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      Uncovering the etiology of conversion disorder: insights from functional neuroimaging

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          Abstract

          Conversion disorder (CD) is a syndrome of neurological symptoms arising without organic cause, arguably in response to emotional stress, but the exact neural substrates of these symptoms and the underlying mechanisms remain poorly understood with the hunt for a biological basis afoot for centuries. In the past 15 years, novel insights have been gained with the advent of functional neuroimaging studies in patients suffering from CDs in both motor and nonmotor domains. This review summarizes recent functional neuroimaging studies including functional magnetic resonance imaging (fMRI), single photon emission computerized tomography (SPECT), and positron emission tomography (PET) to see whether they bring us closer to understanding the etiology of CD. Convergent functional neuroimaging findings suggest alterations in brain circuits that could point to different mechanisms for manifesting functional neurological symptoms, in contrast with feigning or healthy controls. Abnormalities in emotion processing and in emotion-motor processing suggest a diathesis, while differential reactions to certain stressors implicate a specific response to trauma. No comprehensive theory emerges from these clues, and all results remain preliminary, but functional neuroimaging has at least given grounds for hope that a model for CD may soon be found.

          Most cited references53

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          Neural systems underlying the suppression of unwanted memories.

          M Anderson (2004)
          Over a century ago, Freud proposed that unwanted memories can be excluded from awareness, a process called repression. It is unknown, however, how repression occurs in the brain. We used functional magnetic resonance imaging to identify the neural systems involved in keeping unwanted memories out of awareness. Controlling unwanted memories was associated with increased dorsolateral prefrontal activation, reduced hippocampal activation, and impaired retention of those memories. Both prefrontal cortical and right hippocampal activations predicted the magnitude of forgetting. These results confirm the existence of an active forgetting process and establish a neurobiological model for guiding inquiry into motivated forgetting.
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            Functional specialization within rostral prefrontal cortex (area 10): a meta-analysis.

            One of the least well understood regions of the human brain is rostral prefrontal cortex, approximating Brodmann's area 10. Here, we investigate the possibility that there are functional subdivisions within this region by conducting a meta-analysis of 104 functional neuroimaging studies (using positron emission tomography/functional magnetic resonance imaging). Studies involving working memory and episodic memory retrieval were disproportionately associated with lateral activations, whereas studies involving mentalizing (i.e., attending to one's own emotions and mental states or those of other agents) were disproportionately associated with medial activations. Functional variation was also observed along a rostral-caudal axis, with studies involving mentalizing yielding relatively caudal activations and studies involving multiple-task coordination yielding relatively rostral activations. A classification algorithm was trained to predict the task, given the coordinates of each activation peak. Performance was well above chance levels (74% for the three most common tasks; 45% across all eight tasks investigated) and generalized to data not included in the training set. These results point to considerable functional segregation within rostral prefrontal cortex.
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              Opposing Mechanisms Support the Voluntary Forgetting of Unwanted Memories

              Introduction The ability to remember one’s past is a two-sided coin. It allows us to relive cherished episodes but also confronts us with past events that we would rather forget. Research over the last decade indicates that this latter side is, to some degree, under voluntary control. When people confront an unwelcome reminder of a past event, they can exclude the unwanted memory from awareness. This process, in turn, impairs retention of the suppressed memory (Anderson and Green, 2001; Hertel and Calcaterra, 2005; Anderson and Huddleston, 2011). Though recent studies have started to elucidate the neural basis of this phenomenon (Anderson et al., 2004; Depue et al., 2007; Butler and James, 2010), they all leave a fundamental question unanswered: what exactly are the neurocognitive mechanisms that underlie memory suppression? The present fMRI experiment scrutinized the existence of two possible routes to forgetting unwanted memories. Both of these putative mechanisms are hypothesized to induce forgetting by limiting momentary awareness of an unwanted memory, yet they achieve this function in fundamentally opposite ways that are mediated by different neural networks. One way to exclude a memory from awareness would be to inhibit the retrieval process directly (Bergström et al., 2009). If such direct suppression were possible, it may be mediated by a disruption of mnemonic processes supported by the hippocampus (HC), a structure known to be critical to conscious recollection (Squire, 1992; Eldridge et al., 2000; Eichenbaum et al., 2007). In support of this hypothesis, blood oxygen level-dependent (BOLD) signal in the HC is typically reduced during attempts to limit awareness of a memory compared with attempts to recall a memory (Anderson et al., 2004; Depue et al., 2007; Butler and James, 2010). Thus, these situations might recruit a direct suppression mechanism that disengages retrieval processes supported by the HC (cf. Anderson et al., 2004). At the same time, attempts to exclude a memory from awareness are associated with increased activation in right dorsolateral prefrontal cortex (DLPFC; approximating Brodmann area [BA] 46/9; Anderson et al., 2004; Depue et al., 2007; Butler and James, 2010), and a stronger recruitment of this region predicts greater subsequent forgetting of the avoided memories (Anderson et al., 2004; Depue et al., 2007). Importantly, across individuals, greater DLPFC activation correlates with decreased HC activation (Depue et al., 2007). This pattern suggests that the DLPFC may inhibit HC processing to prevent the retrieval of unwanted memories and that precluding awareness in this fashion impairs the suppressed memory traces (Anderson et al., 2004). However, it is unknown whether the activation changes in these two regions reflect such direct suppression attempts, and whether they indeed compose a functional network that supports retrieval inhibition. Here, using dynamic causal modeling, we examine the hypothesis that a negative DLPFC-HC coupling mediates such a mechanism of voluntary forgetting. The opposite way of excluding an unwanted memory from awareness would be to occupy the limited focus of awareness with another competing thought, such as another memory (Hertel and Calcaterra, 2005). Because such thought substitution requires an alternative memory to be retrieved, it would presumably engage HC processing, not disengage it. It therefore could not be based on a systemic inhibition of this structure. Instead, this mechanism requires the selection between the substitute memory and the prepotent, unwanted memory. Previous research indicates that selective retrieval can weaken competing memory traces (Anderson et al., 1994; Norman et al., 2007) and that it is supported by two prefrontal regions (Wimber et al., 2008). One of these approximates to left BA 44/9. This part of caudal PFC (cPFC) is engaged during the retrieval of weak memories in the context of stronger, interfering memories (Wimber et al., 2008; Kuhl et al., 2008). Greater activation in cPFC has also been linked to reduced proactive interference from intruding memories in working memory tasks (Nee and Jonides, 2008). Accordingly, this region may also support processes that enable substitute recall while weakening the trace of the avoided memory. The second structure, left midventrolateral PFC (mid-VLPFC; approximating posterior parts of BA 45), has been implicated in the selection of a target from among retrieved memories (Kuhl et al., 2007, 2008; Badre and Wagner, 2007). Thus, controlling awareness of unwanted memories by thought substitution may be achieved by cooperative interactions between left cPFC and mid-VLPFC that bias retrieval toward the selective recollection of distracting substitute thoughts that occupy awareness. To scrutinize the two putative mechanisms of voluntary forgetting, two groups of participants encoded reminder-memory pairs (e.g., BEACH-AFRICA). Participants then received substitute memories for a subset of these reminders (e.g., BEACH-SNORKEL) (Figure 1A). Afterward, they were scanned by fMRI while they recalled some of the associates and suppressed others (Anderson and Green, 2001). Critically, one group accomplished this in a manner likely to engage the hypothesized direct suppression mechanism. These participants attended to the reminder on the screen (e.g., BEACH) while trying to prevent retrieval of the associated memory (e.g., AFRICA). They were carefully instructed to not engage in any distracting activity (Bergström et al., 2009). If the memory entered awareness inadvertently, they were asked to block it out. By contrast, the other group performed a task likely to engage the thought-substitution mechanism, i.e., they recalled the substitute memory (e.g., SNORKEL) to help them preclude or supersede awareness of the to-be-avoided memory (e.g., AFRICA) (Hertel and Calcaterra, 2005). Afterward, we tested the mnemonic consequences of these mechanisms by probing retention of the suppressed, recalled, and baseline memories (i.e., items that were initially learned but not encountered during the suppression phase). We gauged the existence of these two opposing neurocognitive mechanisms first by examining whether they are supported by selective engagements of the hypothesized brain structures, and then by determining whether these structures compose functional networks that could mediate voluntary forgetting. Results Behavioral Results Distinct Characteristics of Direct Suppression versus Thought Substitution Debriefing confirmed that the thought substitution group predominantly controlled awareness of the unwanted memories by retrieving the substitutes (Figure 1B). The direct suppression group, by contrast, reported that they controlled awareness by focusing on the reminder as it appeared on the screen while attempting to inhibit the memory. The group differences were significant (substitute focus: t(32) = 10.59, p  recall). These regressors and their interaction term (i.e., the PPI regressor) were estimated at the first level. Contrast images associated with the PPI regressor were then entered into the regression analyses at the second level. SPMs were thresholded at p < 0.05, small-volume FWE corrected for the mid-VLPFC ROI.
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                Author and article information

                Journal
                Neuropsychiatr Dis Treat
                Neuropsychiatr Dis Treat
                Neuropsychiatric Disease and Treatment
                Neuropsychiatric Disease and Treatment
                Dove Medical Press
                1176-6328
                1178-2021
                2016
                13 January 2016
                : 12
                : 143-153
                Affiliations
                Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, VIC, Australia
                Author notes
                Correspondence: Maryam Ejareh dar, Department of Psychiatry, University of Melbourne, Austin Health, Level 10 Lance Townsend Building Austin Hospital, 145 Studley Road, Heidelberg, 3084 VIC, Australia, Tel +61 3 9496 3351, Fax +61 3 9459 0821, Email maryam.ejareh@ 123456unimelb.edu.au
                Article
                ndt-12-143
                10.2147/NDT.S65880
                4716724
                26834476
                0cde66a2-de57-429a-9e4e-8bb5f1def384
                © 2016 Ejareh dar and Kanaan. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Categories
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                Neurology
                conversion disorder,neuroimaging,functional neurology,hysteria,mechanisms
                Neurology
                conversion disorder, neuroimaging, functional neurology, hysteria, mechanisms

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