27 healthy controls (22 women, 5 men; mean age=40.5±10.8). Post hoc analyses stratified patients with FND by mental and physical health scores (Short Form Health Survey-36). Within-group analyses investigated associations with mental health, physical health, trait anxiety and depression in patients with FND. RESULTS There were no volumetric differences between the complete FND cohort and controls. In stratified analyses, however, patients with FND reporting the most severe physical health impairments showed reduced left anterior insular volume compared with controls. In within-group analyses, impaired mental health and elevated trait anxiety were associated with increased right amygdalar volumes in patients with FND. The relationship between amygdalar volume and mental health, driven by emotional well-being deficits and role limitations due to emotional problems, was independent of sensorimotor functional neurological symptom severity and motor FND subtype. In secondary within-group analyses, increased periaqueductal grey volume was associated with role limitations due to emotional problems. Impaired physical functioning correlated with decreased left anterior insular volumes. CONCLUSIONS These findings support roles for several regions of the salience network in the pathophysiology of FND.
Collapse
Affiliation(s)
- David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Boston, Massachusetts, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nassim Matin
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Alpert Medical School, Providence, Rhode Island, USA
| | - Victor Costumero-Ramos
- Department of Methodology, University of Valencia, Valencia, Spain.,Department of Basic and Clinical Psychology and Psychobiology, University Jaume I, Castellón de la Plana, Spain
| | - Gregory L Fricchione
- Department of Psychiatry, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jorge Sepulcre
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bradford C Dickerson
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA.,Department of Neurology, Frontotemporal Disorders Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
43
|
Pujol J, Blanco-Hinojo L, Coronas R, Esteba-Castillo S, Rigla M, Martínez-Vilavella G, Deus J, Novell R, Caixàs A. Mapping the sequence of brain events in response to disgusting food. Hum Brain Mapp 2017; 39:369-380. [PMID: 29024175 DOI: 10.1002/hbm.23848] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 09/19/2017] [Accepted: 10/04/2017] [Indexed: 12/16/2022] Open
Abstract
Warning signals indicating that a food is potentially dangerous may evoke a response that is not limited to the feeling of disgust. We investigated the sequence of brain events in response to visual representations of disgusting food using a dynamic image analysis. Functional MRI was acquired in 30 healthy subjects while they were watching a movie showing disgusting food scenes interspersed with the scenes of appetizing food. Imaging analysis included the identification of the global brain response and the generation of frame-by-frame activation maps at the temporal resolution of 2 s. Robust activations were identified in brain structures conventionally associated with the experience of disgust, but our analysis also captured a variety of other brain elements showing distinct temporal evolutions. The earliest events included transient changes in the orbitofrontal cortex and visual areas, followed by a more durable engagement of the periaqueductal gray, a pivotal element in the mediation of responses to threat. A subsequent core phase was characterized by the activation of subcortical and cortical structures directly concerned not only with the emotional dimension of disgust (e.g., amygdala-hippocampus, insula), but also with the regulation of food intake (e.g., hypothalamus). In a later phase, neural excitement extended to broad cortical areas, the thalamus and cerebellum, and finally to the default mode network that signaled the progressive termination of the evoked response. The response to disgusting food representations is not limited to the emotional domain of disgust, and may sequentially involve a variety of broadly distributed brain networks. Hum Brain Mapp 39:369-380, 2018. © 2017 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Jesus Pujol
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, 08003, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, 08003, Spain
| | - Laura Blanco-Hinojo
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, 08003, Spain.,Centro Investigación Biomédica en Red de Salud Mental, CIBERSAM G21, Barcelona, 08003, Spain
| | - Ramón Coronas
- Mental Health Center, Corporació Sanitària Parc Taulí, Sabadell, 08208, Spain
| | - Susanna Esteba-Castillo
- Specialized Service in Mental Health and Intellectual Disability, Institut Assistència Sanitària (IAS), Parc Hospitalari Martí i Julià, Girona, 17190, Spain
| | - Mercedes Rigla
- Endocrinology and Nutrition Department, Sabadell University Hospital (UAB), Corporació Sanitària Parc Taulí, Sabadell, 08208, Spain
| | | | - Joan Deus
- MRI Research Unit, Department of Radiology, Hospital del Mar, Barcelona, 08003, Spain.,Guttmann Neurorehabilitation Institute, Autonomous University of Barcelona, Barcelona, 08916, Spain.,Department of Clinical and Health Psychology, Autonomous University of Barcelona, Barcelona, 08193, Spain
| | - Ramón Novell
- Specialized Service in Mental Health and Intellectual Disability, Institut Assistència Sanitària (IAS), Parc Hospitalari Martí i Julià, Girona, 17190, Spain
| | - Assumpta Caixàs
- Endocrinology and Nutrition Department, Sabadell University Hospital (UAB), Corporació Sanitària Parc Taulí, Sabadell, 08208, Spain
| |
Collapse
|