Early effects of exposure-based cognitive behaviour therapy on the neural correlates of anxiety

Exposure-based cognitive-behaviour therapy (CBT) for anxiety disorders is an effective intervention, but the brain mechanisms driving recovery are largely unknown. In this experimental medicine study, we investigated to what degree CBT affects neural markers of anxiety at an early stage of treatment, to identify dynamic mechanistic changes which might be crucial in the process of recovery as opposed to those seen following full treatment completion. In a randomised controlled trial, unmedicated patients with panic disorder either received four weekly sessions of exposure-based CBT (N = 14) or were allocated to a waiting group (N = 14). Symptom severity was measured before and after the intervention. During functional magnetic resonance imaging (fMRI), patients performed an emotion regulation task, either viewing negative images naturally, or intentionally down-regulating negative affect using previously taught strategies. Four-session CBT led to marked reductions in symptoms and 71% of patients reached recovery status (versus 7% in the control group). This intervention normalised brain hyperactivation previously seen in panic disorder, particularly in areas linked to threat monitoring, fear memory, and maladaptive emotion regulation, such as amygdala, dorsomedial and dorsolateral prefrontal cortex, and temporal gyrus. Our findings suggest that optimal treatment doses for panic disorder might be much lower than previously thought. Furthermore, this is the first study to show that neural markers of anxiety change very early during CBT, highlighting potential neural mechanisms that might drive clinical recovery. Such knowledge is important for the development of more compact combination treatments targeting these mechanisms more effectively. (Neural Effects of Cognitive-behaviour Therapy in Panic Disorder; clinicaltrials.gov; NCT03251235).

Vestibular inputs to human motion-sensitive visual cortex

Two crucial sources of information available to an organism when moving through an environment are visual and vestibular stimuli. Macaque cortical area MSTd processes visual motion, including cues to self-motion arising from optic flow and also receives information about self-motion from the vestibular system. In humans, whether human MST (hMST) receives vestibular afferents is unknown. We have combined 2 techniques, galvanic vestibular stimulation and functional MRI (fMRI), to show that hMST is strongly activated by vestibular stimulation in darkness, whereas adjacent area MT is unaffected. The activity cannot be explained in terms of somatosensory stimulation at the electrode site. Vestibular input appears to be confined to the anterior portion of hMST, suggesting that hMST as conventionally defined may contain 2 subregions. Vestibular activity was also seen in another area previously implicated in processing visual cues to self-motion, namely the cingulate sulcus visual area (CSv), but not in visual area V6. The results suggest that cross-modal convergence of cues to self-motion occurs in both hMST and CSv.

Spatial attention changes excitability of human visual cortex to direct stimulation

Conscious perception depends not only on sensory input, but also on attention [1, 2]. Recent studies in monkeys [3-6] and humans [7-12] suggest that influences of spatial attention on visual awareness may reflect top-down influences on excitability of visual cortex. Here we tested this specifically, by providing direct input into human visual cortex via cortical transcranial magnetic stimulation (TMS) to produce illusory visual percepts, called phosphenes. We found that a lower TMS intensity was needed to elicit a conscious phosphene when its apparent spatial location was attended, rather than unattended. Our results indicate that spatial attention can enhance visual-cortex excitability, and visual awareness, even when sensory signals from the eye via the thalamic pathway are bypassed.

Chronostasis without voluntary action

In a previous study we explored auditory chronostasis and suggested an arousal account of this temporal illusion rather than one dependent on backdating actions to the onset of a motor event. Here we present three experiments designed to distinguish between two competing accounts of the mechanisms underlying the illusion. Experiment 1 investigated whether voluntary movements are necessary for the illusion to occur. Experiment 2 sought to clarify whether auditory chronostasis occurs when the intervals to be judged are continuous (temporally contiguous) rather than separate events. Experiment 3 was designed to establish whether increased task demands account for the illusion. Together the results from these experiments show that chronostasis is an illusion that is not dependent on voluntary action, can occur without a change in the spatial location of the stimulus (thus precluding an account based on spatial attention), occurs with discrete as well as continuous events, and is affected by the salience of the termination of the event to be timed rather than the onset. Collectively these findings suggest that the mechanisms underlying chronostasis are best explained by an arousal hypothesis since neither attention nor backdating to action can account for the commonalities between chronostasis in the auditory, visual and tactile domains.

Phosphene threshold as a function of contrast of external visual stimuli

Transcranial magnetic stimulation (TMS) of the occipital lobe is frequently used to induce visual percepts by direct stimulation of visual cortex. The threshold magnetic field strength necessary to elicit a visual percept is often regarded as a measure of electrical excitability of visual cortex. Using single-pulse TMS during visual motion stimulus presentation, we investigated the relationship between different degrees of visual cortical preactivation and cortical phosphene threshold (PT). The two possible, mutually exclusive, predictions on the outcome of this experiment were that a) PT increases with stronger preactivation because of a decrease in the signal-to-noise ratio, or b) that PT decreases with increased preactivation because of the increase in neuronal response towards some threshold. PTs for single-pulse stimulation of the occipital lobe were determined for eight subjects while they passively viewed a horizontally drifting luminance-modulated sinewave grating. Gratings used were of four different luminance contrasts while the spatial and temporal frequencies remained constant. PTs were shown to increase significantly as the background grating increased in contrast. These results suggest that the neural activity underlying the perception of a phosphene can be considered a type of signal that can be partially masked by another signal, in this case the visual cortical activation produced by passive viewing of drifting gratings.

The site of saccadic suppression

During rapid eye movements, or saccades, stable vision is maintained by active reduction of visual sensitivity. The site of this saccadic suppression remains uncertain. Here we show that phosphenes--small illusory visual perceptions--induced by transcranial magnetic stimulation (TMS) to the human occipital cortex are immune to saccadic suppression, whereas phosphenes induced by retinal stimulation are not, thus providing direct physiological evidence that saccadic suppression occurs between the retina and the occipital visual cortex.

Perception of self-motion from peripheral optokinetic stimulation suppresses visual evoked responses to central stimuli

In a previous functional neuroimaging study we found that early visual areas deactivated when a rotating optical flow stimulus elicited the illusion of self-motion (vection) compared with when it was perceived as a moving object. Here, we investigated whether electrical cortical responses to an independent central visual probe stimulus change as a function of whether optical flow stimulation in the periphery induces the illusion of self-motion or not. Visual-evoked potentials (VEPs) were obtained in response to pattern-reversals in the central visual field in the presence of a constant peripheral large-field optokinetic stimulus that rotated around the naso-occipital axis and induced intermittent sensations of vection. As control, VEPs were also recorded during a stationary peripheral stimulus and showed no difference than those obtained during optokinetic stimulation. The VEPs during constant peripheral stimulation were then divided into two groups according to the time spans where the subjects reported object- or self-motion, respectively. The N70 VEP component showed a significant amplitude reduction when, due to the peripheral stimulus, subjects experienced self-motion compared to when the peripheral stimulus was perceived as object-motion. This finding supplements and corroborates our recent evidence from functional neuroimaging that early visual cortex deactivates when a visual flow stimulus elicits the illusion of self-motion compared with when the same sensory input is interpreted as object-motion. This dampened responsiveness might reflect a redistribution of sensorial and attentional resources when the monitoring of self-motion relies on a sustained and veridical processing of optic flow and may be compromised by other sources of visual input.

Posture and mental task performance when viewing a moving visual field

We investigated the characteristics of standing posture and performance of concurrent cognitive tasks in subjects confronted by whole field visual motion. Movements of the head and centre of pressure (COP) were recorded in 12 subjects who performed modified Brooks spatial and verbal tasks when in quiet stance viewing a chequerboard pattern, planar, visual field, moving with uniform velocity (25 degrees /s, 50 degrees /s and 76 degrees /s). Eight subjects were also tested seated to control for the effect of stance. Task load was monitored by heart rate and eye movements were recorded to ensure viewing compliance. Subjects rated their quotidian susceptibility to visual disorientation on a validated scale. In both lateral and antero-posterior directions there were small amplitude but significant increases in COP sway path length and standard deviations of both COP and head sway during exposure to visual motion in proportion to visual flow speed. Performing cognitive tasks during visual motion attenuated sway S.D. The effects on sway of task and visual flow were independent. Visual motion induced a slight tilt and turn of the head and body in the direction of flow together with slight neck flexion. Errors on both verbal and spatial tasks increased >250% during visual motion both when standing and when seated. Ratings of subjects' susceptibility to disorientation were un-related to either verbal or spatial task error rates. A current hypothesis is that the enhancement of sway by visual motion is destabilisation. We propose an alternative explanation that sway enhancement could be exploratory 'testing of the ground' movements to check for self motion. Hence decrease in sway magnitude during a cognitive task could be caused by a reduction in exploratory movement because attention is diverted from postural control to a secondary task. Mere passive viewing of a moving visual field may interfere with cognitive tasks possibly because the threat of disorientation by whole field motion diverts attentional resources.

Repetitive transcranial magnetic stimulation for Tourette syndrome

In a single-blinded, placebo-controlled, crossover repetitive transcranial magnetic stimulation (rTMS) trial, 16 patients with Gilles de la Tourette syndrome (GTS) received in random sequence 1 Hz motor, premotor, and sham rTMS, which each consisted of two 20-minute rTMS sessions applied on 2 consecutive days. In the 12 patients who completed the trial, there was no significant improvement of symptoms after any of the rTMS conditions as assessed with the Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey.

Parietal magnetic stimulation delays visuomotor mental rotation at increased processing demands

Visuomotor rotation (VMR) is a variant of the classic mental rotation paradigm. Subjects perform a center-out arm reaching movement, with the instruction to point clockwise or anticlockwise away from the direction of a reaction signal by a prespecified amount. Like classic mental rotation (MR) tasks, there is a linear relationship between reaction time (RT) and required angle of rotation (angular disparity). Although functional imaging studies have consistently demonstrated parietal activations centered around the intraparietal sulcus during MR tasks, the involvement of parietal cortex in VMR has not been investigated. The aim of the present experiments was to test in human subjects whether VMR also involves activity in parietal areas. We used short trains of transcranial magnetic stimulation (TMS) to produce a temporary "virtual lesion" of the posterior parietal cortex (PPC) around the intraparietal sulcus during the reaction period of a VMR task. Four pulses of 20-Hz rTMS were applied to the left PPC, right PPC, or vertex (control condition) 100 ms after the presentation of an instruction cue. Reaction times (RTs) were evenly prolonged by right or left parietal TMS compared with vertex stimulation, but only for large angles of rotation, and without affecting the spatial accuracy of the final response. A control experiment showed that parietal rTMS did not impair visual perception or the ability to judge the size of visual angles. The data thus provide evidence for bilateral involvement of the PPC in VMR that increases with processing demands.

Auditory chronostasis: hanging on the telephone

The perception of time can be illusory: we have all waited anxiously for important seconds to tick away slowly at the end of a football game and have experienced the truth of the adage "time flies when you're having fun." One illusion of time experience that has recently been investigated, the apparent slowing of the movement of the second hand on the clock when one first looks at it, has been termed "chronostasis," and it has been suggested that the effect is unique to vision and is dependent on eye movements. We sought to test whether the effect is really unique to vision or whether it can also be produced with auditory stimuli. Subjects were asked to judge the length of a silent gap between two tones presented through headphones. When the tones were presented to one ear, subjects judged the duration of the gap veridically. When subjects were required to shift concentration from one ear to the other, however, the judgement of time showed that the auditory system is also susceptible to chronostasis. We suggest that this generalization of chronostasis to another sensory system is consistent with theories of time perception that emphasize a single, multimodal clock for duration estimation rather than a mechanism that is dependent on motor acts.

Visual motion stimulation, but not visually induced perception of self-motion, biases the perceived direction of verticality

Large-field torsional optokinetic stimulation is known to affect the perceived direction of gravity with verticality judgements deviating towards the direction of visual stimulus rotation. The present study aimed to replicate this effect and to examine it further by subjecting participants to optokinetic stimulation in roll, resulting in spontaneous alternations between the perception of object-motion and that of contradirectional self-motion (vection), as reported by the subjects. Simultaneously, subjects were oscillated laterally in a flight simulator and indicated their perception of postural verticality. Results confirmed that rotation of the visual environment in the frontal plane biases the perceived orientation of gravity towards the direction of visual stimulus motion. However, no differential effect of perceptual state on postural verticality was obtained when contrasting verticality judgements made during the perception of object-motion with those obtained during reported self-motion perception. This finding is likely to reflect a functional segregation of central nervous visual-vestibular subsystems that process the perception of self-tilt and that of self-rotation to some degree independently.

Neural correlates of visual-motion perception as object- or self-motion

Both self-motion and objects moving in our visual field generate visual motion by displacing images on the retina. Resolving this ambiguity may seem effortless but large-field visual-motion stimuli can yield perceptual rivalry between the real percept of object-motion and the illusory percept of self-motion (vection). We used functional magnetic resonance imaging to record brain activity in human observers exposed to constant-velocity roll-motion. This stimulus induced responses in areas reaching from calcarine to parieto-occipital and to ventral and lateral temporo-occipital cortex and the anterior insula. During vection, early motion-sensitive visual areas and vestibular parieto-insular cortex deactivated, whereas higher-order parieto- and temporo-occipital areas known to respond to optical flow retained identical activity levels. Within this sustained response, these latter areas displayed transient activations in response to each perceptual switch as identified in event-related analyses. Our results thus show that these areas are responsive to the type of visual motion stimulus and highly sensitive to its perceptual bistability. The only region to be more active during perceived self-motion was in, or close to, the cerebellar nodulus. This activation may correspond to the gain increase of torsional optokinetic nystagmus during vection and/or to changes in sensory processing related to the rotational percept. In conclusion, we identified neural correlates of perceiving self-motion from vision alone, i.e., in the absence of confirmatory vestibular or proprioceptive input. These functional properties preserve the organism's ability to move accurately in its environment by relying on visual cues under conditions when the other spatial senses fail to provide such information.

Percept-related changes in horizontal optokinetic nystagmus at different body orientations in space

Large-field motion of the visual environment is a powerful stimulus to induce the perception of contra-directional self-motion in a stationary observer. We investigated the interrelations between horizontal optokinetic nystagmus and subjective states of motion perception under variation of subjects' orientation with respect to gravity. Subjects were tested sitting upright and lying supine, and signalled transitions between object- and self-motion perception whilst viewing an optokinetic stimulus rotating about the subjects' longitudinal axis at a range of angular velocities. Optokinetic stimulation in the supine condition resulted in subjects perceiving a graviceptive conflict and the illusory perception of whole body tilt in a direction opposite to optokinetic stimulus rotation, whereas during upright viewing the axis of stimulus rotation was aligned with the direction of gravity and thus did not result in a conflict or perception of tilt. In both postures, self-motion perception coincided with an increased deviation of mean horizontal gaze position in the perceived direction of heading with a concurrent reduction in optokinetic nystagmus slow-phase gain. Slow-phase gain was also significantly reduced in the supine position as well as at increasing stimulus velocities. The results demonstrate that spontaneous transitions between the perception of object-motion and that of self-motion consistently coincide with spatial attentional and orientational strategies, shifting from passive monitoring to active oculomotor exploration and anticipation.

Positional down beating nystagmus in 50 patients: cerebellar disorders and possible anterior semicircular canalithiasis

OBJECTIVES

To clarify the clinical significance of positional down beat nystagmus (pDBN).

METHODS

A discussion of the neuro-otological findings in 50 consecutive patients with pDBN.

RESULTS

In 38 patients there was evidence of CNS disease (central group) but in 12 there was not (idiopathic group). In the CNS group, presenting symptoms were gait, speech, and autonomic dysfunction whereas in the idiopathic group patients mostly reported positional vertigo. The main neurological and oculomotor signs in the CNS group were explained by cerebellar dysfunction, including 13 patients with multiple system atrophy. In patients with multiple system atrophy with a prominent extrapyramidal component, the presence of pDBN was helpful in the differential diagnosis of atypical parkinsonism. No patient with pDBN had the Arnold-Chiari malformation, a common cause of constant down beat nystagmus (DBN). In the idiopathic group, the pDBN had characteristics which suggested a peripheral labyrinthine disorder: vertigo, adaptation, and habituation. In six patients an additional torsional component was found (concurrently with the pDBN in three). Features unusual for peripheral disorder were: bilateral positive Dix-Hallpike manoeuvre in nine of 12 patients and selective provocation by the straight head-hanging manoeuvre in two.

CONCLUSION

It is argued that some patients with idiopathic pDBN have benign paroxysmal positional vertigo (BPPV) with lithiasis of the anterior canal. The torsional component may be weak, because of the predominantly sagittal orientation of the anterior canal, and may not be readily seen clinically. Nystagmus provocation by bilateral Dix-Hallpike and straight head-hanging may be explained by the vertical upwards orientation of the ampullary segment of the anterior canal in the normal upright head position. Such orientation makes right-left specificity with the Dix-Hallpike manoeuvre less important than for posterior canal BPPV. This orientation requires a further downwards movement of the head, often achieved with the straight head-hanging position, to provoke migration of the canaliths. The straight head-hanging manoeuvre should be carried out in all patients with a history of positional vertigo and a negative Dix-Hallpike manoeuvre.

Vision: when the clock appears to stop

Eye movements produce a temporary loss of visual sensitivity known as saccadic suppression, and a distortion of space perception known as saccadic compression. A new study has reported a seemingly related phenomenon --chronostasis---in which one's perception of time also undergoes an illusory distortion during rapid movements of the eyes.

Influence of action and expectation on visual control of posture

Previous studies have shown that human subjects presented with a moving visual environment initiate a postural re-adjustment in the direction of motion. The present study investigated how active control or expectation of the displacement of a visual scene affects this postural response. Center of foot pressure (COP) and head displacement were recorded using a sway platform and a tracking system, respectively. The subjects faced a visual scene (1 x 1 m, at a distance of 45 cm) which moved transiently (with a velocity of 1 cm/s) in a direction parallel to the interaural axis. When the displacement of the visual scene was under the active control of the subjects, visually induced body sway was strongly inhibited, in comparison with the response to unexpected stimuli. Prior knowledge of the characteristics of the forthcoming displacement was sufficient, in most subjects, to reduce postural re-adjustment, even when subjects did not exert active control. Finally, the visually induced postural response was strongly reduced even when subjects only triggered the stimulus, without any knowledge about the direction of motion. In conclusion, it appears that although vision is of primary importance in the control of postural orientation, high level processes such as expectation can modulate its impact by providing cues as to whether forthcoming visual flow is the consequence of self-motion or object-motion.

Transcranial magnetic stimulation of medial-frontal cortex impairs the processing of angry facial expressions

Growing evidence suggests that the recognition of different emotional states involves at least partly separable neural circuits. Here we assessed the discrimination of both anger and happiness in healthy subjects receiving transcranial magnetic stimulation (TMS) over the medial-frontal cortex or over a control site (mid-line parietal cortex). We found that TMS over the medial-frontal cortex impairs the processing of angry, but not happy, facial expressions of emotion.

Visual control of postural orientation and equilibrium in congenital nystagmus

PURPOSE

To investigate how humans with congenital nystagmus (CN) use visual information to stabilize and orient their bodies in space.

METHODS

Center of foot pressure (COP) and head displacements in the lateral plane were recorded using a sway platform and Schottky barrier photodetector, respectively. In experiment 1, a comparison was made of the oscillatory characteristics of body sway with eyes open compared with eyes closed. Experiment 2 studied the postural readjustments made in response to absolute or relative motion (motion parallax) of objects in the visual scene, generated by lateral displacement of background scenery.

RESULTS

Experiment 1 revealed that subjects with CN were not able to use visual information to stabilize COP but were able to stabilize the head at frequencies lower than 1 Hz. Experiment 2 showed that in response to the displacement of a visual display, for both absolute motion and motion parallax, subjects with CN reoriented their body in space in a manner similar to control subjects.

CONCLUSIONS

The results suggest that despite involuntary eye movements, subjects with CN use orientation cues to control their posture, but not dynamic cues useful to control the rapid oscillations that are particularly important at the level of COP. These findings suggest that in CN, visual control of posture is restricted by low-frequency sampling of the visual scene.

Changes in horizontal oculomotor behaviour coincide with a shift in visual motion perception

During full-field rotation of the visual field, subjects commonly experience an initial perception of object-motion which 'switches' to a perception of self-motion. We studied the characteristics of the horizontal optokinetic nystagmus responses evoked by a moving visual stimulus in these two perceptual states over a range of stimulus velocities. During self-motion perception mean eye position was found to shift more in the direction of the newly appearing stimulus elements with a slight reduction in slow phase gain in comparison to the nystagmus evoked during object-motion perception. The results may reflect a modified strategy of spatial attention with increased emphasis on anticipatory eye movements during visually induced self-motion perception.

Autonomic response to real versus illusory motion (vection)

This study explored the cardiovascular responses to illusions of self-motion (vection) induced in normal subjects according to the hypothesis that vection may be a model for vertigo in vestibular disease. Responses were obtained from 10 men who were exposed to rapid tilts of 20 degrees and 30 degrees rolling from the upright position down to the right or left shoulder. These responses were compared with those evoked during the illusion of roll-tilt vection provoked by a torsionally rotating visual field. Comparisons were made between 10-second data epochs before and after stimulus onset. In response to vection, blood pressure (BP) in the radial artery rose consistently in six subjects, and in all of these, a pressor response to real tilt was also observed. The remaining four subjects consistently had decreased BP in response to vection, and their BPs were affected little by tilt. Subjects whose BP increased with vection and tilt may have been dominated by tendency to arousal, whereas those whose BP decreased may reveal the more appropriate response to tilt from the upright position, which is a decrease in BP. This may reflect individual stereotypes and differences in the relative contributions of somatosensory and vestibular control of autonomic regulation.

Torsional eye movements are facilitated during perception of self-motion

Visual motion in the roll plane elicits torsional optokinetic nystagmus (tOKN) with intermittent periods of illusory, contradirectional self-motion (circularvection, CV). The CV may also have a component of whole-body tilt if the axis of stimulus rotation is not aligned with the direction of gravity. We report how the characteristics of tOKN are affected by the presence of CV. Subjects had their eye movements recorded by VOG whilst viewing a full-field stimulus rotating at 30-60 degrees/s about their naso-occipital axis. They were tested in upright and supine posture and signalled the presence-absence of CV with a pushbutton. In both postures, during CV, tOKN slow-phase gain was found to be enhanced and average torsional eye position shifted in the direction opposite to stimulus rotation. When supine, slow-phase gain was greater than when upright both during the perception of object-motion and during CV. The effects may be explained in terms of a relegation of restraining vestibular input to the torsional oculomotor system during CV and illusory tilt.