Non-motor aspects in dystonia are now well recognized. The sense of agency, which refers to the experience of controlling one's own actions, has been scarcely studied in dystonia, even though its disturbances can contribute to movement disorders.
Among various brain structures, the cerebral cortex, the cerebellum, and the basal ganglia are involved in shaping the sense of agency. In myoclonus-dystonia, resulting from a dysfunction of the motor network, an altered sense of agency may contribute to the clinical phenotype of the condition.
In this study, we compared the explicit and implicit sense of agency in patients with myoclonus-dystonia caused by a pathogenic variant of SGCE (DYT-SGCE) and control participants. We utilized behavioral tasks to assess the sense of agency and performed neuroimaging analyses, including structural, resting-state functional connectivity, and dynamic causal modeling, to explore the relevant brain regions involved in the sense of agency. Additionally, we examined the relationship between behavioral performance, symptom severity, and neuroimaging findings.
We compared 19 patients with DYT-SGCE and 24 healthy volunteers. Our findings revealed that patients with myoclonus-dystonia exhibited a specific impairment in explicit sense of agency, particularly when implicit motor learning was involved. However, their implicit sense of agency remained intact. These patients also displayed grey matter abnormalities in the motor cerebellum, as well as increased functional connectivity between the cerebellum and pre-supplementary motor area (pre-SMA). Dynamic causal modeling analysis further identified reduced inhibitory effects of the cerebellum on the pre-SMA, decreased excitatory effects of the pre-SMA on the cerebellum, and increased self-inhibition within the pre-SMA. Importantly, both cerebellar grey matter alterations and functional connectivity abnormalities between the cerebellum and pre-SMA were found to correlate with explicit sense of agency impairment. Increased self-inhibition within the pre-SMA was associated with less severe myoclonus symptoms.
These findings highlight the disruption of higher-level cognitive processes in patients with myoclonus-dystonia, further expanding the spectrum of neurological and psychiatric dysfunction already identified in this disorder.