Eye movements reflect impaired face processing in patients with schizophrenia

Visual Field Restriction in the Recognition of Basic Facial Expressions: A Combined Eye Tracking and Gaze Contingency Study

Uncertainties and discrepant results in identifying crucial areas for emotional facial expression recognition may stem from the eye tracking data analysis methods used. Many studies employ parameters of analysis that predominantly prioritize the examination of the foveal vision angle, ignoring the potential influences of simultaneous parafoveal and peripheral information. To explore the possible underlying causes of these discrepancies, we investigated the role of the visual field aperture in emotional facial expression recognition with 163 volunteers randomly assigned to three groups: no visual restriction (NVR), parafoveal and foveal vision (PFFV), and foveal vision (FV). Employing eye tracking and gaze contingency, we collected visual inspection and judgment data over 30 frontal face images, equally distributed among five emotions. Raw eye tracking data underwent Eye Movements Metrics and Visualizations (EyeMMV) processing. Accordingly, the visual inspection time, number of fixations, and fixation duration increased with the visual field restriction. Nevertheless, the accuracy showed significant differences among the NVR/FV and PFFV/FV groups, despite there being no difference in NVR/PFFV. The findings underscore the impact of specific visual field areas on facial expression recognition, highlighting the importance of parafoveal vision. The results suggest that eye tracking data analysis methods should incorporate projection angles extending to at least the parafoveal level.

Searching for Signs of Plastic Surgery on the Face: Tracking the Eyes of Where Observers Look

Background: Objective measurement of where observers direct their attention to faces when searching for signs of facial plastic surgery (FPS) is currently lacking. Objective: To compare where laypersons direct their attention on facial photographs using eye-tracking software when they are asked to (1) search for signs of aesthetic facial surgery or (2) allowed to gaze without direction (free-gaze). Methods: Naïve observers either free-gazed or examined faces for signs of FPS (FPS-prompted) for 10 s per face while their gaze was recorded by an eye-tracking system. Faces had no known history or signs/stigmata of FPS and were selected from the FACES and CFD databases with a diverse demographic distribution. Gaze times in nine facial subregions were analyzed using mixed-effects linear regression. Results: In FPS-prompted observers (n = 50, mean age 32.7 ± 11.3 years, 23/50 (46%) female), the nose, mouth, cheeks, and forehead experienced the most substantial increases (p < 0.001) and a high percentage of overall gaze time (17.9%, 12.5%, 12.0%, 9.6%, respectively) compared to free-gazing observers [n = 57, 35.5 ± 13.9 years, 31/57 (54%) female]. Conclusions: Observers direct attention differently on a face when searching for signs of plastic surgery with increased attention on the nose, mouth, cheeks, and forehead.

Strange-face-in-the-mirror illusions: specific effects on derealization, depersonalization, and dissociative identity

Anomalous strange-face illusions (SFIs) are produced when mirror gazing under a low level of face illumination. In contrast to past studies in which an observer's task was to pay attention to the reflected face and to perceive potential facial changes, the present research used a mirror gazing task (MGT) that instructed participants to fixate their gaze on a 4-mm hole in a glass mirror. The participants' eye-blink rates were thus measured without priming any facial changes. Twenty-one healthy young individuals participated in the MGT and a control panel-fixation task (staring at a hole in a gray non-reflective panel). The Revised Strange-Face Questionnaire (SFQ-R) indexed derealization (deformations of facial features; FD), depersonalization (bodily face detachment; BD), and dissociative identity (new or unknown identities; DI) scales. Mirror-fixation increased FD, BD, and DI scores compared to panel-fixation. In mirror-fixation, FD scores revealed fading specific to facial features, distinct from "classical" Troxler- and Brewster-fading. In mirror-fixation, eye-blink rates correlated negatively with FD scores. Panel-fixation produced low BD scores, and, in a few participants, face pareidolias as detected on FD scores. Females were more prone to early derealization and males to compartmentalization of a dissociative identity. SFQ-R may be a valuable instrument for measuring face-specific dissociation (FD, BD, DI) produced by MGT. Use of MGT and panel-fixation task for differential diagnoses between schizophrenia and dissociative identity disorder is discussed.

Strange face illusions: A systematic review and quality analysis

BACKGROUND

Strange face illusions describe a range of visual apparitions that occur when an observer gazes at their image reflected in a mirror or at another person's face in a dimly lit room. The illusory effects range from mild alterations in colour, or contrast, to the perception of distorted facial features, or new strange faces.The current review critically evaluates studies investigating strange face illusions, their methodological quality, and existing interpretations.

METHOD

Searches conducted using Scopus, PubMed, ScienceDirect and the grey literature until June 2022 identified 21 studies (N = 1,132; healthy participants n = 1,042; clinical participants n = 90) meeting the inclusion criteria (i.e., providing new empirical evidence relating to strange face illusions). The total sample had a mean age of 28.3 years (SD = 10.31) and two thirds (67 %) of participants tested to date are female. Results are reported using the Preferred Reporting Items for Systematic Reviews and meta-Analyses (PRISMA) guidelines. The review was preregistered at the Open Science Framework (OSF: https://osf.io/ek48d).

RESULTS

Pooling data across studies, illusory new strange faces are experienced by 58% (95%CI 48 to 68) of nonclinical participants. Study quality as assessed by the Appraisal Tool for Cross-Sectional Studies (AXIS) revealed that 3/21 (14.28%) studies were rated as high, 9/21 (42.86%) as moderate and 9/21 (42.86%) as low quality. Whilst the items relating specifically to reporting quality scored quite highly, those relating to study design and possible biases were lower and more variable. Overall, study quality accounted for 87% of the variance in reporting rates for strange faces, with higher quality being associated with lower illusion rates. The prevalence of illusions was also significantly greater in samples that were older, had higher proportions of female participants and for the interpersonal dyad (IGDT) compared to the mirror gaze paradigm (MGT). The moderating impact of study quality persisted in a multiple meta-regression involving participant age, paradigm type (IGDT vs MGT) and level of feature distortion. Our review point to the importance of reduced light levels, face stimuli and prolonged eye fixation for strange face illusions to emerge.

CONCLUSION

Strange face illusions reliably occur in both mirror-gazing and interpersonal gazing dyad paradigms. Further research of higher quality is required to establish the prevalence and particularly, the mechanisms underpinning strange face illusions.

Gender differences in attentive bias during social information processing in schizophrenia: An eye-tracking study

Interpersonal communication is a specific scenario in which patients with psychiatric symptoms may manifest different behavioral patterns due to psychopathology. This was a pilot study by eye-tracking technology to investigate attentive bias during social information processing in schizophrenia. We enrolled 39 patients with schizophrenia from Shanghai Mental Health Center and 42 age-, gender- and education-matched healthy controls. The experiment was a free-viewing task, in which pictures with three types of degree of interpersonal communication were shown. We used two measures: 1) initial fixation duration, 2) total gaze duration. The Positive and Negative Syndrome Scale (PANSS) was used to determine symptom severity. The ratio of first fixation duration for pictures of communicating vs. non-communicating persons was significantly lower in patients than in controls (Mann-Whitney U = 512, p = 0.004). We found that male patients showed a significantly lower ratio of first fixation duration than male controls (Mann-Whitney U = 190, p = 0.028), while it was marginally lower in female patients than female controls (Mann-Whitney U = 77, p = 0.057). The ratio of first fixation duration for pictures of communicating persons vs. no persons was negatively correlated with PANSS negative symptoms in male patients (rho = -0.458, p = 0.024). In contrast, it was negatively correlated with PANSS positive symptoms in female patients (-0.701, p = 0.004). These findings suggest altered attentive bias during social information processing with a pattern of avoidance at first sight towards pictures of communicating persons in schizophrenia. It is worthwhile to note that social functioning impairment is associated with the severity of symptoms.

Normal Gaze Patterns of the Face in Lateral View

Importance: Current efforts to quantify the attentional distraction of facial deformities have been limited to deformities that are best perceived when the face is in frontal view, and there remains a paucity of knowledge of societal perception of the face in lateral view. To date, no attempts have been made to characterize the fixation patterns of the face in lateral view. Objective: To characterize the fixation patterns and gaze patterns of the face in lateral view. Design, Setting, and Participants: This was a prospective randomized controlled trial at an academic tertiary medical center. Eighty participants (mean age 23.6 ± 1.7 years, 52.5% female) gazed freely at 11 images of faces in lateral view for 10 s each as an infrared eye-tracker recorded eye movements in real time. Main Outcomes and Measures: Recorded eye movements are superimposed on the images to visualize areas of interest (AOIs) that attract the most attention. Fixation duration targeted at each AOI is transformed into relative fixation of the entire face and neck. Hotelling's test of variance followed by post hoc t-testing assessed for the significance of fixation differences between the mouth and cheeks. Results: Participants spent an average of 6.0 (95% CI 5.8-6.2) s gazing at the face and neck areas of each image. Of this attention, 2.8 s or 49.8% (45.4-54.2%) was directed toward the eye, followed distantly by the nose (mean, 95% CI) (16.4%, 14.5-18.3%), cheek (12.0%, 11.4-14.5%), neck (4.6%, 3.8-5.4%), and mouth (4.0%, 3.4-4.6%). These differences were found to be significant by Hotelling's analysis and post hoc testing. A student's t-test also indicated observers directed significantly more attention within the eye-nose-cheek triangle [4.6 s or 79.5% (75.6-83.5)] compared with the eye-nose-mouth triangle [4.1 s or 71.2% (66.9-75.5)] (p < 0.001). Conclusions and Relevance: When perceiving novel faces in lateral view, casual observers preferentially directed attention toward the eye, nose, and cheek. These findings suggest that we draw from a slightly different collection of features to build a schema of the sagittal face, which may serve to complement the central triangle and build upon a three-dimensional model of the "normal" human face. Level of Evidence: NA.

Dermal Fat Grafting to Reconstruct the Parotidectomy Defect Normalizes Facial Attention

OBJECTIVES/HYPOTHESIS

Use validated eye-tracking technology to objectively measure 1) the attentional distraction of facial contour defects after superficial and total parotidectomy and 2) changes in attentional distraction with abdominal dermal fat graft reconstruction.

METHODS

Standardized frontal and oblique facial images of 16 patients who had undergone superficial or total parotidectomy with or without fat graft reconstruction; four normal controls were obtained. One hundred casual observers were recruited to view these images, and gaze data were collected using a Tobii Pro eye-tracking system. Gaze durations for predefined facial areas of interest were analyzed using mixed-effects linear regression to test study hypotheses.

RESULTS

For frontal images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (92 milliseconds, 95% confidence interval [CI]: 48-138 milliseconds, P < .001). Fat grafting normalized the attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .414). For oblique images, total parotidectomy increased gaze to the operated parotid area compared to the contralateral nonoperated parotid area (658 milliseconds, 95% CI: 463-854 milliseconds, P < .001). Fat grafting normalized this attentional distraction, with no difference in gaze time on the operated parotid region compared to normal control faces (P = .504). In both views, superficial parotidectomy demonstrated no significant attentional distractions, with or without fat grafting.

CONCLUSIONS

This eye-tracking study objectively demonstrates that total parotidectomy results in a facial contour deformity that is distracting to observers, whereas superficial parotidectomy does not. For total parotidectomy, this attentional distraction can be normalized with dermal fat graft reconstruction.

LEVEL OF EVIDENCE

3b Laryngoscope, 131:E124-E131, 2021.

The attenuated visual scanpaths of patients with schizophrenia whilst recognizing emotional facial expressions are worsened in natural social scenes

Alteration of visual scanpaths under emotional facial expression in schizophrenia patients has been described in recent years; however, it is not clear whether such results are different when they transfer to faces in natural social scenes. The present study was designed to investigate the effects of emotional faces in natural social scenes on the gaze patterns of patients with schizophrenia, compared to gaze at isolated faces. A novel theme identification task was used where participants selected a positive, neutral or negative word to describe an emotional picture. Participants were 29 patients with schizophrenia and 31 healthy controls. The Positive and Negative Syndrome Scale (PANSS) and the Scale of Social Function in Psychosis Inpatients (SSPI) were used to assess symptoms and social functioning. In total, patients with schizophrenia showed significantly fewer fixations, saccades numbers and decreased fixations in areas of interest. As expected, patients showed shorter scanpath length, but only in the pictures with social settings. Furthermore, the effect size of scanpaths parameters under social scene was all greater than isolated face. In addition, patients compared to controls showed more abnormal scanpath parameters processing negative and neutral faces than positive faces, especially in social scene. The present study suggests that scanpath length for social scene faces may be more sensitive than for isolated face pictures. Our findings further support restricted scanpath whilst recognizing emotional facial expressions in natural social scenes as a favorable topic for further investigation as a trait marker.

Measuring Outcomes of Mohs Defect Reconstruction Using Eye-Tracking Technology

Importance

Objectively measuring how Mohs defect reconstruction changes casual observer attention has important implications for patients and facial plastic surgeons.

Objective

To use eye-tracking technology to objectively measure the ability of Mohs facial defect reconstruction to normalize facial attention.

Design, Setting, and Participants

This observational outcomes study was conducted at an academic tertiary referral center from January to June 2016. An eye-tracking system was used to record how 82 casual observers directed attention to photographs of 32 patients with Mohs facial defects of varying sizes and locations before and after reconstruction as well as 16 control faces with no facial defects. Statistical analysis was performed from November 2018 to January 2019.

Main Outcomes and Measures

First, the attentional distraction caused by facial defects was quantified in milliseconds of gaze time using eye tracking. Second, the eye-tracking data were analyzed using mixed-effects linear regression to assess the association of facial defect reconstruction with normalized facial attention.

Results

The 82 casual observers (63 women and 19 men; mean [SD] age, 34 [12] years) viewed control faces in a similar and consistent fashion, with most attention (65%; 95% CI, 62%-69%) directed at the central triangle, which includes the eyes, nose, and mouth. The eyes were the most visually important feature, capturing a mean of 60% (95% CI, 57%-64%) of fixation time within the central triangle and 39% (95% CI, 36%-43%) of total observer attention. The presence of Mohs defects was associated with statistically significant alterations in this pattern of normal facial attention. The larger the defect and the more centrally a defect was located, the more attentional distraction was observed, as measured by increased attention on the defect and decreased attention on the eyes, ranging from 729 (95% CI, 526-931) milliseconds for small peripheral defects to 3693 (95% CI, 3490-3896) milliseconds for large central defects. Reconstructive surgery was associated with improved gaze deviations for all faces and with normalized attention directed to the eyes for all faces except for those with large central defects.

Conclusions and Relevance

Mohs defects are associated with altered facial perception, diverting attention from valuable features such as the eyes. Reconstructive surgery was associated with normalized attentional distraction for many patients with cutaneous Mohs defects. These data are important to patients who want to know how reconstructive surgery could change the way people look at their face. The data also point to the possibility of outcomes prediction based on facial defect size and location before reconstruction. Eye tracking is a valuable research tool for outcomes assessment that lays the foundation for understanding how reconstructive surgery may change perception and normalize facial deformity.

How Old Do I Look? Exploring the Facial Cues of Age in a Tasked Eye-Tracking Study

Importance: This is the first eye-tracking study to use a tasked age estimation paradigm to explore the facial cues of age as seen by casual observers. Objectives: Determine where observers gaze on faces when tasked with estimating an individual's age. Design, Setting, and Participants: This was a prospective controlled experiment, which took place at an academic tertiary referral center. In total, 220 casual observers (80 untasked, 140 tasked) viewed frontal facial images of women while an infrared eye-tracking monitor recorded their eye movements and fixations in real time. Main Outcomes and Measures: Multivariate Hotelling's analysis followed by planned posthypothesis testing was used to compare fixation durations for predefined regions of interest, including the central triangle, upper face, midface, lower face, and neck between tasked and untasked observers. Results: A total of 80 observers (mean age 23.6 years, 53% female) successfully completed the first untasked eye-tracking experiment. A total of 140 observers (mean age 26.1 years, 60% female) successfully completed the second age estimation experiment. On multivariate analysis, there were significant differences in the distribution of attention between observers in the two experiments (T² = 99.70; F(5,2084) = 19.9012, p < 0.0001). On planned posthypothesis testing, observers attended significantly more to the lower third of the face (0.20 s, p < 0.0001, 95% confidence interval (CI) 0.14-0.27 s) and neck (0.05 s, p = 0.0074, 95% CI 0.01-0.08 s) and less to the upper third of the face (-0.27 s, p < 0.0001, 95% CI -0.40 to -0.14 s) when tasked. There was no significant difference in time spent on the whole face in the two experiments, suggesting that peripheral elements such as hair color or jewelry did not significantly influence gaze patterns. Conclusions and Relevance: Humans form judgments about others every day of their lives, and age perception colors their every interaction. To our knowledge, this study is the first to use eye tracking to investigate facial cues of age. The results showed that when tasked with estimating age, casual observer visual attention was shifted toward the lower face when compared with those who were untasked. These data inform our understanding of facial age perception and potential areas to target for facial rejuvenation. Level of Evidence: NA.

In the eye of the beholder? Oxytocin effects on eye movements in schizophrenia

BACKGROUND

Individuals with schizophrenia have difficulty in extracting salient information from faces. Eye-tracking studies have reported that these individuals demonstrate reduced exploratory viewing behaviour (i.e. reduced number of fixations and shorter scan paths) compared to healthy controls. Oxytocin has previously been demonstrated to exert pro-social effects and modulate eye gaze during face exploration. In this study, we tested whether oxytocin has an effect on visual attention in patients with schizophrenia.

METHODS

Nineteen male participants with schizophrenia received intranasal oxytocin 40UI or placebo in a double-blind, placebo-controlled, crossover fashion during two visits separated by seven days. They engaged in a free-viewing eye-tracking task, exploring images of Caucasian men displaying angry, happy, and neutral emotional expressions; and control images of animate and inanimate stimuli. Eye-tracking parameters included: total number of fixations, mean duration of fixations, dispersion, and saccade amplitudes.

RESULTS

We found a main effect of treatment, whereby oxytocin increased the total number of fixations, dispersion, and saccade amplitudes, while decreasing the duration of fixations compared to placebo. This effect, however, was non-specific to facial stimuli. When restricting the analysis to facial images only, we found the same effect. In addition, oxytocin modulated fixation rates in the eye and nasion regions.

DISCUSSION

This is the first study to explore the effects of oxytocin on eye gaze in schizophrenia. Oxytocin had enhanced exploratory viewing behaviour in response to both facial and inanimate control stimuli. We suggest that the acute administration of intranasal oxytocin may have the potential to enhance visual attention in schizophrenia.

Transoral neck surgery prevents attentional bias towards the neck compared to open neck surgery

OBJECTIVE

Measure attentional distraction of neck scars after open neck surgery compared to transoral endoscopic thyroidectomy via a vestibular approach (TOETVA) or transoral endoscopic parathyroidectomy via a vestibular approach (TOEPVA) using eye-tracking technology.

METHODS

Casual observers viewed facial images of patients who underwent open neck surgery, TOETVA/TOEPVA, or no surgery (controls). An eye-tracking monitor recorded eye fixations in real time. Multivariate Hotelling's analysis followed by post-hypothesis testing compared fixation durations for predefined regions of interest, including the eyes, nose, mouth, neck, and remaining face between open neck surgery patients, transoral neck surgery patients, and controls.

RESULTS

One hundred forty observers completed the experiment. The majority of their attention was directed towards the central triangle (eyes, nose, mouth). On multivariate analysis, distribution of attention was significantly different on the faces of those who underwent open neck surgery versus TOETVA/TOEPVA (T² = 43.66; F[32,131] = 14.5389, P < .0001). Observers attended significantly more to the neck (0.20 seconds, P < .0001; 95% CI, 0.13, 0.26 s) and less to the peripheral face (-0.24 seconds, P = .0031; 95% CI, -0.39, -0.08 s) of open neck surgery patients. In patients who followed up months after surgery, significant differences persisted (T² = 13.97; F[3451] = 4.6377, P = .0033). By contrast, fixation patterns for TOETVA/TOEPVA patients were not significantly different from controls (T² = 5.59, F[31,186] = 1.8602, P = .1345). Observer race and gender did not significantly affect attention to neck scars.

CONCLUSION

Scars following open neck surgery draw attention in casual observers. This attentional distraction is prevented in TOETVA/TOEPVA patients due to the absence of a scar, even months after surgery. Moreover, visual processing of TOETVA/TOEPVA patients' faces is similar to that of controls. These data support the effectiveness of transoral neck surgery in giving patients a cosmetic result that does not distract the attention of observers.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1603-1608, 2020.

Oxytocin increases eye gaze in schizophrenia

Abnormal eye gaze is common in schizophrenia and linked to functional impairment. The hypothalamic neuropeptide oxytocin modulates visual attention to social stimuli, but its effects on eye gaze in schizophrenia are unknown. We examined visual scanning of faces in men with schizophrenia and neurotypical controls to quantify oxytocin effects on eye gaze. In a randomized, double-blind, crossover study, 33 men with schizophrenia and 39 matched controls received one dose of intranasal oxytocin (40 IU) and placebo on separate testing days. Participants viewed 20 color photographs of faces while their gaze patterns were recorded. We tested for differences in fixation time on the eyes between patients and controls as well as oxytocin effects using linear mixed-effects models. We also tested whether attachment style, symptom severity, and anti-dopaminergic medication dosage moderated oxytocin effects. In the placebo condition, patients showed reduced fixation time on the eyes compared to controls. Oxytocin was associated with an increase in fixation time among patients, but a decrease among controls. Higher attachment anxiety and greater symptom severity predicted increased fixation time on the eyes on oxytocin versus placebo. Anti-dopaminergic medication dosage and attachment avoidance did not impact response to oxytocin. Consistent with findings that oxytocin optimizes processing of social stimuli, intranasal oxytocin enhanced eye gaze in men with schizophrenia. Further work is needed to determine whether changes in eye gaze impact social cognition and functional outcomes. Both attachment anxiety and symptom severity predicted oxytocin response, highlighting the importance of examining potential moderators of oxytocin effects in future studies.

Societal Identification of Facial Paralysis and Paralysis Location

Importance

When able to identify facial paralysis, members of society regard individuals with facial paralysis differently. They perceive a decrease in attractiveness, more negative affect, and lower quality of life. However, the ability of lay people in society to accurately identify the presence of facial paralysis has not yet been defined.

Objective

To determine societal members' ability to (1) identify paralysis in varying degrees of paralysis severity and (2) localize the defect on the face.

Design, Setting, and Participants

A prospective observational study conducted in an academic tertiary referral center using a group of 380 casual observers was carried out.

Main Outcomes and Measures

Surveys were designed containing smiling and repose images of normal faces and faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) as categorized by House-Brackmann (HB) grade. The photographs were then shown to casual observers in a web-based survey. After reviewing both normal faces and faces with varying degrees of paralysis, they then indicated (1) whether paralysis was present and (2) if so, where the paralysis was on the face.

Results

A total of 380 participants (267 [70.3%] women and 113 [29.7%] men with a mean [SD] age of 29 [12] years) successfully completed the survey, viewing 2860 facial photographs in aggregate. The accuracy rate of identifying paralysis increased from low-grade through high-grade paralysis. Facial paralysis was identified in 249 (34.6%) of 719 facial photographs with low-grade paralysis, 448 (63.2%) of 709 with medium-grade paralysis, and 696 (96.7%) of 720 with high-grade paralysis (χ2 = 912.6, P < .001); 6.2% (44/731) of normal faces were incorrectly identified as having paralysis (χ2 = 912.6, P < .001). Participants correctly localized paralysis in 157 (63.0%) of 249 low-grade photographs, 307 (68.5%) of 448 medium-grade photographs, and 554 (79.6%) of 696 high-grade photographs (χ2 = 32.5, P < .001). In general, participants tended to identify facial paralysis more accurately in smiling vs repose faces (48.6% vs 20.6%, 92.4% vs 33.7%, and 96.7% vs 96.6% in low-, medium-, and high-grade paralysis, respectively) (χ2 = 62.2, P < .001; χ2 = 262.6, P < .001; χ2 = 0.0, P = .96, respectively).

Conclusions and Relevance

The ability of individuals to identify the presence of facial paralysis increased as paralysis severity increased. Further, smiling increased accurate identification. However, even when individuals can identify paralysis, they are not necessarily able to accurately localize the paralysis on a face. This may speak to a phenomenon in which perception of a facial defect comes from a holistic interpretation of a face, rather than a clinically accurate specification of the defect location. These findings are important in the future counseling of patients.

Level of Evidence

NA.

Visual exploration of emotional faces in schizophrenia using masks from the Japanese Noh theatre

Studying eye movements during visual exploration is widely used to investigate visual information processing in schizophrenia. Here, we used masks from the Japanese Noh theatre to study visual exploration behavior during an emotional face recognition task and a brightness evaluation control task using the same stimuli. Eye movements were recorded in 25 patients with schizophrenia and 25 age-matched healthy controls while participants explored seven photos of Japanese Noh masks tilted to seven different angles. Additionally, participants were assessed on seven upright binary black and white pictures of these Noh masks (Mooney-like pictures), seven Upside-down pictures (180° upside-down turned Mooneys), and seven Neutral pictures. Participants either had to indicate whether they had recognized a face and its emotional expression, or they had to evaluate the brightness of the picture (total N = 56 trials). We observed a clear effect of inclination angle of Noh masks on emotional ratings (p < 0.001) and visual exploration behavior in both groups. Controls made larger saccades than patients when not being able to recognize a face in upside-down Mooney pictures (p < 0.01). Patients also made smaller saccades when exploring pictures for brightness (p < 0.05). Exploration behavior in patients was related to depressive symptom expression during emotional face recognition but not during brightness evaluation. Our findings suggest that visual exploration behavior in patients with schizophrenia is less flexible than in controls depending on the specific task requirements, specifically when exploring physical aspects of the environment.

Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty

IMPORTANCE

The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied.

OBJECTIVE

To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology.

DESIGN, SETTING, AND PARTICIPANTS

In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness.

MAIN OUTCOMES AND MEASURES

The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time.

RESULTS

Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times.

CONCLUSIONS AND RELEVANCE

Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group.

LEVEL OF EVIDENCE

NA.

Objectively Measuring Observer Attention in Severe Thyroid-Associated Orbitopathy: A 3D Study

OBJECTIVE

Measure the attentional distraction of facial deformity related to severe thyroid-associated orbitopathy using three-dimensional (3D) images and eye-tracking technology.

METHODS

Observers recruited at an academic tertiary referral center viewed 3D facial images of patients with severe thyroid-associated orbitopathy (TAO) and controls without TAO. An infrared eye-tracking monitor recorded their eye movements and fixations in real time. Multivariate Hotelling's analysis, followed by planned posthypothesis testing, was used to compare fixation durations for predefined regions of interest, including the eyes, nose, mouth, central triangle, and remaining face without the central triangle between severe TAO patients and controls.

RESULTS

One hundred sixteen observers (mean age 26.4 years, 51% female) successfully completed the eye-tracking experiment. The majority of their attention was directed toward the central triangle (eyes, nose, mouth). On multivariate analysis, there were significant differences in the distribution of attention between control and severe TAO faces (T²  = 49.37; F(5,922) = 9.8314, P < 0.0001). On planned posthypothesis testing, observers attended significantly more to the eyes (0.77 seconds, P < 0.0001, 95% confidence interval [CI], 0.51, 1.03 seconds) and less to the nose (-0.42 seconds, P < 0.0001, 95% CI, -0.23, -0.62 seconds) in severe TAO patients. There was no significant difference in time spent on the mouth, the total time spent on the central triangle, or time spent in the remaining face between the two groups.

CONCLUSION

Severe TAO distracted observer attention toward the eyes compared to control patients. These data lend insight into how TAO may alter observers' perceptions of these patients. Future studies should investigate how these changes in observer gaze patterns may reflect the social perception of TAO patients.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1250-1254, 2019.

Association of Rhinoplasty With Perceived Attractiveness, Success, and Overall Health

IMPORTANCE

To date, the impact of rhinoplasty surgery on social perceptions has not been quantified.

OBJECTIVE

To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health.

DESIGN, SETTING, AND PARTICIPANTS

In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain.

MAIN OUTCOMES AND MEASURES

The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health.

RESULTS

A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual's perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively.

CONCLUSIONS AND RELEVANCE

As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes.

LEVEL OF EVIDENCE

NA.

Looking but not seeing: Increased eye fixations in behavioural-variant frontotemporal dementia

Face processing plays a central role in human communication, with the eye region a particularly important cue for discriminating emotions. Indeed, reduced attention to the eyes has been argued to underlie social deficits in a number of clinical populations. Despite well-established impairments in facial affect recognition in behavioural-variant frontotemporal dementia, whether these patients also have perturbed facial scanning is yet to be investigated. The current study employed eye tracking to record visual scanning of faces in 20 behavioural-variant frontotemporal dementia patients and 21 controls. Remarkably, behavioural-variant frontotemporal dementia patients displayed more fixations to the eyes of emotional faces, compared to controls. Neural regions associated with fixations to the eyes included the left inferior frontal gyrus, right cerebellum and middle temporal gyrus. Our study is the first to show such compensatory functions in behavioural-variant frontotemporal dementia and suggest a feedback-style network, including anterior and posterior brain regions, is involved in early face processing.

A Dual Approach to Understanding Facial Perception Before and After Blepharoplasty

Importance

Blepharoplasty consistently ranks among the most common facial plastic surgery procedure sought by both men and women. Despite the popularity of blepharoplasty, there has been little research focused on quantifying how eyelid surgery changes facial perceptions.

Objectives

To quantify the effect of blepharoplasty on facial perceptions and measure patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions.

Design, Setting, and Participants

A web-based survey experiment was conducted from January to February 2017, featuring photographs of female patients before and after blepharoplasty. Observers were randomly shown independent images of each patient and asked to rate perceived age, attractiveness, health, and energy level. Respondents saw only preoperative or postoperative photographs of each patient to reduce bias due to priming. Patient-reported outcomes were also collected.

Main Outcomes and Measures

A multivariate mixed effects regression model was used to quantify the changes in each domain after surgery. Ordinal rank change was calculated to provide a measure of clinical effect size across the domains. To analyze patient-reported outcomes, a Kruskal-Wallis test followed by Mann-Whitney tests were performed to determine if there were differences in patient-perceived tiredness based on operative status.

Results

A total of 401 participants (243 women, 152 men, and 6 not specified; mean age 25.9 years [range, 18-73 years]) successfully completed the survey and evaluated before-and-after photographs of 10 female patients (mean age, 59.8 years). The multivariable mixed effects model revealed that individuals are perceived as appearing significantly younger (-1.04 years; 95% CI, -1.70 to -0.37 years) and more attractive (coefficient, 4.92; 95% CI, 3.91-5.93) after blepharoplasty. Ratings of perceived health (coefficient, 4.33; 95% CI, 3.28-5.37) and energy level (coefficient, 9.83; 95% CI, 8.51-11.16) also improved significantly. After undergoing blepharoplasty, patients had significantly improved ratings of energy level compared with those who had not undergone blepharoplasty.

Conclusions and Relevance

This is the first study, to date, aimed at quantifying the perceptions of facial aesthetic changes following blepharoplasty. The data demonstrate that individuals are rated as appearing more youthful, attractive, and healthy following blepharoplasty. Furthermore, both patients and casual observers perceived a significant improvement in energy level following blepharoplasty, a meaningful finding as the appearance of fatigue is a chief concern of the patients before they undergo blepharoplasty.

Level of Evidence

NA.

Comparing Patient, Casual Observer, and Expert Perception of Permanent Unilateral Facial Paralysis

Importance

Differences in perception of facial paralysis among patients, casual observers, and experts may have implications for outcomes research and patient care.

Objective

To compare multiple domains of casual observer and expert perception with the actual experience of patients with permanent unilateral facial paralysis.

Design, Setting, and Participants

This investigation was a prospective cohort study conducted at an academic tertiary referral center. Patients with permanent unilateral facial paralysis (House-Brackmann grades IV to VI) were randomly selected from The Johns Hopkins University Division of Facial Plastic and Reconstructive Surgery clinic. A diverse group of casual observers and experts were recruited to rate their perception of each patient with facial paralysis. The study dates were July 2014 to July 2015.

Main Outcomes and Measures

Patients rated their paralysis severity, attractiveness, quality of life, and affect using established metrics. Casual observers and experts viewed standardized facial videos of each patient and then used the same metrics to rate each patient's paralysis severity, attractiveness, quality of life, and affect.

Results

The analysis yielded 40 patient observations, 6400 casual observer observations, and 200 expert observations for each outcome metric in the study. Compared with the patients' self-perception, casual observers and experts rated patients with facial paralysis more negatively in all measured domains. A multivariable mixed-effects regression showed that observers perceived patients as having greater paralysis severity (8.49 [95% CI, -0.65 to 17.64] of 100 points; SE, 4.67), being less attractive (-7.71 [95% CI, -14.92 to -0.50] of 100 points; SE, 3.68), and having a worse quality of life (-7.76 [95% CI, -14.18 to -1.34] of 100 points; SE, 3.28) compared with the patients' perceptions. Logistic regression demonstrated that observers were less likely to rate patients' affect as positive (odds ratio, 0.28 [95% CI, 0.14-0.58]; SE, 0.10) compared with the patients' self-rating. The raw data and regression analyses also showed that patients, casual observers, and experts perceived faces with higher House-Brackmann grades more negatively in all measured domains of facial perception.

Conclusions and Relevance

This study found that casual observers and experts generally perceive patients with facial paralysis more negatively than patients perceive themselves. These findings have implications for patients and facial plastic surgeons alike. They also emphasize the importance of assessing outcomes from all 3 perspectives. This pilot study lays the groundwork for developing new tools to assess the social perception of facial deformity that could lead to advancement in facial paralysis outcomes research and improved care for patients with facial paralysis.

Level of Evidence

NA.

Association Between Facial Rejuvenation and Observer Ratings of Youth, Attractiveness, Success, and Health

IMPORTANCE

Surgical procedures for the aging face-including face-lift, blepharoplasty, and brow-lift-consistently rank among the most popular cosmetic services sought by patients. Although these surgical procedures are broadly classified as procedures that restore a youthful appearance, they may improve societal perceptions of attractiveness, success, and health, conferring an even larger social benefit than just restoring a youthful appearance to the face.

OBJECTIVES

To determine if face-lift and upper facial rejuvenation surgery improve observer ratings of age, attractiveness, success, and health and to quantify the effect of facial rejuvenation surgery on each individual domain.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical experiment was performed from August 30 to September 18, 2016, using web-based surveys featuring photographs of patients before and after facial rejuvenation surgery. Observers were randomly shown independent images of the 12 patients; within a given survey, observers saw either the preoperative or postoperative photograph of each patient to reduce the possibility of priming. Observers evaluated patient age using a slider bar ranging from 30 to 80 years that could be moved up or down in 1-year increments, and they ranked perceived attractiveness, success, and health using a 100-point visual analog scale. The bar on the 100-point scale began at 50; moving the bar to the right corresponded to a more positive rating in these measures and moving the bar to the left, a more negative rating.

MAIN OUTCOMES AND MEASURES

A multivariate mixed-effects regression model was used to understand the effect of face-lift and upper facial rejuvenation surgery on observer perceptions while accounting for individual biases of the participants. Ordinal rank change was calculated to understand the clinical effect size of changes across the various domains after surgery.

RESULTS

A total of 504 participants (333 women, 165 men, and 6 unspecified; mean age, 29 [range, 18-70] years) successfully completed the survey. A multivariate mixed-effects regression model revealed a statistically significant change in age (-4.61 years; 95% CI, -4.97 to -4.25) and attractiveness (6.72; 95% CI, 5.96-7.47) following facial rejuvenation surgery. Observer-perceived success (3.85; 95% CI, 3.12-4.57) and health (7.65; 95% CI; 6.87-8.42) also increased significantly as a result of facial rejuvenation surgery.

CONCLUSIONS AND RELEVANCE

The data presented in this study demonstrate that patients are perceived as younger and more attractive by the casual observer after undergoing face-lift and upper facial rejuvenation surgery. These procedures also improved ratings of perceived success and health in our patient population. These findings suggest that facial rejuvenation surgery conveys an even larger societal benefit than merely restoring a youthful appearance to the face.

LEVEL OF EVIDENCE

NA.

Association of Face-lift Surgery With Social Perception, Age, Attractiveness, Health, and Success

IMPORTANCE

Evidence quantifying the influence of face-lift surgery on societal perceptions is lacking.

OBJECTIVE

To measure the association of face-lift surgery with observer-graded perceived age, attractiveness, success, and overall health.

DESIGN, SETTING, AND PARTICIPANTS

In a web-based survey, 526 casual observers naive to the purpose of the study viewed independent images of 13 unique female patient faces before or after face-lift surgery from January 1, 2016, through June 30, 2016. The Delphi method was used to select standardized patient images confirming appropriate patient candidacy and overall surgical effect. Observers estimated age and rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, with higher scores corresponding to more positive responses. To evaluate the accuracy of observer age estimation, the patients' preoperative estimated mean age was compared with the patients' actual mean age. A multivariate mixed-effects regression model was used to determine the effect of face-lift surgery. To further characterize the effect of face-lift surgery, estimated ordinal-rank change was calculated for each domain.

MAIN OUTCOMES AND MEASURES

Blinded casual observer ratings of patients estimated age, attractiveness, perceived success, and perceived overall health.

RESULTS

A total of 483 observers (mean [SD] age, 29 [8.6] years; 382 women [79.4%]) successfully completed the survey. Comparing patients' preoperative estimated mean (SD) age (59.6 [9.0] years) and patients' actual mean (SD) age (58.4 [6.9] years) revealed no significant difference (t2662 = -0.47; 95% CI, -6.07 to 3.72; P = .64). On multivariate regression, patients after face-lift surgery were rated as significantly younger (coefficient, -3.69; 95% CI -4.15 to -3.23; P < .001), more attractive (coefficient, 8.21; 95% CI, 7.41-9.02; P < .001), more successful (coefficient, 5.82; 95% CI, 5.05 to 6.59; P < .001), and overall healthier (coefficient, 8.72; 95% CI, 7.88-9.56; P < .001). The ordinal rank changes for an average individual were -21 for perceived age, 21 for attractiveness, 16 for success, and 21 for overall health.

CONCLUSIONS AND RELEVANCE

In this study, observer perceptions of face-lift surgery were associated with views that patients appeared younger, more attractive, healthier, and more successful. These findings highlight observer perceptions of face-lift surgery that could positively influence social interactions.

LEVEL OF EVIDENCE

NA.

Societal Value of Surgery for Facial Reanimation

Importance

Patients with facial paralysis are perceived negatively by society in a number of domains. Society's perception of the health utility of varying degrees of facial paralysis and the value society places on reconstructive surgery for facial reanimation need to be quantified.

Objective

To measure health state utility of varying degrees of facial paralysis, willingness to pay (WTP) for a repair, and the subsequent value of facial reanimation surgery as perceived by society.

Design, Setting, and Participants

This prospective observational study conducted in an academic tertiary referral center evaluated a group of 348 casual observers who viewed images of faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) categorized by House-Brackmann grade. Structural equation modeling was performed to understand associations among health utility metrics, WTP, and facial perception domains. Data were collected from July 16 to September 26, 2015.

Main Outcomes and Measures

Observer-rated (1) quality of life (QOL) using established health utility metrics (standard gamble, time trade-off, and a visual analog scale) and (2) their WTP for surgical repair.

Results

Among the 348 observers (248 women [71.3%]; 100 men [28.7%]; mean [SD] age, 29.3 [11.6] years), mixed-effects linear regression showed that WTP increased nonlinearly with increasing severity of paralysis. Participants were willing to pay $3487 (95% CI, $2362-$4961) to repair low-grade paralysis, $8571 (95% CI, $6401-$11 234) for medium-grade paralysis, and $20 431 (95% CI, $16 273-$25 317) for high-grade paralysis. The dominant factor affecting the participants' WTP was perceived QOL. Modeling showed that perceived QOL decreased with paralysis severity (regression coefficient, -0.004; 95% CI, -0.005 to -0.004; P < .001) and increased with attractiveness (regression coefficient, 0.002; 95% CI, 0.002 to 0.003; P < .001). Mean (SD) health utility scores calculated by the standard gamble metric for low- and high-grade paralysis were 0.98 (0.09) and 0.77 (0.25), respectively. Time trade-off and visual analog scale measures were highly correlated. We calculated mean (SD) WTP per quality-adjusted life-year, which ranged from $10 167 ($14 565) to $17 008 ($38 288) for low- to high-grade paralysis, respectively.

Conclusions and Relevance

Society perceives the repair of facial paralysis to be a high-value intervention. Societal WTP increases and perceived health state utility decreases with increasing House-Brackmann grade. This study demonstrates the usefulness of WTP as an objective measure to inform dimensions of disease severity and signal the value society places on proper facial function.

Level of Evidence

NA.

The Cost of Facial Deformity: A Health Utility and Valuation Study

IMPORTANCE

The impact of facial defects on quality of life as perceived by society and the value society places on facial reconstruction are important outcomes measures.

OBJECTIVE

To measure the health state utility and dollar value of surgically reconstructing facial defects as perceived by society.

DESIGN, SETTING, AND PARTICIPANTS

A randomized observational study conducted in an academic tertiary referral center using a socioeconomically diverse group of 200 casual observers.

MAIN OUTCOMES AND MEASURES

Observers viewed images of faces with defects of varying sizes and locations before and after surgical reconstruction. Observers imagined if the defect in each image were on their own face and rated (1) their health state utility with the defect and (2) how much they would be willing to pay to have the defect surgically repaired to normal (perfect repair). Established health state utility and contingent valuation metrics were used.

RESULTS

Data from 200 observers were analyzed. Facial defects significantly decreased perceived health state utility with the greatest penalty attributed to large and centrally located defects. Surgical reconstruction of the facial defects increased health state utility to near-normal ranges for all groups except large central defects. Participants were willing to pay an average of $1170 (95% CI, $767-$1572) to repair a de novo small peripheral defect; they were willing to pay $4274 more than the average (95% CI, $3296-$5251) to repair a large defect and $2372 more (95% CI, $1379-$3366) to repair a central defect. Using these valuation and health utility data, we calculated willingness to pay per quality-adjusted life-year (WTP/QALY), a value-related metric. Mean WTP/QALY ratios ranged from $639/QALY for repairing small peripheral defects to $2838/QALY for repairing large central defects, well below all cost-effectiveness thresholds.

CONCLUSIONS AND RELEVANCE

Casual observers perceived that facial defects significantly decrease quality of life, an effect improved by reconstructive surgery. Measuring WTP and calculating WTP/QALY provides novel data to assess the social importance and value of facial reconstructive surgery. To our knowledge, these are the first data demonstrating that surgical reconstruction of facial defects is a high-value intervention as perceived by society. These findings have implications for a broad range of stakeholders, including patients, surgeons, health policy makers, and payers.

LEVEL OF EVIDENCE

NA.

The categories, frequencies, and stability of idiosyncratic eye-movement patterns to faces

The spatial pattern of eye-movements to faces considered typical for neurologically healthy individuals is a roughly T-shaped distribution over the internal facial features with peak fixation density tending toward the left eye (observer's perspective). However, recent studies indicate that striking deviations from this classic pattern are common within the population and are highly stable over time. The classic pattern actually reflects the average of these various idiosyncratic eye-movement patterns across individuals. The natural categories and respective frequencies of different types of idiosyncratic eye-movement patterns have not been specifically investigated before, so here we analyzed the spatial patterns of eye-movements for 48 participants to estimate the frequency of different kinds of individual eye-movement patterns to faces in the normal healthy population. Four natural clusters were discovered such that approximately 25% of our participants' fixation density peaks clustered over the left eye region (observer's perspective), 23% over the right eye-region, 31% over the nasion/bridge region of the nose, and 20% over the region spanning the nose, philthrum, and upper lips. We did not find any relationship between particular idiosyncratic eye-movement patterns and recognition performance. Individuals' eye-movement patterns early in a trial were more stereotyped than later ones and idiosyncratic fixation patterns evolved with time into a trial. Finally, while face inversion strongly modulated eye-movement patterns, individual patterns did not become less distinct for inverted compared to upright faces. Group-averaged fixation patterns do not represent individual patterns well, so exploration of such individual patterns is of value for future studies of visual cognition.

Restricted attention to social cues in schizophrenia patients

Deficits of psychosocial functioning are a robust finding in schizophrenia. Research on social cognition may open a new avenue for the development of effective interventions. As a correlate of social perceptive information processing deficits, schizophrenia patients (SZP) show deviant gaze behavior (GB) while viewing emotional faces. As understanding of a social environment requires gathering complex social information, our study aimed at investigating the gaze behavior of SZP related to social interactions and its impact on the level of social and role functioning. GB of 32 SZP and 37 healthy control individuals (HCI) was investigated with a high-resolution eye tracker during an unguided viewing of 12 complex pictures of social interaction scenes. Regarding whole pictures, SZP showed a shorter scanpath length, fewer fixations and a shorter mean distance between fixations. Furthermore, SZP exhibited fewer and shorter fixations on faces, but not on the socially informative bodies nor on the background, suggesting a cue-specific abnormality. Logistic regression with bootstrapping yielded a model including two GB parameters; a subsequent ROC curve analysis indicated an excellent ability of group discrimination (AUC .85). Face-related GB aberrations correlated with lower social and role functioning and with delusional thinking, but not with negative symptoms. Training of spontaneous integration of face-related social information seems promising to enable a holistic perception of social information, which may in turn improve social and role functioning. The observed ability to discriminate SZP from HCI warrants further research on the predictive validity of GB in psychosis risk prediction.

Design of a Virtual Reality System for Affect Analysis in Facial Expressions (VR-SAAFE); Application to Schizophrenia

Schizophrenia is a life-long, debilitating psychotic disorder with poor outcome that affects about 1% of the population. Although pharmacotherapy can alleviate some of the acute psychotic symptoms, residual social impairments present a significant barrier that prevents successful rehabilitation. With limited resources and access to social skills training opportunities, innovative technology has emerged as a potentially powerful tool for intervention. In this paper, we present a novel virtual reality (VR)-based system for understanding facial emotion processing impairments that may lead to poor social outcome in schizophrenia. We henceforth call it a VR System for Affect Analysis in Facial Expressions (VR-SAAFE). This system integrates a VR-based task presentation platform that can minutely control facial expressions of an avatar with or without accompanying verbal interaction, with an eye-tracker to quantitatively measure a participants real-time gaze and a set of physiological sensors to infer his/her affective states to allow in-depth understanding of the emotion recognition mechanism of patients with schizophrenia based on quantitative metrics. A usability study with 12 patients with schizophrenia and 12 healthy controls was conducted to examine processing of the emotional faces. Preliminary results indicated that there were significant differences in the way patients with schizophrenia processed and responded towards the emotional faces presented in the VR environment compared with healthy control participants. The preliminary results underscore the utility of such a VR-based system that enables precise and quantitative assessment of social skill deficits in patients with schizophrenia.

Facial affect recognition in body dysmorphic disorder versus obsessive-compulsive disorder: An eye-tracking study

BACKGROUND

Body dysmorphic disorder (BDD) is characterised by repetitive behaviours and/or mental acts occurring in response to preoccupations with perceived defects or flaws in physical appearance (American Psychiatric Association, 2013). This study aimed to investigate facial affect recognition in BDD using an integrated eye-tracking paradigm.

METHOD

Participants were 21 BDD patients, 19 obsessive-compulsive disorder (OCD) patients and 21 healthy controls (HC), who were age-, sex-, and IQ-matched. Stimuli were from the Pictures of Facial Affect (Ekman & Friesen, 1975), and outcome measures were affect recognition accuracy as well as spatial and temporal scanpath parameters.

RESULTS

Relative to OCD and HC groups, BDD patients demonstrated significantly poorer facial affect perception and an angry recognition bias. An atypical scanning strategy encompassing significantly more blinks, fewer fixations of extended mean durations, higher mean saccade amplitudes, and less visual attention devoted to salient facial features was found.

CONCLUSIONS

Patients with BDD were substantially impaired in the scanning of faces, and unable to extract affect-related information, likely indicating deficits in basic perceptual operations.

Correlations between psychometric schizotypy, scan path length, fixations on the eyes and face recognition

Psychometric schizotypy in the general population correlates negatively with face recognition accuracy, potentially due to deficits in inhibition, social withdrawal, or eye-movement abnormalities. We report an eye-tracking face recognition study in which participants were required to match one of two faces (target and distractor) to a cue face presented immediately before. All faces could be presented with or without paraphernalia (e.g., hats, glasses, facial hair). Results showed that paraphernalia distracted participants, and that the most distracting condition was when the cue and the distractor face had paraphernalia but the target face did not, while there was no correlation between distractibility and participants' scores on the Schizotypal Personality Questionnaire (SPQ). Schizotypy was negatively correlated with proportion of time fixating on the eyes and positively correlated with not fixating on a feature. It was negatively correlated with scan path length and this variable correlated with face recognition accuracy. These results are interpreted as schizotypal traits being associated with a restricted scan path leading to face recognition deficits.

A motivational determinant of facial emotion recognition: regulatory focus affects recognition of emotions in faces

Two studies examined an unexplored motivational determinant of facial emotion recognition: observer regulatory focus. It was predicted that a promotion focus would enhance facial emotion recognition relative to a prevention focus because the attentional strategies associated with promotion focus enhance performance on well-learned or innate tasks - such as facial emotion recognition. In Study 1, a promotion or a prevention focus was experimentally induced and better facial emotion recognition was observed in a promotion focus compared to a prevention focus. In Study 2, individual differences in chronic regulatory focus were assessed and attention allocation was measured using eye tracking during the facial emotion recognition task. Results indicated that the positive relation between a promotion focus and facial emotion recognition is mediated by shorter fixation duration on the face which reflects a pattern of attention allocation matched to the eager strategy in a promotion focus (i.e., striving to make hits). A prevention focus did not have an impact neither on perceptual processing nor on facial emotion recognition. Taken together, these findings demonstrate important mechanisms and consequences of observer motivational orientation for facial emotion recognition.

Effects of Training of Affect Recognition on the recognition and visual exploration of emotional faces in schizophrenia

BACKGROUND

Schizophrenia patients have impairments in facial affect recognition and display scanpath abnormalities during the visual exploration of faces. These abnormalities are characterized by fewer fixations on salient feature areas and longer fixation durations. The present study investigated whether social-cognitive remediation not only improves performance in facial affect recognition but also normalizes patients' gaze behavior while looking at faces.

METHODS

Within a 2 × 2-design (group × time), 16 schizophrenia patients and 16 healthy controls performed a facial affect recognition task with concomitant infrared oculography at baseline (T0) and after six weeks (T1). Between the measurements, patients completed the Training of Affect Recognition (TAR) program. The influence of the training on facial affect recognition (percent of correct answers) and gaze behavior (number and mean duration of fixations into salient or non-salient facial areas) was assessed.

RESULTS

In line with former studies, at baseline patients showed poorer facial affect recognition than controls and aberrant scanpaths, and after TAR facial affect recognition was improved. Concomitant with improvements in performance, the number of fixations in feature areas ('mouth') increased while fixations in non-feature areas ('white space') decreased. However, the change in fixation behavior did not correlate with the improvement in performance.

CONCLUSIONS

After TAR, patients pay more attention to facial areas that contain information about a displayed emotion. Although this may contribute to the improved performance, the lack of a statistical correlation implies that this factor is not sufficient to explain the underlying mechanism of the treatment effect.

Seeing is believing: objectively evaluating the impact of facial reanimation surgery on social perception

OBJECTIVES/HYPOTHESIS

Objectively measure the ability of facial reanimation surgery to normalize the appearance of facial paralysis using eye-tracking technology.

STUDY DESIGN

Prospective randomized controlled experiment.

METHODS

An eye-tracker system was used to record the eye-movement patterns, called scanpaths, of 86 naïve observers gazing at pictures of paralyzed faces (House-Brackmann IV-VI), smiling and in repose; before and after facial reanimation surgery; as well as normal, nonparalyzed faces. Observers gazed at each face for 10 seconds. Fixation durations for all predefined facial areas of interest were analyzed using mixed-effects linear regression.

RESULTS

Observers spent the majority of time (6.6 of 10 seconds) gazing in the central triangle region (eyes, nose, and mouth) of normal faces and paralyzed faces. There were significant deviations in fixation within the central triangle of paralyzed faces as compared to normal faces. Total fixation on the eyes remained conserved. However, total nose fixation decreased and mouth fixation increased on paralyzed faces. Facial reanimation surgery normalized many of the hemifacial gaze asymmetries caused by unilateral facial paralysis, and restored a normal distribution of gaze between the functional and paralyzed sides of the face and mouth.

CONCLUSION

There were objective differences in the way observers directed their attention to facial features when viewing normal and paralyzed faces. After facial reanimation surgery, the attentional distraction caused by facial feature irregularities was reduced. These findings are important additions to the emerging body of objective evidence indicating the effectiveness of reanimation surgery; they also suggest opportunities to optimize reconstruction.

LEVEL OF EVIDENCE

N/A.

Advanced analysis of free visual exploration patterns in schizophrenia

Background: Visual scanpath analyses provide important information about attention allocation and attention shifting during visual exploration of social situations. This study investigated whether patients with schizophrenia simply show restricted free visual exploration behavior reflected by reduced saccade frequency and increased fixation duration or whether patients use qualitatively different exploration strategies than healthy controls.

Methods: Scanpaths of 32 patients with schizophrenia and age-matched 33 healthy controls were assessed while participants freely explored six photos of daily life situations (20 s/photo) evaluated for cognitive complexity and emotional strain. Using fixation and saccade parameters, we compared temporal changes in exploration behavior, cluster analyses, attentional landscapes, and analyses of scanpath similarities between both groups.

Results: We found fewer fixation clusters, longer fixation durations within a cluster, fewer changes between clusters, and a greater increase of fixation duration over time in patients compared to controls. Scanpath patterns and attentional landscapes in patients also differed significantly from those of controls. Generally, cognitive complexity and emotional strain had significant effects on visual exploration behavior. This effect was similar in both groups as were physical properties of fixation locations.

Conclusions: Longer attention allocation to a given feature in a scene and less attention shifts in patients suggest a more focal processing mode compared to a more ambient exploration strategy in controls. These visual exploration alterations were present in patients independently of cognitive complexity, emotional strain or physical properties of visual cues implying that they represent a rather general deficit. Despite this impairment, patients were able to adapt their scanning behavior to changes in cognitive complexity and emotional strain similar to controls.

Abnormal fixation in individuals with age-related macular degeneration when viewing an image of a face

PURPOSE

It has been reported that patients with macular disease have difficulties with face perception. Some of this difficulty may be caused by the sensory and perceptual consequences of using peripheral retina. However, strong correlations have not always been found between performance on face tasks and clinical measure of function. Based on the evidence of abnormal eye movements by patients with age-related macular degeneration (AMD), we explored whether abnormal fixation patterns occur when these patients view an image of a face.

METHODS

An OPKO OCT/SLO was used to collect structural and functional data. For each subject, the structural location of disease was determined, and the locus and stability of fixation were quantified. A SLO movie of fundus movements was recorded while the subject viewed an image of a face.

RESULTS

The number of fixations on internal (eyes, nose, and mouth) and external features were measured. A two-way repeated-measures analysis of variance found significant differences between the control and patient groups and among locations. A significant interaction between group and location was also found. Post hoc comparisons found a significantly greater proportion of fixations on external features for the AMD group than that in the control group.

CONCLUSIONS

The observed patterns of fixations of our subjects with AMD were similar to those observed in other groups of patients who have difficulties with face perception. For example, individuals with social phobias, Williams syndrome, autism, schizophrenia, or prosopagnosia have altered face perceptions and also have a significantly greater proportion of fixations on external features of faces. Abnormal eye movement patterns and fixations may contribute to deficits in face perception in AMD patients.

Looking just below the eyes is optimal across face recognition tasks

When viewing a human face, people often look toward the eyes. Maintaining good eye contact carries significant social value and allows for the extraction of information about gaze direction. When identifying faces, humans also look toward the eyes, but it is unclear whether this behavior is solely a byproduct of the socially important eye movement behavior or whether it has functional importance in basic perceptual tasks. Here, we propose that gaze behavior while determining a person's identity, emotional state, or gender can be explained as an adaptive brain strategy to learn eye movement plans that optimize performance in these evolutionarily important perceptual tasks. We show that humans move their eyes to locations that maximize perceptual performance determining the identity, gender, and emotional state of a face. These optimal fixation points, which differ moderately across tasks, are predicted correctly by a Bayesian ideal observer that integrates information optimally across the face but is constrained by the decrease in resolution and sensitivity from the fovea toward the visual periphery (foveated ideal observer). Neither a model that disregards the foveated nature of the visual system and makes fixations on the local region with maximal information, nor a model that makes center-of-gravity fixations correctly predict human eye movements. Extension of the foveated ideal observer framework to a large database of real-world faces shows that the optimality of these strategies generalizes across the population. These results suggest that the human visual system optimizes face recognition performance through guidance of eye movements not only toward but, more precisely, just below the eyes.

Simple viewing tests can detect eye movement abnormalities that distinguish schizophrenia cases from controls with exceptional accuracy

BACKGROUND

We have investigated which eye-movement tests alone and combined can best discriminate schizophrenia cases from control subjects and their predictive validity.

METHODS

A training set of 88 schizophrenia cases and 88 controls had a range of eye movements recorded; the predictive validity of the tests was then examined on eye-movement data from 34 9-month retest cases and controls, and from 36 novel schizophrenia cases and 52 control subjects. Eye movements were recorded during smooth pursuit, fixation stability, and free-viewing tasks. Group differences on performance measures were examined by univariate and multivariate analyses. Model fitting was used to compare regression, boosted tree, and probabilistic neural network approaches.

RESULTS

As a group, schizophrenia cases differed from control subjects on almost all eye-movement tests, including horizontal and Lissajous pursuit, visual scanpath, and fixation stability; fixation dispersal during free viewing was the best single discriminator. Effects were stable over time, and independent of sex, medication, or cigarette smoking. A boosted tree model achieved perfect separation of the 88 training cases from 88 control subjects; its predictive validity on retest assessments and novel cases and control subjects was 87.8%. However, when we examined the whole data set of 298 assessments, a cross-validated probabilistic neural network model was superior and could discriminate all cases from controls with near perfect accuracy at 98.3%.

CONCLUSIONS

Simple viewing patterns can detect eye-movement abnormalities that can discriminate schizophrenia cases from control subjects with exceptional accuracy.

Smooth pursuit and visual scanpaths: Independence of two candidate oculomotor risk markers for schizophrenia

OBJECTIVES

Smooth pursuit and visual scanpath deficits are candidate trait markers for schizophrenia. It is not clear whether eye tracking dysfunction (ETD) and atypical scanpath behaviour are the product of the same underlying neurobiological processes. We have examined co-occurrence of ETD and scanpath disturbance in individuals with schizophrenia and healthy volunteers.

METHODS

Eye movements of individuals with schizophrenia (N = 96) and non-clinical age-matched comparison participants (N = 100) were recorded using non-invasive infrared oculography during smooth pursuit in both predictable (horizontal sinusoid) and less predictable (Lissajous sinusoid) conditions and a free viewing scanpath task.

RESULTS

Individuals with schizophrenia demonstrated scanning deficits in both tasks. There was no association between performance measures of smooth pursuit and scene scanpaths in patient or control groups. Odds ratios comparing the likelihood of scanpath dysfunction when ETD was present, and the likelihood of finding scanpath dysfunction when ETD was absent were not significant in patients or controls in either pursuit variant, suggesting that ETD and scanpath dysfunction are independent anomalies in schizophrenia.

CONCLUSION

ETD and scanpath disturbance appear to reflect independent oculomotor or neurocognitive deficits in schizophrenia. Each task may confer unique information about the pathophysiology of psychosis.

Inflexible information acquisition strategies mediate visuo-spatial reasoning in stabilized schizophrenia patients

OBJECTIVES

Cognitive deficits are of fundamental importance to the clinical picture of schizophrenia and are on the verge to be included as diagnostic criteria in the DSM-V. While focusing on information processing deficits, no emphasis has been put on whether patients' deficits can be accounted for by maladaptive information acquisition strategy deployment.

METHODS

We tested 24 stabilized patients with schizophrenia and 25 matched controls in a visuo-spatial analogy task with graded difficulty. Eye movement recordings served to identify information acquisition strategies.

RESULTS

Patients compared to healthy controls showed slower reaction times in the easiest condition and higher error rates in the more difficult conditions. Eye movement recordings illustrated that overall mean fixation duration increased with increasing task difficulty in healthy controls only. Further, patients deployed a more efficient strategy ("constructive matching") less often than healthy controls in the easier conditions.

CONCLUSIONS

These results suggest that information acquisition strategies mediate visuo-spatial cognitive performance in schizophrenia. Patients adopt a less efficient strategy independently of task difficulty indicated by a characteristic behavioural pattern. Our results point to a powerful tool of improving patients' performance in cognitively demanding tasks by training them in more flexible cognitive (e.g., information acquisition) strategy deployment.

Current visual scanpath research: a review of investigations into the psychotic, anxiety, and mood disorders

The human visual system is comprised of an array of complex organs, which jointly decode information from visible light to construct a meaningful representation of the surrounding environment. The study of visual scanpaths transpired in a bid to enhance our understanding of the role of eye movements underpinning adaptive functioning as well as psychopathology and was further aided by the advent of modern eye-tracking techniques. This review provides a background to the nature of visual scanpaths, followed by an overview and critique of eye movement studies in specific clinical populations involving the psychotic, anxiety, and mood disorders, and concludes with suggested directions for future research. We performed a Medline and PsycInfo literature search, based on variations of the terms "visual scanpath," "eye-tracking," and "eye movements," in relation to articles published from 1986 to the present. Eye-tracking studies in schizophrenia mostly concurred with the existence of a "restricted" scanning strategy, characterized by fewer number of fixations of increased durations, with shorter scanpath lengths, and a marked avoidance of salient features, especially in relation to facial emotion perception. This has been interpreted as likely reflecting dual impairments in configural processing as well as gestalt perception. Findings from the anxiety and mood disorders have conversely failed to yield coherent results, with further research warranted to provide corroborating evidence and overcome identified methodological limitations. Future studies should also look toward applying similar techniques to related disorders as well as conducting parallel neuroimaging investigations to elucidate potential neurobiological correlates.

Clair DM, Benson PJ. Atypical scanpaths in schizophrenia: evidence of a trait- or state-dependent phenomenon?

The development of trait markers of schizophrenia would represent an important advance in understanding the genetic architecture of the disease. To date, no candidate markers have satisfied all of the trait marker criteria, and many are not specific to the schizophrenia spectrum. Abnormalities in visual scanpaths are frequently reported in patients with schizophrenia and are emerging as a novel candidate for a schizophrenia biomarker. Here we review the suitability of scanpath measures as a target for trait marker research in schizophrenia. Papers reporting scanpath patterns in patients with schizophrenia were identified by PubMed and Google Scholar searches and by scanning reference lists in relevant articles. Search terms included "schizophrenia," "psychosis," "scanpath," "scan path," "fixation," "saccade" and "eye movement." Scanpath abnormalities afford impressive sensitivity and specificity and appear largely independent of psychotropic medications. Scanpaths may demonstrate some fluctuation with symptomatology and may be useful in illuminating illness state or subtypes. However, there is evidence that viewing behaviours remain atypical regardless of symptom remission and may be present in unaffected relatives of individuals with schizophrenia. This research is in its early stages, and further investigation regarding patterns of inheritance is required. Our findings support scanpath measures as a favourable topic for further investigation as a trait marker.

Visuo-spatial cognition in schizophrenia: confirmation of a preference for local information processing

During visuo-spatial cognitive tasks, patients with schizophrenia show a preference for local (detailed) rather than global (holistic) information processing. The efficiency of such information processing is influenced by task difficulty. We tested whether patients' preference for local processing would persist if task demands favored global or local processing. Twenty-four stabilized patients with schizophrenia (SZ) and 25 healthy, matched controls (C) were tested in a mental mirroring task. Task difficulty was manipulated while stimulus surface structures were maintained unchanged. Information processing was assessed by recording eye movements. SZ were slower than C in the easiest condition but they made more errors than C in the more difficult conditions. Further, SZ did not adapt their average fixation duration to task demands resulting in longer fixation duration in the easiest condition and shorter fixation duration in the most difficult condition compared to C. These findings suggest that patients employ local information processing even when it is maladaptive for task demands. That is, patients do not adapt their fixation duration to task demands implicating (i) a preference for scanning local stimuli features and (ii) information processing inflexibility. These features need to be taken into account when evaluating visuo-spatial cognitive performance in schizophrenia.

Neuronal correlates of affective theory of mind in schizophrenia out-patients: evidence for a baseline deficit

BACKGROUND

Schizophrenia out-patients have deficits in affective theory of mind (ToM) but also on more basal levels of social cognition, such as the processing of neutral and emotional expressions. These deficits are associated with changes in brain activation in the amygdala and the superior temporal sulcus (STS). However, until now there have been no studies that examined these different levels of social cognition and their neurobiological underpinnings in patients within one design.

METHOD

Sixteen medicated schizophrenia out-patients and 16 matched healthy controls were studied with functional magnetic resonance imaging (fMRI) during a social cognition task that allows the investigation of affective ToM (aToM), emotion recognition and the processing of neutral facial expressions.

RESULTS

Patients showed a deficit in emotion recognition and a more prominent deficit in aToM. The performance in aToM and in emotion recognition was correlated in the control group but not in the schizophrenia group. Region-of-interest analysis of functional brain imaging data revealed no difference between groups during aToM, but a hyperactivation in the schizophrenia group in the left amygdala and right STS during emotion recognition and the processing of neutral facial expressions.

CONCLUSIONS

The results indicate that schizophrenia out-patients have deficits at several levels of social cognition and provide the first evidence that deficits on higher-order social cognitive processes in schizophrenia may be traced back to an aberrant processing of faces per se.

Encoding deficit during face processing within the right fusiform face area in schizophrenia

Face processing is crucial to social interaction, but is impaired in schizophrenia patients, who experience delays in face recognition, difficulties identifying others, and misperceptions of affective content. The right fusiform face area plays an important role in the early stages of human face processing and thus may be affected in schizophrenia. The aim of the study was therefore to investigate whether face processing deficits are related to dysfunctions of the right fusiform face area in schizophrenia patients compared with controls. In a rapid, event-related functional magnetic resonance imaging (fMRI) design, we investigated the encoding of new faces, as well as the recognition of newly learned, famous, and unfamiliar faces, in 13 schizophrenia patients and 21 healthy controls. We applied region of interest analysis to each individual's right fusiform face area and tested for group differences. Controls displayed higher blood oxygenation level dependent (BOLD) activation during the memorization of faces that were later successfully recognized. In schizophrenia patients, this effect was not observed. During the recognition task, schizophrenia patients exhibited lower BOLD responses, less accuracy, and longer reaction times to famous and unfamiliar faces. Our results support the hypothesis that impaired face processing in schizophrenia is related to early-stage deficits during the encoding and recognition of faces.