Narcolepsy type 1 is a neurological sleep disorder mainly characterized by excessive daytime sleepiness, fragmented night sleep, and cataplexy (muscle atonia triggered by emotions). To characterize brain activation patterns in response to neutral-rated and fun-rated movies in narcolepsy type 1 we performed functional magnetic resonance imaging during a paradigm consisting of 30 short movies (25/30 with a humorous punchline; 5/30 without a humorous punchline (but with similar build-up/anticipation)) that the participants rated based on their humor experience. We included 41 narcolepsy type 1 patients (31 females, mean age 23.6 years, 38/41 H1N1-vaccinated, 41/41 HLA-DQB1*06:02-positive, 40/40 hypocretin-deficient) and 44 first-degree relatives (24 females, mean age 19.6 years, 30/44 H1N1-vaccinated, 27/44 HLA-DQB1*06:02-positive) as controls. Group-level inferences were made using permutation testing. Permutation testing revealed no significant differences in the average ratings of patients and controls. Functional magnetic resonance imaging analysis revealed that both groups showed higher activations in response to fun-rated movies in several brain regions associated with humor processing, with no significant group differences. In contrast, patients showed significantly higher activation compared to controls during neutral-rated movies; including bilaterally in the thalamus, pallidum, putamen, amygdala, hippocampus, middle temporal gyrus, cerebellum, brainstem and in the left precuneus, supramarginal gyrus and caudate. The presence of a humorous punchline in a neutral-rated movie is important since we found no brain overactivation for narcolepsy type 1 patients for movies without a humorous punchline (89.0% neutral-rated) compared with controls. Further, a comparison between fun-rated and neutral-rated movies revealed a pattern of higher activation during fun-rated movies in controls, patients showed no significant differentiation between these states. Group analyses revealed significantly stronger differentiation between fun-rated and neutral-rated movies in controls compared with patients, including bilaterally in the inferior frontal gyrus, thalamus, putamen, precentral gyrus, lingual gyrus, supramarginal gyrus, occipital areas, temporal areas, cerebellum and in the right hippocampus, postcentral gyrus, pallidum and insula. In conclusion, during neutral-rated movies, narcolepsy type 1 patients showed significantly higher activation in several cortical and subcortical regions previously implicated in humor and REM sleep, including the thalamus and basal ganglia. The relative lack of differentiation between neutral-rated and fun-rated movies in narcolepsy type 1 patients might represent insight into the mechanisms associated with cataplexy, in which a long-lasting hypervigilant state could represent risk (hypersensitivity to potential humorous stimuli) for the narcolepsy type 1 patients, which seem to have a lower threshold for activating the humor response, even during neutral-rated movies.
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