Prosopagnosia Without Apparent Cause: Overview and Diagnosis of Six Cases

We compared six cases of congenital prosopagnosia to unimpaired participants using standardized test batteries, tailor-made experimental paradigms, and clinical questionnaires. Every prosopagnosic participant displayed deficits in recognizing famous faces and retaining novel faces over short periods of time. Other aspects of face perception such as judgment of emotional expression, speech reading and memory for faces and names were impaired to a lesser degree or only in single cases. No evidence was found for general visual deficits or social dysfunctions. Two of our six cases are first order relatives, and a further three report first-order relatives suffering from prosopagnosic symptoms. The results are in line with the idea of a genetic component to congenital prosopagnosia.

Les visages et leurs émotions

Faces represent a crucial vector of interhuman communication. The message transmitted by the face has multiple features. Recognition of each feature can be impaired independently or in combination with others. In order to understand the behavioral consequences of such impairments, which can be a major social handicap, we first must specify the neural networks involved in face recognition. We propose in this first part to present the systems involved in face recognition, in particular the question of identity and prosopagnosia. Different neural networks are indeed implicated in the recognition of invariant facial features such as identity, gender, ethnicity, and recognition of variant features like facial expression and eye gaze. This paper is illustrated by some of our scalp and intracranial electrophysiological studies performed in humans allowing us to describe some aspects of face recognition dynamics combining an excellent spatial and temporal resolution. Intracranial recordings were performed in drug refractory epileptical patients implanted with depth electrodes. These studies demonstrate that numerous deep brain and cortical structures participate early and sometimes in a sustained manner in face recognition.

Functional and structural deficits in brain regions subserving face perception in schizophrenia

OBJECTIVE

Schizophrenia impairs many cognitive functions, including face perception. Veridical face perception is critical for social interaction, including distinguishing friend from foe and familiar from unfamiliar faces. The main aim of this study was to determine whether patients with schizophrenia show less activation in neural networks related to face processing, compared with healthy subjects, and to investigate the relationships between this functional abnormality and anatomical abnormalities in the fusiform gyrus shown with magnetic resonance imaging (MRI).

METHOD

Twenty male chronic schizophrenia patients and 16 healthy comparison subjects matched with the patients for age, gender, handedness, and parental socioeconomic status underwent high-spatial-resolution MRI. Event-related potentials elicited by images of faces, cars, and hands were recorded in a separate session.

RESULTS

Compared to the healthy subjects, the patients with schizophrenia showed bilateral N170 amplitude reduction in response to images of faces but not to images of other objects. The patients also had smaller bilateral anterior and posterior fusiform gyrus gray matter volumes, compared to the healthy subjects. In addition, right posterior fusiform gyrus volume was significantly correlated with N170 amplitude measured at the right posterior temporal electrode site in response to images of faces in the schizophrenia patients but not in the healthy comparison subjects.

CONCLUSIONS

The results provide evidence for deficits in the early stages of face perception in schizophrenia. The association of these deficits with smaller fusiform gyrus volume in patients with schizophrenia, relative to healthy subjects, suggests that the fusiform gyrus is the site of a defective anatomical substrate for face processing in schizophrenia.

The Cambridge Face Memory Test: Results for neurologically intact individuals and an investigation of its validity using inverted face stimuli and prosopagnosic participants

The two standardized tests of face recognition that are widely used suffer from serious shortcomings [Duchaine, B. & Weidenfeld, A. (2003). An evaluation of two commonly used tests of unfamiliar face recognition. Neuropsychologia, 41, 713-720; Duchaine, B. & Nakayama, K. (2004). Developmental prosopagnosia and the Benton Facial Recognition Test. Neurology, 62, 1219-1220]. Images in the Warrington Recognition Memory for Faces test include substantial non-facial information, and the simultaneous presentation of faces in the Benton Facial Recognition Test allows feature matching. Here, we present results from a new test, the Cambridge Face Memory Test, which builds on the strengths of the previous tests. In the test, participants are introduced to six target faces, and then they are tested with forced choice items consisting of three faces, one of which is a target. For each target face, three test items contain views identical to those studied in the introduction, five present novel views, and four present novel views with noise. There are a total of 72 items, and 50 controls averaged 58. To determine whether the test requires the special mechanisms used to recognize upright faces, we conducted two experiments. We predicted that controls would perform much more poorly when the face images are inverted, and as predicted, inverted performance was much worse with a mean of 42. Next we assessed whether eight prosopagnosics would perform poorly on the upright version. The prosopagnosic mean was 37, and six prosopagnosics scored outside the normal range. In contrast, the Warrington test and the Benton test failed to classify a majority of the prosopagnosics as impaired. These results indicate that the new test effectively assesses face recognition across a wide range of abilities.

Perceptual Expertise Effects Are Not All or None: Spatially Limited Perceptual Expertise for Faces in a Case of Prosopagnosia

We document a seemingly unique case of severe prosopagnosia, L. R., who suffered damage to his anterior and inferior right temporal lobe as a result of a motor vehicle accident. We systematically investigated each of three factors associated with expert face recognition: fine-level discrimination, holistic processing, and configural processing (Experiments 1-3). Surprisingly, L. R. shows preservation of all three of these processes; that is, his performance in these experiments is comparable to that of normal controls. However, L. R. is only able to apply these processes over a limited spatial extent to the fine-level detail within faces. Thus, when the location of a given change is unpredictable (Experiment 3), L. R. exhibits normal detection of features and spatial configurations only for the lower half of each face. Similarly, when required to divide his attention over multiple face features, L. R. is able to determine the identity of only a single feature (Experiment 4). We discuss these results in the context of forming a better understanding of prosopagnosia and the mechanisms used in face recognition and visual expertise. We conclude that these mechanisms are not “all-or-none”, but rather can be impaired incrementally, such that they may remain functional over a restricted spatial area. This conclusion is consistent with previous research suggesting that perceptual expertise is acquired in a spatially incremental manner [Gauthier, I., & Tarr, M. J. Unraveling mechanisms for expert object recognition: Bridging brain activity and behavior. Journal of Experimental Psychology: Human Perception & Performance, 28, 431-446, 2002].

The fusiform face area is not sufficient for face recognition: Evidence from a patient with dense prosopagnosia and no occipital face area

We tested functional activation for faces in patient D.F., who following acquired brain damage has a profound deficit in object recognition based on form (visual form agnosia) and also prosopagnosia that is undocumented to date. Functional imaging demonstrated that like our control observers, D.F. shows significantly more activation when passively viewing face compared to scene images in an area that is consistent with the fusiform face area (FFA) (p < 0.01). Control observers also show occipital face area (OFA) activation; however, whereas D.F.'s lesions appear to overlap the OFA bilaterally. We asked, given that D.F. shows FFA activation for faces, to what extent is she able to recognize faces? D.F. demonstrated a severe impairment in higher level face processing--she could not recognize face identity, gender or emotional expression. In contrast, she performed relatively normally on many face categorization tasks. D.F. can differentiate faces from non-faces given sufficient texture information and processing time, and she can do this is independent of color and illumination information. D.F. can use configural information for categorizing faces when they are presented in an upright but not a sideways orientation and given that she also cannot discriminate half-faces she may rely on a spatially symmetric feature arrangement. Faces appear to be a unique category, which she can classify even when she has no advance knowledge that she will be shown face images. Together, these imaging and behavioral data support the importance of the integrity of a complex network of regions for face identification, including more than just the FFA--in particular the OFA, a region believed to be associated with low-level processing.

Reality confusion in spontaneous confabulation

A woman produced spontaneous confabulations after rupture of an anterior communicating artery aneurysm. She confused currently irrelevant with currently relevant information in implicit memory; confabulations about people concerned only new acquaintances; false reality could be induced by an intensive 5-minute discussion; and in a recognition task, she confused false repetitions in another modality with real item repetitions. The findings support the theory that the defect causing spontaneous confabulation precedes conscious memory processing.

Detailed Exploration of Face-related Processing in Congenital Prosopagnosia: 1. Behavioral Findings

We show that five individuals with congenital prosopagnosia (CP) are impaired at face recognition and discrimination and do not exhibit the normal superiority for upright over inverted faces despite intact visual acuity, low-level vision and intelligence, and in the absence of any obvious neural concomitant. Interestingly, the deficit is not limited to faces: The CP individuals were also impaired at discriminating common objects and novel objects although to a lesser extent than discriminating faces. The perceptual deficit may be attributable to a more fundamental visual processing disorder; the CP individuals exhibited difficulty in deriving global configurations from simple visual stimuli, even with extended exposure duration and considerable perceptual support in the image. Deriving a global configuration from local components is more critical for faces than for other objects, perhaps accounting for the exaggerated deficit in face processing. These findings elucidate the psychological mechanisms underlying CP and support the link between configural and face processing.

Perceptual functions in prosopagnosia

Some patients with prosopagnosia may have an apperceptive basis to their recognition defect. Perceptual abnormalities have been reported in single cases or small series, but the causal link of such deficits to prosopagnosia is unclear. Our goal was to identify candidate perceptual processes that might contribute to prosopagnosia, by subjecting several prosopagnosic patients to a battery of functions that may be necessary for accurate facial perception. We tested seven prosopagnosic patients. Three had unilateral right occipitotemporal lesions, two had bilateral posterior occipitotemporal lesions, and one had right anterior-to-occipital temporal damage along with a small left temporal lesion. These lesions all included the fusiform face area, in contrast to one patient with bilateral anterior temporal lesions. Most patients had impaired performance on face-matching tests and difficulty with subcategory judgments for non-face objects. The most consistent deficits in patients with lesions involving the fusiform face area were impaired perception of spatial relations in dot patterns and reduced contrast sensitivity in the 4 to 8 cycles deg(-1) range. Patients with bilateral lesions were impaired in saturation discrimination. Luminance discrimination was normal in all but two patients, and spatial resolution was uniformly spared. Curvature and line-orientation discrimination were impaired in only one patient, who also had the most difficulty with more basic-level object recognition. We conclude that deficits in luminance, spatial resolution, curvature, line orientation, and contrast at low spatial frequencies are unlikely to contribute to apperceptive prosopagnosia. More relevant may be contrast sensitivity at higher spatial frequencies and the analysis of object spatial structure. Deficits in these functions may impair perception of subtle variations in object shape, and may be one mechanism by which the recognition defect in prosopagnosia can extend to other classes of object subcategorization.

The covert priming effect of faces in prosopagnosia

BACKGROUND

There are many methods of testing covert face recognition in prosopagnosia, but it is not clear whether different types of covert recognition share a common mechanism.

OBJECTIVE

To determine whether direct forced-choice techniques and indirect face-priming methods yielded similar behavioral estimates of covert ability in a series of prosopagnosic patients.

METHODS

The authors tested seven control subjects and seven prosopagnosic patients. Six patients had an apperceptive prosopagnosia: one with childhood onset, three with bilateral lesions, and two with unilateral occipitotemporal lesions. The last had an associative prosopagnosia from bilateral anterior temporal lesions. The direct tests of covert function involved sorting faces by occupation or the forced choosing of which of two faces was famous with a name cue. The indirect test assessed name classification by occupation after priming with a facial stimulus.

RESULTS

In normal subjects, the chief priming effect was facilitation by the true face. In the six patients with apperceptive prosopagnosia, direct covert measures were correlated with the face-priming effect, with better covert ability in patients with unilateral posterior lesions. In the patient with associative prosopagnosia, there was a dissociation between excellent direct covert function and absent face priming.

CONCLUSIONS

Direct and indirect covert functions likely share similar mechanisms in patients with apperceptive prosopagnosia and may reflect residual activity in anterior and left hemispheric components of the normal face-processing network. However, face priming may be ineffectual in patients with severely degraded facial memories from anterior temporal damage. This may indicate a difference between residual patterns of face-related activity in associative and apperceptive prosopagnosia.

Exploring the role of motion in prosopagnosia: recognizing, learning and matching faces

HJA has been completely unable to recognize faces since suffering a stroke some 22 years ago. Previous research has shown that he is poor at judging expressions from static photographs of faces, but performs relatively normally at these judgements when presented with moving point-light patterns (Humphreys et al., 1993). Recent research with non-prosopagnosic participants has suggested a beneficial role for facial motion when recognizing familiar faces and learning new faces. Three experiments are reported that investigate the role of face motion for HJA when recognizing (Experiment 1), learning (Experiment 2) and matching faces (Experiment 3). The results indicate that HJA is unable to use face motion to explicitly recognize faces and is no better at learning names for moving faces than static ones. However, HJA is significantly better at matching moving faces for identity, an opposite pattern to that found with age-matched and undergraduate control participants. We suggest that HJA is not impaired at processing motion information but remains unable to use motion as a cue to identity.

Progressive prosopagnosia: Clinical and neuroimaging results

The authors report the longitudinal case study of a patient with the right temporal variant of frontotemporal lobar degeneration. His deficit, initially limited to visuoperceptual disturbances, progressed 2 years later to a severe semantic breakdown. Neuroimaging data indicate that the underlying degenerative process, initially confined to unimodal visual associative cortices, progressed along the ventral pathways to multimodal areas in charge of integrating knowledge from various modalities (the anterior temporal lobes).

Differences in olfactory and visual memory in patients with pathologically confirmed Alzheimer's disease and the Lewy body variant of Alzheimer's disease

Recognition and remote memory for odors, faces, and symbols were assessed in patients with pathologically confirmed Lewy body variant of Alzheimer's disease (LBV), patients with pathologically confirmed Alzheimer's disease (AD), and healthy elderly controls. On recognition memory tasks, LBV and AD patients showed significantly lower discriminability (d') than controls, particularly for olfactory stimuli. However no significant differences were found in the bias measure (c). When participants rated familiarity (a proposed measure of remote memory) of olfactory stimuli LBV and AD patients reported significantly lower familiarity than controls. Familiarity ratings were significantly lower in LBV patients than in AD patients for olfactory, but not for visual stimuli. Consistent with prior reports, the LBV patients showed significantly poorer odor thresholds than AD patients. The results suggest that recognition memory for olfactory stimuli is impaired in LBV and AD. However, patients with LBV are more impaired than patients with AD on tasks requiring remote memory for olfactory but not visual stimuli. The findings suggest that odor memory tasks may be useful in the assessment of LBV and AD.

Are patients with social developmental disorders prosopagnosic? Perceptual heterogeneity in the Asperger and socio-emotional processing disorders

It has been hypothesized that social developmental disorders (SDD) like autism, Asperger's disorder and the social-emotional processing disorder may be associated with prosopagnosic-like deficits in face recognition. We studied the ability to recognize famous faces in 24 adults with a variety of SDD diagnoses. We also measured their ability to discriminate changes in internal facial configuration, a perceptual function that is important in face recognition, and their imagery for famous faces, an index of their facial memory stores. We contrasted their performance with both healthy subjects and prosopagnosic patients. We also performed a cluster analysis of the SDD patients. One group of eight SDD subjects performed normally on all tests of face perception and recognition. The other 16 subjects were impaired in recognition, though most were better than prosopagnosic patients. One impaired SDD subgroup had poor perception of facial structure but relatively preserved imagery, resembling prosopagnosic patients with medial occipitotemporal lesions. Another subgroup had better perception than imagery, resembling one prosopagnosic with bilateral anterior temporal lesions. Overall, SDD subgroup membership by face recognition did not correlate with a particular SDD diagnosis or subjective ratings of social impairment. We conclude that the social disturbance in SDD does not invariably lead to impaired face recognition. Abnormal face recognition in some SDD subjects is related to impaired perception of facial structure in a manner suggestive of occipitotemporal dysfunction. Heterogeneity in the perceptual processing of faces may imply pathogenetic heterogeneity, with important implications for genetic and rehabilitative studies of SDD.

Normal pressure hydrocephalus manifesting as transient prosopagnosia, topographical disorientation, and visual objective agnosia

Usually, dementia, gait disturbance and urinary incontinence are an integral part of the clinical presentation of normal pressure hydrocephalus (NPH). However, NPH with transient visual cognitive disorders has not been reported previously. We herein describe an extremely rare case of NPH that presented with transient visual cognitive disorders and long lasting visual memory disturbances that subsided after CSF shunting. A 38-years-old man developed transient prosopagnosia, topographical disorientation, color vision disturbance, and visual objective agnosia that progressed over 5 years. Magnetic resonance images showed ventriculomegaly with ischemic lesions in the paraventricular deep white matter. ECD-SPECT showed a reduction of the cerebral blood flow (CBF) in the periventricular deep white matter. Three months after CSF shunting, the radiological findings normalized with dramatic improvement of the extremely rare symptoms.

Visual agnosia

The visual agnosias are an intriguing class of clinical phenomena that have important implications for current theories of high-level vision. Visual agnosia is defined as impaired object recognition that cannot be attributed to visual loss, language impairment, or a general mental decline. At least in some instances, agnostic patients generate an adequate internal representation of the stimulus but fail to recognize it. In this review, we begin by describing the classic works related to the visual agnosias, followed by a description of the major clinical variants and their occurrence in degenerative disorders. In keeping with the theme of this issue, we then discuss recent contributions to this domain. Finally, we present evidence from functional imaging studies to support the clinical distinction between the various types of visual agnosias.

Normal recognition of emotion in a prosopagnosic

In the leading model of face perception, facial identity and facial expressions of emotion are recognized by separate mechanisms. In this report, we provide evidence supporting the independence of these processes by documenting an individual with severely impaired recognition of facial identity yet normal recognition of facial expressions of emotion. NM, a 40-year-old prosopagnosic, showed severely impaired performance on five of six tests of facial identity recognition. In contrast, she performed in the normal range on four different tests of emotion recognition. Because the tests of identity recognition and emotion recognition assessed her abilities in a variety of ways, these results provide solid support for models in which identity recognition and emotion recognition are performed by separate processes.

A network of occipito-temporal face-sensitive areas besides the right middle fusiform gyrus is necessary for normal face processing

Neuroimaging studies have identified at least two bilateral areas of the visual extrastriate cortex that respond more to pictures of faces than objects in normal human subjects in the middle fusiform gyrus [the 'fusiform face area' (FFA)] and, more posteriorly, in the inferior occipital cortex ['occipital face area' (OFA)], with a right hemisphere dominance. However, it is not yet clear how these regions interact which each other and whether they are all necessary for normal face perception. It has been proposed that the right hemisphere FFA acts as an isolated ('modular') processing system for faces or that this region receives its face-sensitive inputs from the OFA in a feedforward hierarchical model of face processing. To test these proposals, we report a detailed neuropsychological investigation combined with a neuroimaging study of a patient presenting a deficit restricted to face perception, consecutive to bilateral occipito-temporal lesions. Due to the asymmetry of the lesions, the left middle fusiform gyrus and the right inferior occipital cortex were damaged but the right middle fusiform gyrus was structurally intact. Using functional MRI, we disclosed a normal activation of the right FFA in response to faces in the patient despite the absence of any feedforward inputs from the right OFA, located in a damaged area of cortex. Together, these findings show that the integrity of the right OFA is necessary for normal face perception and suggest that the face-sensitive responses observed at this level in normal subjects may arise from feedback connections from the right FFA. In agreement with the current literature on the anatomical basis of prosopagnosia, it is suggested that the FFA and OFA in the right hemisphere and their re-entrant integration are necessary for normal face processing.

A modulatory role for facial expressions in prosopagnosia

Brain-damaged patients experience difficulties in recognizing a face (prosopagnosics), but they can still recognize its expression. The dissociation between these two face-related skills has served as a keystone of models of face processing. We now report that the presence of a facial expression can influence face identification. For normal viewers, the presence of a facial expression influences performance negatively, whereas for prosopagnosic patients, it improves performance dramatically. Accordingly, although prosopagnosic patients show a failure to process the facial configuration in the interest of face identification, that ability returns when the face shows an emotional expression. Accompanying brain-imaging results indicate activation in brain areas (amygdala, superior temporal sulcus, parietal cortex) outside the occipitotemporal areas normally activated for face identification and lesioned in these patients. This finding suggests a modulatory role of these areas in face identification that is independent of occipitotemporal face areas.