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Research Letters |

Functional Brain Imaging in a Woman With Spatial Neglect Due to Conversion Disorder FREE

Arnaud Saj, PhD; Shahar Arzy, MD, PhD; Patrik Vuilleumier, MD
JAMA. 2009;302(23):2552-2554. doi:10.1001/jama.2009.1834.
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Published online

To the Editor: Conversion disorder is a neurological disturbance that cannot be attributed to an organic disease but arises from unconscious psychological stress.1 Patients most often present with a motor, sensory, or visual deficit. Other cognitive symptoms such as amnesia, aphasia, or pseudodementia may also occur, but to our knowledge, spatial neglect (lateralized deficits in spatial attention typically following right-brain damage2) has not been reported in relation to conversion.1 We describe a patient who developed a spatial neglect syndrome of conversion origin in whom brain activity was investigated by functional magnetic resonance imaging (fMRI). The patient provided written informed consent for publication of her case, and the study was approved by the ethics committee of Geneva University Hospital.

A 56-year-old right-handed woman came to the hospital emergency department after briefly fainting. She was married with 5 children. She reported experiencing a poor marital relationship for many years but being too dependent on her husband to leave. Shortly after their last child left home, the patient began to develop brief episodes of dizziness and self-described disorientation. One episode occurred on the day of admission and was followed by sudden collapse with transient unresponsiveness but no convulsion.

Neurological examination showed hypoesthesia and weakness of the left arm and leg, sparing the face. Neuropsychological assessment demonstrated left spatial neglect in line-bisection and bell-cancellation tests but no other deficit (testing details available from author). Cerebral MRI, electroencephalogram, and arterial ultrasound findings were normal. Psychiatric interview indicated depressed mood and acute exacerbation of conjugal conflicts. Sensorimotor symptoms disappeared within 5 days, but spatial neglect persisted for more than 20 days and then also remitted. Based on the exclusion of an organic cause and psychiatric evaluation, the patient's deficits were diagnosed as a conversion disorder (consistent with Diagnostic and Statistical Manual of Mental Disorders [Fourth Edition] criteria).

While the patient was experiencing neglect, fMRI was performed during a line-bisection task. The patient was shown premarked lines,3 half correctly centered and half deviated (rightward or leftward), and asked to report whether the bisection mark was placed at the midpoint (testing details available from author). Behavioral performance confirmed neglect signs with more errors for leftward-bisected (72%; 95% confidence interval [CI], 59%-85%) and centrally bisected (96%; 95% CI, 90%-100%) than rightward-bisected lines (20%; 95% CI, 9%-31%). Results from fMRI showed selective activation of the posterior parietal cortex with right predominance when comparing lines with deviated bisection (rightward or leftward) relative to centered bisection, similar to healthy persons performing comparable tasks3 (Figure). These findings indicate that brain systems mediating spatial attention were still differentially recruited by the left and right shifts in attention that were induced by deviated bisection marks, despite the lack of explicit report by the patient. Additional activity was also observed in the anterior cingulate cortex.

Place holder to copy figure label and caption
Figure. Neuroimaging in a Patient Experiencing Left Spatial Neglect Due to Conversion Disorder
Graphic Jump Location

Significant activation was evoked in the left (L) and right (R) intraparietal sulcus (IPS) and anterior cingulate cortex (ACC), indicated by arrows, in response to rightward and leftward shifts of the bisection marks, while there was no significant response to central bisection. A, The significance of functional magnetic resonance imaging (fMRI) activation is indicated by color-coded t values, from the least (red) to the most significant (white); all P ≤ .05 corrected for multiple comparisons. B, Graphs plot the magnitude of event-related fMRI activity in each region of interest (mean beta value) in arbitrary units (with 95% confidence intervals, indicated by error bars) corresponding to parameter estimates of activity at each voxel, calculated by general linear model analysis and averaged across responsive voxels (using SPM2, Wellcome Department of Imaging Neuroscience, London, England; analytic details available from the author). There were no statistically significant differences between findings for left- and right-bisected lines.

The findings of this case, suggesting neglect of conversion origin, indicate that such symptoms may not simply reflect symbolic behavior or beliefs (as postulated by Freud and Breuer1) but appear to affect cognitive processes that can be selectively disconnected from conscious awareness, as observed for neglect after organic lesions.1,2 The fMRI data support this hypothesis by showing preserved activation of parietal cortex (normally recruited by line bisection),3 together with increases in anterior cingulate that might relate to attention,2 conflict between instructions and intentions,1,4 and inhibitory processes specifically related to the production of conversion.5

Automatic shifts of attention in both directions (indicating spontaneous and symmetric responses to lateralized stimuli), combined with no shift of attention when judging centrally bisected stimuli, point to involuntary control of attentional processes in the parietal cortex, consistent with impaired access to conscious control. This study highlights the existence of neglect symptoms due to conversion, demonstrates specific functional neuroanatomical correlates, and confirms and extends previous evidence for increased cingulate activity during conversion with other purely motor symptoms.5,6

Author Contributions: Dr Saj had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Saj, Arzy, Vuilleumier.

Acquisition of data: Saj, Arzy, Vuilleumier.

Analysis and interpretation of data: Saj, Arzy, Vuilleumier.

Drafting of the manuscript: Saj, Arzy, Vuilleumier.

Critical revision of the manuscript for important intellectual content: Saj, Arzy, Vuilleumier.

Statistical analysis: Saj, Arzy, Vuilleumier.

Obtained funding: Vuilleumier.

Financial Disclosures: None reported.

Funding/Support: Dr Saj receives support from the Swiss National Foundation (3200B0-114014).

Role of the Sponsor: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Vuilleumier P. Hysterical conversion and brain function.  Prog Brain Res. 2005;150:309-329
PubMed
Mesulam MM. Spatial attention and neglect: parietal, frontal and cingulate contributions to the mental representation and attentional targeting of salient extrapersonal events.  Philos Trans R Soc Lond B Biol Sci. 1999;354(1387):1325-1346
PubMed   |  Link to Article
Fink GR, Marshall JC, Shah NJ,  et al.  Line bisection judgments implicate right parietal cortex and cerebellum as assessed by fMRI.  Neurology. 2000;54(6):1324-1331
PubMed   |  Link to Article
Aybek S, Kanaan RA, David AS. The neuropsychiatry of conversion disorder.  Curr Opin Psychiatry. 2008;21(3):275-280
PubMed   |  Link to Article
Halligan PW, Athwal BS, Oakley DA, Frackowiak RS. Imaging hypnotic paralysis: implications for conversion hysteria.  Lancet. 2000;355(9208):986-987
PubMed   |  Link to Article
Marshall JC, Halligan PW, Fink GR, Wade DT, Frackowiak RS. The functional anatomy of a hysterical paralysis.  Cognition. 1997;64(1):B1-B8
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure. Neuroimaging in a Patient Experiencing Left Spatial Neglect Due to Conversion Disorder
Graphic Jump Location

Significant activation was evoked in the left (L) and right (R) intraparietal sulcus (IPS) and anterior cingulate cortex (ACC), indicated by arrows, in response to rightward and leftward shifts of the bisection marks, while there was no significant response to central bisection. A, The significance of functional magnetic resonance imaging (fMRI) activation is indicated by color-coded t values, from the least (red) to the most significant (white); all P ≤ .05 corrected for multiple comparisons. B, Graphs plot the magnitude of event-related fMRI activity in each region of interest (mean beta value) in arbitrary units (with 95% confidence intervals, indicated by error bars) corresponding to parameter estimates of activity at each voxel, calculated by general linear model analysis and averaged across responsive voxels (using SPM2, Wellcome Department of Imaging Neuroscience, London, England; analytic details available from the author). There were no statistically significant differences between findings for left- and right-bisected lines.

Tables

References

Vuilleumier P. Hysterical conversion and brain function.  Prog Brain Res. 2005;150:309-329
PubMed
Mesulam MM. Spatial attention and neglect: parietal, frontal and cingulate contributions to the mental representation and attentional targeting of salient extrapersonal events.  Philos Trans R Soc Lond B Biol Sci. 1999;354(1387):1325-1346
PubMed   |  Link to Article
Fink GR, Marshall JC, Shah NJ,  et al.  Line bisection judgments implicate right parietal cortex and cerebellum as assessed by fMRI.  Neurology. 2000;54(6):1324-1331
PubMed   |  Link to Article
Aybek S, Kanaan RA, David AS. The neuropsychiatry of conversion disorder.  Curr Opin Psychiatry. 2008;21(3):275-280
PubMed   |  Link to Article
Halligan PW, Athwal BS, Oakley DA, Frackowiak RS. Imaging hypnotic paralysis: implications for conversion hysteria.  Lancet. 2000;355(9208):986-987
PubMed   |  Link to Article
Marshall JC, Halligan PW, Fink GR, Wade DT, Frackowiak RS. The functional anatomy of a hysterical paralysis.  Cognition. 1997;64(1):B1-B8
PubMed   |  Link to Article
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