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Wei LC, Sung CH. Expanding Perspectives on Visual Mental Imagery in Autism: Aphantasia, Enhanced Abilities, and Future Directions. Autism Res 2025. [PMID: 39887955 DOI: 10.1002/aur.3311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2024] [Revised: 12/18/2024] [Accepted: 01/09/2025] [Indexed: 02/01/2025]
Affiliation(s)
- Lien-Chung Wei
- Department of Addiction Psychiatry, Republic of China Ministry of Health and Welfare, Taoyuan City, Taiwan
| | - Cheng-Hsien Sung
- Department of Child and Adolescent Psychiatry, Taoyuan Psychiatric Center, Republic of China Ministry of Health and Welfare, Taoyuan City, Taiwan
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2
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Reeder RR, Sala G, van Leeuwen TM. A novel model of divergent predictive perception. Neurosci Conscious 2024; 2024:niae006. [PMID: 38348335 PMCID: PMC10860603 DOI: 10.1093/nc/niae006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/15/2024] Open
Abstract
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.
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Affiliation(s)
- Reshanne R Reeder
- Department of Psychology, Institute of Population Health, University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - Giovanni Sala
- Department of Psychology, Institute of Population Health, University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - Tessa M van Leeuwen
- Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
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Taylor MJ, van Leeuwen TM, Kuja-Halkola R, Lundström S, Larsson H, Lichtenstein P, Bölte S, Neufeld J. Genetic and environmental architecture of synaesthesia and its association with the autism spectrum-a twin study. Proc Biol Sci 2023; 290:20231888. [PMID: 37876199 PMCID: PMC10598415 DOI: 10.1098/rspb.2023.1888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/26/2023] [Indexed: 10/26/2023] Open
Abstract
Synaesthesia is a sensory phenomenon where external stimuli, such as sounds or letters, trigger additional sensations (e.g. colours). Synaesthesia aggregates in families but its heritability is unknown. The phenomenon is more common in people on the autism spectrum compared with the general population and associated with higher autistic traits. Using classical twin design, we assessed the heritability of individual differences in self-reported synaesthesia and the genetic and environmental contributions to their association with autistic traits within a population twin cohort (n = 4262, age = 18 years). We estimated individual differences in synaesthesia to be heritable and influenced by environmental factors not shared between twins. The association between individual differences in synaesthesia and autistic traits was estimated to be predominantly under genetic influence and seemed to be mainly driven by non-social autistic traits (repetitive behaviours, restricted interests and attention to detail). Our study suggests that the link between synaesthesia and autism might reside in shared genetic causes, related to non-social autistic traits such as alterations in perception. Future studies building on these findings may attempt to identify specific groups of genes that influence both autism, synaesthesia and perception.
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Affiliation(s)
- Mark J. Taylor
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17165 Stockholm, Sweden
| | - Tessa M. van Leeuwen
- Tilburg School of Humanities and Digital Sciences, Department of Communication and Cognition, Tilburg University, 5037 AB Tilburg, The Netherlands
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, 6525 XZ Nijmegen, The Netherlands
| | - Ralf Kuja-Halkola
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17165 Stockholm, Sweden
| | - Sebastian Lundström
- Gillberg Neuropsychiatry Centre, Centre for Ethics, Law and Mental Health, University of Gothenburg, 405 30 Gothenburg, Sweden
| | - Henrik Larsson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17165 Stockholm, Sweden
- School of Medical Sciences, Örebro University, 70281 Örebro, Sweden
| | - Paul Lichtenstein
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, 17165 Stockholm, Sweden
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, 11364 Stockholm, Sweden
- Curtin Autism Research Group, Curtin School of Allied Health, Curtin University, WA 66102 Perth, Western Australia
- Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm, 11364 Stockholm, Sweden
| | - Janina Neufeld
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet, Stockholm Health Care Services, Region Stockholm, 11364 Stockholm, Sweden
- Swedish Collegium for Advanced Study (SCAS), 75238 Uppsala, Sweden
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Abstract
INTRODUCTION This study determines whether there is a familial aggregation between synaesthesia and two neuropsychiatric conditions (autism and schizophrenia). METHOD We examined the prevalence of autism and schizophrenia among synaesthetes and non-synaesthetic controls, and among their first-degree relatives. RESULTS As predicted, autism occurred at elevated levels among synaesthetes and-we document for the first time-amongst their relatives. This was not found for schizophrenia, where a link may be expected, or in a control condition (type 1 diabetes) where we had no a priori reason to assume a link. Synaesthetes, compared to controls, were also more likely to have other synaesthetes in their family. People with three or more types of synaesthesia were more likely (compared to synaesthetes with fewer types) to have synaesthetic relatives and to report autism in themselves. People with two or more types of synaesthesia (compared to synaesthetes with only one type) were more likely to report familial autism. CONCLUSIONS The results suggest a shared genetic predisposition between synaesthesia and autism, and more extreme synaesthetes may tend to hail from more neurodiverse families.
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Affiliation(s)
- Max Nugent
- School of Psychology University of Sussex, Brighton, UK
| | - Jamie Ward
- School of Psychology University of Sussex, Brighton, UK
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van Leeuwen TM, Wilsson L, Norrman HN, Dingemanse M, Bölte S, Neufeld J. Perceptual processing links autism and synesthesia: A co-twin control study. Cortex 2021; 145:236-249. [PMID: 34763130 DOI: 10.1016/j.cortex.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 05/21/2021] [Accepted: 09/02/2021] [Indexed: 11/19/2022]
Abstract
Synesthesia occurs more commonly in individuals fulfilling criteria for an autism spectrum diagnosis than in the general population. It is associated with autistic traits and autism-related perceptual processing characteristics, including a more detail-focused attentional style and altered sensory sensitivity. In addition, these characteristics correlate with the degree of grapheme-color synesthesia (consistency of grapheme-color associations) in non-synesthetes. We investigated a predominantly non-synesthetic twin sample, including individuals fulfilling criteria for an autism spectrum diagnosis or other neurodevelopmental disorders (n = 65, 14-34 years, 60% female). We modelled linear relationships between the degree of grapheme-color synesthesia and autistic traits, sensory sensitivity, and visual perception, both within-twin pairs (22 pairs) where all factors shared by twins are implicitly controlled (including 50-100% genetics), and across the entire cohort. We found that the degree of grapheme-color synesthesia was associated with autistic traits within the domain of Attention to Details and with sensory hyper-, but not hypo-sensitivity. These associations were stronger within-twin pairs than across the sample. Further, twins with a higher degree of grapheme-color synesthesia were better than their co-twins at identifying fragmented images (Fragmented Pictures Test). This is the first twin study on the association between synesthesia and autism-related perceptual features and traits. The results suggest that investigating these associations within-twin pairs, implicitly adjusting for potential confounding factors shared by twins, is more sensitive than doing so in non-related individuals. Consistent with previous findings, the results suggest an association between the degree of grapheme-color synesthesia and autism-related perceptual features, while utilizing a different measure for sensory sensitivity. The novel finding of enhanced fragmented picture integration in twins with a higher degree of grapheme-color synesthesia challenges the view of a generally more detail-focused attentional style in synesthesia and might be related to enhanced memory or mental imagery in more synesthetic individuals.
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Affiliation(s)
- Tessa M van Leeuwen
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Department of Communication and Cognition, Tilburg School of Humanities and Digital Sciences, Tilburg University, Tilburg, the Netherlands
| | - Lowe Wilsson
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Hjalmar Nobel Norrman
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Mark Dingemanse
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands; Centre for Language Studies, Radboud University, Nijmegen, the Netherlands
| | - Sven Bölte
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Child and Adolescent Psychiatry, Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden; Curtin Autism Research Group, Curtin School of Allied Health, Curtin University, Perth, WA, Australia
| | - Janina Neufeld
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden.
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Ward J. Synaesthesia as a model system for understanding variation in the human mind and brain. Cogn Neuropsychol 2021; 38:259-278. [PMID: 34266374 DOI: 10.1080/02643294.2021.1950133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The aim of this article is to reposition synaesthesia as model system for understanding variation in the construction of the human mind and brain. People with synaesthesia inhabit a remarkable mental world in which numbers can be coloured, words can have tastes, and music is a visual spectacle. Key questions remain unanswered about why it exists, and how the study of synaesthesia might inform theories of the human mind. This article argues we need to rethink synaesthesia as not just representing exceptional experiences, but as a product of an unusual neurodevelopmental cascade from genes to brain to cognition of which synaesthesia is only one outcome. Specifically, differences in the brains of synaesthetes support a distinctive way of thinking (enhanced memory, imagery etc.) and may also predispose towards particular clinical vulnerabilities. In effect, synaesthesia can act as a paradigmatic example of a neuropsychological approach to individual differences.
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Affiliation(s)
- Jamie Ward
- School of Psychology, University of Sussex, Brighton, UK
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Lungu L, Rothen N, Terhune DB. The time course of synaesthetic colour perception. Cortex 2021; 141:322-330. [PMID: 34126287 DOI: 10.1016/j.cortex.2021.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 01/31/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
Grapheme-colour synaesthesia is a neurodevelopmental condition wherein perception of numbers and letters consistently and involuntarily elicits concurrent experiences of colour photisms. Accumulating evidence suggests that heterogeneity in the visuospatial phenomenology of synaesthesia is attributable to the operation of top-down processes underlying photisms experienced as representations in associator synaesthetes and bottom-up processes subserving photisms experienced as spatially localized in projector synaesthetes. An untested corollary of this hypothesis is that bottom-up mechanisms will actuate earlier photism perception in projector than associator synaesthetes. We tested this prediction in a pre-registered study wherein associators and projectors completed adaptive temporal order judgement tasks for graphemes, colours, and photisms. In corroboration of the hypothesis of differential photism access across subtypes, projectors displayed lower photism colour thresholds than associators whereas the two subtypes did not significantly differ in veridical colour thresholds. Synaesthetes did not differ in grapheme or colour thresholds relative to non-synaesthete controls. These results are consistent with the proposal of differential neural mechanisms underlying photism perception in subtypes of grapheme-colour synaesthesia and warrant renewed attention to heterogeneity in the mechanisms and phenomenology of this condition.
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Affiliation(s)
- Laura Lungu
- Department of Psychology, Goldsmiths, University of London, UK
| | - Nicolas Rothen
- Faculty of Psychology, Swiss Distance University Institute, Brig, Switzerland
| | - Devin B Terhune
- Department of Psychology, Goldsmiths, University of London, UK.
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Benítez-Burraco A, Progovac L. Language evolution: examining the link between cross-modality and aggression through the lens of disorders. Philos Trans R Soc Lond B Biol Sci 2021; 376:20200188. [PMID: 33745319 PMCID: PMC8059641 DOI: 10.1098/rstb.2020.0188] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/12/2022] Open
Abstract
We demonstrate how two linguistic phenomena, figurative language (implicating cross-modality) and derogatory language (implicating aggression), both demand a precise degree of (dis)inhibition in the same cortico-subcortical brain circuits, in particular cortico-striatal networks, whose connectivity has been significantly enhanced in recent evolution. We examine four cognitive disorders/conditions that exhibit abnormal patterns of (dis)inhibition in these networks: schizophrenia (SZ), autism spectrum disorder (ASD), synaesthesia and Tourette's syndrome (TS), with the goal of understanding why the two phenomena altered reactive aggression and altered cross-modality cluster together in these disorders. Our proposal is that enhanced cross-modality (necessary to support language, in particular metaphoricity) was a result, partly a side-effect, of self-domestication (SD). SD targeted the taming of reactive aggression, but reactive impulses are controlled by the same cortico-subcortical networks that are implicated in cross-modality. We further add that this biological process of SD did not act alone, but was engaged in an intense feedback loop with the cultural emergence of early forms of language/grammar, whose high degree of raw metaphoricity and verbal aggression also contributed to increased brain connectivity and cortical control. Consequently, in conjunction with linguistic expressions serving as approximations/'fossils' of the earliest stages of language, these cognitive disorders/conditions serve as confident proxies of brain changes in language evolution, helping us reconstruct certain crucial aspects of early prehistoric languages and cognition, as well as shed new light on the nature of the disorders. This article is part of the theme issue 'Reconstructing prehistoric languages'.
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Affiliation(s)
- Antonio Benítez-Burraco
- Department of Spanish, Linguistics and Theory of Literature (Linguistics), Faculty of Philology, University of Seville, Seville, Spain
| | - Ljiljana Progovac
- Linguistics Program, Department of English, Wayne State University, Detroit, MI, USA
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van Leeuwen TM, Sauer A, Jurjut AM, Wibral M, Uhlhaas PJ, Singer W, Melloni L. Perceptual Gains and Losses in Synesthesia and Schizophrenia. Schizophr Bull 2020; 47:722-730. [PMID: 33150444 PMCID: PMC8084450 DOI: 10.1093/schbul/sbaa162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Individual differences in perception are widespread. Considering inter-individual variability, synesthetes experience stable additional sensations; schizophrenia patients suffer perceptual deficits in, eg, perceptual organization (alongside hallucinations and delusions). Is there a unifying principle explaining inter-individual variability in perception? There is good reason to believe perceptual experience results from inferential processes whereby sensory evidence is weighted by prior knowledge about the world. Perceptual variability may result from different precision weighting of sensory evidence and prior knowledge. We tested this hypothesis by comparing visibility thresholds in a perceptual hysteresis task across medicated schizophrenia patients (N = 20), synesthetes (N = 20), and controls (N = 26). Participants rated the subjective visibility of stimuli embedded in noise while we parametrically manipulated the availability of sensory evidence. Additionally, precise long-term priors in synesthetes were leveraged by presenting either synesthesia-inducing or neutral stimuli. Schizophrenia patients showed increased visibility thresholds, consistent with overreliance on sensory evidence. In contrast, synesthetes exhibited lowered thresholds exclusively for synesthesia-inducing stimuli suggesting high-precision long-term priors. Additionally, in both synesthetes and schizophrenia patients explicit, short-term priors-introduced during the hysteresis experiment-lowered thresholds but did not normalize perception. Our results imply that perceptual variability might result from differences in the precision afforded to prior beliefs and sensory evidence, respectively.
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Affiliation(s)
- Tessa M van Leeuwen
- Department of Neurophysiology, Max Planck Institute for Brain Research, Frankfurt am Main, Germany,Ernst Strüngmann Institute (ESI) for Neuroscience in Cooperation with Max Planck Society, Frankfurt am Main, Germany,Radboud University, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, the Netherlands
| | - Andreas Sauer
- Department of Neurophysiology, Max Planck Institute for Brain Research, Frankfurt am Main, Germany,Ernst Strüngmann Institute (ESI) for Neuroscience in Cooperation with Max Planck Society, Frankfurt am Main, Germany
| | - Anna-Maria Jurjut
- Department of Neurophysiology, Max Planck Institute for Brain Research, Frankfurt am Main, Germany
| | - Michael Wibral
- Magnetoencephalography Unit, Brain Imaging Center, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Peter J Uhlhaas
- Department of Neurophysiology, Max Planck Institute for Brain Research, Frankfurt am Main, Germany,Institute of Neuroscience and Psychology, University of Glasgow, Scotland,Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Wolf Singer
- Department of Neurophysiology, Max Planck Institute for Brain Research, Frankfurt am Main, Germany,Ernst Strüngmann Institute (ESI) for Neuroscience in Cooperation with Max Planck Society, Frankfurt am Main, Germany,Frankfurt Institute for Advanced Studies, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Lucia Melloni
- Department of Neurophysiology, Max Planck Institute for Brain Research, Frankfurt am Main, Germany,Department of Neurology, New York University School of Medicine, New York, NY,Department of Neuroscience, Max Planck Institute for Empirical Aesthetics, Frankfurt am Main, Germany,To whom correspondence should be addressed; Max-Planck-Institute for Empirical Aesthetics, Department of Neuroscience, Grüneburgweg 14, 60322 Frankfurt am Main, Germany. tel: +49 (0)69-8300479-330, fax: +49 69 8300 479 399, e-mail:
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van Leeuwen TM, Neufeld J, Hughes J, Ward J. Synaesthesia and autism: Different developmental outcomes from overlapping mechanisms? Cogn Neuropsychol 2020; 37:433-449. [PMID: 32845799 DOI: 10.1080/02643294.2020.1808455] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Synaesthesia, a mixing of the senses, is more common in individuals with autism. Here, we review the evidence for the association between synaesthesia and autism with regard to their genetic background, brain connectivity, perception, cognitive mechanisms and their contribution to exceptional talents. Currently, the overlap between synaesthesia and autism is established most convincingly at the level of alterations in sensory sensitivity and perception, with synaesthetes showing autism-like profiles of sensory sensitivity and a bias towards details in perception. Shared features may include a predominance of local over global connectivity in the brain. When autism and synaesthesia co-occur in the same individual, the chance of developing heightened cognitive and memory abilities is increased. We discuss how the same theoretical models could potentially explain both conditions. Given the evidence, we believe the phenotypical overlap between autism and synaesthesia has been established clearly enough to invite future research to confirm overlapping mechanisms.
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Affiliation(s)
- Tessa M van Leeuwen
- Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, the Netherlands
| | - Janina Neufeld
- Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research, Department of Women's and Children's Health, Karolinska Institutet & Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - James Hughes
- School of Psychology, University of Sussex, Brighton, UK
| | - Jamie Ward
- School of Psychology, University of Sussex, Brighton, UK
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Fisher SE, Tilot AK. Bridging senses: novel insights from synaesthesia. Philos Trans R Soc Lond B Biol Sci 2019; 374:20190022. [PMID: 31630657 DOI: 10.1098/rstb.2019.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Simon E Fisher
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The Netherlands
| | - Amanda K Tilot
- Language and Genetics Department, Max Planck Institute for Psycholinguistics, Nijmegen, The Netherlands.,Imaging Genetics Center, Mark and Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA
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