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A systems approach to the brain basis of emotion also needs developmental and locationist views – the case of Tourette's Syndrome
Published online by Cambridge University Press: 23 May 2012
Abstract
The closeness of somatosensory phenomena and emotional states can be critically extended into a clinical perspective by referring to Tourette's Syndrome (TS). Two examples are discussed in this commentary: (1) the neurodevelopmental approach to the pre- and post-tic sensorimotor urges, and (2) the TS treatment with deep brain stimulation. It is shown that in TS, both views (locationist and constructionist) need to be combined along the lifespan in order to get a more realistic picture of the brain basis of emotion.
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References
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Lindquist et al. touch upon the closeness of and the interaction between somatosensory phenomena and emotional states (see target article, sect. 5.2). They refer to the anterior insula as a body-based, affectively guided attentional system, and thus present the insula as an integrational area for certain aspects of emotion, cognition, and movement, supporting their constructionist view. I would like to critically extend this aspect into a clinical perspective using data from research in Tourette's Syndrome (TS), a complex developmental neuropsychiatric disorder with motor and vocal tics as core symptoms (Cath et al. Reference Cath, Hedderly, Ludolph, Stern, Murphy, Hartmann, Czernecki, Robertson, Martino, Münchau and Rizzo2011; Müller-Vahl et al. Reference Müller-Vahl, Cath, Cavanna, Dehning, Porta, Robertson and Visser-Vandewalle2011; Roessner et al. Reference Roessner, Plessen, Rothenberger, Ludolph, Rizzo, Skov, Strand, Stern, Termine and Hoekstra2011a; Reference Roessner, Rothenberger, Rickards and Hoekstra2011b; Verdellen et al. Reference Verdellen, van de Griendt, Hartmann and Murphy2011).
Besides its overt tics, TS shows a covert drumbeat of sensorimotor phenomena such as unpleasant inner urges, with the consequence of acting out a tic in order to reach a “just right” somatosensory feeling for the patient's own bodily well-being. So far, it is assumed that the insula (in concert with the supplementary motor area and anterior cingulum) plays a central role in this respect (Münchau et al. Reference Münchau, Thomalla and Roessner2011). This fits with the fact that electrical stimulation to the anterior insula may lead to visceral sensations such as feelings of movement, tension, twitching, and tingling (see sect. 5.2 of the target article), which may be reported by patients with TS as an announcement of a tic. It is likely that in TS the insula represents the pathophysiological link between the disturbance of the “sensorimotor-loop” related to the sensorimotor dissonance, which TS patients may realize around their tics, and the “affect-loop” related to cognitive-emotional dissonance in obsessive-compulsive behavior/disorder (Rothenberger et al. Reference Rothenberger, Roessner and Banaschewski2007), thus explaining why the “just-right” procedure in TS, although it mimics ritualized-compulsive behavior, prevails without any anxiety.
The general pre-tic body signal awareness in TS appears around the age of 10 years (i.e., several years after tic-onset), closely followed over time by the specific awareness of inner pre- and post-tic sensorimotor phenomena (including urges). There is no relationship between these phenomena and the duration of TS. Hence, usual cognitive brain development is the most important factor in order to explain this observation (Banaschewski et al. Reference Banaschewski, Woerner and Rothenberger2003). This highlights that one could optimize the constructionist hypothesis while using a neurodevelopmental approach. One should consider that local brain systems are sequentially more and more coordinated in order to finally form high-functioning, flexible constructionistic brain networks without losing locationist accounts. This view can be represented best by looking at the brain as an oscillatory system (Rothenberger Reference Rothenberger2009).
A further example of TS may show how locationist and constructionist approaches need each other. “In 1999 for the first time (thalamic) deep brain stimulation (DBS) was suggested as an alternative therapeutic option for treatment resistant, severely affected patients with TS” (Müller-Vahl et al. Reference Müller-Vahl, Cath, Cavanna, Dehning, Porta, Robertson and Visser-Vandewalle2011). The different local targets used (e.g., globus pallidus internus, nucleus accumbens) lead to more or less similar clinical results. This is probably because all selected targets belong to the ventral striatal-thalamo-cortical circuitries, which are thought to be the basic dysfunctional system in TS. The DBS story elucidates that certain local “nodes” or “areas” may be essential for certain brain systems, suggesting a locationist view within a constructionist approach.
In sum, the case of TS, with its complex neurobiology and behavior, underlines that both views (locationist and constructionist) need to be combined along the lifespan in order to get a more realistic picture of the brain basis of emotions, cognitions, and movements. In this respect, I agree with the authors that, in addition to these considerations, the actual context is also very important, as even subliminal contextual features can unconsciously bias the biology of brain systems at work (Banaschewski et al. Reference Banaschewski, Yordanova, Kolev, Heinrich, Albrecht and Rothenberger2008).