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Disease Entity: Aphantasia

Aphantasia is defined as the inability or significantly decreased ability to visualize imagery in the mind. (1) Mental visualization is a phenomenon that ranges as an ability, from hyperphantasia (the ability to produce highly vivid mental imagery) to aphantasia. Because aphantasia is often a congenital condition with no outwardly perceptible symptoms, many patients may not realize that they have it until adulthood. On some occasions, patients who were previously able to produce mental images may acquire aphantasia due to a psychological or neurological event, including traumatic brain injury, affective disorder, and stroke. (2) Aphantasia is not known to have long-term complications but may cause patients psychological distress, especially in cases of acquired aphantasia. (3,4) It is estimated that 2-4% of the generalized population have aphantasia. (3,5,6)

History

The history of aphantasia as a recorded condition began with Sir Francis Galton’s “Breakfast Table Survey” in 1880, where research participants were asked to imagine a breakfast table with food, rating how vivid the image was. (16) In 2015, Adam Zeman, Michaela Dewar, and Sergio De Salla coined the term “aphantasia”, based on the Greek for imagination, and defined it as a ‘condition of reduced or absent visual imagery’. (1)

Etiology

The etiology of congenital aphantasia has not yet been elucidated. A 2017 study using fMRI to compare neural activity between low and high visualizers found that ability to visualize was associated with high levels of activity in the posterior brain, while low visualization was correlated with activity in the anterior brain. (7)

Acquired aphantasia may be neurogenic or psychogenic. According to a 2021 preliminary report, the most reported cause of neurogenic acquired aphantasia is traumatic brain injury (TBI) and the second is stroke. (2) A 2021 case report details a case of acquired aphantasia after COVID-19 illness. (8) Dementia is another neurogenic cause of acquired aphantasia, with declines in capacity to visualize present across all subtypes of dementia disorders. (9)

Psychogenic aphantasia has been reported to be caused by depression, anxiety, and dissociative disorders in multiple case reports and studies. (10–12) However, one study found that there was no difference in visualizing ability between healthy controls and patients with bipolar, anxiety, and depressive disorders. (13) Thus, it is currently unclear how psychological disorders may impact visualization ability.

Risk Factors

Specific risk factors for congenital aphantasia have not yet been elucidated. Some studies implicate a potentially hereditary pattern, as aphantasiac patients report affected relatives (1,4).

Neurogenic aphantasia may be due to dementia, stroke, or traumatic brain injury, among other disorders (2). Thus, factors that increase the risk of these disorders may also indirectly increase the risk of acquiring aphantasia.

Psychogenic aphantasia has been associated with mood disorders such as major depressive disorder and generalized anxiety disorder, as well as dissociative disorders such as depersonalization/derealization disorder. (2,10) These disorders may increase the risk of acquiring aphantasia.

Pathophysiology

The full pathogeneses of psychogenic aphantasia and congenital aphantasia have not yet been elucidated. A 2017 fMRI study suggests that, during visualization tasks, low visualizers show more activity in the anterior cingulate cortex and frontal regions of the brain, while high visualizers show activity in the fusiform gyri, parahippocampal gyri, and posterior cingulate cortex. (7) These results were consistent with a previous case report of acquired aphantasia after a stroke. (14)

Neurogenic aphantasia, including aphantasia caused by traumatic brain injury, stroke, dementia, may be caused by damage to the regions of the brain responsible for episodic memory. (9) One case of acquired aphantasia occurred in a patient receiving autologous stem cell transplant for the treatment of multiple myeloma, immediately following a spontaneous pneumothorax. The authors posit that the etiology may be hypoxemic brain injury due to pneumothorax. (15)

Diagnosis

Symptoms

Aphantasia is a heterogenous diagnosis, with a range of symptoms reported. Some patients report decreased vividness in imagery, while others report full inability to visualize. A diagnostic scale, such as the Vividness of Visual Imagery Questionnaire (VVIQ), can measure and compare visual imagery ability (1,3,4). Aphantasia may also include impairment of other functions. In multiple studies, aphantasia patients self-reported and demonstrated impaired autobiographical memory, difficulty recognizing faces, decreased navigational ability, and inability to have visual dreams at increased prevalence compared to non-aphantasiacs. (1,17)

Clinical diagnosis

Because aphantasia is largely based on self-reported symptoms, there are no official diagnostic criteria. However, the Vividness of Visual Imagery Questionnaire (VVIQ), described above, has been used in multiple clinical case reports, as well as larger studies, to assess aphantasia. Multiple studies defined a VVIQ score between 16 to 32 as aphantasia. (1,5,18) A recent 2022 validation study, however, found that self-identified patients with aphantasia scored above 33 on the VVIQ. Additionally, the VVIQ does not assess other types of sensory imagery, which may underreport patients with higher visual imagery abilities but lower imagery in other senses. (19) Thus, the VVIQ score should not be used as a definitive clinical marker for aphantasia.

Diagnostic procedures

There are several diagnostic procedures used by researchers to identify aphantasia, but no standardized clinical diagnostic procedure has been specified yet.

Self-report is the primary method of identifying aphantasia, as many people with congenital aphantasia do not realize they have it until adolescence or early adulthood. (1)

Aphantasia, whether congenital or acquired, is most often assessed using the Vividness of Visual Imagery Questionnaire (VVIQ). (1,4,15,20) The VVIQ has 16 visualization questions, and participants rate the vividness of a mental image on a scale of five to one. The lowest score is 16, while the highest is 80. (7) However, the VVIQ does not account for loss of non-visual sensory imagery. (19)

Differential diagnosis

Preliminary research and case reports have indicated an association between anxiety and depressive disorders and acquired aphantasia. Thus, in cases of acquired aphantasia, psychogenic causes should be investigated. (2,9,10) Research has also indicated a connection between dementias and acquired aphantasia. (9)

Management

General treatment

Currently, there is no approved treatment for congenital or acquired aphantasia.

Prognosis

Congenital aphantasia has been observed as a lifelong condition that does not improve over the life course. There is currently no treatment for acquired aphantasia. One case report of acquired aphantasia after a stroke reported mild improvement, but not full recovery. (15)

References

1. Zeman A, Dewar M, Della Sala S. Lives without imagery – Congenital aphantasia. Cortex. 2015 Dec;73:378–80.

2. #3112 Acquired aphantasia in 88 cases: a preliminary report | Journal of Neurology, Neurosurgery & Psychiatry [Internet]. [cited 2022 Aug 1]. Available from: https://jnnp.bmj.com/content/92/8/A6.3

3. Keogh R, Pearson J, Zeman A. Aphantasia: The science of visual imagery extremes. Handb Clin Neurol. 2021;178:277–96.

4. Zeman A, Milton F, Della Sala S, Dewar M, Frayling T, Gaddum J, et al. Phantasia–The psychological significance of lifelong visual imagery vividness extremes. Cortex. 2020 Sep 1;130:426–40.

5. Dance CJ, Ipser A, Simner J. The prevalence of aphantasia (imagery weakness) in the general population. Conscious Cogn. 2022 Jan 1;97:103243.

6. Faw B. Conflicting intuitions may be based on differing abilities: Evidence from mental imaging research. J Conscious Stud. 2009;16(4):45–68.

7. Fulford J, Milton F, Salas D, Smith A, Simler A, Winlove C, et al. The neural correlates of visual imagery vividness – An fMRI study and literature review. Cortex. 2018 Aug 1;105:26–40.

8. Gaber TAZK, Eltemamy M. Post-COVID-19 aphantasia. Prog Neurol Psychiatry. 2021;25(3):16–7.

9. Mental imagery in psychiatry: conceptual & clinical implications | CNS Spectrums | Cambridge Core [Internet]. [cited 2022 Aug 10]. Available from: https://www.cambridge.org/core/journals/cns-spectrums/article/mental-imagery-in-psychiatry-conceptual-clinical-implications/9B72ED99BA371CC60D7CE5C5417AE673

10. de Vito S, Bartolomeo P. Refusing to imagine? On the possibility of psychogenic aphantasia. A commentary on Zeman et al. (2015). Cortex. 2016 Jan;74:334–5.

11. Morrison AS, Amir N, Taylor CT. A Behavioral Index of Imagery Ability in Social Anxiety. Cogn Ther Res. 2011 Aug 1;35(4):326–32.

12. Zarrinpar A, Deldin P, Kosslyn SM. Effects of depression on sensory/motor vs. central processing in visual mental imagery. Cogn Emot. 2006 Sep 1;20(6):737–58.

13. Di Simplicio M, Renner F, Blackwell SE, Mitchell H, Stratford HJ, Watson P, et al. An investigation of mental imagery in bipolar disorder: Exploring “the mind’s eye.” Bipolar Disord. 2016;18(8):669–83.

14. Zeman AZJ, Della Sala S, Torrens LA, Gountouna VE, McGonigle DJ, Logie RH. Loss of imagery phenomenology with intact visuo-spatial task performance: A case of ‘blind imagination.’ Neuropsychologia. 2010 Jan 1;48(1):145–55.

15. Bumgardner AL, Yuan K, Chiu AV. I cannot picture it in my mind: acquired aphantasia after autologous stem cell transplantation for multiple myeloma. Oxf Med Case Rep. 2021 May 24;2021(5):omab019.

16. Galton F. Visualised Numerals. Nature. 1880 Jan 15;21:252–6.

17. Palermo L, Boccia M, Piccardi L, Nori R. Congenital lack and extraordinary ability in object and spatial imagery: An investigation on sub-types of aphantasia and hyperphantasia. Conscious Cogn. 2022 Aug 1;103:103360.

18. Keogh R, Pearson J. The blind mind: No sensory visual imagery in aphantasia. Cortex. 2018 Aug;105:53–60.

19. Diversity of aphantasia revealed by multiple assessments of the capability for multi-sensory imagery [Internet]. 2022 [cited 2022 Nov 2]. Available from: https://www.researchsquare.com

20. Thorudottir S, Sigurdardottir HM, Rice GE, Kerry SJ, Robotham RJ, Leff AP, et al. The Architect Who Lost the Ability to Imagine: The Cerebral Basis of Visual Imagery. Brain Sci. 2020 Jan 21;10(2):59.