The association between eye-tracking dysfunctions and thought disorder in psychosis

Linkage and whole genome sequencing identify a locus on 6q25-26 for formal thought disorder and implicate MEF2A regulation

Formal thought disorder is a major feature of schizophrenia and other psychotic disorders. It is heritable, found in healthy relatives of patients with schizophrenia and other mental disorders but knowledge of specific genetic factors is lacking. The aim of this study was to search for biologically relevant high-risk variants. Formal thought disorder was assessed in participants in the Copenhagen Schizophrenia Linkage Study (N=236), a unique high-risk family study comprised of six large pedigrees. Microsatellite linkage analysis of formal thought disorder was performed and subsequent haplotype analysis of the implicated region using phased microsatellite and SNP genotypes. Whole genome sequencing (N=3) was used in the attempt to identify causative variants in the linkage region. Linkage analysis of formal thought disorder resulted in a single peak at chromosome 6(q26-q27) centred on marker D6S1277, with a maximum LOD score of 4.0. Phasing and fine mapping of the linkage peak identified a 5.5Mb haplotype (chr6:162242322-167753547, hg18) in 31 individuals, all belonging to the same pedigree sharing the haplotype from a common ancestor. The haplotype segregated with increased total thought disorder index score (P=4.9 × 10(-5)) and qualitatively severe forms of thought disturbances. Whole genome sequencing identified a novel nucleotide deletion (chr6:164377205 AG>A, hg18) predicted to disrupt the potential binding of the transcription factor MEF2A. The MEF2A binding site is located between two genes previously reported to associate with schizophrenia, QKI (HGNC:21100) and PDE10A (HGNC:8772). The findings are consistent with MEF2A deregulation conferring risk of formal thought disorder.

Increased saccadic rate during smooth pursuit eye movements in patients at Ultra High Risk for developing a psychosis

Abnormalities in eye tracking are consistently observed in schizophrenia patients and their relatives and have been proposed as an endophenotype of the disease. The aim of this study was to investigate the performance of patients at Ultra High Risk (UHR) for developing psychosis on a task of smooth pursuit eye movement (SPEM). Forty-six UHR patients and twenty-eight age and education matched controls were assessed with a task of SPEM and psychiatric questionnaires. Our results showed that both the corrective and non-corrective saccadic rates during pursuit were higher in the UHR group. There were however no differences in smooth pursuit gain between the two groups. The saccadic rate was related to positive UHR symptoms. Our findings indicate that abnormalities in SPEM are already present in UHR patients, prior to a first psychotic episode. These abnormalities occur only in the saccadic system.

SPEM dysfunction and general schizotypy as measured by the SSQ: a controlled study

Background

SPEM dysfunction is a well-known phenomenon in schizophrenia. The principal aim of the present study was to examine whether SPEM dysfunction is already observable in subjects scoring high on a specific measure of schizotypy (SSQ General Schizotypy) that was selected because of its intimate relationship with schizophrenic prodromal unfolding.

Methods

Applying ANOVAs, we determined the relationship of subjects' scores on SSQ General Schizotypy and eye movements elicited by targets of different speed. We also examined whether there exists an association between our schizotypy measure and pupil size.

Results

We found more SPEM dysfunction in subjects scoring high on SSQ General Schizotypy than in subjects scoring average on that factor, irrespective of the speed of the target. No relationship was found between baseline pupil size and General Schizotypy.

Conclusion

The present study provides additional evidence that SPEM dysfunction is associated with schizotypic features that precede the onset of schizophrenia and is already observable in general population subjects that show these features.

Antisaccade and smooth pursuit performance in positive- and negative-symptom schizotypy

Schizophrenic patients have well-documented abnormalities in smooth pursuit eye movements and antisaccade performance. In populations at risk for schizophrenia, smooth pursuit abnormalities are also well documented. Antisaccade deficits have been replicated in high-risk populations as well, but the findings are more variable and the reasons for the variability are not clear. Some evidence suggests that antisaccade deficits increase in high-risk populations in relation to the presence of positive symptoms. Whether antisaccade deficits increase in relation to negative symptoms in high-risk populations is relatively uninvestigated. We evaluated antisaccade and pursuit performance in "psychometric schizotypes" who had elevated scores on either the Perceptual Aberration Scale (PerAb; i.e., positive symptoms) or the Physical Anhedonia Scale (PhysAnh; i.e., negative symptoms) but not both, and in normal controls. We used the standard version of the antisaccade task, for which results in positive-symptom schizotypes have previously been reported, and investigated performance on a gap and overlap version. We replicated the finding that a significantly larger percentage of positive-symptom schizotypes than controls have elevated antisaccade error rates on the standard antisaccade task (P=0.03); the percentage of negative-symptom schizotypes with elevated antisaccade error rates did not differ from that of control subjects. Neither schizotypal group was impaired on the gap or overlap versions of the task. On the pursuit task, a higher percentage of positive- and negative-symptom schizotypes were classified as having deviant performance than control subjects (both Ps<0.04). These findings suggest that antisaccade deficits may be better at identifying high-risk subjects with positive symptoms. Pursuit deficits identified both positive- and negative-symptom schizotypes, but was better at identifying the latter.

Thinking within the spectrum: schizophrenic thought disorder in six Danish pedigrees

Formal thought disorder (FTD), a major symptom of schizophrenia, is known to aggregate in families. Our aim was to examine the specificity of FTD in the schizophrenia spectrum disorders and the hypothesized linear aggregation of FTD within pedigrees. Six individuals with a diagnosis of schizophrenia were identified in the Copenhagen High-Risk study and each pedigree was centered on one of the six original schizophrenic probands' nuclear families. The 329 pedigree members in the study were considered at risk for schizophrenia spectrum disorders because most were genetically related to the originating schizophrenic probands. The participants were administered the Copenhagen Interview of Functional Illness to determine diagnoses and the Thought Disorder Index (TDI) was used to assess FTD. Individuals with a schizophrenia diagnosis had higher global levels of FTD, exhibited more severe types of FTD, and had a qualitatively different type of FTD than did participants with other diagnoses or no mental illness. Individuals with Cluster A diagnoses exhibited more FTD and FTD similar in quality to participants with schizophrenia. These results support the construct of a spectrum of schizophrenia conditions. There was a generally high level of FTD in the pedigrees, in part due to assortative mating in this sample. However, there was no apparent pattern of linear aggregation of FTD within the families.

Pupillary dilation to simple vs. complex tasks and its relationship to thought disturbance in schizophrenia patients

Task-evoked pupil dilation is a measure of attentional allocation. Schizophrenia patients have pupil dilation deficits during high cognitive load tasks, which have been attributed to attentional resource deficits. Moreover, this attentional impairment is thought to be linked to cognitive fragmentation and thought disturbance. Previous attempts to associate attentional deficits to thought disturbance have typically measured these domains at distinct times, incorrectly assuming that both are static variables. In this study, we compared the pupil dilation of 24 schizophrenia patients to 15 non-patients during complex (Rorschach blots) vs. simple visual (line drawings) processing tasks while simultaneously assessing their verbal responses for thought disturbance. Schizophrenia patients' dilation to the simple stimuli was similar to the non-patients; however, they demonstrated significantly less dilation to the complex stimuli. Reduced dilation was also significantly correlated with reduced response complexity and more severe thought disorder. The results suggest that, in the face of complex problem-solving situations, greater attentional impairment and cognitive overload in schizophrenia is associated with higher levels of disturbed and impoverished thinking. These findings support the 'resource limitations hypothesis' of schizophrenia and underscore the utility of a simultaneous paradigm when studying the relationship between attentional deficits and thought disturbance.

Syndromes of schizophrenia and smooth-pursuit eye movement dysfunction

There have been a number of studies on smooth pursuit eye movement (SPEM) dysfunction in schizophrenia. However, the association between SPEM dysfunction and particular clinical symptoms remains unclear. We examined SPEM dysfunction in relation to schizophrenic symptoms using both the positive/negative dichotomy and the three-syndrome model. Subjects included 78 patients with schizophrenia and 60 healthy control subjects. SPEM performance was indexed by root mean square error. Symptom profiles were assessed using the Positive and Negative Syndrome Scale (PANSS), and the three-primary syndromes were identified by factor analysis of PANSS ratings (Psychomotor poverty: deficit negative symptoms; Disorganization: defined primarily by thought disorder; and Reality distortion: hallucinations and delusions). Compared with controls, the schizophrenia group showed significant impairment in global SPEM function. The three-syndrome approach produced more specific findings than the dichotomous model. Of the three syndromes, only the Disorganization dimension showed a significant association with increased global SPEM dysfunction. The specificity of SPEM dysfunction to Disorganization was verified in comparisons among schizophrenia subgroups and the control group. By contrast, the general domains of positive and negative symptoms were both found to be modestly associated with SPEM dysfunction. The separation of positive and negative symptoms that contribute to Disorganization from those that define Reality Distortion and Psychomotor Poverty has revealed significant new associations between SPEM and schizophrenic symptoms. These findings are interpreted in light of the proposal that the Disorganization syndrome is the central form of pathology in schizophrenia.

Eye movement dysfunction as a biological marker of risk for schizophrenia

OBJECTIVE

Our aim was to review smooth pursuit eye movement (SPEM) studies in schizophrenia and groups at high risk for schizophrenia, with a view to evaluating the utility of SPEM dysfunction as a biological marker of risk for schizophrenia.

METHOD

Smooth pursuit eye movement studies, related saccade function and the unresolved issues in this area of schizophrenia research were addressed. The different perspectives on the trait marker status of SPEM dysfunction, provided by both high-risk studies and related developmental research were considered. Attention was also given to the relationship between eye movement dysfunction and symptom profiles.

RESULTS

Converging evidence points to the robust and specific nature of SPEM dysfunction in schizophrenia, and highlights the role of frontal lobe and a related network dysfunction. The vast majority of 'high risk' studies support the view that SPEM dysfunction is also genetically specific to schizophrenia, and is not simply due to the overt expression of this illness. Studies assessing SPEM in relation to symptomatology show an association with the Disorganisation syndrome in particular.

CONCLUSIONS

Evidence for the specificity of SPEM dysfunction to diagnosed schizophrenia, as well as to healthy individuals with a genetic vulnerability to schizophrenia, suggests that the SPEM task has efficacy as a test of gene carrier status in schizophrenia, and therefore as a trait marker of risk for schizophrenia. Future studies should seek to explore the relationships between SPEM and other eye movement dysfunctions (antisaccades, express saccades), in view of evidence that some of these dysfunctions also show specificity for schizophrenia.

Behavioral science foundations of the Rorschach test: research and clinical applications

Never without its critics, the Rorschach Test continues to be widely used in clinical settings. The test continues to be criticized vigorously. Rorschach critics appear to fall into two broad groups: those leveling valid methodological concerns about the test s behavioral science foundations and method critics who appear to deny the validity of the test on strictly a priori or theoretical considerations. Many critics do not appear to be acquainted with the extensive Rorschach research literature. The current paper provides an overview of several domains of applied and laboratory Rorschach behavioral science, including statistical power analysis, interobserver agreement and interrater reliability, Rorschach assessment of thought disorder, and emerging research linking Rorschach variables with diagnostic criteria from the DSM-IV, as a means of educating both adherents and detractors alike concerning the test s scientific track record and applicability to clinical assessment.

Smooth pursuit eye movements in childhood-onset schizophrenia: comparison with attention-deficit hyperactivity disorder and normal controls

Abnormalities of the smooth pursuit eye movements of adults with schizophrenia have been well described. We examined smooth pursuit eye movements in schizophrenic children, contrasting them with normal and attention-deficit hyperactivity disorder (ADHD) subjects, to determine whether there is continuity of eye movement dysfunction between childhood- and adult-onset forms of schizophrenia. Seventeen schizophrenic children with onset of illness by age 12, 18 ADHD children, and 22 normal children were studied while engaged in a smooth pursuit eye tracking task. Eye tracking variables were compared across the three groups. Schizophrenic children exhibited significantly greater smooth pursuit impairments than either normal or ADHD subjects. Within the schizophrenic group, there were no significant relationships between eye tracking variables and clinical variables, or ventricular/brain ratio. Childhood-onset schizophrenia is associated with a similar pattern of smooth pursuit abnormalities to that seen in later-onset schizophrenia.

Eye-tracking performance and adaptive functioning over the short-term course of first-episode psychosis

We examined the relationship of smooth pursuit eye tracking to the course of first-episode psychosis. Various measures of social, occupational, and psychological functioning were obtained for 134 persons with diagnoses of schizophrenia, schizophreniform disorder, or psychotic mood disorder at the time of their psychosis and 9 and 18 months later. Poor eye-tracking performance was associated with generally impaired functioning over the 18-month course of disorder for patients with schizophrenia. A similar association between smooth pursuit and adaptive functioning was not found in patients with schizophreniform or affective disorder. The results suggest that patients with schizophrenia who are characterized by poor eye tracking have a more severe disorder, indications of which are present at the onset of their psychosis.

Smooth pursuit performance in patients with affective disorders or schizophrenia and normal controls: analysis with specific oculomotor measures, RMS error and qualitative ratings

Smooth pursuit performance in schizophrenia and affective disorders has generally been found to be abnormal using a variety of measures. The purpose of this study was to assess patients with these disorders and normal controls in order to compare the different measures across diagnoses. Smooth pursuit was assessed using quantitative specific measures (gain, catch-up saccade rate and amplitude, square-wave jerk rate, number of anticipatory saccades and total time scored), as well as two global measures: root mean-square error (RMS) and qualitative rating. As previously reported, patients with schizophrenia had low gain, increased catch-up saccade rate and spent less time engaged in scoreable smooth pursuit than normal controls. Patients with affective disorders were not statistically different from controls on any of these measures, and had significantly higher gain than patients with schizophrenia. RMS error and qualitative rating measures were highly correlated (r = 0.87). In linear regression analyses, the quantitative specific measures were highly significant predictors of both RMS error and qualitative ratings (P < 0.0001). Linear regression analyses and a modelling study indicated that one quantitative specific measure, the percent of time engaged in scoreable smooth pursuit (total time scored), was most related to global ratings. However, RMS error and qualitative ratings were less sensitive than total time scored to the difference between controls and patients with schizophrenia. These data indicate two smooth pursuit performance deficits in schizophrenia: patients spend less time engaged in scoreable smooth pursuit and have low gain (accompanied by increased compensatory saccades) when the smooth pursuit is engaged.

Comparison of the smooth eye tracking disorder of schizophrenics with that of nonhuman primates with specific brain lesions

The smooth pursuit eye tracking deficit (ETD) often associated with schizophrenia has generated enormous interest over the last 20 years. The deficit is observed in about 80% of schizophrenics and in half of their first degree relatives. It is not affected by neuroleptic medication and is not due to inattention. A review of 52 studies (and actual records when available) on ETD in schizophrenia reveals that the deficit can consistently be described as low gain pursuit augmented with catch-up saccades and often peppered with intrusive saccades. A review of the brain areas that have been shown to be involved in pursuit provides the necessary background for the subsequent section which details the nature of the smooth tracking deficits following experimental lesions. This section reveals that the ETD following lesions of the frontal lobe is unique in that it closely resembles the ETD of schizophrenics. This finding lends further support for frontal lobe theories of schizophrenia.

Association of working memory deficit and eye tracking dysfunction in schizophrenia

This study replicates our earlier findings that schizophrenic but not bipolar patients are impaired on oculomotor delayed response tasks, analogous to those used to assess spatial working memory functions of the dorsolateral prefrontal cortex (DLPFC) in monkeys (Park and Holzman, 1992). In addition, we examined the relation between working memory deficits and smooth pursuit eye movement (SPEM) dysfunction, since data from human neuropsychological and animal lesion studies implicate prefrontal pathology in both deficits. Schizophrenic patients showed marked deficits in the oculomotor memory task and the SPEM task relative to the control groups. However, they were not impaired on the oculomotor sensory task in which their responses were guided by external cues rather than by working memory. This result from outpatients replicates our earlier study which was conducted with inpatients. Within the schizophrenic group those patients with good eye tracking performed better than those with impaired pursuit on the oculomotor memory task but there was no correlation between SPEM and performance on the sensory task. These findings support the hypothesis that schizophrenics show a deficit in representational processes and add to the growing evidence for involvement of the dorsolateral prefrontal cortex in schizophrenic pathology.

SPEM impairment in drug-naive schizophrenic patients: evidence for a trait marker

Smooth-pursuit eye movements (SPEM) were assessed in healthy subjects and in drug-naive, chronic, and residual schizophrenic patients. SPEM gain was found to be decreased in all the schizophrenic patients who also exhibited a significant increase in the rate of saccades. The frequency of square-wave jerks was the same in schizophrenic patients and normal controls, suggesting that the primary abnormality in schizophrenic patients was a low gain rather than a defect of the saccadic system. Patients were retested 1 month later, and stability of gain was high even in formerly drug-naive subjects who had been treated for 1 month with neuroleptic drugs. Altogether these results confirm the conclusions of most previous studies, extend them to drug-naive schizophrenic patients, and favor the hypothesis that SPEM impairment is a trait marker in schizophrenia.

Cerebral laterality, symptoms, and diagnosis in psychotic patients

A dichotic nonsense test and a dichotic word test were used to assess cerebral laterality in 100 acutely symptomatic inpatients. Schizophrenic patients had significantly lower right ear advantages (REAs) than healthy controls, depressed patients, or schizoaffective patients. Manic patients did not differ from any other group, but manics with lower REAs were likely to have more symptoms of thought disorder than of mood disturbance while the reverse was likely to be true for manic patients with higher REAs. A subset of patients tested after symptom remission showed recovery-related increases in REA on the nonsense test and decreases on the word test, replicating previous findings. Those schizophrenics with evidence of greater disease-related decreases in REA on the nonsense than on the word test had predominantly negative symptoms whereas those with similar changes on the two tests had predominantly positive symptoms. These observations suggest the hypothesis that positive symptoms are related to overactivation of a dysfunctional left hemisphere by right hemisphere input while negative symptoms reflect a left hemisphere deficit state.

P300 and smooth eye pursuit: concordance of abnormalities and relation to clinical features in DSM-III schizophrenia

Twenty-five DSM-III-diagnosed schizophrenics and 37 normal and age-matched controls were examined using an oddball paradigm for the generation of P300 and smooth eye-pursuit tasks. Results were compared between groups and related to clinical characteristics, including a family history of psychiatric illness. Group differences were found for P300 amplitudes, latencies and eye-tracking. A family history of psychiatric illness was associated with normal eye-tracking in patients. Small P300 amplitudes alone and in combination with long P300 latencies were associated with a family history in controls.

Association of tardive dyskinesia with increased frequency of eye movement disturbances in chronic schizophrenic patients. A clinical note

The study of eye movement dysfunction in chronic schizophrenics by electronystagmography revealed a significant increase of saccadic dysmetria as well as saccadic intrusions in smooth pursuit in schizophrenic patients with tardive dyskinesia (TD) compared with those without TD and with healthy controls. The pattern of eye movement dysfunction in schizophrenia allows clear discrimination from patients with similar movement disorders due to Huntington's disease. Of several possible explanation's of the schizophrenic eye movement dysfunction the authors favour the hypothesis of a common pathogenetic link between TD and eye movement disorders in schizophrenia, consisting in an underlying dysfunction of regions involved in the regulation of involuntary attention such as the parietal cortex and striatolimbic structures of the right hemisphere. Recent literature supports the assumption of right hemispheric dysfunction in schizophrenia.

Eye tracking, schizophrenic symptoms, and schizotypal personality disorder

Schizophrenic patients and patients with schizotypal personality disorder were significantly more likely than normal controls to demonstrate impaired eye tracking performance. Fifteen of 27 schizophrenics and 15 of 27 schizotypals had impaired eye tracking, compared with 11 of 39 normal controls. In the schizophrenic group, including 10 out-patients in a stable state of relative remission, impaired eye tracking was associated with more severe formal thought disorder and more time spent in psychiatric hospitals. Among stable schizophrenic out-patients, poor eye tracking was related to more severe formal thought disorder and greater overall psychopathology. This pattern of results suggests a possible relation between eye tracking impairment and more severe enduring symptoms across the spectrum of schizophrenic and schizophrenia-related disorders.