Comparing the sensitivity of face matching assessments to detect face perception impairments

Disentangling developmental prosopagnosia: A scoping review of terms, tools and topics

The goal of this preregistered scoping review is to create an overview of the research on developmental prosopagnosia (DP). Through analysis of all empirical studies of DP in adults, we investigate 1) how DP is conceptualized and defined, 2) how individuals are classified with DP and 3) which aspects of DP are investigated in the literature. We reviewed 224 peer-reviewed studies of DP. Our analysis of the literature reveals that while DP is predominantly defined as a lifelong face recognition impairment in the absence of acquired brain injury and intellectual/cognitive problems, there is far from consensus on the specifics of the definition with some studies emphasizing e.g., deficits in face perception, discrimination and/or matching as core characteristics of DP. These differences in DP definitions is further reflected in the vast heterogeneity in classification procedures. Only about half of the included studies explicitly state how they classify individuals with DP, and these studies adopt 40 different assessment tools. The two most frequently studied aspects of DP are the role of holistic processing and the specificity of face processing, and alongside a substantial body of neuroimaging studies of DP, this paints a picture of a research field whose scientific interests and aims are rooted in cognitive neuropsychology and neuroscience. We argue that these roots - alongside the heterogeneity in DP definition and classification - may have limited the scope and interest of DP research unnecessarily, and we point to new avenues of research for the field.

Perceptual heterogeneity in developmental prosopagnosia is continuous, not categorical

Developmental prosopagnosia (DP) is associated with considerable perceptual heterogeneity, though the nature of this heterogeneity and whether there are discrete subgroups versus continuous deficits remains unclear. Bennetts et al. (2022) recently found that holistic versus featural processing deficits distinguished discrete DP subgroups, but their sample was relatively small (N = 37), and subgroups were defined using a single task. To characterize perceptual heterogeneity in DPs more comprehensively, we administered a broad face perception battery to a large sample of 109 DPs and 134 controls, including validated measures of face matching (Cambridge Face Perception Test - CFPT, Computerized Benton Facial Recognition Test, Same/Different Face Matching Task), holistic processing (Part-Whole Task), and feature processing (Georges Task and Part-Whole part trials). When examining face matching measures, DPs exhibited a similar distribution of performance as controls, though shifted towards impairment by an average of 1.4 SD. We next applied Bennetts (2022) hierarchical clustering approach and k-means clustering to the CFPT upright, inverted, and inversion index measures, similarly finding one group of DPs with poorer inverted face performance and another with a decreased face inversion effect (holistic processing). However, these subgroup differences failed to generalize to other measures of feature and holistic processing beyond the CFPT. We finally ran hierarchical and k-means cluster analyses on our larger battery of face matching, feature, and holistic processing measures. Results clearly showed subgroups with generally better versus worse performance across all measures, with the distinction between groups being somewhat arbitrary. Together, these findings support a continuous account of DP perceptual heterogeneity, with performance differing primarily across all aspects of face perception.

The neuropsychological evaluation of face identity recognition

Facial identity recognition (FIR) is arguably the ultimate form of recognition for the adult human brain. Even if the term prosopagnosia is reserved for exceptionally rare brain-damaged cases with a category-specific abrupt loss of FIR at adulthood, subjective and objective impairments or difficulties of FIR are common in the neuropsychological population. Here we provide a critical overview of the evaluation of FIR both for clinicians and researchers in neuropsychology. FIR impairments occur following many causes that should be identified objectively by both general and specific, behavioral and neural examinations. We refute the commonly used dissociation between perceptual and memory deficits/tests for FIR, since even a task involving the discrimination of unfamiliar face images presented side-by-side relies on cortical memories of faces in the right-lateralized ventral occipito-temporal cortex. Another frequently encountered confusion is between specific deficits of the FIR function and a more general impairment of semantic memory (of people), the latter being most often encountered following anterior temporal lobe damage. Many computerized tests aimed at evaluating FIR have appeared over the last two decades, as reviewed here. However, despite undeniable strengths, they often suffer from ecological limitations, difficulties of instruction, as well as a lack of consideration for processing speed and qualitative information. Taking into account these issues, a recently developed behavioral test with natural images manipulating face familiarity, stimulus inversion, and correct response times as a key variable appears promising. The measurement of electroencephalographic (EEG) activity in the frequency domain from fast periodic visual stimulation also appears as a particularly promising tool to complete and enhance the neuropsychological assessment of FIR.

The role of preSMA and STS in face recognition: A transcranial magnetic stimulation (TMS) study

Current models propose that facial recognition is mediated by two independent yet interacting anatomo-functional systems: one processing facial features mainly mediated by the Fusiform Face Area and the other involved in the extraction of dynamic information from faces, subserved by Superior Temporal Sulcus (STS). Also, the pre-Supplementary Motor Area (pre-SMA) is implicated in facial expression processing as it is involved in its motor mimicry. However, the literature only shows evidence of the implication of STS and preSMA for facial expression recognition, without relating it to face recognition. In addition, the literature shows a facilitatory role of facial motion in the recognition of unfamiliar faces, particularly for poor recognizers. The present study aimed at studying the role of STS and preSMA in unfamiliar face recognition in people with different face recognition skills. 34 healthy participants received repetitive transcranial magnetic stimulation over the right posterior STS, pre-SMA and as sham during a task of matching of faces encoded through: facial expression, rigid head movement or as static (i.e., absence of any facial or head motion). All faces were represented without emotional content. Results indicate that STS has a direct role in recognizing identities through rigid head movement and an indirect role in facial expression processing. This dissociation represents a step forward with respect to current face processing models suggesting that different types of motion involve separate brain and cognitive processes. PreSMA interacts with face recognition skills, increasing the performance of poor recognizers and decreasing that of good recognizers in all presentation conditions. Together, the results suggest the use of at least partially different mechanisms for face recognition in poor and good recognizers and a different role of STS and preSMA in face recognition.

Face perception and facial emotional expression recognition ability: Both unique predictors of the broader autism phenotype

Autism spectrum disorder (ASD) and the broader autistic phenotype (BAP) have been suggested to be associated with perceptual-cognitive difficulties processing human faces. However, the empirical results are mixed, arguably, in part due to inadequate samples and analyses. Consequently, we administered the Cambridge Face Perception Test (CFPT), the Reading the Mind in the Eyes Test (RMET), a vocabulary test, and the Autism Quotient (AQ) to a sample of 318 adults in the general community. Based on a disattenuated path analytic modelling strategy, we found that both face perception ability (β = -.21) and facial emotional expression recognition ability (β = -.27) predicted uniquely and significantly the Communication dimension of AQ. Vocabulary failed to yield a significant, direct effect onto the Communication dimension of the AQ. We conclude that difficulties perceiving information from the faces of others may contribute to difficulties in nonverbal communication, as conceptualised and measured within the context of BAP.

Both identity and non-identity face perception tasks predict developmental prosopagnosia and face recognition ability

Developmental prosopagnosia (DP) is characterised by deficits in face identification. However, there is debate about whether these deficits are primarily perceptual, and whether they extend to other face processing tasks (e.g., identifying emotion, age, and gender; detecting faces in scenes). In this study, 30 participants with DP and 75 controls completed a battery of eight tasks assessing four domains of face perception (identity; emotion; age and gender; face detection). The DP group performed worse than the control group on both identity perception tasks, and one task from each other domain. Both identity perception tests uniquely predicted DP/control group membership, and performance on two measures of face memory. These findings suggest that deficits in DP may arise from issues with face perception. Some non-identity tasks also predicted DP/control group membership and face memory, even when face identity perception was accounted for. Gender perception and speed of face detection consistently predicted unique variance in group membership and face memory; several other tasks were only associated with some measures of face recognition ability. These findings indicate that face perception deficits in DP may extend beyond identity perception. However, the associations between tasks may also reflect subtle aspects of task demands or stimuli.

A new way of classifying developmental prosopagnosia: Balanced Integration Score

Despite severe everyday problems recognising faces, some individuals with developmental prosopagnosia (DP) can achieve typical accuracy scores on laboratory face recognition tests. To address this, studies sometimes also examine response times (RTs), which tend to be longer in DPs relative to control participants. In the present study, 24 potential (according to self-report) DPs and 110 age-matched controls completed the Cambridge Face and Bicycle Memory Tests, old new faces task, and a famous faces test. We used accuracy and the Balanced Integration Score (BIS), a measure that adjusts accuracy for RTs, to classify our sample at the group and individual levels. Subjective face recognition ability was assessed using the PI20 questionnaire and semi structured interviews. Fifteen DPs showed a major impairment using BIS compared with only five using accuracy alone. Logistic regression showed that a model incorporating the BIS measures was the most sensitive for classifying DP and showed highest area under the curve (AUC). Furthermore, larger between-group effect sizes were observed for a derived global (averaged) memory measure calculated using BIS versus accuracy alone. BIS is thus an extremely sensitive novel measure for attenuating speed-accuracy trade-offs that can otherwise mask impairment measured only by accuracy in DP.

Familial Transmission of Developmental Prosopagnosia: New Case Reports from an Extended Family and Identical Twins

Existing evidence suggests that developmental prosopagnosia (DP) is a surprisingly prevalent condition, with some individuals describing lifelong difficulties with facial identity recognition. Together with case reports of multiple family members with the condition, this evidence suggests that DP is inherited in at least some instances. Here, we offer some novel case series that further support the heritability of the condition. First, we describe five adult siblings who presented to our lab with symptoms of DP. Second, for the first known time in the literature, we describe a pair of adult identical twins who contacted us in the belief that they both experience DP. The condition was confirmed in three of the five siblings (with minor symptoms observed in the remaining two) and in both twins. Supplementary assessments suggested that all individuals also experienced some degree of difficulty with facial identity perception, but that object recognition was preserved. These findings bolster the evidence supporting the heritability of DP and suggest that it can be a specific impairment in some cases.

Investigating the Influence of Autism Spectrum Traits on Face Processing Mechanisms in Developmental Prosopagnosia

Autism traits are common exclusionary criteria in developmental prosopagnosia (DP) studies. We investigated whether autism traits produce qualitatively different face processing in 43 DPs with high vs. low autism quotient (AQ) scores. Compared to controls (n = 27), face memory and perception were similarly deficient in the high- and low-AQ DPs, with the high-AQ DP group additionally showing deficient face emotion recognition. Task-based fMRI revealed reduced occipito-temporal face selectivity in both groups, with high-AQ DPs additionally demonstrating decreased posterior superior temporal sulcus selectivity. Resting-state fMRI showed similar reduced face-selective network connectivity in both DP groups compared with controls. Together, this demonstrates that high- and low-AQ DP groups have very similar face processing deficits, with additional facial emotion deficits in high-AQ DPs.

Why can people with developmental prosopagnosia recognise some familiar faces? Insights from subjective experience

Developmental prosopagnosia is a relatively common visuo-cognitive condition, characterised by impaired facial identity recognition. Impairment severity appears to reside on a continuum, however, it is unknown whether instances of milder deficits reflect the successful use of spontaneous (typical) face recognition strategies, or the application of extraneous compensatory cues to recognition. Here, we explore this issue in two studies. First, 23 adults with developmental prosopagnosia were asked about their use of spontaneous versus compensatory face recognition techniques in everyday life, using a series of closed- and open-ended questions. Second, the same participants performed a computerised famous face recognition task where they were asked to provide reasons why they could make any successful identifications. Findings from both studies suggest that people with developmental prosopagnosia can successfully, and quite frequently, use compensatory strategies to recognition, and that these cues support the majority of instances of preserved familiar face recognition. In contrast, 16 of the 23 participants were able to spontaneously recognise familiar faces on at least some occasions, but there were vast individual differences in frequencies of success. These findings have important implications for our conceptualisation of the condition, as well as for diagnostic practice.

What is the prevalence of developmental prosopagnosia? An empirical assessment of different diagnostic cutoffs

The prevalence of developmental prosopagnosia (DP), lifelong face recognition deficits, is widely reported to be 2-2.5%. However, DP has been diagnosed in different ways across studies, resulting in differing prevalence rates. In the current investigation, we estimated the range of DP prevalence by administering well-validated objective and subjective face recognition measures to an unselected web-based sample of 3116 18-55 year-olds and applying DP diagnostic cutoffs from the last 14 years. We found estimated prevalence rates ranged from .64-5.42% when using a z-score approach and .13-2.95% when using a percentile approach, with the most commonly used cutoffs by researchers having a prevalence rate of .93% (z-score, .45% when using percentiles). We next used multiple cluster analyses to examine whether there was a natural grouping of poorer face recognizers but failed to find consistent grouping beyond those with generally above versus below average face recognition. Lastly, we investigated whether DP studies with more relaxed diagnostic cutoffs were associated with better performance on the Cambridge Face Perception Test. In a sample of 43 studies, there was a weak nonsignificant association between greater diagnostic strictness and better DP face perception accuracy (Kendall's tau-b correlation, τb =.18 z-score; τb = .11 percentiles). Together, these results suggest that researchers have used more conservative DP diagnostic cutoffs than the widely reported 2-2.5% prevalence. We discuss the strengths and weaknesses of using more inclusive cutoffs, such as identifying mild and major forms of DP based on DSM-5.

The Danish Version of the 20-Item Prosopagnosia Index (PI20): Translation, Validation and a Link to Face Perception

Developmental prosopagnosia (DP) is a neurodevelopmental condition characterized by face recognition problems. Psychometrically sound self-report measures of face recognition problems are important tools in classification of DP. A widely used measure of such problems is the 20-item prosopagnosia index (PI20). Here, we present a Danish translation of the PI20 (PI20_DK). We administered the PI20_DK alongside three objective measures of face and object processing performance to 119 participants to validate the PI20_DK. Further, we assess the underlying factor structure of the PI20_DK. Finally, as the first study in the field, we investigate the association between self-reported face recognition ability and face perception performance. The project was preregistered prior to data collection. The results suggest excellent convergent validity, discriminant validity and internal consistency for the PI20_DK. A confirmatory factor analysis, however, indicates a suboptimal fit of the PI20_DK to a one factor solution. An investigation of the association between the PI20_DK and face perception suggests that the poor fit may reflect that the PI20_DK measures problems with face recognition in general and not specifically face memory problems.

Two face masks are better than one: congruency effects in face matching

Although the positive effects of congruency between stimuli are well replicated in face memory paradigms, mixed findings have been found in face matching. Due to the current COVID-19 pandemic, face masks are now very common during daily life outdoor activities. Thus, the present study aims to further explore congruency effects in matching faces partially occluded by surgical masks. Observers performed a face matching task consisting of pairs of faces presented in full view (i.e., full-view condition), pairs of faces in which only one of the faces had a mask (i.e., one-mask condition), and pairs of faces in which both faces had a mask (i.e., two-mask condition). Although face masks disrupted performance in identity match and identity mismatch trials, in match trials, we found better performance in the two-mask condition compared to the one-mask condition. This finding highlights the importance of congruency between stimuli on face matching when telling faces together.

EXPRESS: Distinct abilities associated with matching same identity faces vs. discriminating different faces: Evidence from individual differences in prosopagnosics and controls

Previous face matching studies provide evidence that matching same identity faces (match trials) and discriminating different face identities (non-match trials) rely on distinct processes. For example, instructional studies geared towards improving face matching in applied settings have often found selective improvements in match or non-match trials only. Additionally, a small study found that developmental prosopagnosics (DPs) have specific deficits in making match but not non-match judgments. In the current study, we sought to replicate this finding in DPs and examine how individual differences across DPs and controls in match vs. non-match performance relate to featural vs. holistic processing abilities. 43 DPs and 27 controls matched face images shown from similar front views or with varied lighting or viewpoint. Participants also performed tasks measuring featural (eyes/mouth) and holistic processing (part-whole task). We found that DPs showed worse overall matching performance than controls and that their relative match vs. non-match deficit depended on image variation condition, indicating that DPs do not consistently show match- or non-match-specific deficits. When examining the association between holistic and featural processing abilities and match vs. non-match trials in the entire group of DPs and controls, we found a very clear dissociation: Match trials significantly correlated with eye processing ability (r=.48) but not holistic processing (r=.11), whereas non-match trials significantly correlated with holistic processing (r=.32) but not eye processing (r=.03). This suggests that matching same identity faces relies more on eye processing while discriminating different faces relies more on holistic processing.

Not so fast! Response times in the computerized Benton Face Recognition Test may not reflect face recognition ability

Response times (RTs) are commonly used to assess cognitive abilities, though it is unclear whether face processing RTs predict recognition ability beyond accuracy. In the current study, we examined accuracy and RT on a widely used face matching assessment modified to collect meaningful RT data, the computerized Benton Facial Recognition Test (BFRT-c), and measured whether RTs predicted face recognition ability and developmental prosopagnosia (DP) vs. control group membership. 62 controls and 36 DPs performed the BFRT-c as well as validated measures of face recognition ability: the Cambridge Face Memory Test (CFMT) and a Famous Faces Memory Test (FFMT). In controls, BFRT-c accuracy robustly predicted CFMT (r = .49, p < .001), FFMT (r = .43, p < .001), and a CFMT-FFMT composite (r = .54, p < .001), whereas BFRT-c RT was not significantly associated with these measures (all r's  .21). We also found that BFRT-c accuracy significantly differed between DPs and controls, but RT failed to differentiate the groups.