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Ramanathan D, Nan J, Grennan G, Jaiswal S, Purpura S, Manchanda J, Maric V, Balasubramani PP, Mishra J. Modulation of Posterior Default Mode Network Activity During Interoceptive Attention and Relation to Mindfulness. BIOLOGICAL PSYCHIATRY GLOBAL OPEN SCIENCE 2024; 4:100384. [PMID: 39416659 PMCID: PMC11480231 DOI: 10.1016/j.bpsgos.2024.100384] [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: 02/22/2024] [Revised: 07/09/2024] [Accepted: 08/13/2024] [Indexed: 10/19/2024] Open
Abstract
Background Interoceptive attention to internal sensory signals, such as the breath, is fundamental to mindfulness. However, interoceptive attention can be difficult to study, with many studies relying on subjective and retrospective measures. Response consistency is an established method for evaluating variability of attention on exteroceptive attention tasks, but it has rarely been applied to interoceptive attention tasks. Methods In this study, we measured consistency of response times on a breath-monitoring task with simultaneous electroencephalography in individuals across the life span (15-91 years of age, N = 324). Results We found that consistency on the breath-monitoring task was positively correlated with attentive performance on an exteroceptive inhibitory control task. Electroencephalography source reconstruction showed that on-task alpha band (8-12 Hz) activity was greater than that measured at rest. Low-consistency/longer breath responses were associated with elevated brain activity compared with high-consistency responses, particularly in posterior default mode network (pDMN) brain regions. pDMN activity was inversely linked with functional connectivity to the frontoparietal network and the cingulo-opercular network on task but not at rest, suggesting a role for these frontal networks in on-task regulation of pDMN activity. pDMN activity within the precuneus region was greater in participants who reported low subjective mindfulness and was adaptively modulated by task difficulty in an independent experiment. Conclusions Elevated pDMN alpha activity serves as an objective neural marker for low-consistency responding during interoceptive breath attention, scales with task difficulty, and is associated with low subjective mindfulness.
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Affiliation(s)
- Dhakshin Ramanathan
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
- Department of Mental Health, Veterans Affairs San Diego Healthcare System, San Diego, California
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Jason Nan
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Gillian Grennan
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Satish Jaiswal
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Suzanna Purpura
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - James Manchanda
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Vojislav Maric
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
| | | | - Jyoti Mishra
- Neural Engineering and Translation Labs, Department of Psychiatry, University of California, San Diego, La Jolla, California
- Center of Excellence for Stress and Mental Health, Veterans Affairs San Diego Healthcare System, San Diego, California
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Koloski MF, Hulyalkar S, Barnes SA, Mishra J, Ramanathan DS. Cortico-striatal beta oscillations as a reward-related signal. COGNITIVE, AFFECTIVE & BEHAVIORAL NEUROSCIENCE 2024; 24:839-859. [PMID: 39147929 PMCID: PMC11390840 DOI: 10.3758/s13415-024-01208-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2024] [Indexed: 08/17/2024]
Abstract
The value associated with reward is sensitive to external factors, such as the time between the choice and reward delivery as classically manipulated in temporal discounting tasks. Subjective preference for two reward options is dependent on objective variables of reward magnitude and reward delay. Single neuron correlates of reward value have been observed in regions, including ventral striatum, orbital, and medial prefrontal cortex. Brain imaging studies show cortico-striatal-limbic network activity related to subjective preferences. To explore how oscillatory dynamics represent reward processing across brain regions, we measured local field potentials of rats performing a temporal discounting task. Our goal was to use a data-driven approach to identify an electrophysiological marker that correlates with reward preference. We found that reward-locked oscillations at beta frequencies signaled the magnitude of reward and decayed with longer temporal delays. Electrodes in orbitofrontal/medial prefrontal cortex, anterior insula, ventral striatum, and amygdala individually increased power and were functionally connected at beta frequencies during reward outcome. Beta power during reward outcome correlated with subjective value as defined by a computational model fit to the discounting behavior. These data suggest that cortico-striatal beta oscillations are a reward signal correlated, which may represent subjective value and hold potential to serve as a biomarker and potential therapeutic target.
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Affiliation(s)
- M F Koloski
- Mental Health Service, VA San Diego Healthcare Syst, La Jolla, CA, USA.
- Department of Psychiatry, UC San Diego, La Jolla, CA, USA.
| | - S Hulyalkar
- Mental Health Service, VA San Diego Healthcare Syst, La Jolla, CA, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA, USA
| | - S A Barnes
- Department of Psychiatry, UC San Diego, La Jolla, CA, USA
| | - J Mishra
- Department of Psychiatry, UC San Diego, La Jolla, CA, USA
| | - D S Ramanathan
- Mental Health Service, VA San Diego Healthcare Syst, La Jolla, CA, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA, USA
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Nan J, Grennan G, Ravichandran S, Ramanathan D, Mishra J. Neural activity during inhibitory control predicts suicidal ideation with machine learning. NPP-DIGITAL PSYCHIATRY AND NEUROSCIENCE 2024; 2:10. [PMID: 38988507 PMCID: PMC11230903 DOI: 10.1038/s44277-024-00012-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/04/2024] [Accepted: 06/04/2024] [Indexed: 07/12/2024]
Abstract
Suicide is a leading cause of death in the US and worldwide. Current strategies for preventing suicide are often focused on the identification and treatment of risk factors, especially suicidal ideation (SI). Hence, developing data-driven biomarkers of SI may be key for suicide prevention and intervention. Prior attempts at biomarker-based prediction models for SI have primarily used expensive neuroimaging technologies, yet clinically scalable and affordable biomarkers remain elusive. Here, we investigated the classification of SI using machine learning (ML) on a dataset of 76 subjects with and without SI(+/-) (n = 38 each), who completed a neuro-cognitive assessment session synchronized with electroencephalography (EEG). SI+/- groups were matched for age, sex, and mental health symptoms of depression and anxiety. EEG was recorded at rest and while subjects engaged in four cognitive tasks of inhibitory control, interference processing, working memory, and emotion bias. We parsed EEG signals in physiologically relevant theta (4-8 Hz), alpha (8-13 Hz), and beta (13-30 Hz) frequencies and performed cortical source imaging on the neural signals. These data served as SI predictors in ML models. The best ML model was obtained for beta band power during the inhibitory control (IC) task, demonstrating high sensitivity (89%), specificity (98%). Shapley explainer plots further showed top neural predictors as feedback-related power in the visual and posterior default mode networks and response-related power in the ventral attention, fronto-parietal, and sensory-motor networks. We further tested the external validity of the model in an independent clinically depressed sample (n = 35, 12 SI+) that engaged in an adaptive test version of the IC task, demonstrating 50% sensitivity and 61% specificity in this sample. Overall, the study suggests a promising, scalable EEG-based biomarker approach to predict SI that may serve as a target for risk identification and intervention.
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Affiliation(s)
- Jason Nan
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA USA
- Department of Bioengineering, University of California, San Diego, La Jolla, CA USA
| | - Gillian Grennan
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA USA
| | - Soumya Ravichandran
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA USA
| | - Dhakshin Ramanathan
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA USA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
- Department of Mental Health, VA San Diego Medical Center, San Diego, CA USA
- Center of Excellence for Stress and Mental Health, VA San Diego Medical Center, San Diego, CA USA
| | - Jyoti Mishra
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA USA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA USA
- Center of Excellence for Stress and Mental Health, VA San Diego Medical Center, San Diego, CA USA
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EEG source derived salience network coupling supports real-world attention switching. Neuropsychologia 2023; 178:108445. [PMID: 36502931 DOI: 10.1016/j.neuropsychologia.2022.108445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 11/30/2022] [Accepted: 12/07/2022] [Indexed: 12/13/2022]
Abstract
While the brain mechanisms underlying selective attention have been studied in great detail in controlled laboratory settings, it is less clear how these processes function in the context of a real-world self-paced task. Here, we investigated engagement on a real-world computerized task equivalent to a standard academic test that consisted of solving high-school level problems in a self-paced manner. In this task, we used EEG-source derived estimates of effective coupling between brain sources to characterize the neural mechanisms underlying switches of sustained attention from the attentive on-task state to the distracted off-task state. Specifically, since the salience network has been implicated in sustained attention and attention switching, we conducted a hypothesis-driven analysis of effective coupling between the core nodes of the salience network, the anterior insula (AI) and the anterior cingulate cortex (ACC). As per our hypothesis, we found an increase in AI - > ACC effective coupling that occurs during the transitions of attention from on-task focused to off-task distracted state. This research may inform the development of future neural function-targeted brain-computer interfaces to enhance sustained attention.
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Grennan G, Balasubramani PP, Vahidi N, Ramanathan D, Jeste DV, Mishra J. Dissociable neural mechanisms of cognition and well-being in youth versus healthy aging. Psychol Aging 2022; 37:827-842. [PMID: 36107693 PMCID: PMC9669243 DOI: 10.1037/pag0000710] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Mental health, cognition, and their underlying neural processes in healthy aging are rarely studied simultaneously. Here, in a sample of healthy younger (n = 62) and older (n = 54) adults, we compared subjective mental health as well as objective global cognition across several core cognitive domains with simultaneous electroencephalography (EEG). We found significantly greater symptoms of anxiety, depression, and loneliness in youth and in contrast, greater mental well-being in older adults. Yet, global performance across core cognitive domains was significantly worse in older adults. EEG-based source imaging of global cognitive task-evoked processing showed reduced suppression of activity in the anterior medial prefrontal default mode network (DMN) region in older adults relative to youth. Global cognitive performance efficiency was predicted by greater activity in the right dorsolateral prefrontal cortex in younger adults and in contrast, by greater activity in right inferior frontal cortex in older adults. Furthermore, greater mental well-being in older adults related to lesser global task-evoked activity in the posterior DMN. Overall, these results suggest dissociated neural mechanisms underlying global cognition and mental well-being in youth versus healthy aging. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Gillian Grennan
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA, USA
| | - Pragathi Priyadharsini Balasubramani
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA, USA
| | - Nasim Vahidi
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA, USA
| | - Dhakshin Ramanathan
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA, USA
- Department of Mental Health, VA San Diego Medical Center, San Diego, CA, USA
| | - Dilip V Jeste
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- Sam and Rose Stein Institute for Research on Aging, University of California San Diego, La Jolla, CA
- Department of Neurosciences, University of California San Diego, La Jolla, CA, USA
| | - Jyoti Mishra
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, La Jolla, CA, USA
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Bordoni B, Escher AR. Functional evaluation of the diaphragm with a noninvasive test. J Osteopath Med 2021; 121:835-842. [PMID: 34523291 DOI: 10.1515/jom-2021-0101] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022]
Abstract
Cardiac surgery with median sternotomy causes iatrogenic damage to the function of the diaphragm muscle that is both temporary and permanent. Myocardial infarction itself causes diaphragmatic genetic alterations, which lead the muscle to nonphysiological adaptation. The respiratory muscle area plays several roles in maintaining both physical and mental health, as well as in maximizing recovery after a cardiac event. The evaluation of the diaphragm is a fundamental step in the therapeutic process, including the use of instruments such as ultrasound, magnetic resonance imaging (MRI), and computed axial tomography (CT). This article reviews the neurophysiological relationships of the diaphragm muscle and the symptoms of diaphragmatic contractile dysfunction. The authors discuss a scientific basis for the use of a new noninstrumental diaphragmatic test in the hope of stimulating research.
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Affiliation(s)
- Bruno Bordoni
- Foundation Don Carlo Gnocchi IRCCS, Department of Cardiology, Institute of Hospitalization and Care with Scientific, Milan, Italy
| | - Allan R Escher
- Anesthesiology/Pain Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Francoeur MJ, Tang T, Fakhraei L, Wu X, Hulyalkar S, Cramer J, Buscher N, Ramanathan DR. Chronic, Multi-Site Recordings Supported by Two Low-Cost, Stationary Probe Designs Optimized to Capture Either Single Unit or Local Field Potential Activity in Behaving Rats. Front Psychiatry 2021; 12:678103. [PMID: 34421671 PMCID: PMC8374626 DOI: 10.3389/fpsyt.2021.678103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/21/2021] [Indexed: 11/13/2022] Open
Abstract
Rodent models of cognitive behavior have greatly contributed to our understanding of human neuropsychiatric disorders. However, to elucidate the neurobiological underpinnings of such disorders or impairments, animal models are more useful when paired with methods for measuring brain function in awake, behaving animals. Standard tools used for systems-neuroscience level investigations are not optimized for large-scale and high-throughput behavioral battery testing due to various factors including cost, time, poor longevity, and selective targeting limited to measuring only a few brain regions at a time. Here we describe two different "user-friendly" methods for building extracellular electrophysiological probes that can be used to measure either single units or local field potentials in rats performing cognitive tasks. Both probe designs leverage several readily available, yet affordable, commercial products to facilitate ease of production and offer maximum flexibility in terms of brain-target locations that can be scalable (32-64 channels) based on experimental needs. Our approach allows neural activity to be recorded simultaneously with behavior and compared between micro (single unit) and more macro (local field potentials) levels of brain activity in order to gain a better understanding of how local brain regions and their connected networks support cognitive functions in rats. We believe our novel probe designs make collecting electrophysiology data easier and will begin to fill the gap in knowledge between basic and clinical research.
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Affiliation(s)
- Miranda J. Francoeur
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Tianzhi Tang
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Leila Fakhraei
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Xuanyu Wu
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Sidharth Hulyalkar
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Jessica Cramer
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Nathalie Buscher
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
| | - Dhakshin R. Ramanathan
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, United States
- Department of Psychiatry, University of California, San Diego, San Diego, CA, United States
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Shah RV, Grennan G, Zafar-Khan M, Alim F, Dey S, Ramanathan D, Mishra J. Personalized machine learning of depressed mood using wearables. Transl Psychiatry 2021; 11:338. [PMID: 34103481 PMCID: PMC8187630 DOI: 10.1038/s41398-021-01445-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/04/2021] [Accepted: 05/13/2021] [Indexed: 02/05/2023] Open
Abstract
Depression is a multifaceted illness with large interindividual variability in clinical response to treatment. In the era of digital medicine and precision therapeutics, new personalized treatment approaches are warranted for depression. Here, we use a combination of longitudinal ecological momentary assessments of depression, neurocognitive sampling synchronized with electroencephalography, and lifestyle data from wearables to generate individualized predictions of depressed mood over a 1-month time period. This study, thus, develops a systematic pipeline for N-of-1 personalized modeling of depression using multiple modalities of data. In the models, we integrate seven types of supervised machine learning (ML) approaches for each individual, including ensemble learning and regression-based methods. All models were verified using fourfold nested cross-validation. The best-fit as benchmarked by the lowest mean absolute percentage error, was obtained by a different type of ML model for each individual, demonstrating that there is no one-size-fits-all strategy. The voting regressor, which is a composite strategy across ML models, was best performing on-average across subjects. However, the individually selected best-fit models still showed significantly less error than the voting regressor performance across subjects. For each individual's best-fit personalized model, we further extracted top-feature predictors using Shapley statistics. Shapley values revealed distinct feature determinants of depression over time for each person ranging from co-morbid anxiety, to physical exercise, diet, momentary stress and breathing performance, sleep times, and neurocognition. In future, these personalized features can serve as targets for a personalized ML-guided, multimodal treatment strategy for depression.
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Affiliation(s)
- Rutvik V Shah
- Department of Psychiatry, University of California, San Diego, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, CA, USA
| | - Gillian Grennan
- Department of Psychiatry, University of California, San Diego, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, CA, USA
| | - Mariam Zafar-Khan
- Department of Psychiatry, University of California, San Diego, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, CA, USA
| | - Fahad Alim
- Department of Psychiatry, University of California, San Diego, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, CA, USA
| | - Sujit Dey
- Mobile Systems Design Lab, Dept. of Electrical and Computer Engineering, University of California, San Diego, CA, USA
| | - Dhakshin Ramanathan
- Department of Psychiatry, University of California, San Diego, CA, USA
- Neural Engineering and Translation Labs, University of California, San Diego, CA, USA
- Department of Mental Health, VA San Diego Medical Center, San Diego, CA, USA
| | - Jyoti Mishra
- Department of Psychiatry, University of California, San Diego, CA, USA.
- Neural Engineering and Translation Labs, University of California, San Diego, CA, USA.
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Fakhraei L, Francoeur M, Balasubramani PP, Tang T, Hulyalkar S, Buscher N, Mishra J, Ramanathan DS. Electrophysiological Correlates of Rodent Default-Mode Network Suppression Revealed by Large-Scale Local Field Potential Recordings. Cereb Cortex Commun 2021; 2:tgab034. [PMID: 34296178 PMCID: PMC8166125 DOI: 10.1093/texcom/tgab034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
The default-mode network (DMN) in humans consists of a set of brain regions that, as measured with functional magnetic resonance imaging (fMRI), show both intrinsic correlations with each other and suppression during externally oriented tasks. Resting-state fMRI studies have previously identified similar patterns of intrinsic correlations in overlapping brain regions in rodents (A29C/posterior cingulate cortex, parietal cortex, and medial temporal lobe structures). However, due to challenges with performing rodent behavior in an MRI machine, it is still unclear whether activity in rodent DMN regions are suppressed during externally oriented visual tasks. Using distributed local field potential measurements in rats, we have discovered that activity in DMN brain regions noted above show task-related suppression during an externally oriented visual task at alpha and low beta-frequencies. Interestingly, this suppression (particularly in posterior cingulate cortex) was linked with improved performance on the task. Using electroencephalography recordings from a similar task in humans, we identified a similar suppression of activity in posterior cingulate cortex at alpha/low beta-frequencies. Thus, we have identified a common electrophysiological marker of DMN suppression in both rodents and humans. This observation paves the way for future studies using rodents to probe circuit-level functioning of DMN function. SIGNIFICANCE Here we show that alpha/beta frequency oscillations in rats show key features of DMN activity, including intrinsic correlations between DMN brain regions, task-related suppression, and interference with attention/decision-making. We found similar task-related suppression at alpha/low beta-frequencies of DMN activity in humans.
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Affiliation(s)
- Leila Fakhraei
- Mental Health Service, VA San Diego Healthcare System., La Jolla, CA 92161, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
| | - Miranda Francoeur
- Mental Health Service, VA San Diego Healthcare System., La Jolla, CA 92161, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
| | | | - Tianzhi Tang
- Mental Health Service, VA San Diego Healthcare System., La Jolla, CA 92161, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
| | - Sidharth Hulyalkar
- Mental Health Service, VA San Diego Healthcare System., La Jolla, CA 92161, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
| | - Nathalie Buscher
- Mental Health Service, VA San Diego Healthcare System., La Jolla, CA 92161, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
| | - Jyoti Mishra
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
| | - Dhakshin S Ramanathan
- Mental Health Service, VA San Diego Healthcare System., La Jolla, CA 92161, USA
- Department of Psychiatry, UC San Diego, La Jolla, CA 92093, USA
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