Progress in Neuro-Psychopharmacology and Biological Psychiatry
Volumetric investigation of brain regions in patients with conversion disorder
Introduction
Conversion disorder (CD) is defined as loss or distortion of neurological function that cannot be fully explained by a known organic neurological disease (American Psychiatric Association, 1994). Yet, their symptoms are not intentionally feigned, not adequately explained by malingering, and may result in significant distress and handicap (Merskey, 1995). In clinical neurological practice, conversion symptoms represent a common disorder, accounting for 1–3% of diagnoses in general hospitals (Marsden, 1986), or even more in some neurological settings (Binzer and Kullgren, 1998, Ron, 1994). Though CD is not very frequent in western societies, it is very common in eastern societies (Pierloot and Ngoma, 1988, Chandrasekaran et al., 1994). The region differs from Western societies and even from Western Turkey in terms of more frequently encountered CD which constitutes an important psychiatric disorder in the region.
Hysterical symptoms long raised questions about mind–body relationships. Described in early medical writings as psychic disorders caused by bodily disturbances, they were later regarded as the physical effect of violent impressions or passions (Merskey, 1995). A role of neurobiological factors is suggested by the fact that symptoms are more frequent on left-side limbs, pointing to possible right-hemisphere involvement (Stern, 1983), and seem occasionally facilitated by a real coexisting brain disease (Eames, 1992). However, specific functional brain correlates of conversion symptoms have not been demonstrated, except for a few recent pioneering studies (Spence et al., 2000). Physicians, like philosophers, still often call upon a ‘disease of the will’ or ‘of the imagination’ (Merskey, 1995), yet little is known about the neural functioning of motor will or imagination, and how it may be affected in hysterical patients (Marshall et al., 1997, Spence et al., 2000). Demonstrating objective brain correlates of hysterical symptoms may therefore help to understand the mechanisms that underlie a subjective experience of abnormal neurological function in these patients. Also, it may provide unique insights into mechanisms that subserve normal conscious experience of sensation and volition. A variety of neuropsychological findings (Flor-Henry et al., 1981) and neurophysiological abnormalities (Tiihonen et al., 1995, Lorenz et al., 1998, Spence et al., 2000) have been reported in patients with hysterical conversion. However, many of these studies included only a few or single patients, and provided relatively conflicting or inconclusive results overall. Vuilleumier et al. (2001) evaluated seven patients with conversion disorder using by single photon emission computerized tomography using 99mTc-ECD and revealed a decrease of regional cerebral blood flow in the thalamus and basal ganglia contralateral to the deficit and suggested that hysterical conversion deficits might entail a functional disorder in striatothalamocortical circuits controlling sensorimotor function and voluntary motor behaviour. However, there is no systematic structural magnetic resonance imaging (MRI) study in the literature. Therefore, taken together, we aimed to use structural MRI to evaluate the brain regions of interest in first applying patients with CD.
Section snippets
Subjects and clinical evaluation
Twelve female patients with unilateral motor symptoms meeting DSM-IV criteria for CD, as determined by the Structured Clinical Interview for DSM-IV (SCID; Spitzer et al., 1997) who consecutively applied to the Firat University School of Medicine Emergency Unit or to directly Department of Psychiatry and 12 healthy female controls were studied. The mean (± S.D.) age of the CD patients was 28.1 (5.1) years and the mean age of the normal subject group was 29.2 (5.6) years. All subjects were
Demographic variables
There were no significant differences in demographic variables of age, gender composition, educational level, and handedness between patients with CD and healthy controls (p > 0.05).
Interrater reliability measurements
All interrater and intrarater reliability scores were equal to or above 0.82, demonstrating sufficient inter- and intra-reliability.
Unadjusted whole brain and regional brain volumes
Table 1 presents the unadjusted volumes of the structures evaluated. ICV, whole brain volume, gray and white matter volumes did not differ between the patient and control groups (p > 0.05).
Discussion
The father of modern psychology, William James remarked long ago (James, 1986): ‘Poor hysterics. First they were treated as victims of sexual trouble…then of moral perversity and mediocrity…then of imagination. Among the various rehabilitation which our age has seen, none are more deserving or humane. It is a real disease, but a mental disease.’ As mentioned in Williams James saying, CD is a real disease but a mental disorder seems to involve some brain volumetric differences when compared to
Conclusion
In conclusion, our findings suggest that patients with CD have significantly smaller mean volumes of the left and right basal ganglia and smaller right thalamus, with a trend toward to smaller left thalamus compared to healthy controls and that these findings provide novel constraints for a modern psychobiological theory of hysteria. Although this reduction may be important in understanding the pathophysiology of CD, its functional and psychopathologic consequences are still unclear. Future
References (49)
- et al.
Motor conversion disorder: a prospective 2- to 5-year follow-up study
Psychosomatics
(1998) - et al.
Negative symptoms: the ‘pathology’ of motivation and goal-directed behaviour
Trends Neurosci
(2000) - et al.
Sustained and transient activity during an object-naming task: a mixed blocked and event-related fMRI study
Neuroimage
(2003) - et al.
Emotion and motivation: the role of the amygdala, ventral striatum, and prefrontal cortex
Neurosci Biobehav Rev
(2002) Roles for perceived voluntary motor commands in motor control
Trends Neurosci
(1987)- et al.
Anatomical MRI study of basal ganglia in major depressive disorder
Psychiatry Res
(2003) - et al.
Basal ganglia and cerebellar loops: motor and cognitive circuits
Brain Res Brain Res Rev
(2000) The basal ganglia: focused selection and inhibition of competing motor programs
Prog Neurobiol
(1996)- et al.
From motivation to action: functional interface between the limbic system and the motor system
Prog Neurobiol
(1980) - et al.
Volumetric evaluation of the thalamus in schizophrenic male patients using magnetic resonance imaging
Biol Psychiatry
(1998)
Neuroimaging and neuropsychology of the striatum: bridging basic science and clinical practice
Psychiatr Clin North Am
Discrete neurophysiological correlates in prefrontal cortex during hysterical and feigned disorder of movement [letter]
Lancet
Altered cerebral blood flow during hysterical paresthesia [letter]
Biol Psychiatry
Noxious hot and cold stimulation produce common patterns of brain activation in humans: a functional magnetic resonance imaging study
Neurosci Lett
Extrapersonal visual unilateral spatial neglect and its neuroanatomy
Neuroimage
Decreased volume and increased asymmetry of the anterior limb of the internal capsule in patients with schizophrenia
Biol Psychiatry
Diagnostic and statistical manual of mental disorders. DSM-IV
Neuronal activity in substantia nigra pars reticulata during target selection
J Neurosci
Hysterical neurosis
Acta Psychiatr Scand
Hysteria following brain injury
J Neurol Neurosurg Psychiatry
A neuropsychological study of the stable syndrome of hysteria
Biol Psychiatry
Role of the basal ganglia in the control of purposive saccadic eye movements
Physiol Rev
MRI anatomy: a new angle on the brain
On exceptional mental states: the 1896 Lowell lectures
Cited by (56)
Magnetic resonance imaging histogram analysis of amygdala in functional neurological disorder: Histogram Analysis of Amygdala in Functional Neurological Disorder
2022, Psychiatry Research - NeuroimagingCitation Excerpt :Certain studies suggested the presence of significant brain findings that accompany FND symptoms (Atmaca et al., 2006; Atmaca et al., 2016; Aybek et al., 2015; Baumann and Mattingley, 2012; Bègue et al., 2019; Byrd et al., 1990; Giedd et al., 2012; Maurer et al., 2018; Vuilleumier et al., 2001). These findings have emphasized on FND symptoms that could be identified with brain imaging and neurophysiological measurements (Atmaca et al., 2006; Atmaca et al., 2016; Aybek et al., 2015; Baumann and Mattingley, 2012; Byrd et al., 1990; Giedd et al., 2012; Perez et al., 2017b; Vuilleumier et al., 2001). Findings of imaging studies suggest altered neural activity in emotion processing areas in FND, especially in the amygdala (Aybek et al., 2015; Hassa et al., 2017; Pick et al., 2019; Voon et al., 2011).
Biomarkers of Pathological Dissociation: A Systematic Review
2021, Neuroscience and Biobehavioral ReviewsStructural neuroimaging of somatoform disorders: A systematic review
2021, Neuroscience and Biobehavioral ReviewsNeuroimaging in Functional Neurological Disorder: State of the Field and Research Agenda
2021, NeuroImage: ClinicalCitation Excerpt :However, manual tracing can provide a good solution to quantifying volumes in relatively discrete subcortical structures. In FND, studies have used manual tracing to quantify basal ganglia, thalamic and pituitary volumes (Atmaca et al., 2006, 2016). In FND research, manual tracing has been largely replaced by automatic methods such as VBM and surface-based morphometry.
Pathogenesis and pathophysiology of functional (psychogenic) movement disorders
2019, Neurobiology of Disease