The role of the anterior and midcingulate cortex in the neurobiology of functional neurologic disorder

Abstract

Functional neurologic disorder (FND)/conversion disorder is a prevalent and disabling condition at the intersection of neurology and psychiatry. Clinicians often report feeling ill-equipped treating patients with FND, perpetuated by a historically limited understanding of neurobiologic disease mechanisms. In this review, we summarize the neuroimaging literature across the spectrum of sensorimotor FND, including functional imaging studies during rest, sensorimotor performance, and emotional-processing tasks as well as structural magnetic resonance imaging findings. Particular attention is given to studies implicating the anterior and middle cingulate cortex and related salience network structures (insula, amygdala, and periaqueductal gray) in the neurobiology of FND. Neuroimaging studies identify cingulo-insular functional alterations during rest, motor performance, and emotion processing in FND populations. The literature also supports that patients with FND exhibit heightened amygdalar and periaqueductal gray reactivity to emotionally valenced stimuli, enhanced coupling between amygdalar and motor control areas, and increased amygdalar volumes. The structural neuroimaging literature also implicates cingulo-insular areas in the pathophysiology of FND, though these findings require replication and clarification. While more research is needed to fully elucidate the pathophysiology of FND, salience network alterations appear present in some FND populations and can be contextualized using biopsychosocial models for FND.

Keywords: Cingulate cortex; Conversion disorder; Functional movement disorders; Insula; Neuroimaging; Psychogenic nonepileptic seizures; fMRI.