5 Orbitofrontal Cortical Dysfunction and "Sensori-Motor Regression": A Combined Study of FMRI and Personal Constructs in Catatonia

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Orbitofrontal Cortical Dysfunction and Sensorimotor Regression: A Combined Study of fMRI and
Personal Constructs in Catatonia
ab
ac
Georg Northoff M.D., PhD , Andre Richter M.D. , Frank Baumgart PhD , Leschinger
a
ab
M.D. , Cordula von Schmeling M.D. , Cynthia Lenz M.D. , Alexander Heinzel M.D. ,
d
ce
Henning Scheich PhD , Bernhard Bogerts M.D., PhD & Heinz Bker M.D., PhD
a
Psychiatric Hospital, University of Magdeburg.
Department of Behavioral Neurology, Harvard University, Boston/USA.
Psychiatric University Hospital Zrich.
Institut for Neurobiology, University of Magdeburg.
Department of Psychosomatic Medicine and Psychotherapy, University of Frankfurt/M.

Published online: 09 Jan 2014.
To cite this article: Georg Northoff M.D., PhD, Andre Richter M.D., Frank Baumgart PhD, Leschinger M.D., Cordula von
Schmeling M.D., Cynthia Lenz M.D., Alexander Heinzel M.D., Henning Scheich PhD, Bernhard Bogerts M.D., PhD & Heinz
Bker M.D., PhD (2002) Orbitofrontal Cortical Dysfunction and Sensori-motor Regression: A Combined Study of fMRI
and Personal Constructs in Catatonia, Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the
Neurosciences, 4:2, 151-171, DOI: 10.1080/15294145.2002.10773394
To link to this article: http://dx.doi.org/10.1080/15294145.2002.10773394
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151
Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression'':

A Combined Study of fMRI and Personal Constructs in Catatonia
Downloaded by [Adelphi University] at 23:40 22 August 2014
Georg Northoff, M.D., PhD,*{ Andre Richter, M.D.,*{ Frank Baumgart, PhD,}
Leschinger, M.D.,* Cordula von Schmeling, M.D.,} Cynthia Lenz, M.D.,}
Alexander Heinzel M.D.,*{ Henning Scheich, PhD,}
ker, M.D., PhD{}
Bernhard Bogerts, M.D., PhD,* and Heinz Bo
Objective: A close relationship between subjective

experience and neurophysiological mechanisms
could provide a new foundation for neurobiological
correlates underlying psychodynamic processes in
neuropsychiatric diseases. Pursuing a novel methodological approach by combining both techniques we
investigated catatonia a psychomotor syndrome with
uncontrollable anxieties and akinesia i.e., `ìmmobilization by anxieties'' which, psychodynamically, can
be characterized as a ``sensori-motor regression''
reflecting a basic somatic defense mechanism.
However psychological and physiological mechanisms of generation of such ``sensori-motor
regression'' in catatonia remain unclear. We therefore investigated in a combined study operationalized subjective psychological characteristics using
Repertory-Grid Technique as well as prefrontal
cortical activation pattern during emotional-motor
stimulation using functional magnetic resonance
imaging (fMRI).
Method: We investigated 18 catatonic patients
with an underlying affective or schizoaffective
psychosis and compared them with age, sex,
* Psychiatric Hospital, University of Magdeburg.
{
Department of Behavioral Neurology, Harvard University
Boston/USA.
{
Psychiatric University Hospital Zurich.
}
Institut for Neurobiology, University of Magdeburg.
}
Department of Psychosomatic Medicine and Psychotherapy,
University of Frankfurt/M.
Acknowledgement. We thank all patients for participation in
this quite complex study. The study was nancially supported by
grants from the German Research Foundation (DFG) (No 304/1,
Heisenberg grant 304/4, and SFB 426/7) and the Novartis
Foundation to G.N.
Address for correspondence: Georg Northo, MD, PhD, PhD,
Harvard University, Department of Behavioral Neurology, Beth
Israel Hospital, Kirstein Building KS 454, 330 Brookline Avenue,
02215 Boston, Mass, USA.
E-mail: gnorthof@caregroup.harvard.edu
diagnosis, and medication matched non-catatonic

psychiatric controls (n = 69), and healthy controls
(n = 32). Subjective operationalized psychological
characteristics were investigated using the Repertory Grid Technique (GRID) for personal constructs
of the ``self'' in an acute and a post-acute state. In
addition 10 catatonic patients, 10 psychiatric
controls and 10 healthy controls underwent emotional stimulation with motor reaction during
functional magnetic resonance imaging (fMRI).
Results: Subjective operationalized psychological
characteristics of both the acute and post-acute
state could be characterized by significant lack of
social contact, decreased self-esteem, and reduced
emotional arousal compared to non-catatonic
psychiatric and healthy controls. fMRI revealed
significant dysfunctional activation patterns in
orbitofrontal cortex and alterations in medial
prefrontal and premotor cortex during negative
emotional stimulation which correlated significantly (p = 0.0080.042) with affective, behavioral,
and motor alterations in catatonia as well as with
the GRID dimensions of self-esteem, emotional
arousal, and social contact.
Conclusions: Subjective operationalized psychological characteristics demonstrate the central importance of lack of emotional control as well as of
alterations in interactions between emotional,
social, and motor functions in catatonia. Orbitofrontal cortical dysfunction and related alterations
in medial prefrontal and premotor cortical activity
may account for lack of emotional control with
consecutive ``sensori-motor regression'' as an
`ìmmobilization by anxieties'' in catatonia. In
general one may conclude that orbitofrontal
cortical dysfunction may be closely related with
regression to somatic defense mechanisms as
paradigmatically observed in catatonia.
152
Georg Northoff, Andre Richter, Frank Baumgart et al.
Introduction
A closer relationship between subjective experience and neurophysiological mechanisms could
provide a new foundation for neurobiological
correlates underlying psychodynamic features in
neuropsychiatric diseases (Kandel, 1999). Psychoanalysis investigates mental processes from a
subjective perspective (Solms, 1998) which however does not readily lend itself to objective
empirical analysis. Consequently one needs to
apply operationalized and validated techniques
for investigation of subjective psychological
characteristics underlying psychodynamic features.
Moreover connecting subjective operationalized
psychological characteristics to objective neurobiological phenomena may reveal empirical correlates of psychodynamic features. Somatic
defense mechanisms with regression to the bodily
level may serve as well-suited examples for
application of such a combined methodology:
Objectively visible psychomotor alterations may
bridge the gap between subjective experience and
psychodynamic features on the one hand and
objective and physiological correlates on the
other. Within such a methodological framework
catatonia as a psychomotor syndrome showing a
unique constellation of aective, behavioral and
motor symptoms (Bush et al., 1996; Fink et al.,
1993; Kahlbaum, 1874; Northo et al., 1998,
1999; Perkins, 1982; Rosebush et al., 1990;
Taylor, 1990) may be regarded as a paradigmatic
example for investigation of somatic defense
mechanisms since it can be characterized by total
`ìmmobilization by anxieties'' (Perkins, 1982)
reecting ``sensori-motor regression'' (Arieti,
1972; Boker and Lempa, 1996; Johnson, 1984).
Psychodynamically catatonic patients can be
characterized by somatic defense mechanisms
replacing cognitive defense mechanisms (Boker
and Lempa, 1996; Johnson, 1984). Relying on
cognitive mechanisms schizophrenic and aective
psychotic patients either externalize (i.e., schizophrenic patients) or internalize (i.e., aective
patients) their anxieties (Johnson, 1984). Such
cognitive mechanisms of internalization or externalization are apparently no longer available for
catatonic patients who instead use somatic defense
mechanisms with sensori-motor regression resulting in total `ìmmobilization by anxieties'' (Arieti,
Why are Catatonic Patients no Longer Able to use
Cognitive Defense Mechanisms?
The kind of defense mechanism a person relies on
may psychologically be closely related to the way

it considers his own self with its various dimensions. Subsequently one may assume dierences
in construction of the own self between catatonic
patients on the one hand and aective and
schizophrenic patients on the other. Dierences
may predominantly concern those dimensions of
the self which are closely related with acute
catatonic `ìmmobilization by anxieties'' such as
emotional arousal, social contact, and self-esteem.
Emotional arousal may be closely related with
aective symptoms in catatonia and thus with
subjective experience of an inability to control
intense anxieties (Northo et al., 1998; Perkins,
1982). Self-esteem and social contact may be
closely related with behavioral and motor symptoms and thus with ``sensori-motor regression'' in
catatonia since total immobilization reects disruption of any kind of social contact which by
itself may be associated with low self-esteem.
What are Potential Physiological Correlates for
such Abnormalities in these Particular Dimensions
of the Catatonic Self?
Alterations in emotional arousal may assumed to
be closely related with dysfunction in orbitofrontal cortex for the following reasons. First the
orbitofrontal cortex has been shown to be
particularly activated during induction of negative emotional experience (Baker et al., 1997;
Beauregard et al., 1998; Damasio, 1995; George
et al., 1995; Lane et al., 1997; Mayberg et al.,
1999; Northo et al., 2000; Phillips et al., 1997)
which would be consistent with strong anxieties
occurring in the acute catatonic state (Northo et
al., 1998; Perkins, 1982). Second psychodynamically patients with lesions in orbitofrontal cortex
show a strong tendency towards projection of
psychological experience onto bodily functions
(Solms, 1998) which may parallel with psychodynamic features in catatonia. Third the orbitofrontal cortex especially the lateral one is not only
involved in emotional processing but in addition
in behavioral-motor control (Damasio, 1995;
Shore, 1996) which may account for the unique
constellation of aective, behavioral, and motor
symptoms in catatonia. Based on these observation we assume orbitofrontal cortical dysfunction
in catatonia which may especially account for
potential alterations in emotional arousal in the
self of catatonic patients. Since the orbitofrontal
cortex is closely connected with medial prefrontal
cortex the latter particularly accounting for
behavioral-social functions (Damasio, 1995) we
assume alterations in medial prefrontal cortex as
152
Introduction
A closer relationship between subjective experience and neurophysiological mechanisms could
provide a new foundation for neurobiological
correlates underlying psychodynamic features in
neuropsychiatric diseases (Kandel, 1999). Psychoanalysis investigates mental processes from a
subjective perspective (Solms, 1998) which however does not readily lend itself to objective
empirical analysis. Consequently one needs to
apply operationalized and validated techniques
for investigation of subjective psychological
characteristics underlying psychodynamic features.
Moreover connecting subjective operationalized
psychological characteristics to objective neurobiological phenomena may reveal empirical correlates of psychodynamic features. Somatic
defense mechanisms with regression to the bodily
level may serve as well-suited examples for
application of such a combined methodology:
Objectively visible psychomotor alterations may
bridge the gap between subjective experience and
psychodynamic features on the one hand and
objective and physiological correlates on the
other. Within such a methodological framework
catatonia as a psychomotor syndrome showing a
unique constellation of aective, behavioral and
motor symptoms (Bush et al., 1996; Fink et al.,
1993; Kahlbaum, 1874; Northo et al., 1998,
1999; Perkins, 1982; Rosebush et al., 1990;
Taylor, 1990) may be regarded as a paradigmatic
example for investigation of somatic defense
mechanisms since it can be characterized by total
`ìmmobilization by anxieties'' (Perkins, 1982)
reecting ``sensori-motor regression'' (Arieti,
Psychodynamically catatonic patients can be
characterized by somatic defense mechanisms
replacing cognitive defense mechanisms (Boker
and Lempa, 1996; Johnson, 1984). Relying on
cognitive mechanisms schizophrenic and aective
psychotic patients either externalize (i.e., schizophrenic patients) or internalize (i.e., aective
patients) their anxieties (Johnson, 1984). Such
cognitive mechanisms of internalization or externalization are apparently no longer available for
catatonic patients who instead use somatic defense
mechanisms with sensori-motor regression resulting in total `ìmmobilization by anxieties'' (Arieti,
Why are Catatonic Patients no Longer Able to use
Cognitive Defense Mechanisms?
The kind of defense mechanism a person relies on
may psychologically be closely related to the way

it considers his own self with its various dimensions. Subsequently one may assume dierences
in construction of the own self between catatonic
patients on the one hand and aective and
schizophrenic patients on the other. Dierences
may predominantly concern those dimensions of
the self which are closely related with acute
catatonic `ìmmobilization by anxieties'' such as
emotional arousal, social contact, and self-esteem.
Emotional arousal may be closely related with
aective symptoms in catatonia and thus with
subjective experience of an inability to control
intense anxieties (Northo et al., 1998; Perkins,
1982). Self-esteem and social contact may be
closely related with behavioral and motor symptoms and thus with ``sensori-motor regression'' in
catatonia since total immobilization reects disruption of any kind of social contact which by
itself may be associated with low self-esteem.
What are Potential Physiological Correlates for
such Abnormalities in these Particular Dimensions
of the Catatonic Self?
Alterations in emotional arousal may assumed to
be closely related with dysfunction in orbitofrontal cortex for the following reasons. First the
orbitofrontal cortex has been shown to be
particularly activated during induction of negative emotional experience (Baker et al., 1997;
Beauregard et al., 1998; Damasio, 1995; George
et al., 1995; Lane et al., 1997; Mayberg et al.,
1999; Northo et al., 2000; Phillips et al., 1997)
which would be consistent with strong anxieties
occurring in the acute catatonic state (Northo et
al., 1998; Perkins, 1982). Second psychodynamically patients with lesions in orbitofrontal cortex
show a strong tendency towards projection of
psychological experience onto bodily functions
(Solms, 1998) which may parallel with psychodynamic features in catatonia. Third the orbitofrontal cortex especially the lateral one is not only
involved in emotional processing but in addition
in behavioral-motor control (Damasio, 1995;
Shore, 1996) which may account for the unique
constellation of aective, behavioral, and motor
symptoms in catatonia. Based on these observation we assume orbitofrontal cortical dysfunction
in catatonia which may especially account for
potential alterations in emotional arousal in the
self of catatonic patients. Since the orbitofrontal
cortex is closely connected with medial prefrontal
cortex the latter particularly accounting for
behavioral-social functions (Damasio, 1995) we
assume alterations in medial prefrontal cortex as
Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression''

well which may assumed to be related with lack of
social contact and low self-esteem.
In order to test our rst assumption i.e.,
alteration in emotional arousal as a dimension of
the self in catatonic patients we applied the
Repertory Grid test. The ``Role-ConstructRepertory Grid'' is an operationalized and
validated idiographic instrument accounting for
psychological characteristics from a subjective
point of view (Boker, 1999; Boker et al., 2000a;
Kelly, 1955; Winter, 1985, 1992). The ``RoleConstruct-Repertory Grid'' relies on a standardized, operationalized and validated methodology
by combining intrasubjective self-appreciation
with intersubjective categorial evaluation (Boker,
1999; Boker et al., 2000a; Winter, 1985, 1992).
The operationalized methodology was developed
in the context of the psychology of personal
constructs (Boker et al., 2000b). The psychology
of personal constructs (Kelly, 1955) is based on
the assumption that subjective experiences of the
self and other persons are actively created or
constructed and therefore presuppose certain
related psychological characteristics determining
personal constructs.
In order to test our second assumption i.e.,
relation of low social contact and self-esteem with
behavioral and motor symptoms in catatonia we
performed correlation analysis between distinct
kinds of catatonic symptoms (aective, motor,
behavioral) and the respective dimensions of the
self in GRID.
In order to test our third assumption i.e.,
relation between altered emotional arousal and
orbitofrontal cortical dysfunction we investigated
post-acute catatonic patients in functional magnetic resonance imaging (fMRI) during emotional-motor stimulation which in prior studies
in healthy controls (Baker et al., 1997; Beauregard et al., 1998; George et al., 1995; Lane et al.,
1997; Mayberg et al., 1999; Northo et al., 2000;
Phillips et al., 1997) has been demonstrated to
lead to activation in orbitofrontal cortex.
In order to test our fourth assumption i.e.,
relation between low social contact/self-esteem
and medial prefrontal cortical dysfunction we
performed correlation analyses between medial
prefrontal cortical signals from fMRI, catatonic
symptoms, and personal constructs from GRID.
Methods
Subjects
Catatonic syndrome was diagnosed according to
criteria by Lohr and Wiesniewski (1987; 3 from 11
symptoms) and Rosebush et al. (1990; 4 from 12
153
symptoms) on the day of admission by agreement

of two independent psychiatrists. Catatonic
symptoms had to be present for at least half an
hour in the presence of both psychiatrists. All 18
catatonic patients (9 women, 9 man; age:
34,5 6.5) were admitted in an acute akinetic
catatonic state into the hospital (9 patients were
admitted for the rst time and 9 patients had
previous hospitalizations; incidence of 2.9% in
relation to all admitted patients) and showed the
following the catatonic symptoms (according to
Rosebush) on the day of admission: Immobility
(18 patients), staring (16), mutism (17), autism
(18), posturing (18), rigidity (13), negativism (14),
catalepsy (18), grimacing (14), echolalia/praxia
(8), stereotypies (9) and verbigerations (7). In
addition catatonic symptoms were diagnosed and
investigated with the Bush Francis Scale (Bush et
al., 1996) and the Northo Catatonic Scale (NCS;
Northo et al., 1999a) which are both well
validated rating scales for catatonia.
In the following 24 hours after admission
patients were treated exclusively with lorazepam
(24 mg/day; means: 3,4 1,9 mg; 14 responders
and 4 non-responders to lorazepam) which was
discontinued after 24 hours. After 24 hours
lorazepam was taken o and, depending on the
underlying psychiatric disease, replaced by neuroleptics (atypical antipsychotics such as risperidone,
olanzapine, or clozapine; n = 8)), antidepressants
(serotonine reuptake inhibitors; n = 13) and/or
carbamazepin/lithium (n = 14). 14 of the 18
catatonic patients remained catatonic for more
than 3 days. Two catatonic patients needed
electroconvulsive therapy (ECT) because their
catatonic syndrome persisted over more than 46
weeks without any signs of remission. Catatonic
patients stayed for an average duration of
13,6 8,9 weeks in our hospital. Discharge
diagnosis was made according to DSM III/R
with a semistructured clinical interview by an
independent psychiatrist. The following diagnosis
underlying catatonic syndrome were made
according to DSM III/R: Bipolar depression
(n = 7), Unipolar depression (n = 4), Schizoaective psychosis (n = 7). All patients were
interviewed with the Repertory Grid Technique
shortly before discharge. Catatonic patients with
major cognitive disabilities as investigated with a
neuropsychological test battery (Northo et al.,
1999b) were excluded at a prior stage because
they would have not been able to perform the
repertory grid.
In addition to catatonic patients the following
groups have been investigated as non-catatonic
psychiatric controls patients and healthy controls:
23 bipolar depressive patients (10 women, 13 men;
154
age: 35.6 6.7), 16 unipolar depressive patients

(10 women, 6 men; age: 35.7 7.2), 8 unipolar
manic patients (4 women, 4 men; age: 36.3 8.4),
22 schizoaective patients (11 women, 11 men;
age: 32.5 6.5), and 32 healthy controls (16
women, 16 men; age: 34.5 6.3). All groups were
age- and sex-matched to the catatonic group.
Psychiatric controls were also matched with
regard to medication to catatonic patients. All
patients were admitted into the psychiatric
hospital and diagnosed according to DSM III/R
(296.5; 296.3; 295.7) with a semistructured interview by an independent psychiatrist. They received similar medication and treatment as
catatonic patients so that groups were matched
with regard to age, sex, and medication. Depressive and schizoaective patients with prior but
not present catatonic episodes were excluded
from the study. Similar to catatonic patients
patients with major cognitive disabilities as
investigated in a neuropsychological test battery
(Northo et al., 1999b) were excluded.
In addition the following exclusion criteria
were subject to all groups: (i) history of alcohol,
drug, or substance abuse; (ii) structural-morphological abnormalities in CT-scan; (iii) patients
suering from other extrapyramidal motor or
neurological disorders; (iv) patients with severe
neuroleptic-induced extrapyramidal side-eects
(as elucidated by SEPS > 6 (Simpson and Angus,
1970) and AIMS > 6 (Guy, 1976)) were excluded
from the study in order to avoid confounding
eects on subjective experience; (v) patients
suering from medical or surgical disorders.
In addition to Repertory-Grid Test 10 catatonic patients (5 women, 5 men; Age: 40.4 4.1
years, means SD; all responders to lorazepam;
n = 5 bipolar depression, n = 5 schizophrenic
psychosis), 10 age-, sex-, medication-, and diagnosis matched non-catatonic psychiatric controls
(40.1 4.8 years; means SD), and 10 age- and
sex-matched healthy controls (41.1 5.9 years,
means SD) underwent emotional-motor stimulation in fMRI.
Repertory Grid Technique
Constructs of the Self
The Repertory Grid Technique is an operationalized and validated interview technique to document subjective individual psychological
characteristics of ``personal constructs'' in dierent situations (Boker, 1999; Boker et al., 2000a,b;
Kelly, 1955; Winter, 1985, 1992). Based on prior
methodological studies (Boker, 1999) we investi-
gated ``personal constructs'' of the ``self'' in the

post-acute state, the ``self'' in the acute disease
state as the ``Me in the acute catatonic/depressive/
manic state'', and the `ìdeal-self'' as the optimal
``self''. The constructs were obtained by means of
the triadic method. A six step rating scale was
used to characterize the elements. The Repertory
Grid technique as an idiographic procedure is
directed at each patient's individual feature,
comparison of individually conducted grids
makes it necessary to work out more evaluation
strategies, which enable the comparison between
subjects and groups. The rst systematic approach to categorizing individual constructs
based on more general aspects was made by
Landeld (1971). He examined content and
structure of personal constructs. In his rep-testscoring manual Landeld dened 20 categories
(Boker, 1999; Egle and Habrich, 1993). On
account of the missing connection between the
Landeld categories and the object-relation
theoretical theories of psychoses, the categorizing
system put forward and modied by Landeld
(1971) himself has also been modied in this study
(Boker, 1999). Construct categories were dened
that showed high intra- and interrater reliability
and seemed suitable for comprehending dimensions and conicts described in the object-relation
theoretical models of aective and schizophrenic
psychoses (Boker and Lempa, 1996; Mentzos,
1991). The following construct categories (in a
positive and negative mode respectively) were
presupposed in the present study (see Boker,
1999; Boker et al., 2000a,b for further details):
Social interaction (No. 1), insistence (2), structure
(3), self-esteem (4), status orientation (5), facts
(6), intellectual abilities (7), imagination (8),
alternatives (9), sexuality (10), conscience (morals)
(11), outward appearance (12), emotional arousal
(aect) (13), self-centredness (14), empathy (15),
time-orientation (16), mood (17).
The objective evaluation of subjective constructs developed by catatonic and aect-psychotic patients was performed by means of this
category system. After intensive training of
investigators by an external supervisor, the intraand interrater reliabilities were calculated. Intrarater reliability showed high intraclass correlation coecients between 0.91 and 0.98. Strong
interrater reliabilities were maintained with
Kappa coecients averaged 0.86 (SD = 0.03).
In total intra- and interrater variabilities were
lower than 4.3% which is lower than 1 SD
(<0.02) of values from categories. Investigators
were blind to diagnosis of patients as well as
patients were blind to scientic purposes of the
present study. In contrast to Landeld (1971) one

construct was exclusively related to one category.
Constructs which could not be classied were
listed separately (nc no classication).
Statistical Analysis
First global frequencies of positive and negative

modied Landeld categories were computed in
general and statistically (Kruskal-Wallis-H-Test
and Mann-Whitney U-Test) evaluated with regard to signicant dierences.
Second frequencies of modied Landeld
categories were counted for the ``Self'' and the
`Ìdeal Self''. In order to raise the number of noncatatonic psychiatric controls (and thus statistical
validity) we put the four groups (bipolar depressive (n = 23), unipolar depressive (n = 16), unipolar manic (n = 8), schizoaective (n = 22))
together into one group (n = 69) comparing them
with catatonic patients (n = 18) and healthy
controls (n = 32). Exact dierences between the
four non-catatonic psychiatric controls groups
are reported in Boker et al. (1999). Frequencies of
categories were compared between the three
groups (catatonic, psychiatric controls, healthy
controls) with the Kruskal-Wallis-H-Test and
Mann Whitney U-Test for post-hoc comparison.
Third we compared the ``Me in the acute
disease state'' between catatonic patients (n = 18),
non-catatonic depressive (n = 58), and noncatatonic manic (n = 52) psychiatric controls.
All non-catatonic psychiatric control patients
were no longer grouped according to their
underlying diagnosis but rather in orientation
on previous depressive (n = 58) and/or manic
(n = 52) episodes. Frequencies of Landeld categories in the ``Me in the acute disease state'' in
these three groups (catatonic, depressive, manic)
were statistically compared with the KruskalWallis-H-Test and Mann Whitney-U-Test for
post-hoc comparisons.
Fourth we compared the three personal
constructs, the ``Me in the acute disease state'',
the ``Self'', and the `Ìdeal-Self'', statistically
within each of the three groups (catatonic,
depressive, manic) using Wilcoxon-Test.
In view of a high risk of type I error due to
the large number of group comparisons Bonferroni corrections for multiple comparisons were
performed for all statistical measures.
Emotional Stimulation
Emotions
Emotional stimulation was performed with pictures from the International Aective Picture
155
System (IAPS) (Lang et al., 1997) which was

validated also on a German population (Hamm
and Vaitl, 1993). Based on the large-sample
valence (positive-negative) ratings, pictures were
selected as negative (e.g., a face expressing disgust
or fear) or positive (e.g., smiling baby). Neutral
(e.g., a book) and purely gray (with dierent
tones of gray) pictures served as control conditions in order to control for potentially confounding features of the emotion-generating
pictures such as emotionally irrelevant visual
stimulation and attentional eects. Details of
selection and presentation of pictures are described in Northo et al. (2000). It should be noted
that slide sets were matched for contents/properties (colours, scenery, objects, people, close-ups of
faces, animals), dominance (according to subjective ratings in IAPS in norm group), and arousal
(according to subjective ratings in IAPS in norm
group) (see Northo et al., 2000 for further
details). Subsequently pictures diered only in
emotional valence (positive, negative, neutral) but
neither in dominance nor in arousal so that
especially arousal is equated for pleasant and
unpleasant pictures.
Each picture was presented for 6 seconds (in
orientation on studies by the Lang group who
used a similar duration for presentation of
pictures), 10 pictures of one condition were
presented within one block which accordingly
lasted 1 minute. Subsequently we induced one
particular emotional (positive or negative) (or
non-emotional) experience within each block. The
duration of 1 minute per block with 10 pictures of
the same condition was chosen as a compromise
between emotional perception (where presentation of pictures and duration of blocks would
probably be much shorter) and dominance of
cognitive processes (like memory, etc. which may
dominate in longer presentation and duration
times).
Each picture was presented only once, the
same picture set was used in all subjects though in
counterbalanced and randomized order between
subjects; pictures were projected automatically via
a computer and a backprojection system on a
biconvex lens in fMRI (see Northo et al., 2000
for further details). Details of paradigm implementation and subjects instruction were similar to
those as described in Northo et al. (2000). It
should be noted that we rather focused on
induction of emotional experience than on emotional perception since we presented each picture
for 6 seconds and experimental blocks lasting for
a minute per emotion type (see below for further
details). Subjects were asked to view the picture
whereas they were not told to focus particularly
156
on emotionality of pictures. In addition they were

instructed to press the button (i.e., mouse click)
once after the onset of each new picture without
particularly speeding and concentrating on the
response since the primary focus was not put on
the reaction time itself.
Behavioral and Psychological Monitoring
Reaction time as the time from the appearance of

a new picture to the execution of the nger
movement (i.e., press on the touch switch) was
registered. For analysis we calculated the means
of reaction time for each condition (i.e., positive,
negative, neutral, grey) and compared them
statistically using Friedman tests for dependent
samples. We chose reaction time as a behavioral
measure of emotional valence since it is known
that the time necessary for movement preparation
and initiation depends on the respective functional context (other movements, concomitant
visual stimuli, etc.), the more complex the content
(and the movement) the longer the reaction time
(Naito et al., 1998). Hence we expected dierences
in reaction times between negative, positive, and
neutral (i.e., more complex) pictures on the one
hand and gray (i.e., less complex) pictures on the
other hand. The following analyses for reaction
time were carried out: (i) analysis of variance
testing for eects of group, condition, and
condition by group interaction for analysis of
general eects with application of post-hoc t-tests
to test for specic eects expecting dierences
between psychiatric and non-psychiatric subjects;
(ii) Spearman correlation analyses (using Bonferroni correction with a signicance level of p =
0.042) for calculation of relation between reaction
times and subjective ratings of pictures in order to
account for relationship between subjective emotional experience/perception and motor reaction.
In order to control for preexperimental
psychological states, which might inuence
emotional induction, all subjects had to ll out
the Bf-s, the Bendlichkeitsskala (Zerssen, 1976),
a well validated instrument for self-evaluation of
the actual psychological state, which was compared between groups by analysis of variance
(ANOVA) with post-hoc t-tests. Pictures from the
IAPS were subjectively rated for valence, dominance and arousal with the Self-Assessment
Manikin (SAM) (Lang et al., 1997). Subjective
ratings of IAPS were done one day after fMRI
investigation, in a quite room. Subjective ratings
were done for valence, dominance, and arousal
for each picture respectively which were then
compared with ratings obtained by Hamm and
Vaitl (1993) who validated the IAPS for a
German population. In addition we compared

subjective ratings (arousal, dominance, valence)
between the three groups (catatonic, non-catatonic psychiatric controls, healthy controls) using
analysis of variance (ANOVA) and post-hoc
analysis with t-tests. It should be noted that
subjective ratings were made one day after fMRI
investigation so that subjective ratings do neither
reect the emotional state during the acute
catatonic state nor exactly the one during scanning but rather some kind of psychological trait
marker indicating a certain predisposition for
subjective rating of emotional pictures. Therefore
we were unable to account for the dierence
between emotions as state and trait marker in our
patients implying that both physiological ndings
obtained in fMRI during emotional experience
induced by pictures and psychological ndings
obtained in subjective ratings of emotional
pictures can reect only trait markers. Such
psychophysiological trait markers indicate predisposition for an altered physiological and/or
psychological capacity for negative/positive emotions in patients suering from catatonia whereas
in contrast they do not reect psychophysiological status of the acute catatonic state itself.
Finally it should be noted that we did not control
for the cognitive status which may have inuenced the ability to make subjective ratings. Due
to the inuence of the magnetic eld we were
unfortunately unable to obtain vegetative measures of emotional responses (skin resistance, etc.)
during scanning.
Functional MRI
Data Acquisition
The images were acquired in a Bruker Biospec

3T/60cm head scanner equipped with a quadrupolar birdcage head coil. The subjects heads
were immobilized with a vacuum cushion with
attached ear mus. An imaging session started
with low noise (SPL, 62 dBA), low contrast
FLASH images in sagittal and coronal directions.
The use of a FLASH-sequence oers the possibility to slow down the gradient switching.
Together with an optimized excitation pulse and
modied spoiler gradients the nal ``low noise''
imaging sequence, focused on a few slices,
produced a noise peak level of 58 dB sound
pressure level (SPL) at the position of the ear.
Since EPI-sequences are much noisier especially
in a 3T scanner, which may thus produce
activation by themselves, we preferred FLASHsequence (see Northo et al., 2000 for further
details concerning images and anatomical scans).

Five contiguous axial planes of the frontal lobe
including the medial and lateral frontal cortex,
the motor and premotor cortex, the upper
orbitofrontal cortex and the anterior cingulate
(i.e., from upper orbitofrontal cortex and ventricles up to central sulcus) were taken for
functional imaging (i.e., thickness of 8 mm,
160 mm eld of view, and 64 64 matrix size)
(see Figure 1).
240 functional images for each slice were
collected using a low noise conventional gradient
echo sequence (SPL, 58 dBA; TE, 40 ms; TR,
313 ms; ip angle, 8 ) with medium high
resolution (2, 5*2, 5*4 mm) within 40 min. For
each block of visual stimuli (i.e., 10 valenceconstant pictures each presented for 6 seconds
resulting in a total duration of one block of one
minute; see above) 6 images (i.e., each including
all 5 slices) were acquired (i.e., each image lasted
10 seconds), resulting in a total acquisition time
of one minute (i.e., 6 10 s) per block. Consequently 60 images were acquired for each condition (i.e., 10 blocks of positive, negative, neutral
and gray pictures respectively) resulting in a total
of 240 images and due to breaks between all
blocks, total duration of measurement lasted 45
min. The order of blocks was counterbalanced
with regard to emotional valence across subjects
in order to control for potential order eects. All
subjects tolerated the measurement quite well,
only 4 patients (2 catatonics, 2 psychiatric
controls) complained afterwards of increasing
motor restlessness within the scanner; these 4
subjects were among the 5 subjects which had to
be excluded from nal fMRI analyses on the basis
of movement artifacts (see below).
High T1-contrast imaging (MDEFT) was
used to obtain anatomical landmarks with 3D
high-resolution and immediately followed fMRI
with the following parameters: 256 mm eld of
view, 2,25 mm slice thickness, 64 slices, and
256 256 in-plane matrix size. On the basis of
these anatomical images, localization of slices/
activity in fMRI were determined.
Image Analysis
Data were analysed as follows: First, subject

movement was monitored using the AIR package.
Data were selected for further analysis on the
basis of the absence of head motion artifacts in
general and task-correlated head motion artefacts
in particular. In orientation on the standard
(Bandettini et al., 1993; Gaschler-Markewski et
al., 1997) subjects with head movements >2 mm
and/or >1 were excluded from initial analysis.
We unfortunately had to exclude 2 catatonic
157
patients (means: 3.4 mm and 2.1 ; both suering

from aective disorder) and 3 psychiatric controls
(means: 3.5 mm and 2.0 ; for details in healthy
controls see Northo et al., 2000) which thus did
not enter into nal fMRI analysis; otherwise no
signicant group-related dierences were found in
the amount of movement correction. Furthermore we excluded those scans associated with rst
and last picture of each block respectively in order
to account for movement artifacts related to
altered level of arousal/attention at the beginning
and ending of blocks. Second, activation analysis
was performed by computing the correlation
coecients between voxel time response and
box-car waveform representing the stimulation.
Irrespective of their actual serial position in the
sequence all negative and positive blocks were
modeled as `òn'' whereas all neutral and gray
blocks were dened as `ò''. Voxels having
correlation coecients with a statistical signicance p > 0,01 (corrected) were rejected. Then the
functional images were superimposed on the
individual anatomic reference images (GaschlerMarkewski et al., 1997).
In each slice, dierent anatomical regions of
interest (ROI's) were outlined on the respective
anatomical MRI without functional overlays for
each individual subject separately. For each
individual 11 brain regions (see Figure 1) were
dened individually by landmarks (i.e., the
respective gyri with upper part of orbital gyrus,
inferior, middle and superior frontal gyri, cingulate gyrus, and medial frontal gyrus) and manually delineated on the T1-weighted images
(Kammer et al., 1997). Fiducial marks were then
made on the anterior commissure, posterior
commissure, midsaggital point, and on most
anterior, posterior, superior, inferior, left, and
right points of the brain which were used to
standardize each participants anatomy in a
normalized space so that the various brain regions
could be identied in orientation on the Talairach
atlas (Talairach and Tournoux, 1988) and characterized by the corresponding Brodman areas. The
corresponding regions on adjacent slices were
aggregated and then dened as upper part
(exclusion of lower part) of the orbitofrontal
cortex (Brodman area (BA) upper 11 and 12),
lateral prefrontal (BA 9, 45, 46, 47), medial
prefrontal (BA 8, 9, 10), premotor (BA 6) and
motor (BA 4) cortex on the right and left side
respectively and anterior cingulate cortex (BA 24,
32) bilaterally (see Kammer et al., 1997 for a
similar method). Since the orbitofrontal cortex is
close to regions with a high potential for magnetic
susceptibility artifacts we, in orientation on
Breiter et al. (1996), checked that orbitofrontal
158
activations did not overlap regions of susceptibility artefact otherwise (i.e., if artefacts were as
high or even higher than stimulus-correlated
activity) they were excluded from analysis (3
subjects (2 psychiatric controls, 1 catatonic) had
to be excluded for susceptibility artifacts, however
these three were identical with 3 of the 5 subjects
who were excluded on the basis of movement
artifacts (see above) so that the number of
catatonics (n = 8), psychiatric controls (n = 7),
and healthy controls (n = 10) entering into nal
analyses was not further reduced by analysis for
susceptibility artifacts; see also methodological
limitations). Even if the determination of regions
of interest in orientation on Talairach and
Tournoux has considerable shortcomings (especially with regard to the ventral prefrontal cortex)
we nevertheless applied it since most current
imaging studies use it for anatomical determination so that our localizations could be compared
with the other studies. Activity in these regions of
interest in both hemispheres was analyzed by
correlation analysis (Bandettini et al., 1993) to
obtain a statistical parametric map. Such a map
displays the spatial distribution of the Z score for
each of the dierences or ``contrasts'' positivenegative, positive-neutral, positive-gray, negativeneutral, negative-gray, and neutral-gray. Then
these functional t-maps were thresholded
(Z = 3.09 or p < 0,01 corrected for multiple
comparisons in orientation on Lang et al., 1998)
and constrained to include four continuous voxels
in the nal map, which eectively reduces the rate
of false positives (see Breiter et al., 1997).
Constraining the nal maps on the basis of
cluster size allows fMRI analyses to control for
multiple comparisons without the concomitant
loss of power that would occur with a Bonferroni
correction method. Finally t-statistic maps overlaid onto our anatomical template image to
attribute each activation focus to an anatomical
area. Percentages of signicantly activated voxels
and intensity weighted volumes (IWV) (product
of the absolute number of voxels and average
signal change in each ROI in all slices) were
determined for positive (positive IWV probably
reecting activation) and negative (negative IWV
probably reecting deactivation; see methodological limitations) correlated activations
(Gaschler-Markewski et al., 1997). Number of
IWV's were normalized for each subject in
orientation on the total number of IWV and
were then calculated for each region for every
individual subject in all conditions which then
entered into statistical analyses for comparison of
conditions between groups and correlation analyses (with clinical symptoms and reaction times)
as described below in further detail (see statistical

analyses of IWV's between groups relying on a
signicance level of p < 0.05, corrected)).
Statistical Analysis
Comparison between groups: Statistical analyses

of the various fMRI signals (i.e., positive and
negative IWV) between conditions within groups
(i.e., comparison of early (blocks 15) versus late
(blocks 510) conditions as well as across all
conditions (blocks 120 versus blocks 2040)
within each group for exclusion of habituation
and attention eects) as well as between groups
within conditions (comparison of conditions
between groups for determination of specic
alterations in catatonia) were made with
Kruskal-Wallis/Friedman analysis and post-hoc
comparisons with Mann-Whitney U/Wilcoxon
tests applying Bonferroni correction for multiple
comparisons. In addition to group comparisons
between catatonics, and psychiatric and healthy
controls we performed a so-called ``nosological
analysis'' (see Northo et al., 1998, 1999a for
further details). In this analysis patients were no
longer classied syndromatically according to the
presence/absence of catatonic syndrome independent from the respective underlying psychiatric
disease. Instead they were rather classied according to their underlying psychiatric disease as
either schizophrenic or aective psychosis.
Correlation between variables: First in an
exploratory way we correlated regional signals in
fMRI, behavioral measures, clinical symptoms
(from day 0) and variables, and constructs of the
self using Spearman correlation with Bonferroni
correction for multiple comparisons. Since we
correlated acute clinical symptoms from day 0
with fMRI signals and self-constructs obtained in
a post-acute state physiological and psychological
ndings correlating signicantly with clinical
symptoms may reect trait markers indicating
predisposition for development of catatonic symptoms. Following the recommendations by Curtin
and Schulz (1998) only those results from fMRI
and self-constructs were selected for correlational
analyses which showed signicant dierences
between catatonia on the one hand and psychiatric and healthy controls on the other in order to
reduce the number of comparisons. Furthermore
we performed partial correlations to control for
eects of age, illness duration, and neuroleptics on
those tests for which correlations were signicant.
If correlations turned out to be signicant in both
kinds of analyses they were considered as relevant
relationships between variables so that only these
are mentioned in the results section.

Results
Analysis of Constructs of Self in Repertory-Grid

Focusing on subjective psychological constructs
of the own self we rst analyzed global frequencies of categories of constructs in order to
investigate the general importance of the self in
catatonic patients. In a second step we then
analyzed dierent states of the self the ``me in the
acute disease state'', the self in a post-acute state
i.e., the ``self'', and the `ìdeal self'' in order to
further specify the role of dierent states of the
self in catatonia. Particular categories in dierent states of the selves may be altered in
catatonia compared to both control groups
which may then be regarded as relevant for
construction of the self in these patients and may
therefore potentially allow inferences on underlying psychodynamic processes (see introduction
and discussion for further explanation of relationship between self and psychodynamic processes). Statistical comparisons of the dierent
states of the self between groups were made with
Kruskall-Wallis and Mann-Whitney U-tests (see
methods).
Global Frequencies of Categories
Category 4a (high self-esteem) was signicantly

less frequent in catatonic patients than in noncatatonic psychiatric (p < 0.004) and healthy
(p < 0.002) controls. In addition categories 4b
(low self-esteem; p < 0.007), 15 a (high empathy,
p < 0.006), 15 b (low empathy, p < 0.004) were
signicantly more frequent in catatonic patients
than in healthy controls.
In summary, analysis of global frequencies
points out the particular importance of the
category 4 (self-esteem) in catatonic patients
compared to both control groups.
``Me in the Acute Disease State''
Catatonic patients diered signicantly from both

depressive and manic state in psychiatric controls
in categories 1 b (lack of social contact,
p = 0.002(dep)/0.000(man), higher than both), 4
b (low self-esteem, p = 0.0037/0.000, higher than
both), 6 (facts, p < 0.020/0.009, higher than
both), 13 b (low emotional arousal, p = 0.032/
0.000, higher than both), and 15 a (high empathy,
p < 0.023/0.024, lower than both) (see Table 1
and Figure 2). In addition catatonics diered in
categories 1 a (active social interaction, p < 0.001,
lower), 2 a (high insistence, p = 0.000, lower), 2 b
(low insistence, p = 0.000, higher), 4 a (high self-
159
esteem, p < 0.020, lower), 17 a (high mood,

p < 0.002, lower), and 17 b (low mood,
p < 0.008, higher) from manic patients in the
acute state (see Table 1 and Figure 3).
In summary, analysis of the ``Me in the acute
disease state'' points out the particular relevance
of the categories 1 b (lack of social contact), 4
(self-esteem), 13 (emotional arousal), and 15
(empathy) in the catatonic state compared to
the depressive and manic state.
``Self''
Catatonic patients showed signicantly more

frequencies in categories 6 (facts, p < 0.010) and
13 b (more low emotional arousal, p < 0.026)
than psychiatric control patients (see Table 2).
Catatonic patients diered signicantly from
healthy controls in categories 1a (active social
interaction; p < 0.003; lower), 2 a (less ``high
insistence''; p < 0.006, lower), and 4 b (low selfesteem, p < 0.011, higher) (see Table 2).
Both catatonic and non-psychiatric control
patients diered signicantly from healthy controls in categories 1 a (less social interaction,
p = 0.003(cat)/0.000(cont), both lower) and 15 a
(high empathy, p < 0.002/0.004, both higher) (see
Table 2). In addition, psychiatric controls diered
signicantly from healthy controls in category 17
b (low mood, p < 0.019, higher).
In summary, analysis of the ``self'' between
groups reveals the particular importance of the
categories 1 a (active social interaction), 4 (selfesteem), 13 (emotional arousal), and 15 (empathy) in catatonia.
`Ìdeal Self''
Catatonic patients diered signicantly from

psychiatric controls in categories 4 a (high selfesteem, p = 0.001), and 6 (facts, p < 0.015,
higher) as well as from healthy controls in
category 4 a (high self-esteem, p = 0.001, higher).
Both catatonics and psychiatric controls diered
signicantly from healthy controls in category 15
a (high empathy, p < 0.002/0.005, both higher)
whereas psychiatric controls diered signicantly from healthy controls in category 1 a
(active social interaction, p < 0.002, lower) (see
Table 3).
In summary, analysis of the `Ìdeal-Self''
between groups reveals the particular importance
of the category 4 a (high self-esteem) in catatonia
whereas categories 1 a (active social interaction)
and 15 (empathy) seem to be relevant in both
catatonic and non-catatonic psychiatric control
patients.
160
Comparisons of Different Selves Within Groups
In order to investigate relationship and compare

the dierent states of the self within each group
we used Wilcoxon test (see methods for further
details) for comparison of dierent selves within
each group. Relationship between the dierent
states of the self may allow further specication
and validation of categories found to be diering
between groups. If in both analyses similar
categories are found to be statistically signicant
in catatonic patients one may regard these
categories as specic for the distinct selves in
catatonia from which one may infer on potential
mechanisms of psychodynamic processes underlying the distinct selves and their relationship in
such patients.
In catatonic patients the ``self'' diered
signicantly from the `Ìdeal-Self'' in categories
2 b (low insistence, p < 0.007, lower), category 4 a
(high self-esteem, p < 0.003, lower), and category
4 b (low self-esteem, p < 0.003, higher). The ``Me
in the acute catatonic state'' diered signicantly
from the ``self'' and the `ìdeal-self'' only in
categories 1 b (lack of social contact, p < 0.002/
0.003, lower than both) and 4 b (low self-esteem,
p < 0.002/0.003, higher than both).
In non-catatonic psychiatric controls we
found signicant dierences between ``self'',
`ìdeal-self'', and ``Me in the depressive/manic
state'' in various categories (1 a, 1 b, 2 a, 2 b, 4 a,
4 b, 5 a, 13 a, 13 b, 14 b, 15 a, 15 b, 17 a, 17 b; p =
0.0000.007).
In summary, analysis of dierences between
``self'', `ìdeal-self'', and ``Me in the acute state'' in
catatonic patients revealed signicant dierences
only in categories 1 b (lack of social contact) and
4 (self-esteem). In contrast non-catatonic psychiatric controls showed signicant dierences between ``self'', `ìdeal-self'', and ``Me in the acute
disease state'' in several categories including
social contact (category 1), insistence (category
2), self-esteem (category 4), emotional arousal
(category 13), empathy (category 15), and mood
(category 17).
Overall Summary of Constructs of Self
First the self of patients in the acute catatonic

state can be characterized by low emotional
arousal and low self-esteem, and lack of social
contact.
Second the self of patients in the post-acute
catatonic state may be characterized by decreased
emotional arousal and lack of social interaction.
Third the `ìdeal self'' can be characterized by
high self esteem and high social contact which is
exactly at the opposite compared to both the

acute and post-acute catatonic self.
In conclusion categories of emotional
arousal, social contact, and self-esteem seem to
be of particular importance in construction of the
dierent states of the self in catatonia.
Cortical Activation in fMRI
Behavioral Parameters
Statistical analysis (ANOVA) revealed signicant

dierences in reaction times (p < 0.05, corrected)
between groups in negative, neutral, and positive
conditions whereas no signicant dierences were
found in gray pictures (see Table 4). Post-hoc
comparisons (t-tests) showed signicant dierences (p < 0.05; corrected) in reaction times only
between catatonic patients and healthy controls
as well as between psychiatric and healthy
controls whereas catatonics and psychiatric controls did not dier signicantly from each other
(see Table 4 for further details). Preexperimental
psychological states as measured with the Bendlichkeitsskala (BF's) (see Methods) did not dier
signicantly between groups though catatonic
(20,00 9,51) and psychiatric control (19,45
8,56) patients showed higher values than healthy
controls (13,33 5,01) indicating increased stress
and arousal. Ratings of valence, dominance, and
arousal of pictures from IAPS (see method) did
neither dier from ratings of the already investigated healthy population nor between groups
(catatonics, psychiatric controls, healthy controls)
indicating no dierences in emotional perception/
attention/arousal between groups.
In summary, catatonic and psychiatric control patients showed signicantly longer reaction
times in neutral, positive, and negative emotional
pictures than healthy controls whereas no signicant dierences were found between catatonics
and psychiatric controls.
Healthy Controls
Since details of results in healthy subjects are

described extensively in Northo et al., 2000a we
just mention the main results. Negative and
positive emotional pictures led to dierent activation patterns in orbitofrontal, lateral prefrontal,
and premotor cortex. Negative emotional pictures
induced strong activation (i.e., positive correlated
IWV's) in medial orbitofrontal cortex and
marked negative correlated activity in lateral
prefrontal cortex. Positive emotional processing
lead to an inverse pattern with strong activation

in lateral prefrontal cortex and marked negative
correlated activity in orbitofrontal cortex (see
Table 5 and Figures 4 and 5).
Catatonic Patients
Negative emotions: First catatonic patients

showed signicantly lower activity (positive
IWV) and signicantly higher number of negative
IWV in right orbitofrontal cortex than psychiatric
(F = 4.5/4.2, p = 0.012/0.023) and healthy
(F = 4.1/4.3, p = 0.032/0.028) controls whereas
neither alterations in left orbitofrontal cortex nor
in psychiatric controls compared to healthy
controls were found (see Table 5 and Figures 4
and 5).
Second catatonic patients showed signicantly higher (F = 4.83.1, p = 0.00790.048)
positive and negative IWV in both right and left
medial prefrontal cortex compared to psychiatric
and healthy controls.
Third both catatonic and non-catatonic
psychiatric patients showed signicantly higher
positive IWV's in right and left lateral prefrontal
cortex than healthy controls (F = 4.02.8,
p = 0.0120.024).
Fourth both catatonic and psychiatric control patients showed signicantly higher positive
IWV in left premotor cortex (F = 4.13.3,
p = 0.021/0.033) than healthy controls.
In summary catatonic patients show specic
abnormalities in right orbitofrontal cortex and
right/left medial prefrontal cortex in negative
emotions with decrease of activation (positive
IWV) and increase of deactivation (negative
IWV) in the former (see Figure 5) and an increase
of activation (positive IWV) in the latter.
Positive emotions: First catatonic patients show
signicantly (F = 2.7/3.4, p = 0.042/0.026) higher
activity (positive IWV) in right and left orbitofrontal cortex than healthy controls and signicantly lower negative IWV (F = 3.2/4.3, p =
0.017/0.011) in right and left orbitofrontal cortex
than psychiatric and healthy controls (see Table 5
and Figure 5). Compared to negative emotions
there is a reversal in pattern of orbitofrontal
activity. Whereas in negative emotions positive
IWV were lower and negative IWV were higher in
catatonia this pattern is reversed in positive
emotions with higher positive IWV and lower
negative IWV compared to both controls groups
(see Table 5 and Figure 5).
Second we found signicantly lower
(F =4.23.3, p = 0.0130.032) activity in catatonic and psychiatric control patients in right and
left lateral prefrontal cortex than healthy controls.
161
Note that unlike in negative emotions both

psychiatric groups do no longer show increased
activity in lateral prefrontal cortex but rather
decreased activity.
Third no alterations in medial prefrontal
cortex were found in positive emotions.
Fourth catatonic patients showed signicantly (F = 3.4/3.1, p = 0.013/0.036) lower activity in left motor cortex compared to psychiatric
and healthy controls.
In summary catatonic patients show specic
abnormalities in right orbitofrontal cortex in
positive emotions with increase of activation
(positive IWV) and decrease of deactivation
(negative IWV) (see Figure 5).
Neutral condition: First both catatonic and
psychiatric control patients showed signicantly
(F = 3.12.5, p = 0.0170.048) higher activation
(positive IWV) in right orbitofrontal cortex,
anterior cingulate, left lateral prefrontal cortex,
and right motor cortex (see Table 5) whereas no
signicant dierences between catatonics and
psychiatric controls were found in these regions.
Second comparison between early and late
phases of the experiment (see statistical analyses
in methods for statistical details) for each condition separately (blocks 15 versus blocks 510)
and for all conditions (blocks 120 versus blocks
2040) revealed no signicant dierences in either
group (see Richter, 2001 for further details).
In summary analysis of neutral condition
dos not reveal any specic alterations in catatonia
distinguishing them from psychiatric controls.
However there are specic eects in both catatonics and psychiatric controls showing increased
activation in some regions compared to healthy
controls which may be related with attention
eects.
Nosological Analysis
Comparisons between catatonic and non-catatonic patients yielded the above mentioned
results. Nosological analysis (see above and
(Northo et al., 1998, 1999a for further details)
with regard to underlying psychiatric diagnosis of
either schizophrenic or aective psychosis showed
signicant dierences in medial prefrontal cortex,
anterior cingulate cortex, and lateral prefrontal
cortex compared to healthy controls. In contrast
to analysis with catatonia nosological analysis
revealed no signicant (or marginally signicant)
dierences between groups in orbitofrontal cortex.
Therefore orbitofrontal alterations must be considered as specic for catatonic syndrome itself
and not its underlying disease entity. However
162
due to low number of cases results from

nosological analysis should be regarded as preliminary. Nevertheless it gives further evidence
though rather weak and indirect to our assumption of orbitofrontal cortical dysfunction as
specically related with catatonic syndrome.
In summary nosological comparison between
aective and schizophrenic patients and healthy
controls revealed no signicant dierences in
those measures where catatonic patients diered
signicantly from psychiatric and healthy controls. Hence orbitofrontal cortical dysfunction
seem rather related with catatonic syndrome itself
than with underlying psychiatric disease so that it
must be regarded as specic for catatonic
syndrome itself.
Overall Summary of fMRI
First catatonia can be characterized by specic

alterations in right orbitofrontal cortex in negative emotions with decreased activation and
increased deactivation (see Table 5 and Figure 5).
Second catatonia can be characterized by an
abnormal pattern of activation and deactivation
in right orbitofrontal cortex in positive emotions
with increased activation and decreased deactivation (see Figure 5).
Third catatonia can be characterized by an
almost reversed pattern of activity in both
emotional conditions activation (positive IWV)
being low in negative and high in positive
emotions and deactivation (negative IWV) being
high in negative and low in positive emotions (see
Figure 5).
Fourth catatonia can be characterized by
specic alterations in medial prefrontal cortex in
negative emotions.
Fifth catatonia showed no major and/or
systematic alterations in premotor/motor cortex.
Sixth catatonia showed no specic abnormalities in neutral condition compared to psychiatric controls.
Correlations Between fMRI Signals,
Behavioral Measures, Clinical Symptoms, and
Constructs of the Self
Clinical SymptomsfMRI Signals
In order to relate abnormalities in fMRI signals

with clinical symptoms we correlated both kinds
of variables (see methods for details of statistical
analyses). Reducing the numbers of variables to
be correlated only those fMRI signals entered
into correlation analyses which were specic for
catatonia as pointed out above. In a second step

we performed the similar correlation analyses for
psychiatric controls calculating only those fMRI
signals which diered signicantly between psychiatric and healthy controls. Furthermore it
should be noted that, due to correlation of data
obtained in dierent states (clinical symptoms
from acute state on day 0 and fMRI signals in
post-acute state), signicant relationships can be
interpreted only as trait markers predisposing for
development of such symptoms whereas they do
not indicate state markers.
First we found signicant correlations between fMRI signals and clinical symptoms (from
day 0) only in the case of catatonic symptoms.
Furthermore catatonic symptoms correlated signicantly only with fMRI signals related to
negative emotions whereas no signicant correlations were found with positive or neutral conditions. Therefore all correlations described in the
following do refer to negative emotions.
Second general catatonic symptoms (Rosebush, NCStot) correlated signicantly positively
with negative IWVs in right medial/lateral prefrontal cortex (Rosebush/NCStot: r = 0,820,87;
p = 0,0420,049) (i.e., the more symptoms the
more negative IWV's in medial/lateral prefrontal
cortex) and signicantly negatively with negative
IWV's in right and left orbitofrontal cortex
(Rosebush/NCStot: r = 0,840.95; p = 0.008
0,044) (i.e., the more symptoms the less negative
IWV's in orbitofrontal cortex) (see Table 6).
Third catatonic motor symptoms (NCSmot)
correlated positively with positive and negative
IWVs in right and left medial/lateral prefrontal
and orbitofrontal cortex (r = 0,840,93;
p = 0,0080,048) (i.e., the more motor symptoms
the more negative IWV's in medial/lateral prefrontal and orbitofrontal cortex) (see Table 6).
Fourth catatonic behavioral (NCSbehav)
and aective (NCSa) symptoms correlated
negatively with negative IWVs in right and left
orbitofrontal cortex (r = 0,850,94; p = 0,008
0,049) (i.e., the more aective/behavioral symptoms the less negative IWV's in orbitofrontal
cortex) (see Table 6).
Fifth no signicant correlations were obtained between fMRI signals and clinico-demographic data including psychopharmacological
treatment (i.e., neuroleptics in chlorpromazin
equivalents) in both psychiatric groups.
In summary correlation of catatonic symptoms with fMRI signals could be characterized by
a dierential correlation pattern between aective/behavioral and motor symptoms concerning
the nature (positive versus negative), signal
(positive or negative IWV in fMRI signals), and

region (orbitofrontal, medial/lateral prefrontal).
In negative emotions aective/behavioral symptoms correlated negatively with negative IWV in
orbitofrontal cortex whereas motor symptoms
correlated positively with negative IWV's in
medial/lateral prefrontal and orbitofrontal cortex.
Such a dierential correlation pattern may
indicate particular alterations in dierent prefrontal cortical networks predisposing for development of aective/behavioral and motor
symptoms respectively.
Reaction TimefMRI Signals
Since (i) duration of reaction time may be related

with emotional processing (see above in methods),
(ii) psychiatric patients showed higher reaction
times than healthy controls (see above in results),
and (iii) catatonic patients show alterations in
emotional-motor transformation (see introduction) we correlated reaction times with fMRI
signals obtained during induction of emotional
experience.
First both healthy controls (see Northo et al.,
2000) and catatonic patients showed no signicant correlations between reaction time and fMRI
signals. Psychiatric controls showed signicant
correlations between reaction time and positive
correlated activity in negative contrasts in right
orbitofrontal (r = 0.975, p = 0.005; r = 0.900,
p = 0.037) and right medial prefrontal (r = 0.975,
p = 0.005) cortex (i.e., the longer the reaction time
the less activity). It may be hypothesized that in
contrast to catatonics and healthy controls psychiatric controls may recruit prefrontal cortical
areas for motor function in an abnormal way.
In summary relation between reaction time
and fMRI signals was only abnormal in psychiatric controls but not in catatonic patients
indicating that cortical motor function showed
no major alterations in catatonia.
Constructs of SelffMRI Signals
We correlated categories characterizing the distinct states of the self (i.e., Grid) with regional
fMRI signals obtained during emotional-motor
stimulation. In order to (i) reduce the number of
variables and (ii) pursue a hypothesis-driven
approach we correlated only those variables from
both Grid and fMRI with each other (see
methods for further statistical details) which
showed signicant dierences between catatonic
patients and both control groups. Such a correlation may relate altered constructs of the distinct
states of the self with alterations in activation in
particular regions. Since the orbitofrontal and
163
medial prefrontal cortex showed specic alterations in catatonia (see above) we focused correlation analyses on these regions which were
correlated with self-esteem, social contact, and
emotional arousal as the categories being altered
specically in catatonia (see above). In order to
point out specicity of relationships for catatonia
we performed correlation analyses of these variables in all three groups.
First all signicant correlations between
fMRI signals and categories of self concerned
those activation obtained during negative emotional stimulation (negative-neutral, negativegray) whereas signicant correlations were neither
found in positive (positive-neutral, positive-gray)
nor in neutral (neutral-gray) conditions.
Second categories 1 (social contact), 4 (selfesteem), and 15 (empathy) showed signicant
positive correlations with negative IWV in right
(and partially with left) orbitofrontal activity
c or r el at i n g s i g ni c an t l y ( r = 0 . 78 0 . 98 ;
p = 0.0060.023) with activity in orbitofrontal
cortex during negative emotional stimulation in
catatonic patients exclusively. In addition we
found a marginally signicant correlation
(r = 0.75, p = 0.052) between category 13 (emotional arousal) and negative IWV in right
orbitofrontal cortex in catatonic patients exclusively (see Table 6).
Third categories 4 (self-esteem) and 15
(empathy) correlated signicantly positive
(r = 0.710.89; p = 0.0070.034) with negative
IWV in right and left medial prefrontal cortex
during negative emotional stimulation in both
catatonic and psychiatric control patients.
In summary correlation analyses revealed a
relationship between altered right (and left)
orbitofrontal cortical deactivation (negative
IWV) in negative emotions and those categories
of the self (emotional arousal, lack of social
contact, self esteem) which were specically
altered in catatonia. Consequently there may be
a relationship between orbitofrontal cortical
dysfunction and altered construction of the self
in catatonia.
Constructs of SelfClinical Symptoms
In order to relate the constructs of the self with

catatonia we performed correlation analyses of
those categories of the self which were found
abnormal in catatonia (self-esteem, lack of social
contact, emotional arousal, empathy) with the
distinct kinds of catatonic symptoms (general,
aective, behavioral, motor).
First we found signicant negative correlations (r = 0.790.93, p = 0.0320.0065) between
164
aective/behavioral catatonic symptoms and the

categories of self-esteem and emotional arousal
(i.e., the less emotional arousal/self-esteem the
more aective and behavioral symptoms).
Second we found signicant positive correlations (r = 0.81/0.87, p = 0.010/0.0076) between
lack of social contact on the one hand and general
and motor catatonic symptoms on the other (i.e.,
the more lack of social contact the more motor
symptoms).
In summary we found a dierential relationship between the distinct kinds of catatonic
symptoms and the distinct categories of the self
being specically altered in catatonia.
Overall Summary of Correlations
First right orbitofrontal cortical dysfunction

correlates with both behavioral/aective catatonic symptoms and altered categories of the self
(self-esteem, emotional arousal) in catatonia.
Second aective/behavioral symptoms correlate signicantly with altered categories of the self
(self-esteem, emotional arousal) in catatonia.
Third orbitofrontal and medial prefrontal
cortical dysfunction correlates with both motor
symptoms and lack of social contact in catatonia.
Fourth motor symptoms correlates with lack
of social contact in catatonia.
In conclusion we found a dierential correlation pattern of aective/behavioral and motor
symptoms with regard to both regional fMRI
signals and constructs of the self.
Discussion
We investigated both subjective psychological
characteristics and objective prefrontal cortical
activation pattern during emotional stimulation
with motor reaction in catatonia. Analysis of
results revealed the following ndings in catatonic
patients compared to non-catatonic psychiatric
and healthy controls: (i) specic alterations in
emotional arousal, self-esteem, and social contact
in personal constructs of the self in catatonic
patients in distinct states i.e., acute, post-acute,
and ideal states; (ii) orbitofrontal and medial
prefrontal cortical dysfunction during negative
emotional stimulation in catatonia; (iii) relationship between orbitofrontal cortical dysfunction,
aective/behavioral symptoms, and alterations in
emotional arousal and self-esteem in catatonia;
(iv) relationship between orbitofrontal/medial
prefrontal cortical dysfunction, motor symptoms,
and lack of social contact in catatonia.
Present results support our rst assumption
i.e., alteration in emotional arousal in personal

constructs of the self in catatonic patients (see
introduction) whereas our second assumption was
only partially conrmed. Whereas the self-dimension of social contact showed a relationship with
motor symptoms, as suggested, it did not
correlate with behavioral symptoms. Furthermore self-esteem did not show a relationship with
motor symptoms but rather with aective and
behavioral symptoms. Subsequently results conrm distinction between aective and motor
symptoms with regard to distinct dimensions of
the self but they do not support relationship
between motor and behavioral symptoms in
catatonia. Instead they rather suggest close
relationship between aective and behavioral
symptoms on the one hand and emotional arousal
and self-esteem on the other. fMRI results
conrm our third assumption i.e., orbitofrontal
cortical dysfunction during emotional stimulation
as well as our fourth assumption i.e., relationship
between social contact, motor symptoms, and
medial prefrontal cortical dysfunction.
Both GRID and fMRI results do therefore
support our initial assumptions. They point out
the crucial role of the orbitofrontal cortex even in
a much stronger way since orbitofrontal cortical
function was not only related with emotional
arousal and aective catatonic symptoms, as
initially suggested (see introduction), but in
addition with self-esteem and behavioral symptoms as well. Therefore catatonia should be
regarded as a psycho-motor syndrome in a literal
sense which furthermore may give some insight
into psychophysiological mechanisms potentially
underlying ``sensori-motor regression'' in general.
Psychodynamic and Psychological Mechanisms of
``Sensori-motor Regression'' in Catatonia
Subjective psychological characteristics of the self
revealed signicantly reduced emotional arousal
(category 13) in catatonic patients compared to
non-catatonic psychiatric and healthy controls.
Therefore alterations in emotional reaction to the
environment seem to be of central importance in
personal constructs of catatonic patients characterizing both the acute catatonic state as well as
their post-acute self (see above). Such a central
and specic role of emotional arousal in catatonia
is further supported by the following ndings: (i)
signicantly more intense anxieties in catatonic
patients compared to non-catatonic psychiatric
controls (Northo et al., 1998; Rosebush et al.,
1990); (ii) subjective reports of lack of control of
anxieties in catatonic patients (Northo et al.,

1998; Rosebush et al., 1990); (iii) dramatic
therapeutic ecacy of the anxiolytic agent lorazepam in catatonic patients with intense and
uncontrollable anxieties (Bush et al., 1996; Northo et al., 1998; Rosebush et al., 1990).
The lack of emotional control may be
complemented by the present nding of reduced
emotional arousal in both the acute and postacute state. According to the theory of personal
constructs (Boker et al., 2000a; Kelly, 1955)
uncontrollable anxiety results if emotional events
can neither be evaluated nor anticipated any
longer by means of cognitions (Boker, 1999;
Winter, 1985). Such lack of cognitive control of
emotional processing as the inability to anticipate
and evaluate emotional events does necessarily go
along with a ``deadlock in the cycles of construction'' of personal constructs. The ``deadlock in
the cycles of construction'' may be reected in the
inability of cognitive control of anxieties so that
cognitive defense mechanisms are no longer
available for catatonic patients (Boker and
Lempa, 1996; Johnson, 1984). Lack of availability
of cognitive defense mechanisms may go along
with decrease of self-esteem since patients can no
longer control their emotions voluntarily as
implied by cognitive control. If cognitive defense
mechanisms are no longer available anxieties can
be defended only by somatic mechanisms with
consecutive regression to the bodily level i.e.,
``sensori-motor regression''. Total immobilization
of the body may therefore serve for prevention of
total disintegration of the self by overwhelming
and increasingly uncontrollable anxieties. Such an
assumption is supported by the following observations: (i) alteration in social contact in self of
catatonic patients (see results) which is closely
related with i.e., disrupted by sensori-motor
regression; (ii) relationship between alteration in
social contact and motor symptoms in catatonia
(see results); (iii) dierence between inward
experience and outward appearance in catatonic
patients (Northo et al., 1998) which therefore
may be characterized as an immobilized `èmotional volcano of not at all petried feelings''
(Arieti, 1972).
Catatonic patients are no longer able to
evaluate or anticipate anxieties. Accordingly their
action and behavior is governed by concrete
constructs covering sensations and motor dimensions rather than by psychological constructs
anticipating intention, emotions and meaning
required for the anticipation of human conduct
and interaction. From a psychodynamic point of
view immobilization of the body can be considered the nal measure i.e., regressive reaction and
defensive compensation of the catatonic patient
165
with the aim to avoid total disintegration of the

self. In contrast to depressive and schizophrenic
patients catatonic patients are no longer able to
either internalize (i.e., aective patients) or
externalize (i.e., schizophrenic patients) their
anxieties by means of cognitions (Boker and
Lempa, 1996; Johnson, 1984). Instead they
project their anxieties onto their bodies by means
of ``sensori-motor regression''.
Why do catatonic patients remain unable to
either externalize or internalize their anxieties in
the same way as schizophrenic or aective
patients?
First it may just be a matter of severity of
either schizophrenic or aective psychosis until
the possibility of cognitive defense by either
externalization or internalization breaks down
resulting in sensori-motor regression. Such an
assumption would be consistent with the fact that
catatonic syndrome occurs in both aective and
schizophrenic patients (Bush et al., 1996; Fink et
al., 1993; Northo et al., 1998, 1999; Rosebush et
al., 1990; Taylor, 1990). Second if catatonia may
be regarded as a psychomotor syndrome being
associated with both aective and schizophrenic
psychosis it may show psychodynamic features of
both kinds of psychosis. If this would be the case
breakdown in cognitive defense mechanisms may
result from alternative between internalization
and externalization of their anxieties which may
be impossible to make in the acute state.
Subsequently psychomotor immobilization and
sensori-motor regression would then result from
an intrapsychic deadlock caused by insurmountable cognitive-emotional ambiguities (see also
Northo et al., 1998) with breakdown of any kind
of usually available cognitive defense mechanism.
Orbitofrontal Cortical Dysfunction and
``Sensori-motor Regression'' in Catatonia
Results in fMRI demonstrated dysfunction in
orbitofrontal cortex in catatonia showing an
altered pattern of activation and deactivation in
negative and positive emotional stimulation (see
Figure 5) conrming our third assumption (see
introduction).
Several studies pointed out the central role of
orbitofrontal cortical function particularly in
negative emotions (Baker et al., 1997; Beauregard
et al., 1998; Drevets and Raichle, 1998; George et
al., 1995; Irwin et al., 1998; Lane et al., 1997;
Mayberg et al., 1999; Northo et al., 2000;
Paradiso et al., 1997; Phillips et al., 1997). There
is a functional dissociation between medial
orbitofrontal (area 11 according to Brodman)
166
and lateral orbitofrontal/lateral lower prefrontal

(area 12 and 47 according to Brodman) cortical
activity since activation in medial areas is
accompanied by deactivation in lateral areas
and vice versa (Baker et al., 1997; Drevets and
Raichle, 1998; Mayberg et al., 1999; Northo et
al., 2000). The medial orbitofrontal cortex is
reciprocally connected with the amygdala (Barbas, 1995; Carmichael and Price, 1995; Morecraft
and Hoesens, 1998; Morecraft et al., 1992) which
both have been shown to be activated specically
during negative emotional stimulation (Baker et
al., 1997; Beauregard et al., 1998; Breiter et al.,
1996, 1997; George et al., 1995; Lane et al., 1997;
Mayberg et al., 1999; Morris et al., 1996, 1998;
Phillips et al., 1997). In contrast to negative
emotional processing in medial orbitofrontal
cortex the lateral orbitofrontal cortex is rather
related to cognitive operations associated with
emotional processing (Baker et al., 1997; Drevets
and Raichle, 1998; Mayberg et al., 1999; Rolls,
1995, 1998). Therefore lateral orbitofrontal cortical function may be responsible for evaluation
and anticipation of emotional events and thus for
cognitive control of emotional processing such as
for example aective inhibition (Dias et al., 1996,
1997). Since in catatonia the pattern of activation
and deactivation in medial and lateral orbitofrontal cortex was reversed both negative emotional processing and cognitive control of
emotional processing may be altered as well.
Such an assumption of relationship between
reversed pattern of medio-lateral orbitofrontal
activity and altered emotional-cognitive interaction is supported by the following ndings in the
present study: (i) signicant correlation between
orbitofrontal cortical activity, aective symptoms, and emotional arousal; (ii) signicant
correlation between orbitofrontal cortical activity, behavioral symptoms, and self-esteem. It may
be speculated that the rst nding may be closely
related with emotional processing and thus with
medial orbitofrontal cortical function whereas the
second nding may rather be associated with
cognitive control of emotional processing and
thus with lateral orbitofrontal cortical function.
Alteration in medial orbitofrontal cortical function may lead to intense anxieties which then, due
to lateral orbitofrontal cortical dysfunction, can
no longer be controlled by cognitions anymore.
Such a hypothesis would be in accordance with
both subjective experience and personal constructs of the self in catatonia. Catatonic patients
do indeed report about intense anxieties and
altered emotional arousal both reecting emotional processing. In addition they report uncontrollable anxieties and low self-esteem which
both may be related with cognitive control of

emotional processing.
Catatonic patients showed alterations and
correlations predominantly in right orbitofrontal
cortex which may be of crucial importance. Due
to earlier development neurons in right orbitofrontal cortex show a higher density with stronger
functional connections than in the left one (Shore,
1996). Functional imaging (Binkofski et al., 1999;
Fallgatter et al., 1997; Kiefer et al., 1998; Strik et
al., 1999) and lesion (Rolls, 1995, 1998; Shore,
1996; Solms, 1998) studies demonstrated that the
right orbitofrontal cortex, as in contrast to the
left, seems to be particularly involved in processes
of inhibition. These inhibitory processes may be
related to aective inhibition and thus to cognitive control of emotional processing (see above).
Subsequently right orbitofrontal cortical dysfunction must apparently be considered as specic for
patients with catatonic syndrome distinguishing
them from aective and schizophrenic patients
without catatonic syndrome. If the right orbitofrontal cortex accounts for inhibition of emotional processing its dysfunction may go along
with an inability of cognitive emotional control
which psychodynamically results in breakdown of
cognitive defense mechanisms. Since in contrast
right orbitofrontal cortical function seems to be
preserved in non-catatonic aective and schizophrenic patients they are still able to control and
defend their intense emotions by either internalization or externalization reecting intact cognitive defense mechanisms.
In addition to orbitofrontal cortical dysfunction catatonic patients showed alteration in
medial prefrontal cortex. The orbitofrontal cortex
is closely connected with medial orbitofrontal
cortex which is supposed to be involved in
regulation and modulation of social and motor
behavior (see Carmichael and Price, 1994;
Damasio, 1995; Sarazin et al., 1998; Shore,
1996). Subsequently one may assume relationship
between medial prefrontal cortical dysfunction
and motor symptoms in catatonia which is
supported by the following ndings: (i) correlation between medial prefrontal cortical activity
with motor symptoms; (ii) correlation between
altered medial prefrontal cortical activity and lack
of social contact; (iii) correlation between lack of
social contact and motor symptoms. Alteration in
medial prefrontal cortical activity may be closely
related with orbitofrontal cortical dysfunction
which may be supported by the following
observations: (i) correlation of motor symptoms
with both orbitofrontal and medial prefrontal
cortical activity; (ii) altered functional connectivity between orbitofrontal and medial prefrontal

cortex in catatonia (Schlagenhauf, 2001). In
addition to medial prefrontal cortex the orbitofrontal cortex is connected with premotor/motor
and parietal cortex (see also Figure 6). Connections from orbitofrontal cortex to premotor/
motor cortex may account for minor alterations
in the latter areas found in catatonic patients (see
Table 5). Dysfunction in right orbitofrontal
cortex may account for functional alterations in
right posterior parietal cortex, and potentially for
posturing as the most bizarre symptom in
catatonia, as it has been reported in several
studies (Fukutake et al., 1993; Galynker et al.,
1997; Northo et al., 1999b; Satoh et al., 1993;
Saver et al., 1993). However exact relationship
between right orbitofrontal cortex, right posterior
parietal cortical function, and posturing remains
unclear. Nevertheless alteration in orbitofrontal
cortical functional connectivity to medial prefrontal and posterior parietal cortex may be
regarded as specic for catatonia (see Schlagenhauf, 2001) since lesions in orbitofrontal cortex
do not necessarily lead to total immobilization
and posturing (Sarazin et al., 1998; Solms, 1998)
as it is the case in catatonia.
Subsequently one may conclude that breakdown of cognitive defense mechanisms with
consecutive regression to somatic defense mechanisms may be closely related with alteration in
pattern of medial and lateral orbitofrontal
activity as it can be observed in patients with
orbitofrontal lesions (Solms, 1998). The particular form of ``sensori-motor regression'' in catatonia i.e., total `ìmmobilization by anxiety'' may
be accounted for by specic alteration in right
orbitofrontal cortex and additional alterations in
orbitofrontal connectivity to medial prefrontal
and posterior parietal cortex.
Methodological Limitations
First considering the fact that some authors
postulate an amnesia for the acute catatonic state
(Lohr and Wiesniewski, 1987) the retrospective
character of our study with regard to the ``Me in
the acute catatonic state'' is problematic. However, due to symptoms such as mutism, stupor,
etc. subjective experiences cannot be explored in
the acute catatonic state itself. We observed that
catatonic patients have diculties only recollecting and verbalizing their experiences during the
acute catatonic state. After recovering from the
catastrophic collapse of the cycles of construction
our catatonic patients became more open and
began to recount the subjective experiences they
had made in the process of construing ``Me in the
167
acute catatonic state''. In order to avoid confusions between memory decits and retrospective
account, patients with cognitive decits were
excluded (see Methods) from the study at an
early stage.
Second several authors emphasize the
heterogeneity of the subjective experience in
catatonic patients (Lohr and Wiesniewski, 1987;
Northo et al., 1998). In the scope of this the
study individual constructs have been classied by
means of modied Landeld Categories so that
an inter-individual comparison became possible.
These categories focus on particular structures of
experiences rather than on specic contents. Even
if contents may dier between catatonic patients
the underlying structure of their experiences may
nevertheless be the same. For example, almost all
catatonic patients suered from strong and
uncontrollable anxieties which however were
related to dierent contents respectively in delusions, hallucinations, ego-disturbances, etc.
Third reports of subjective experiences may
be confounded by side-eects of neuroleptic
medication. However patients with strong extrapyramidal side-eects were excluded from the
study (see Methods) to avoid that subjective
experience was confounded by neuroleptic-induced movement disorders. Moreover non-catatonic psychiatric controls were matched in their
medication and psychiatric disease to catatonic
patients so that dierences between both psychiatric groups can neither be related to medication
nor to underlying psychiatric disease.
Fourth we investigated only akinetic catatonic patients responding well to lorazepam (see
Methods) whereas hyperkinetic catatonics as well
as catatonic non-responders to lorazepam were
excluded. This limitation is important to mention
since hypokinetic and hyperkinetic catatonia as
well as responders and non-responders to lorazepam may probably be characterized by distinct
underlying pathophysiological mechanisms
(Northo et al., 1998). Subsequently our nding
of orbitofrontal cortical dysfunction does only
apply to akinetic catatonic patients responding
well to lorazepam whereas hyperkinetic catatonics and non-responders should be investigated
separately. In addition one may criticize the low
number of cases which however may be understandable considering the rareness of catatonia
and the complexity of the study design. Furthermore patients were investigated only in a postacute state but not in an acute state so that the
present ndings cannot be interpreted as state
markers but rather as trait markers which, as has
been shown in nosological analysis, nevertheless
distinguish catatonic from non-catatonic patients.
168
Fifth we applied several strategies to minimize arousal and attention eects though such
inuences can however not entirely be excluded in
our activation paradigm. Positive, negative, and
neutral pictures were matched for content,
dominance, and arousal (see above). Psychological
states as measured with the Bf-S and subjective
evaluation of pictures in our subjects did not
dier from those in both control groups. Consequently dierences in fMRI
signals can neither be accounted for by
increased preexperimental arousal nor by altered
emotional perception/attention in our subjects. In
order to further exclude attentional/arousal eects
related to switches between dierent conditions
we excluded the rst and last picture within each
block from analysis. In addition we included two
non-emotional control conditions neutral and
gray pictures to control for arousal and attention
eects.
Sixth we found a high proportion of
negatively correlated activity in fMRI which can
be interpreted in several ways. Negatively correlated activity in fMRI, which was particularly
strong in negative emotions, could reect a
decrease of neuronal activity with neural inhibition in the activation condition, an increase of
neuronal activity in the control condition, a ``steal
eect'' of regional cerebral blood ow, or an
altered coupling mechanism between oxygen
consumption and rCBF. Several PET studies
found concomitant increases and decreases of
rCBF during emotional stimulation (Baker et al.,
1997; Beauregard et al., 1998; Drevets and
Raichle, 1998; George et al., 1995; Irwin et al.,
1998; Lane et al., 1997; Mayberg et al., 1999;
Northo et al., 2000; Paradiso et al., 1997;
Phillips et al., 1997; Raichle et al., 2001) so that
it seems quite plausible, at least in the present
study, to relate such negatively correlated voxels
to altered i.e., decreased regional activity in either
of the two conditions within the respective
contrast. Even if similar regions are involved,
their pattern of increased and decreased activity
(i.e., positive and negative correlated activity)
may nevertheless dier between two conditions as
it is apparently the case in negative and positive
emotions as well as in catatonia. Regions, which
are activated during negative emotions, as for
example the orbitofrontal cortex, may be suppressed (or deactivated) in neural processing of
positive emotions and vice versa (Drevets and
Raichle, 1998; Mayberg et al., 1999; Northo et
al., 2000; Raichle et al., 2001). This pattern of
activation/deactivation during negative and positive emotional stimulation seems to be specically
disturbed in catatonic patients since they showed
dierent activation patterns than psychiatric and

healthy controls.
Conclusions
We applied a novel method by directly combining
search for subjective psychological characteristics
of the self with investigation of underlying
objective prefrontal cortical activation pattern
during emotional-motor stimulation in catatonia
a psychomotor syndrome with a unique constellation of aective, behavioral, and motor symptoms. Subjective psychological characteristics of
the self showed particular alterations in emotional
arousal, self-esteem, and social contact in catatonic patients whereas fMRI revealed dysfunction
in orbitofrontal and medial prefrontal cortex.
Lack of emotional arousal and low self-esteem
may reect a cognitive failure to anticipate and
evaluate emotional events with consecutive breakdown of cognitive defense mechanisms which may
be accounted for by alteration in activation/
deactivation pattern in medial and lateral orbitofrontal cortex. Lack of social contact may be
reected in functional imbalance between medial
orbitofrontal and medial prefrontal cortical activity
which may account for motor symptoms and
``sensori-motor regression'' in such patients (see
Figure 6). It is concluded that alteration in
orbitofrontal cortical function by itself may lead
to breakdown of cognitive defense mechanisms in
general whereas additional alterations in orbitofrontal connectivity may account for the particular form of somatic defense mechanism with
``sensori-motor regression'' and `ìmmobilization
by anxiety'' as observed in catatonia.
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5 Orbitofrontal Cortical Dysfunction and "Sensori-Motor Regression": A Combined Study of FMRI and Personal Constructs in Catatonia

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This article was downloaded by: [Adelphi University]

On: 22 August 2014, At: 23:40

Neuropsychoanalysis: An Interdisciplinary Journal for

Psychiatric Hospital, University of Magdeburg.

Department of Behavioral Neurology, Harvard University, Boston/USA.

Psychiatric University Hospital Zrich.

Institut for Neurobiology, University of Magdeburg.

Department of Psychosomatic Medicine and Psychotherapy, University of Frankfurt/M.

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Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression'':

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Objective: A close relationship between subjective

diagnosis, and medication matched non-catatonic

Georg Northoff, Andre Richter, Frank Baumgart et al.

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may psychologically be closely related to the way

Georg Northoff, Andre Richter, Frank Baumgart et al.

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may psychologically be closely related to the way

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Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression''

symptoms) on the day of admission by agreement

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Georg Northoff, Andre Richter, Frank Baumgart et al.

age: 35.6  6.7), 16 unipolar depressive patients

gated ``personal constructs'' of the ``self'' in the

Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression''

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First global frequencies of positive and negative

System (IAPS) (Lang et al., 1997) which was

Georg Northoff, Andre Richter, Frank Baumgart et al.

on emotionality of pictures. In addition they were

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Behavioral and Psychological Monitoring

Reaction time as the time from the appearance of

German population. In addition we compared

The images were acquired in a Bruker Biospec

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Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression''

Data were analysed as follows: First, subject

patients (means: 3.4 mm and 2.1 ; both suering

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Georg Northoff, Andre Richter, Frank Baumgart et al.

as described below in further detail (see statistical

Comparison between groups: Statistical analyses

Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression''

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Analysis of Constructs of Self in Repertory-Grid

Category 4a (high self-esteem) was signicantly

Catatonic patients diered signicantly from both

esteem, p < 0.020, lower), 17 a (high mood,

Catatonic patients showed signicantly more

Catatonic patients diered signicantly from

Georg Northoff, Andre Richter, Frank Baumgart et al.

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Comparisons of Different Selves Within Groups

In order to investigate relationship and compare

First the self of patients in the acute catatonic

exactly at the opposite compared to both the

Statistical analysis (ANOVA) revealed signicant

Since details of results in healthy subjects are

Orbitofrontal Cortical Dysfunction and ``Sensori-motor Regression''

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age: 35.6 6.7), 16 unipolar depressive patients

patients (means: 3.4 mm and 2.1 ; both suering