Imagine that: elevated sensory strength of mental imagery in individuals with Parkinson's disease and visual hallucinations

Parkinson disease psychosis: from phenomenology to neurobiological mechanisms

Parkinson disease (PD) psychosis (PDP) is a spectrum of illusions, hallucinations and delusions that are associated with PD throughout its disease course. Psychotic phenomena can manifest from the earliest stages of PD and might follow a continuum from minor hallucinations to structured hallucinations and delusions. Initially, PDP was considered to be a complication associated with dopaminergic drug use. However, subsequent research has provided evidence that PDP arises from the progression of brain alterations caused by PD itself, coupled with the use of dopaminergic drugs. The combined dysfunction of attentional control systems, sensory processing, limbic structures, the default mode network and thalamocortical connections provides a conceptual framework to explain how new incoming stimuli are incorrectly categorized, and how aberrant hierarchical predictive processing can produce false percepts that intrude into the stream of consciousness. The past decade has seen the publication of new data on the phenomenology and neurobiological basis of PDP from the initial stages of the disease, as well as the neurotransmitter systems involved in PDP initiation and progression. In this Review, we discuss the latest clinical, neuroimaging and neurochemical evidence that could aid early identification of psychotic phenomena in PD and inform the discovery of new therapeutic targets and strategies.

A novel model of divergent predictive perception

Predictive processing theories state that our subjective experience of reality is shaped by a balance of expectations based on previous knowledge about the world (i.e. priors) and confidence in sensory input from the environment. Divergent experiences (e.g. hallucinations and synaesthesia) are likely to occur when there is an imbalance between one's reliance on priors and sensory input. In a novel theoretical model, inspired by both predictive processing and psychological principles, we propose that predictable divergent experiences are associated with natural or environmentally induced prior/sensory imbalances: inappropriately strong or inflexible (i.e. maladaptive) high-level priors (beliefs) combined with low sensory confidence can result in reality discrimination issues, a characteristic of psychosis; maladaptive low-level priors (sensory expectations) combined with high sensory confidence can result in atypical sensory sensitivities and persistent divergent percepts, a characteristic of synaesthesia. Crucially, we propose that whether different divergent experiences manifest with dominantly sensory (e.g. hallucinations) or nonsensory characteristics (e.g. delusions) depends on mental imagery ability, which is a spectrum from aphantasia (absent or weak imagery) to hyperphantasia (extremely vivid imagery). We theorize that imagery is critically involved in shaping the sensory richness of divergent perceptual experience. In sum, to predict a range of divergent perceptual experiences in both clinical and general populations, three factors must be accounted for: a maladaptive use of priors, individual level of confidence in sensory input, and mental imagery ability. These ideas can be expressed formally using nonparametric regression modeling. We provide evidence for our theory from previous work and deliver predictions for future research.

Abnormal higher-order network interactions in Parkinson's disease visual hallucinations

Visual hallucinations in Parkinson's disease can be viewed from a systems-level perspective, whereby dysfunctional communication between brain networks responsible for perception predisposes a person to hallucinate. To this end, abnormal functional interactions between higher-order and primary sensory networks have been implicated in the pathophysiology of visual hallucinations in Parkinson's disease, however the precise signatures remain to be determined. Dimensionality reduction techniques offer a novel means for simplifying the interpretation of multidimensional brain imaging data, identifying hierarchical patterns in the data that are driven by both within- and between-functional network changes. Here, we applied two complementary non-linear dimensionality reduction techniques-diffusion-map embedding and t-distributed stochastic neighbour embedding (t-SNE)-to resting state functional MRI data, in order to characterize the altered functional hierarchy associated with susceptibility to visual hallucinations. Our study involved 77 people with Parkinson's disease (31 with hallucinations; 46 without hallucinations) and 19 age-matched healthy control subjects. In patients with visual hallucinations, we found compression of the unimodal-heteromodal gradient consistent with increased functional integration between sensory and higher order networks. This was mirrored in a traditional functional connectivity analysis, which showed increased connectivity between the visual and default mode networks in the hallucinating group. Together, these results suggest a route by which higher-order regions may have excessive influence over earlier sensory processes, as proposed by theoretical models of hallucinations across disorders. By contrast, the t-SNE analysis identified distinct alterations in prefrontal regions, suggesting an additional layer of complexity in the functional brain network abnormalities implicated in hallucinations, which was not apparent in traditional functional connectivity analyses. Together, the results confirm abnormal brain organization associated with the hallucinating phenotype in Parkinson's disease and highlight the utility of applying convergent dimensionality reduction techniques to investigate complex clinical symptoms. In addition, the patterns we describe in Parkinson's disease converge with those seen in other conditions, suggesting that reduced hierarchical differentiation across sensory-perceptual systems may be a common transdiagnostic vulnerability in neuropsychiatric disorders with perceptual disturbances.

Where's Wanda? The influence of visual imagery vividness on visual search speed measured by means of hidden object pictures

Previous research demonstrated effects of visual imagery on search speed in visual search paradigms. However, these effects were rather small, questioning their ecological validity. Thus, our present study aimed to generalize these effects to more naturalistic material (i.e., a paradigm that allows for top-down strategies in highly complex visual search displays that include overlapping stimuli while simultaneously avoiding possibly confounding search instructions). One hundred and four participants with aphantasia (= absence of voluntary mental imagery) and 104 gender and age-matched controls were asked to find hidden objects in several hidden object pictures with search times recorded. Results showed that people with aphantasia were significantly slower than controls, even when controlling for age and general processing speed. Thus, effects of visual imagery might be strong enough to influence the perception of our real-life surroundings, probably because of the involvement of visual imagery in several top-down strategies.

Neuropsychiatric symptoms and imbalance of atrophy in behavioral variant frontotemporal dementia

Behavioral variant frontotemporal dementia is characterized by heterogeneous frontal, insular, and anterior temporal atrophy patterns that vary along left-right and dorso-ventral axes. Little is known about how these structural imbalances impact clinical symptomatology. The goal of this study was to assess the frequency of frontotemporal asymmetry (right- or left-lateralization) and dorsality (ventral or dorsal predominance of atrophy) and to investigate their clinical correlates. Neuropsychiatric symptoms and structural images were analyzed for 250 patients with behavioral variant frontotemporal dementia. Frontotemporal atrophy was most often symmetric while left-lateralized (9%) and right-lateralized (17%) atrophy were present in a minority of patients. Atrophy was more often ventral (32%) than dorsal (3%) predominant. Patients with right-lateralized atrophy were characterized by higher severity of abnormal eating behavior and hallucinations compared to those with left-lateralized atrophy. Subsequent analyses clarified that eating behavior was associated with right atrophy to a greater extent than a lack of left atrophy, and hallucinations were driven mainly by right atrophy. Dorsality analyses showed that anxiety, euphoria, and disinhibition correlated with ventral-predominant atrophy. Agitation, irritability, and depression showed greater severity with a lack of regional atrophy, including in dorsal regions. Aberrant motor behavior and apathy were not explained by asymmetry or dorsality. This study provides additional insight into how anatomical heterogeneity influences the clinical presentation of patients with behavioral variant frontotemporal dementia. Behavioral symptoms can be associated not only with the presence or absence of focal atrophy, but also with right/left or dorsal/ventral imbalance of gray matter volume.

Measuring imagery strength in schizophrenia: no evidence of enhanced mental imagery priming

INTRODUCTION

Recent research shows ambivalent results regarding the relationship between mental imagery and schizophrenia. The role of voluntary visual imagery in schizophrenic hallucinations remains unclear. The aim of the study was to investigate the association between visual imagery, schizophrenia, and the occurrence of schizophrenic hallucinations using an objective visual imagery task.

METHODS

The sample consisted of 16 participants with schizophrenia (59.1% female; MAge  = 45.55) and 44 participants without schizophrenia (62.5% female; MAge  = 43.94). Visual imagery was measured using the Vividness of Visual Imagery Questionnaire (VVIQ) as well as the well-validated Binocular Rivalry Task (BRT). Occurrences of hallucinations were assessed using the Launay-Slade Hallucination Scale.

RESULTS

Participants with schizophrenia showed more hallucinatory experiences but did not score higher on either the VVIQ or the BRT than participants without schizophrenia. A correlation between the VVIQ and the BRT was found, validating the measurement of visual imagery and enabling the interpretation that visual imagery vividness is not enhanced in people with schizophrenia.

CONCLUSION

The association between mental imagery vividness and schizophrenia found in previous studies may be based on other facets of mental imagery than visual imagery.

A multicentre study on grey matter morphometric biomarkers for classifying early schizophrenia and parkinson's disease psychosis

Psychotic symptoms occur in a majority of schizophrenia patients and in ~50% of all Parkinson's disease (PD) patients. Altered grey matter (GM) structure within several brain areas and networks may contribute to their pathogenesis. Little is known, however, about transdiagnostic similarities when psychotic symptoms occur in different disorders, such as in schizophrenia and PD. The present study investigated a large, multicenter sample containing 722 participants: 146 patients with first episode psychosis, FEP; 106 individuals in at-risk mental state for developing psychosis, ARMS; 145 healthy controls matching FEP and ARMS, Con-Psy; 92 PD patients with psychotic symptoms, PDP; 145 PD patients without psychotic symptoms, PDN; 88 healthy controls matching PDN and PDP, Con-PD. We applied source-based morphometry in association with receiver operating curves (ROC) analyses to identify common GM structural covariance networks (SCN) and investigated their accuracy in identifying the different patient groups. We assessed group-specific homogeneity and variability across the different networks and potential associations with clinical symptoms. SCN-extracted GM values differed significantly between FEP and Con-Psy, PDP and Con-PD, PDN and Con-PD, as well as PDN and PDP, indicating significant overall grey matter reductions in PD and early schizophrenia. ROC analyses showed that SCN-based classification algorithms allow good classification (AUC ~0.80) of FEP and Con-Psy, and fair performance (AUC ~0.72) when differentiating PDP from Con-PD. Importantly, the best performance was found in partly the same networks, including the thalamus. Alterations within selected SCNs may be related to the presence of psychotic symptoms in both early schizophrenia and PD psychosis, indicating some commonality of underlying mechanisms. Furthermore, results provide evidence that GM volume within specific SCNs may serve as a biomarker for identifying FEP and PDP.

Grey matter volume loss in Parkinson's disease psychosis and its relationship with serotonergic gene expression: A meta-analysis

BACKGROUND

Neuroanatomical alterations underlying psychosis in Parkinson's Disease (PDP) remain unclear. We carried out a meta-analysis of MRI studies investigating the neural correlates of PDP and examined its relation with dopaminergic and serotonergic receptor gene expression.

METHODS

PubMed, Web of Science and Embase were searched for MRI studies (k studies = 10) of PDP compared to PD patients without psychosis (PDnP). Seed-based d Mapping with Permutation of Subject Images and multiple linear regression analyses was used to examine the relationship between pooled estimates of grey matter volume (GMV) loss in PDP and D1/D2 and 5-HT1a/5-HT2a receptor gene expression estimates from Allen Human Brain Atlas.

RESULTS

We observed lower grey matter volume in parietal-temporo-occipital regions (PDP n = 211, PDnP, n = 298). GMV loss in PDP was associated with local expression of 5-HT1a (b = 0.109, p = 0.012) and 5-HT2a receptors (b= -0.106, p = 0.002) but not dopaminergic receptors.

CONCLUSION

Widespread GMV loss in the parieto-temporo-occipital regions may underlie PDP. Association between grey matter volume and local expression of serotonergic receptor genes may suggest a role for serotonergic receptors in PDP.

No common factor for illusory percepts, but a link between pareidolia and delusion tendency: A test of predictive coding theory

Predictive coding theory is an influential view of perception and cognition. It proposes that subjective experience of the sensory information results from a comparison between the sensory input and the top-down prediction about this input, the latter being critical for shaping the final perceptual outcome. The theory is able to explain a wide range of phenomena extending from sensory experiences such as visual illusions to complex pathological states such as hallucinations and psychosis. In the current study we aimed at testing the proposed connection between different phenomena explained by the predictive coding theory by measuring the manifestation of top-down predictions at progressing levels of complexity, starting from bistable visual illusions (alternating subjective experience of the same sensory input) and pareidolias (alternative meaningful interpretation of the sensory input) to self-reports of hallucinations and delusional ideations in everyday life. Examining the correlation structure of these measures in 82 adult healthy subjects revealed a positive association between pareidolia proneness and a tendency for delusional ideations, yet without any relationship to bistable illusions. These results show that only a subset of the phenomena that are explained by the predictive coding theory can be attributed to one common underlying factor. Our findings thus support the hierarchical view of predictive processing with independent top-down effects at the sensory and cognitive levels.

A generative adversarial model of intrusive imagery in the human brain

The mechanisms underlying the subjective experiences of mental disorders remain poorly understood. This is partly due to long-standing over-emphasis on behavioral and physiological symptoms and a de-emphasis of the patient's subjective experiences when searching for treatments. Here, we provide a new perspective on the subjective experience of mental disorders based on findings in neuroscience and artificial intelligence (AI). Specifically, we propose the subjective experience that occurs in visual imagination depends on mechanisms similar to generative adversarial networks that have recently been developed in AI. The basic idea is that a generator network fabricates a prediction of the world, and a discriminator network determines whether it is likely real or not. Given that similar adversarial interactions occur in the two major visual pathways of perception in people, we explored whether we could leverage this AI-inspired approach to better understand the intrusive imagery experiences of patients suffering from mental illnesses such as post-traumatic stress disorder (PTSD) and acute stress disorder. In our model, a nonconscious visual pathway generates predictions of the environment that influence the parallel but interacting conscious pathway. We propose that in some patients, an imbalance in these adversarial interactions leads to an overrepresentation of disturbing content relative to current reality, and results in debilitating flashbacks. By situating the subjective experience of intrusive visual imagery in the adversarial interaction of these visual pathways, we propose testable hypotheses on novel mechanisms and clinical applications for controlling and possibly preventing symptoms resulting from intrusive imagery.

Changes in both top-down and bottom-up effective connectivity drive visual hallucinations in Parkinson's disease

Visual hallucinations are common in Parkinson's disease and are associated with a poorer quality of life and a higher risk of dementia. An important and influential model that is widely accepted as an explanation for the mechanism of visual hallucinations in Parkinson's disease and other Lewy body diseases is that these arise due to aberrant hierarchical processing, with impaired bottom-up integration of sensory information and overweighting of top-down perceptual priors within the visual system. This hypothesis has been driven by behavioural data and supported indirectly by observations derived from regional activation and correlational measures using neuroimaging. However, until now, there was no evidence from neuroimaging for differences in causal influences between brain regions measured in patients with Parkinson's hallucinations. This is in part because previous resting-state studies focused on functional connectivity, which is inherently undirected in nature and cannot test hypotheses about the directionality of connectivity. Spectral dynamic causal modelling is a Bayesian framework that allows the inference of effective connectivity-defined as the directed (causal) influence that one region exerts on another region-from resting-state functional MRI data. In the current study, we utilize spectral dynamic causal modelling to estimate effective connectivity within the resting-state visual network in our cohort of 15 Parkinson's disease visual hallucinators and 75 Parkinson's disease non-visual hallucinators. We find that visual hallucinators display decreased bottom-up effective connectivity from the lateral geniculate nucleus to primary visual cortex and increased top-down effective connectivity from the left prefrontal cortex to primary visual cortex and the medial thalamus, as compared with non-visual hallucinators. Importantly, we find that the pattern of effective connectivity is predictive of the presence of visual hallucinations and associated with their severity within the hallucinating group. This is the first study to provide evidence, using resting-state effective connectivity, to support a model of aberrant hierarchical predictive processing as the mechanism for visual hallucinations in Parkinson's disease.

Changes in dynamic transitions between integrated and segregated states underlie visual hallucinations in Parkinson's disease

Hallucinations are a core feature of psychosis and common in Parkinson's. Their transient, unexpected nature suggests a change in dynamic brain states, but underlying causes are unknown. Here, we examine temporal dynamics and underlying structural connectivity in Parkinson's-hallucinations using a combination of functional and structural MRI, network control theory, neurotransmitter density and genetic analyses. We show that Parkinson's-hallucinators spent more time in a predominantly Segregated functional state with fewer between-state transitions. The transition from integrated-to-segregated state had lower energy cost in Parkinson's-hallucinators; and was therefore potentially preferable. The regional energy needed for this transition was correlated with regional neurotransmitter density and gene expression for serotoninergic, GABAergic, noradrenergic and cholinergic, but not dopaminergic, receptors. We show how the combination of neurochemistry and brain structure jointly shape functional brain dynamics leading to hallucinations and highlight potential therapeutic targets by linking these changes to neurotransmitter systems involved in early sensory and complex visual processing.

The pupillary light response as a physiological index of aphantasia, sensory and phenomenological imagery strength

The pupillary light response is an important automatic physiological response which optimizes light reaching the retina. Recent work has shown that the pupil also adjusts in response to illusory brightness and a range of cognitive functions, however, it remains unclear what exactly drives these endogenous changes. Here, we show that the imagery pupillary light response correlates with objective measures of sensory imagery strength. Further, the trial-by-trial phenomenological vividness of visual imagery is tracked by the imagery pupillary light response. We also demonstrated that a group of individuals without visual imagery (aphantasia) do not show any significant evidence of an imagery pupillary light response, however they do show perceptual pupil light responses and pupil dilation with larger cognitive load. Our results provide evidence that the pupillary light response indexes the sensory strength of visual imagery. This work also provides the first physiological validation of aphantasia.

Mapping brain structural differences and neuroreceptor correlates in Parkinson's disease visual hallucinations

Parkinson's psychosis (PDP) describes a spectrum of symptoms that may arise in Parkinson's disease (PD) including visual hallucinations (VH). Imaging studies investigating the neural correlates of PDP have been inconsistent in their findings, due to differences in study design and limitations of scale. Here we use empirical Bayes harmonisation to pool together structural imaging data from multiple research groups into a large-scale mega-analysis, allowing us to identify cortical regions and networks involved in VH and their relation to receptor binding. Differences of morphometrics analysed show a wider cortical involvement underlying VH than previously recognised, including primary visual cortex and surrounding regions, and the hippocampus, independent of its role in cognitive decline. Structural covariance analyses point to the involvement of the attentional control networks in PD-VH, while associations with receptor density maps suggest neurotransmitter loss may be linked to the cortical changes.

A systematic review on resting state functional connectivity in patients with neurodegenerative disease and hallucinations

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Our review produced ten resting functional magnetic resonance imaging studies.

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Most of the included studies focused on synucleinopathies and visual hallucinations.

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Disrupted Default Mode and attentional networks can be involved in hallucinations.

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The intrusion of predictive processes can be responsible for hallucination phenomena.

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Studies on hallucinations in tauopathies and different sensory modality are needed.

Hallucinations are a complex and multidimensional phenomenon which can differ based on the involved pathology, typology and sensory modality. Hallucinations are common in patients with neurodegenerative diseases. Recent sparse evidence from resting state functional magnetic resonance imaging (rs-fMRI) studies has identified altered functional connectivity in those patients within several brain networks, such as the default mode, attentional and sensory ones, without, however, providing an organized picture of the mechanisms involved. This systematic review, following PRISMA guidelines, aims at critically analyzing the current literature on the brain networks associated with the phenomenon of hallucinations in patients with neurodegenerative diseases. Ten rs-fMRI studies fulfilled our selection criteria. All these studies focused on synucleinopathies, and most of them focused on visual hallucinations and were characterized by a heterogeneous methodology. Thus, instead of offering a definite picture of the mechanisms underlying hallucinations in neurodegeneration, this systematic review encourages further research especially concerning tauopathies. Notwithstanding, the findings overall suggest a disruption in the top-down (associated with memory intrusion and difficulty of inhibition) and in the bottom-up processes (associated with the sensory areas involved in the hallucinations). Further investigations are needed in order to disentangle the brain mechanisms involved in hallucinations and to overcome possible limitations characterizing the current literature.

Individual differences in mental imagery in different modalities and levels of intentionality

Mental imagery is a highly common component of everyday cognitive functioning. While substantial progress is being made in clarifying this fundamental human function, much is still unclear or unknown. A more comprehensive account of mental imagery aspects would be gained by examining individual differences in age, sex, and background experience in an activity and their association with imagery in different modalities and intentionality levels. The current online study combined multiple imagery self-report measures in a sample (n = 279) with a substantial age range (18-65 years), aiming to identify whether age, sex, or background experience in sports, music, or video games were associated with aspects of imagery in the visual, auditory, or motor stimulus modality and voluntary or involuntary intentionality level. The findings show weak positive associations between age and increased vividness of voluntary auditory imagery and decreased involuntary musical imagery frequency, weak associations between being female and more vivid visual imagery, and relations of greater music and video game experience with higher involuntary musical imagery frequency. Moreover, all imagery stimulus modalities were associated with each other, for both intentionality levels, except involuntary musical imagery frequency, which was only related to higher voluntary auditory imagery vividness. These results replicate previous research but also contribute new insights, showing that individual differences in age, sex, and background experience are associated with various aspects of imagery such as modality, intentionality, vividness, and frequency. The study's findings can inform the growing domain of applications of mental imagery to clinical and pedagogical settings.

Knowledge domain and emerging trends in visual hallucination research: A scientometric analysis

BACKGROUND

Visual hallucination (VH) refers to a spontaneous visual perception without corresponding external stimuli and often occurs in ophthalmological and neuropsychiatric disorders. It is associated with poor quality of life, and increased patient hospitalization and nursing home admission. To date, a scientometric analysis of research on VH is lacking.

AIM

To objectively summarize the features of VH research and gain insights into the emerging trends in research on VH.

METHODS

CiteSpace V was used in this article. Publication outputs, document types, geographic distributions, co-authorship status, research hotspots, and co-citation status were analyzed. A total of 2176 original articles and 465 reviews were included in the database downloaded from the Web of Science Core Collection. We selected the top 50 most cited or occurring articles or items to create a visualized network with a 1-year interval. In the document co-citation analysis stage, we performed clustering analysis on co-cited references, and log likelihood tests were used to name the clusters.

RESULTS

The results showed that most publications can be classified into neurology, sports, and ophthalmology studies. In addition, North America, Europe, Asia and Australia published the most documents. Some well-known authors have always had a leading role in this field; meanwhile, new authors keep emerging. A relatively stable cooperation has been formed among many authors. Furthermore, neuropsychiatric symptom and functional connectivity are the top hotspots. Research on VH in dementia with Lewy bodies and Parkinson’s disease (PD) have received much attention. Studies on VH in PD are likely to be the new emerging trends in the future, especially the mechanisms of VH.

CONCLUSION

Research on VH has formed a complete system. More large-scale clinical and in-depth basic research are required to better understand the mechanisms underlying VH, which will contribute to our understanding of the pathophysiology and therapeutic options for VH.

Robot-induced hallucinations in Parkinson's disease depend on altered sensorimotor processing in fronto-temporal network

Hallucinations in Parkinson's disease (PD) are disturbing and frequent non-motor symptoms and constitute a major risk factor for psychosis and dementia. We report a robotics-based approach applying conflicting sensorimotor stimulation, enabling the induction of presence hallucinations (PHs) and the characterization of a subgroup of patients with PD with enhanced sensitivity for conflicting sensorimotor stimulation and robot-induced PH. We next identify the fronto-temporal network of PH by combining MR-compatible robotics (and sensorimotor stimulation in healthy participants) and lesion network mapping (neurological patients without PD). This PH-network was selectively disrupted in an additional and independent cohort of patients with PD, predicted the presence of symptomatic PH, and associated with cognitive decline. These robotics-neuroimaging findings extend existing sensorimotor hallucination models to PD and reveal the pathological cortical sensorimotor processes of PH in PD, potentially indicating a more severe form of PD that has been associated with psychosis and cognitive decline.

Anomalous visual experience is linked to perceptual uncertainty and visual imagery vividness

An imbalance between top-down and bottom-up processing on perception (specifically, over-reliance on top-down processing) can lead to anomalous perception, such as illusions. One factor that may be involved in anomalous perception is visual mental imagery, which is the experience of "seeing" with the mind's eye. There are vast individual differences in self-reported imagery vividness, and more vivid imagery is linked to a more sensory-like experience. We, therefore, hypothesized that susceptibility to anomalous perception is linked to individual imagery vividness. To investigate this, we adopted a paradigm that is known to elicit the perception of faces in pure visual noise (pareidolia). In four experiments, we explored how imagery vividness contributes to this experience under different response instructions and environments. We found strong evidence that people with more vivid imagery were more likely to see faces in the noise, although removing suggestive instructions weakened this relationship. Analyses from the first two experiments led us to explore confidence as another factor in pareidolia proneness. We, therefore, modulated environment noise and added a confidence rating in a novel design. We found strong evidence that pareidolia proneness is correlated with uncertainty about real percepts. Decreasing perceptual ambiguity abolished the relationship between pareidolia proneness and both imagery vividness and confidence. The results cannot be explained by incidental face-like patterns in the noise, individual variations in response bias, perceptual sensitivity, subjective perceptual thresholds, viewing distance, testing environments, motivation, gender, or prosopagnosia. This indicates a critical role of mental imagery vividness and perceptual uncertainty in anomalous perceptual experience.

The Ganzflicker experience: High probability of seeing vivid and complex pseudo-hallucinations with imagery but not aphantasia

There are considerable individual differences in visual mental imagery ability across the general population, including a "blind mind's eye", or aphantasia. Recent studies have shown that imagery is linked to differences in perception in the healthy population, and clinical work has found a connection between imagery and hallucinatory experiences in neurological disorders. However, whether imagery ability is associated with anomalous perception-including hallucinations-in the general population remains unclear. In the current study, we explored the relationship between imagery ability and the anomalous perception of pseudo-hallucinations (PH) using rhythmic flicker stimulation ("Ganzflicker"). Specifically, we investigated whether the ability to generate voluntary imagery is associated with susceptibility to flicker-induced PH. We additionally explored individual differences in observed features of PH. We recruited a sample of people with aphantasia (aphants) and imagery (imagers) to view a constant red-and-black flicker for approximately 10 min. We found that imagers were more susceptible to PH, and saw more complex and vivid PH, compared to aphants. This study provides the first evidence that the ability to generate visual imagery increases the likelihood of experiencing complex and vivid anomalous percepts.

Mistaking imagination for reality: Congruent mental imagery leads to more liberal perceptual detection

Visual experiences can be triggered externally, by signals coming from the outside world during perception; or internally, by signals from memory during mental imagery. Imagery and perception activate similar neural codes in sensory areas, suggesting that they might sometimes be confused. In the current study, we investigated whether imagery influences perception by instructing participants to imagine gratings while externally detecting these same gratings at threshold. In a series of three experiments, we showed that imagery led to a more liberal criterion for reporting stimulus presence, and that this effect was both independent of expectation and stimulus-specific. Furthermore, participants with more vivid imagery were generally more likely to report the presence of external stimuli, independent of condition. The results can be explained as either a low-level sensory or a high-level decision-making effect. We discuss that the most likely explanation is that during imagery, internally generated sensory signals are sometimes confused for perception and suggest how the underlying mechanisms can be further characterized in future research. Our findings show that imagery and perception interact and emphasize that internally and externally generated signals are combined in complex ways to determine conscious perception.

The critical role of mental imagery in human emotion: insights from fear-based imagery and aphantasia

One proposed function of imagery is to make thoughts more emotionally evocative through sensory simulation, which can be helpful both in planning for future events and in remembering the past, but also a hindrance when thoughts become overwhelming and maladaptive, such as in anxiety disorders. Here, we report a novel test of this theory using a special population with no visual imagery: aphantasia. After using multi-method verification of aphantasia, we show that this condition, but not the general population, is associated with a flat-line physiological response (skin conductance levels) to reading and imagining frightening stories. Importantly, we show in a second experiment that this difference in physiological responses to fear-inducing stimuli is not found when perceptually viewing fearful images. These data demonstrate that the aphantasic individuals' lack of a physiological response when imaging scenarios is likely to be driven by their inability to visualize and is not due to a general emotional or physiological dampening. This work provides evidence that a lack of visual imagery results in a dampened emotional response when reading fearful scenarios, providing evidence for the emotional amplification theory of visual imagery.

Why do imagery and perception look and feel so different?

Despite the past few decades of research providing convincing evidence of the similarities in function and neural mechanisms between imagery and perception, for most of us, the experience of the two are undeniably different, why? Here, we review and discuss the differences between imagery and perception and the possible underlying causes of these differences, from function to neural mechanisms. Specifically, we discuss the directional flow of information (top-down versus bottom-up), the differences in targeted cortical layers in primary visual cortex and possible different neural mechanisms of modulation versus excitation. For the first time in history, neuroscience is beginning to shed light on this long-held mystery of why imagery and perception look and feel so different. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Hallucinations on demand: the utility of experimentally induced phenomena in hallucination research

Despite the desire to delve deeper into hallucinations of all types, methodological obstacles have frustrated development of more rigorous quantitative experimental techniques, thereby hampering research progress. Here, we discuss these obstacles and, with reference to visual phenomena, argue that experimentally induced phenomena (e.g. hallucinations induced by flickering light and classical conditioning) can bring hallucinations within reach of more objective behavioural and neural measurement. Expanding the scope of hallucination research raises questions about which phenomena qualify as hallucinations, and how to identify phenomena suitable for use as laboratory models of hallucination. Due to the ambiguity inherent in current hallucination definitions, we suggest that the utility of phenomena for use as laboratory hallucination models should be represented on a continuous spectrum, where suitability varies with the degree to which external sensory information constrains conscious experience. We suggest that existing strategies that group pathological hallucinations into meaningful subtypes based on hallucination characteristics (including phenomenology, disorder and neural activity) can guide extrapolation from hallucination models to other hallucinatory phenomena. Using a spectrum of phenomena to guide scientific hallucination research should help unite the historically separate fields of psychophysics, cognitive neuroscience and clinical research to better understand and treat hallucinations, and inform models of consciousness. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

The Phenomenology and Neurobiology of Visual Distortions and Hallucinations in Schizophrenia: An Update

Schizophrenia is characterized by visual distortions in ~60% of cases, and visual hallucinations (VH) in ~25-50% of cases, depending on the sample. These symptoms have received relatively little attention in the literature, perhaps due to the higher rate of auditory vs. visual hallucinations in psychotic disorders, which is the reverse of what is found in other neuropsychiatric conditions. Given the clinical significance of these perceptual disturbances, our aim is to help address this gap by updating and expanding upon prior reviews. Specifically, we: (1) present findings on the nature and frequency of VH and distortions in schizophrenia; (2) review proposed syndromes of VH in neuro-ophthalmology and neuropsychiatry, and discuss the extent to which these characterize VH in schizophrenia; (3) review potential cortical mechanisms of VH in schizophrenia; (4) review retinal changes that could contribute to VH in schizophrenia; (5) discuss relationships between findings from laboratory measures of visual processing and VH in schizophrenia; and (6) integrate findings across biological and psychological levels to propose an updated model of VH mechanisms, including how their content is determined, and how they may reflect vulnerabilities in the maintenance of a sense of self. In particular, we emphasize the potential role of alterations at multiple points in the visual pathway, including the retina, the roles of multiple neurotransmitters, and the role of a combination of disinhibited default mode network activity and enhanced state-related apical/contextual drive in determining the onset and content of VH. In short, our goal is to cast a fresh light on the under-studied symptoms of VH and visual distortions in schizophrenia for the purposes of informing future work on mechanisms and the development of targeted therapeutic interventions.

Hallucinations as intensified forms of mind-wandering

This paper argues for a novel way of thinking about hallucinations as intensified forms of mind-wandering. Starting from the observation that hallucinations are associated with hyperactive sensory areas underlying the content of hallucinatory experiences and a confusion with regard to the reality of the source of these experiences, the paper first reviews the different factors that might contribute to the impairment of reality monitoring. The paper then focuses on the sensory characteristics determining the vividness of an experience, reviews their relationship to the sensory hyperactivity observed in hallucinations, and investigates under what circumstances they can drive reality judgements. Finally, based on these considerations, the paper presents its main proposal according to which hallucinations are intensified forms of mind-wandering that are amplified along their sensory characteristics, and sketches a possible model of what factors might determine if an internally and involuntarily generated perceptual representation is experienced as a hallucination or as an instance of mind-wandering. This article is part of the theme issue 'Offline perception: voluntary and spontaneous perceptual experiences without matching external stimulation'.

Differences in network controllability and regional gene expression underlie hallucinations in Parkinson's disease

Visual hallucinations are common in Parkinson's disease and are associated with poorer prognosis. Imaging studies show white matter loss and functional connectivity changes with Parkinson's visual hallucinations, but the biological factors underlying selective vulnerability of affected parts of the brain network are unknown. Recent models for Parkinson's disease hallucinations suggest they arise due to a shift in the relative effects of different networks. Understanding how structural connectivity affects the interplay between networks will provide important mechanistic insights. To address this, we investigated the structural connectivity changes that accompany visual hallucinations in Parkinson's disease and the organizational and gene expression characteristics of the preferentially affected areas of the network. We performed diffusion-weighted imaging in 100 patients with Parkinson's disease (81 without hallucinations, 19 with visual hallucinations) and 34 healthy age-matched controls. We used network-based statistics to identify changes in structural connectivity in Parkinson's disease patients with hallucinations and performed an analysis of controllability, an emerging technique that allows quantification of the influence a brain region has across the rest of the network. Using these techniques, we identified a subnetwork of reduced connectivity in Parkinson's disease hallucinations. We then used the Allen Institute for Brain Sciences human transcriptome atlas to identify regional gene expression patterns associated with affected areas of the network. Within this network, Parkinson's disease patients with hallucinations showed reduced controllability (less influence over other brain regions), than Parkinson's disease patients without hallucinations and controls. This subnetwork appears to be critical for overall brain integration, as even in controls, nodes with high controllability were more likely to be within the subnetwork. Gene expression analysis of gene modules related to the affected subnetwork revealed that down-weighted genes were most significantly enriched in genes related to mRNA and chromosome metabolic processes (with enrichment in oligodendrocytes) and upweighted genes to protein localization (with enrichment in neuronal cells). Our findings provide insights into how hallucinations are generated, with breakdown of a key structural subnetwork that exerts control across distributed brain regions. Expression of genes related to mRNA metabolism and membrane localization may be implicated, providing potential therapeutic targets.

A Review of Multimodal Hallucinations: Categorization, Assessment, Theoretical Perspectives, and Clinical Recommendations

Hallucinations can occur in different sensory modalities, both simultaneously and serially in time. They have typically been studied in clinical populations as phenomena occurring in a single sensory modality. Hallucinatory experiences occurring in multiple sensory systems-multimodal hallucinations (MMHs)-are more prevalent than previously thought and may have greater adverse impact than unimodal ones, but they remain relatively underresearched. Here, we review and discuss: (1) the definition and categorization of both serial and simultaneous MMHs, (2) available assessment tools and how they can be improved, and (3) the explanatory power that current hallucination theories have for MMHs. Overall, we suggest that current models need to be updated or developed to account for MMHs and to inform research into the underlying processes of such hallucinatory phenomena. We make recommendations for future research and for clinical practice, including the need for service user involvement and for better assessment tools that can reliably measure MMHs and distinguish them from other related phenomena.

Perceptual Representations and the Vividness of Stimulus-Triggered and Stimulus-Independent Experiences

In recent years, researchers from independent subfields have begun to engage with the idea that the same cortical regions that contribute to on-line perception are recruited during and underlie off-line activities such as information maintenance in working memory, mental imagery, hallucinations, dreaming, and mind wandering. Accumulating evidence suggests that in all of these cases the activity of posterior brain regions provides the contents of experiences. This article is intended to move one step further by exploring specific links between the vividness of experiences, which is a characteristic feature of consciousness regardless of its actual content, and certain properties of the content-specific neural-activity patterns. Investigating the mechanisms that underlie mental imagery and its relation to working memory and the processes responsible for mind wandering and its similarities to dreaming form two clusters of research that are in the forefront of the recent scientific study of mental phenomena, yet communication between these two clusters has been surprisingly sparse. Here our aim is to foster such information exchange by articulating a hypothesis about the fine-grained phenomenological structure determining subjective vividness and its possible neural basis that allows us to shed new light on these mental phenomena by bringing them under a common framework.

A cognitive profile of multi-sensory imagery, memory and dreaming in aphantasia

For most people, visual imagery is an innate feature of many of our internal experiences, and appears to play a critical role in supporting core cognitive processes. Some individuals, however, lack the ability to voluntarily generate visual imagery altogether - a condition termed "aphantasia". Recent research suggests that aphantasia is a condition defined by the absence of visual imagery, rather than a lack of metacognitive awareness of internal visual imagery. Here we further illustrate a cognitive "fingerprint" of aphantasia, demonstrating that compared to control participants with imagery ability, aphantasic individuals report decreased imagery in other sensory domains, although not all report a complete lack of multi-sensory imagery. They also report less vivid and phenomenologically rich autobiographical memories and imagined future scenarios, suggesting a constructive role for visual imagery in representing episodic events. Interestingly, aphantasic individuals report fewer and qualitatively impoverished dreams compared to controls. However, spatial abilities appear unaffected, and aphantasic individuals do not appear to be considerably protected against all forms of trauma symptomatology in response to stressful life events. Collectively, these data suggest that imagery may be a normative representational tool for wider cognitive processes, highlighting the large inter-individual variability that characterises our internal mental representations.

Cortical excitability controls the strength of mental imagery

Mental imagery provides an essential simulation tool for remembering the past and planning the future, with its strength affecting both cognition and mental health. Research suggests that neural activity spanning prefrontal, parietal, temporal, and visual areas supports the generation of mental images. Exactly how this network controls the strength of visual imagery remains unknown. Here, brain imaging and transcranial magnetic phosphene data show that lower resting activity and excitability levels in early visual cortex (V1-V3) predict stronger sensory imagery. Further, electrically decreasing visual cortex excitability using tDCS increases imagery strength, demonstrating a causative role of visual cortex excitability in controlling visual imagery. Together, these data suggest a neurophysiological mechanism of cortical excitability involved in controlling the strength of mental images.

Stronger perceptual filling-in of spatiotemporal information in the blind spot compared with artificial gaps

Complete visual information about a scene and the objects within it is often not available to us. For example, objects may be partly occluded by other objects or have sections missing. In the retinal blind spot, there are no photoreceptors and visual input is not detected. However, owing to perceptual filling-in by the visual system we often do not perceive these gaps. There is a lack of consensus on how much of the mechanism for perceptual filling-in is similar in the case of a natural scotoma, such as the blind spot, and artificial scotomata, such as sections of the stimulus being physically removed. Part of the difficulty in assessing this relationship arises from a lack of direct comparisons between the two cases, with artificial scotomata being tested in different locations in the visual field compared with the blind spot. The peripheral location of the blind spot may explain its enhanced filling-in compared with artificial scotomata, as reported in previous studies. In the present study, we directly compared perceptual filling-in of spatiotemporal information in the blind spot and artificial gaps of the same size and eccentricity. We found stronger perceptual filling-in in the blind spot, suggesting improved filling-in for the blind spot reported in previous studies cannot be simply attributed to its peripheral location.

Towards the interpretation of complex visual hallucinations in terms of self-reorganization of neural networks

Patients suffering from dementia with Lewy body (DLB) often see complex visual hallucinations (CVH). Despite many pathological, clinical, and neuroimaging studies, the mechanism of CVH remains unknown. One possible scenario is that top-down information is being used to compensate for the lack of bottom-up information. To investigate this possibility and understand the underlying mathematical structure of the CVH mechanism, we propose a simple computational model of synaptic plasticity with particular focus on the effect of selective damage to the bottom-up network on self-reorganization. We show neurons that undergo a change in activity from a bottom-up to a top-down network framework during the reorganization process, which can be understood in terms of state transitions. Assuming that the pre-reorganization representation of this neuron remains after reorganization, it is possible to interpret neural response induced by top-down information as the sensation of bottom-up information. This situation might correspond to a hallucinatory situation in DLB patients. Our results agree with existing experimental evidence and provide new insights into data that have hitherto not been experimentally validated on patients with DLB.

Modality-general and modality-specific processes in hallucinations

There is a growing recognition in psychosis research of the importance of hallucinations in modalities other than the auditory. This has focused attention on cognitive and neural processes that might be shared by, and which might contribute distinctly to, hallucinations in different modalities. In this article, I address some issues around the modality-generality of cognitive and neural processes in hallucinations, including the role of perceptual and reality-monitoring systems, top-down and bottom-up processes in relation to the psychological and neural substrates of hallucinations, and the phenomenon of simultaneous multimodal hallucinations of the same entity. I suggest that a functional systems approach, inspired by some neglected aspects of the writings of A. R. Luria, can help us to understand patterns of hallucinatory experience across modalities and across clinical and non-clinical groups. Understanding the interplay between modality-general and modality-specific processes may bear fruit for improved diagnosis and therapeutic approaches to dealing with distressing hallucinations.

Between-subject variability in the influence of mental imagery on conscious perception

Mental imagery and visual perception rely on similar neural mechanisms, but the function of this overlap remains unclear. One idea is that imagery can influence perception. Previous research has shown that imagining a stimulus prior to binocular presentation of rivalling stimuli increases the chance of perceiving the imagined stimulus. In this study we investigated how this effect interacts with bottom-up sensory input by comparing psychometric response curves for congruent and incongruent imagery in humans. A Bayesian hierarchical model was used, allowing us to simultaneously study group-level effects as well as effects for individual participants. We found strong effects of both imagery as well as its interaction with sensory evidence within individual participants. However, the direction of these effects were highly variable between individuals, leading to weak effects at the group level. This highlights the heterogeneity of conscious perception and emphasizes the need for individualized investigation of such complex cognitive processes.

Imaging behavioural complications of Parkinson's disease

In addition to motor symptoms, behavioural complications are commonly found in patients with Parkinson's disease (PD). Behavioural complications, including depression, anxiety, apathy, impulse control disorder and psychosis, together have a large impact on PD patient's quality of life. Many neuroimaging studies using PET, SPECT and MRI techniques have been conducted to study the underlying neural mechanisms of PD pathogenesis and pathophysiology in relation to its behavioural complications. This review will survey these PET, SPECT and MRI studies to describe the current understanding of the neuro-chemical, functional and structural changes associated with behavioural complications in PD patients.

A look into hallucinations: the relationship between visual imagery and hallucinations in Alzheimer's disease

Introduction: We investigated the relationship between visual hallucinations and vividness of visual imagery in patients with Alzheimer's disease (AD). Method: We recruited 28 patients with AD and 30 healthy control participants, matched for age and education. We evaluated proneness towards hallucinations with the Launay-Slade Hallucinations Scale, which includes items assessing visual and auditory hallucinations. We also evaluated vividness of visual imagery with the Vividness of Visual Imagery Questionnaire on which participants had to imagine four images (i.e., imagining the face of a friend, the rising sun, a familiar shop-front, and a country scene) and report the vividness of the images they generated. Results: Analysis demonstrated significant positive correlations between visual hallucinations and vividness of visual imagery in AD patients, however, no significant correlations were observed between auditory hallucinations and vividness of visual imagery in these participants. No significant correlations were observed between hallucinations and vividness of visual imagery in healthy control participants, probably due to the lack of hallucinations in these participants. Discussion: These results demonstrate a selective relationship between the occurrence of visual (but not auditory) hallucinations and the ability to generate vivid visual images in AD.

Disruption of the default mode network and its intrinsic functional connectivity underlies minor hallucinations in Parkinson's disease

BACKGROUND

Minor hallucinations and well-structured hallucinations are considered in the severity continuum of the psychotic spectrum associated with Parkinson's disease. Although their chronological relationship is largely unknown, the spatial patterns of brain atrophy in these 2 forms of hallucinations partially overlap, suggesting they share similar pathophysiological processes. Functional connectivity studies show that disruption of functional networks involved in perception and attention could be relevant in the emergence of well-structured hallucinations. However, functional neuroimaging studies in patients with isolated minor hallucinations are lacking. The objectives of this study were to explore the structural and functional changes underlying minor hallucinations.

METHODS

We compared patients with (n = 18) and without (n = 14) minor hallucinations using a multimodal structural (gray-matter volume voxel-based morphometry) and functional (seed-to-whole-brain resting-state functional MRI) neuroimaging study.

RESULTS

Coincident with previously described structural changes in well-structured hallucinations in Parkinson's disease, patients with minor hallucinations exhibited gray-matter atrophy with significant voxel-wise differences in visuoperceptual processing areas and core regions of the default mode network. Functional connectivity changes consisted of altered connectivity within the default mode network, reduced negative correlation with task-positive network, and aberrant connectivity between posterior regions of the default mode network and visual-processing areas. These changes are in accordance with the attentional networks hypothesis proposed for well-structured hallucinations.

CONCLUSIONS

Although longitudinal studies are needed to assess the potential role of minor hallucinations as an early clinical biomarker of progression to well-structured hallucinations, the present findings show that the 2 phenomena share similar structural and functional brain correlates. © 2018 International Parkinson and Movement Disorder Society.

The blind mind: No sensory visual imagery in aphantasia

For most people the use of visual imagery is pervasive in daily life, but for a small group of people the experience of visual imagery is entirely unknown. Research based on subjective phenomenology indicates that otherwise healthy people can completely lack the experience of visual imagery, a condition now referred to as aphantasia. As congenital aphantasia has thus far been based on subjective reports, it remains unclear whether individuals are really unable to imagine visually, or if they have very poor metacognition - they have images in their mind, but are blind to them. Here we measured sensory imagery in subjectively self-diagnosed aphantasics, using the binocular rivalry paradigm, as well as measuring their self-rated object and spatial imagery with multiple questionnaires (VVIQ, SUIS and OSIQ). Unlike, the general population, experimentally naive aphantasics showed almost no imagery-based rivalry priming. Aphantasic participants' self-rated visual object imagery was significantly below average, however their spatial imagery scores were above average. These data suggest that aphantasia is a condition involving a lack of sensory and phenomenal imagery, and not a lack of metacognition. The possible underlying neurological cause of aphantasia is discussed as well as future research directions.

Structural and Functional Neuroimaging of Visual Hallucinations in Lewy Body Disease: A Systematic Literature Review

Patients with Lewy body disease (LBD) frequently experience visual hallucinations (VH), well-formed images perceived without the presence of real stimuli. The structural and functional brain mechanisms underlying VH in LBD are still unclear. The present review summarises the current literature on the neural correlates of VH in LBD, namely Parkinson's disease (PD), and dementia with Lewy bodies (DLB). Following a systematic literature search, 56 neuroimaging studies of VH in PD and DLB were critically reviewed and evaluated for quality assessment. The main structural neuroimaging results on VH in LBD revealed grey matter loss in frontal areas in patients with dementia, and parietal and occipito-temporal regions in PD without dementia. Parietal and temporal hypometabolism was also reported in hallucinating PD patients. Disrupted functional connectivity was detected especially in the default mode network and fronto-parietal regions. However, evidence on structural and functional connectivity is still limited and requires further investigation. The current literature is in line with integrative models of VH suggesting a role of attention and perception deficits in the development of VH. However, despite the close relationship between VH and cognitive impairment, its associations with brain structure and function have been explored only by a limited number of studies.

Remembering verbally-presented items as pictures: Brain activity underlying visual mental images in schizophrenia patients with visual hallucinations

BACKGROUND

Previous research suggests that visual hallucinations in schizophrenia consist of mental images mistaken for percepts due to failure of the reality-monitoring processes. However, the neural substrates that underpin such dysfunction are currently unknown. We conducted a brain imaging study to investigate the role of visual mental imagery in visual hallucinations.

METHOD

Twenty-three patients with schizophrenia and 26 healthy participants were administered a reality-monitoring task whilst undergoing an fMRI protocol. At the encoding phase, a mixture of pictures of common items and labels designating common items were presented. On the memory test, participants were requested to remember whether a picture of the item had been presented or merely its label.

RESULTS

Visual hallucination scores were associated with a liberal response bias reflecting propensity to erroneously remember pictures of the items that had in fact been presented as words. At encoding, patients with visual hallucinations differentially activated the right fusiform gyrus when processing the words they later remembered as pictures, which suggests the formation of visual mental images. On the memory test, the whole patient group activated the anterior cingulate and medial superior frontal gyrus when falsely remembering pictures. However, no differential activation was observed in patients with visual hallucinations, whereas in the healthy sample, the production of visual mental images at encoding led to greater activation of a fronto-parietal decisional network on the memory test.

CONCLUSIONS

Visual hallucinations are associated with enhanced visual imagery and possibly with a failure of the reality-monitoring processes that enable discrimination between imagined and perceived events.

The psychosis spectrum in Parkinson disease

In 2007, the clinical and research profile of illusions, hallucinations, delusions and related symptoms in Parkinson disease (PD) was raised with the publication of a consensus definition of PD psychosis. Symptoms that were previously deemed benign and clinically insignificant were incorporated into a continuum of severity, leading to the rapid expansion of literature focusing on clinical aspects, mechanisms and treatment. Here, we review this literature and the evolving view of PD psychosis. Key topics include the prospective risk of dementia in individuals with PD psychosis, and the causal and modifying effects of PD medication. We discuss recent developments, including recognition of an increase in the prevalence of psychosis with disease duration, addition of new visual symptoms to the psychosis continuum, and identification of frontal executive, visual perceptual and memory dysfunction at different disease stages. In addition, we highlight novel risk factors - for example, autonomic dysfunction - that have emerged from prospective studies, structural MRI evidence of frontal, parietal, occipital and hippocampal involvement, and approval of pimavanserin for the treatment of PD psychosis. The accumulating evidence raises novel questions and directions for future research to explore the clinical management and biomarker potential of PD psychosis.

Predictions penetrate perception: Converging insights from brain, behaviour and disorder

It is argued that during ongoing visual perception, the brain is generating top-down predictions to facilitate, guide and constrain the processing of incoming sensory input. Here we demonstrate that these predictions are drawn from a diverse range of cognitive processes, in order to generate the richest and most informative prediction signals. This is consistent with a central role for cognitive penetrability in visual perception. We review behavioural and mechanistic evidence that indicate a wide spectrum of domains-including object recognition, contextual associations, cognitive biases and affective state-that can directly influence visual perception. We combine these insights from the healthy brain with novel observations from neuropsychiatric disorders involving visual hallucinations, which highlight the consequences of imbalance between top-down signals and incoming sensory information. Together, these lines of evidence converge to indicate that predictive penetration, be it cognitive, social or emotional, should be considered a fundamental framework that supports visual perception.

Visual dysfunction in Parkinson's disease

Patients with Parkinson's disease have a number of specific visual disturbances. These include changes in colour vision and contrast sensitivity and difficulties with complex visual tasks such as mental rotation and emotion recognition. We review changes in visual function at each stage of visual processing from retinal deficits, including contrast sensitivity and colour vision deficits to higher cortical processing impairments such as object and motion processing and neglect. We consider changes in visual function in patients with common Parkinson's disease-associated genetic mutations including GBA and LRRK2 . We discuss the association between visual deficits and clinical features of Parkinson's disease such as rapid eye movement sleep behavioural disorder and the postural instability and gait disorder phenotype. We review the link between abnormal visual function and visual hallucinations, considering current models for mechanisms of visual hallucinations. Finally, we discuss the role of visuo-perceptual testing as a biomarker of disease and predictor of dementia in Parkinson's disease.