Improving the DSM-5 approach to cognitive impairment: Developmental prosopagnosia reveals the need for tailored diagnoses

The Diagnostic Statistical Manual of Mental Disorders (DSM-5) recommends diagnosing neurocognitive disorders (i.e., cognitive impairment) when a patient scores beyond - 1 SD below neurotypical norms on two tests. I review how this approach will fail due to cognitive tests' power limitations, validity issues, imperfect reliabilities, and biases, before summarizing their resulting negative consequences. As a proof of concept, I use developmental prosopagnosia, a condition characterized by difficulties recognizing faces, to show the DSM-5 only diagnoses 62-70% (n1 = 61, n2 = 165) versus 100% (n1 = 61) through symptoms alone. Pooling the DSM-5 missed cases confirmed the presence of group-level impairments on objective tests, which were further evidenced through meta-analyses, thus validating their highly atypical symptoms. These findings support a paradigm shift towards bespoke diagnostic approaches for distinct cognitive impairments, including a symptom-based method when validated effective. I reject dogmatic adherence to the DSM-5 approach to neurocognitive disorders, and underscore the importance of a data driven, transdiagnostic approach to understanding patients' subjective cognitive impairments. This will ultimately benefit patients, their families, clinicians, and scientific progress.

An investigation on the face inversion effect in deaf children

The face inversion effect is an important indicator of holistic face perception and reflects the developmental level of face processing. This study examined the face inversion effect in deaf or hard of hearing (DHH) children aged 7-17 using the face dimensions task. This task uses photographic images of a face, in which configural and featural information in the eye and mouth regions have been parametrically and independently manipulated. The study aimed to discuss the effect of face inversion on facial processing in DHH children, including two aspects of information processing types (configural versus featural) and processing regions (eyes versus mouth) and compared the results with hearing children. The results revealed that DHH children aged 7-17 years exhibit significant face inversion effect, with disruptions observed in both the featural and configural processing of eyes and mouths when faces were inverted. Configural processing was more affected by inversion than featural processing in all children, with larger differences observed in DHH children than in hearing children. This supports the dual-mode hypothesis of holistic face processing. Age correlations were observed in the sensitivity of DHH children to face inversion effect but not among hearing children. The inversion effect of configural mouth processing decreases with age in DHH children.

Investigating the role of the fusiform face area and occipital face area using multifocal transcranial direct current stimulation

The functional role of the occipital face area (OFA) and the fusiform face area (FFA) in face recognition is inconclusive to date. While some research has shown that the OFA and FFA are involved in early (i.e., featural processing) and late (i.e., holistic processing) stages of face recognition respectively, other research suggests that both regions are involved in both early and late stages of face recognition. Thus, the current study aims to further examine the role of the OFA and the FFA using multifocal transcranial direct current stimulation (tDCS). In Experiment 1, we used computer-generated faces. Thirty-five participants completed whole face and facial features (i.e., eyes, nose, mouth) recognition tasks after OFA and FFA stimulation in a within-subject design. No difference was found in recognition performance after either OFA or FFA stimulation. In Experiment 2 with 60 participants, we used real faces, provided stimulation following a between-subjects design and included a sham control group. Results showed that FFA stimulation led to enhanced efficiency of facial features recognition. Additionally, no effect of OFA stimulation was found for either facial feature or whole face recognition. These results suggest the involvement of FFA in the recognition of facial features.

Mapping the Featural and Holistic Face Processing of Bad and Good Face Recognizers

Individual abilities in face recognition (good versus bad recognizers) were explored by means of event-related potentials (ERPs). The adaptation response profile of the N170 component to whole faces, eyes and mouths was used in order to highlight the crucial role of individual abilities in identity repetition processes for unfamiliar faces. The main point of this study is to underline the importance of characterizing the performance (bad or good) of the participants and to show that behaviorally selected groups might reveal neural differences. Good recognizers showed selective right hemisphere N170 repetition effects for whole faces and not for features. On the contrary, bad recognizers showed a general repetition effect not specifically related to faces and more pronounced processing for features. These findings suggest a different contribution of holistic and featural analysis in bad and good performers. In conclusion, we propose that the N170 might be used as a tool to tease apart face encoding processes as a function of individual differences.

Prosopagnosia and disorders of face processing

Face recognition is a form of expert visual processing. Acquired prosopagnosia is the loss of familiarity for facial identity and has several functional variants, namely apperceptive, amnestic, and associative forms. Acquired forms are usually caused by either occipitotemporal or anterior temporal lesions, right or bilateral in most cases. In addition, there is a developmental form, whose functional and structural origins are still being elucidated. Despite their difficulties with recognizing faces, some of these subjects still show signs of covert recognition, which may have a number of explanations. Other aspects of face perception can be spared in prosopagnosic subjects. Patients with other types of face processing difficulties have been described, including impaired expression processing, impaired lip-reading, false familiarity for faces, and a people-specific amnesia. Recent rehabilitative studies have shown some modest ability to improve face perception in prosopagnosic subjects through perceptual training protocols.

The Scanpaths of Subjects with Developmental Prosopagnosia during a Face Memory Task

The scanpaths of healthy subjects show biases towards the upper face, the eyes and the center of the face, which suggests that their fixations are guided by a feature hierarchy towards the regions most informative for face identification. However, subjects with developmental prosopagnosia have a lifelong impairment in face processing. Whether this is reflected in the loss of normal face-scanning strategies is not known. The goal of this study was to determine if subjects with developmental prosopagnosia showed anomalous scanning biases as they processed the identity of faces. We recorded the fixations of 10 subjects with developmental prosopagnosia as they performed a face memorization and recognition task, for comparison with 8 subjects with acquired prosopagnosia (four with anterior temporal lesions and four with occipitotemporal lesions) and 20 control subjects. The scanning of healthy subjects confirmed a bias to fixate the upper over the lower face, the eyes over the mouth, and the central over the peripheral face. Subjects with acquired prosopagnosia from occipitotemporal lesions had more dispersed fixations and a trend to fixate less informative facial regions. Subjects with developmental prosopagnosia did not differ from the controls. At a single-subject level, some developmental subjects performed abnormally, but none consistently across all metrics. Scanning distributions were not related to scores on perceptual or memory tests for faces. We conclude that despite lifelong difficulty with faces, subjects with developmental prosopagnosia still have an internal facial schema that guides their scanning behavior.

A regional composite-face effect for species-specific recognition: Upper and lower halves play different roles in holistic processing of monkey faces

Using a composite-face paradigm, we examined the holistic processing induced by Asian faces, Caucasian faces, and monkey faces with human Asian participants in two experiments. In Experiment 1, participants were asked to judge whether the upper halves of two faces successively presented were the same or different. A composite-face effect was found for Asian faces and Caucasian faces, but not for monkey faces. In Experiment 2, participants were asked to judge whether the lower halves of the two faces successively presented were the same or different. A composite-face effect was found for monkey faces as well as for Asian faces and Caucasian faces. Collectively, these results reveal that own-species (i.e., own-race and other-race) faces engage holistic processing in both upper and lower halves of the face, but other-species (i.e., monkey) faces engage holistic processing only when participants are asked to match the lower halves of the face. The findings are discussed in the context of a region-based holistic processing account for the species-specific effect in face recognition.

Mapping the impairment in decoding static facial expressions of emotion in prosopagnosia

Acquired prosopagnosia is characterized by a deficit in face recognition due to diverse brain lesions, but interestingly most prosopagnosic patients suffering from posterior lesions use the mouth instead of the eyes for face identification. Whether this bias is present for the recognition of facial expressions of emotion has not yet been addressed. We tested PS, a pure case of acquired prosopagnosia with bilateral occipitotemporal lesions anatomically sparing the regions dedicated for facial expression recognition. PS used mostly the mouth to recognize facial expressions even when the eye area was the most diagnostic. Moreover, PS directed most of her fixations towards the mouth. Her impairment was still largely present when she was instructed to look at the eyes, or when she was forced to look at them. Control participants showed a performance comparable to PS when only the lower part of the face was available. These observations suggest that the deficits observed in PS with static images are not solely attentional, but are rooted at the level of facial information use. This study corroborates neuroimaging findings suggesting that the Occipital Face Area might play a critical role in extracting facial features that are integrated for both face identification and facial expression recognition in static images.

The "Eye Avoidance" Hypothesis of Autism Face Processing

Although a growing body of research indicates that children with autism spectrum disorder (ASD) exhibit selective deficits in their ability to recognize facial identities and expressions, the source of their face impairment is, as yet, undetermined. In this paper, we consider three possible accounts of the autism face deficit: (1) the holistic hypothesis, (2) the local perceptual bias hypothesis and (3) the eye avoidance hypothesis. A review of the literature indicates that contrary to the holistic hypothesis, there is little evidence to suggest that individuals with autism do perceive faces holistically. The local perceptual bias account also fails to explain the selective advantage that ASD individuals demonstrate for objects and their selective disadvantage for faces. The eye avoidance hypothesis provides a plausible explanation of face recognition deficits where individuals with ASD avoid the eye region because it is perceived as socially threatening. Direct eye contact elicits a increased physiological response as indicated by heightened skin conductance and amygdala activity. For individuals with autism, avoiding the eyes is an adaptive strategy, however, this approach interferes with the ability to process facial cues of identity, expressions and intentions, exacerbating the social challenges for persons with ASD.

Seeing the eyes in acquired prosopagnosia

Case reports have suggested that perception of the eye region may be impaired more than that of other facial regions in acquired prosopagnosia. However, it is unclear how frequently this occurs, whether such impairments are specific to a certain anatomic subtype of prosopagnosia, and whether these impairments are related to changes in the scanning of faces. We studied a large cohort of 11 subjects with this rare disorder, who had a variety of occipitotemporal or anterior temporal lesions, both unilateral and bilateral. Lesions were characterized by functional and structural imaging. Subjects performed a perceptual discrimination test in which they had to discriminate changes in feature position, shape, or external contour. Test conditions were manipulated to stress focused or divided attention across the whole face. In a second experiment we recorded eye movements while subjects performed a face memory task. We found that greater impairment for eye processing was more typical of subjects with occipitotemporal lesions than those with anterior temporal lesions. This eye selectivity was evident for both eye position and shape, with no evidence of an upper/lower difference for external contour. A greater impairment for eye processing was more apparent under attentionally more demanding conditions. Despite these perceptual deficits, most subjects showed a normal tendency to scan the eyes more than the mouth. We conclude that occipitotemporal lesions are associated with a partially selective processing loss for eye information and that this deficit may be linked to loss of the right fusiform face area, which has been shown to have activity patterns that emphasize the eye region.

Real-life experience with personally familiar faces enhances discrimination based on global information

Despite the agreement that experience with faces leads to more efficient processing, the underlying mechanisms remain largely unknown. Building on empirical evidence from unfamiliar face processing in healthy populations and neuropsychological patients, the present experiment tested the hypothesis that personal familiarity is associated with superior discrimination when identity information is derived based on global, as opposed to local facial information. Diagnosticity and availability of local and global information was manipulated through varied physical similarity and spatial resolution of morph faces created from personally familiar or unfamiliar faces. We found that discrimination of subtle changes between highly similar morph faces was unaffected by familiarity. Contrariwise, relatively more pronounced physical (i.e., identity) differences were more efficiently discriminated for personally familiar faces, indicating more efficient processing of global, as opposed to local facial information through real-life experience.

An other-race effect for configural and featural processing of faces: upper and lower face regions play different roles

We examined whether Asian individuals would show differential sensitivity to configural vs. featural changes to own- and other-race faces and whether such sensitivity would depend on whether the changes occurred in the upper vs. lower regions of the faces. We systematically varied the size of key facial features (eyes and mouth) of own-race Asian faces and other-race Caucasian faces, and the configuration (spacing) between the eyes and between the nose and mouth of the two types of faces. Results revealed that the other-race effect (ORE) is more pronounced when featural and configural spacing changes are in the upper region than in the lower region of the face. These findings reveal that information from the upper vs. lower region of the face contributes differentially to the ORE in face processing, and that processing of face race is influenced more by information location (i.e., upper vs. lower) than by information type (i.e., configural vs. featural).

The effects of information type (features vs. configuration) and location (eyes vs. mouth) on the development of face perception

The goal of the current study was to investigate the development of face processing strategies in a perceptual discrimination task. Children (7-12 years of age) and young adults were administered the Face Dimensions Task. In the Face Dimensions Task, participants were asked to judge whether two simultaneously presented faces were the "same" or "different". For the "same" trials, the two faces were identical. For the "different" trials, the faces differed in either the spacing between the eyes, the spacing between the nose and the mouth, the size of the eyes, or the size of the mouth. The main finding was that 7- to 10-year-old children showed no difference in their ability to discriminate differences in eye size and eye spacing but showed a poor ability to discriminate differences in nose and mouth spacing and, to a lesser extent, mouth size. The developmental lag between nose-mouth discriminations and the other featural and configural discriminations was reduced in older children and eliminated by young adulthood. These results indicate that the type of face information (i.e., configural vs. featural) and its location (i.e., eye vs. mouth) jointly contribute to the development of face perception abilities.

Posterior cortical atrophy: an investigation of scan paths generated during face matching tasks

When viewing a face, healthy individuals focus more on the area containing the eyes and upper nose in order to retrieve important featural and configural information. In contrast, individuals with face blindness (prosopagnosia) tend to direct fixations toward individual facial features—particularly the mouth. Presented here is an examination of face perception deficits in individuals with Posterior Cortical Atrophy (PCA). PCA is a rare progressive neurodegenerative disorder that is characterized by atrophy in occipito-parietal and occipito-temporal cortices. PCA primarily affects higher visual processing, while memory, reasoning, and insight remain relatively intact. A common symptom of PCA is a decreased effective field of vision caused by the inability to “see the whole picture.” Individuals with PCA and healthy control participants completed a same/different discrimination task in which images of faces were presented as cue-target pairs. Eye-tracking equipment and a novel computer-based perceptual task—the Viewing Window paradigm—were used to investigate scan patterns when faces were presented in open view or through a restricted-view, respectively. In contrast to previous prosopagnosia research, individuals with PCA each produced unique scan paths that focused on non-diagnostically useful locations. This focus on non-diagnostically useful locations was also present when using a restricted viewing aperture, suggesting that individuals with PCA have difficulty processing the face at either the featural or configural level. In fact, it appears that the decreased effective field of view in PCA patients is so severe that it results in an extreme dependence on local processing, such that a feature-based approach is not even possible.

Are Faces Special to Infants? An Investigation of Configural and Featural Processing for the Upper and Lower Regions of Houses in 3- to 7-month-olds

Three- to 7-month-olds were administered a house version of the Face Dimensions Test in which the featural and configural information of the upper and lower windows were systematically varied. The Dimensions Test has previously been used to study the processing of face features and their configurations by infants (Quinn & Tanaka, 2009). Just as was the case with faces, infants were shown to be sensitive to configural change in the upper and lower regions and to featural change in the upper region, but not to featural change in the lower region. The outcomes reflect either a face processing system that can generalize broadly to stimuli that are as different from faces as houses or a more general processing system with perceptual operations that can apply to both faces and houses.

Face context advantage explained by vernier and separation discrimination acuity

Seeing facial features in the context of a full face is known to provide an advantage for perception. Using an interocular separation perception task we confirmed that seeing eyes within the context of a face improves discrimination in synthetic faces. We also show that this improvement of the face context can be explained using the presence of individual components of the face such as the nose mouth, or head-outline. We demonstrate that improvements due to the presence of the nose, and head-outline can be explained in terms of two-point separation measurements, obeying Weber’s law as established in the literature. We also demonstrate that performance improvements due to the presence of the mouth can be explained in terms of Vernier acuity judgments between eye positions and the corners of the mouth. Overall, our study shows that the improvements in perception of facial features due to the face context effect can be traced to well understood basic visual measurements that may play a very general role in perceptual measurements of distance. Deficiencies in these measurements may also play a role in prosopagnosia. Additionally, we show interference of the eyebrows with the face-inversion effect for interocular discrimination.

Complementary neural representations for faces and words: a computational exploration

A key issue that continues to generate controversy concerns the nature of the psychological, computational, and neural mechanisms that support the visual recognition of objects such as faces and words. While some researchers claim that visual recognition is accomplished by category-specific modules dedicated to processing distinct object classes, other researchers have argued for a more distributed system with only partially specialized cortical regions. Considerable evidence from both functional neuroimaging and neuropsychology would seem to favour the modular view, and yet close examination of those data reveals rather graded patterns of specialization that support a more distributed account. This paper explores a theoretical middle ground in which the functional specialization of brain regions arises from general principles and constraints on neural representation and learning that operate throughout cortex but that nonetheless have distinct implications for different classes of stimuli. The account is supported by a computational simulation, in the form of an artificial neural network, that illustrates how cooperative and competitive interactions in the formation of neural representations for faces and words account for both their shared and distinctive properties. We set out a series of empirical predictions, which are also examined, and consider the further implications of this account.

Does acquisition of Greeble expertise in prosopagnosia rule out a domain-general deficit?

According to the expertise account of face specialization, a deficit that affects general expertise mechanisms should similarly impair the expert individuation of both faces and other visually homogeneous object classes. To test this possibility, we attempted to train a prosopagnosic patient, LR, to become a Greeble expert using the standard Greeble expertise-training paradigm (Gauthier & Tarr, 2002). Previous research demonstrated that LR's prosopagnosia was related to an inability to simultaneously use multiple features in a speeded face recognition task (Bukach, Bub, Gauthier, & Tarr, 2006). We hypothesized that LR's inability to use multiple face features would manifest in his acquisition of Greeble expertise, even though his basic object recognition is unimpaired according to standard neuropsychological testing. Although LR was eventually able to reach expertise criterion, he took many more training sessions than controls, suggesting use of an abnormal strategy. To further explore LR's Greeble processing strategies, we assessed his ability to use multiple Greeble features both before and after Greeble training. LR's performance in two versions of this task demonstrates that, even after training, he relies heavily on a single feature to identify Greebles. This correspondence between LR's face recognition and post-training Greeble recognition supports the idea that impaired face recognition is simply the most visible symptom of a more general object recognition impairment in acquired prosopagnosia.

Deficits in face perception in the amnestic form of mild cognitive impairment

The fusiform gyrus is involved pathologically at an early stage of the amnestic form of mild cognitive impairment (aMCI), and is also known to be involved in the perceptual stage of face processing. We assessed face perception in patients with aMCI to determine if this cognitive skill was impaired. We compared 12 individuals (4 men) with aMCI and 12 age- and education-matched healthy controls on the ability to discriminate changes in the spatial configuration or color of the eyes or the mouth in faces. Patients with aMCI performed less quickly and accurately for all changes on trials with limited viewing duration. With unlimited duration, they could achieve normal perceptual accuracy for configural changes to the mouth, but remained impaired for changes to eye color or configuration. Patients with aMCI show deficits in face perception that are more pronounced for the highly salient ocular region, a pattern similar to that seen in acquired prosopagnosia. This form of perceptual impairment may be an early marker of additional cognitive deficits beyond memory in aMCI.

Impaired holistic processing in congenital prosopagnosia

It has long been argued that face processing requires disproportionate reliance on holistic or configural processing, relative to that required for non-face object recognition, and that a disruption of such holistic processing may be causally implicated in prosopagnosia. Previously, we demonstrated that individuals with congenital prosopagnosia (CP) did not show the normal face inversion effect (better performance for upright compared to inverted faces) and evinced a local (rather than the normal global) bias in a compound letter global/local (GL) task, supporting the claim of disrupted holistic processing in prosopagnosia. Here, we investigate further the nature of holistic processing impairments in CP, first by confirming, in a large sample of CP individuals, the absence of the normal face inversion effect and the presence of the local bias on the GL task, and, second, by employing the composite face paradigm, often regarded as the gold standard for measuring holistic face processing. In this last task, we show that, in contrast with controls, the CP group perform equivalently with aligned and misaligned faces and was impervious to (the normal) interference from the task-irrelevant bottom part of faces. Interestingly, the extent of the local bias evident in the composite task is correlated with the abnormality of performance on diagnostic face processing tasks. Furthermore, there is a significant correlation between the magnitude of the local bias in the GL and performance on the composite task. These results provide further evidence for impaired holistic processing in CP and, moreover, corroborate the critical role of this type of processing for intact face recognition.

Recognizing famous people

In daily life, face identification requires that the observer select a single representation from hundreds if not thousands in memory. This breadth of choice is nearly impossible to replicate in the laboratory using newly learned faces, especially in the context of a Bubbles experiment (Gosselin & Schyns, 2001). In this study, we obviated this concern by studying the performance of observers in a face-naming task using 210 faces of celebrities. On each trial, we presented a face randomly sampled with Bubbles. We performed least-square multiple linear regressions on the location of the samples and on accuracy to pinpoint the facial features that were used effectively in this task. Correct face identification relied primarily on the eye areas in spatial frequency bands ranging from 4.37 to 70 cycles per face (cpf) and on the mouth and the nose in a spatial frequency band ranging from 8.75 to 17.5 cpf. A comparison with other studies (Caldara et al., 2005; Schyns, Bonnar, & Gosselin, 2002) in which Bubbles was used with a set of 10 newly learned faces revealed that although the eye areas were useful across studies, the mouth area and higher spatial frequencies gained in importance when few newly learned faces were used.

Holistic perception of the individual face is specific and necessary: evidence from an extensive case study of acquired prosopagnosia

We present an extensive investigation (24 experiments) of a new case of prosopagnosia following right unilateral damage, GG, with the aim of addressing two classical issues: (1) Can a visual recognition impairment truly be specific to faces? (2) What is the nature of acquired prosopagnosia? We show that GG recognizes nonface objects perfectly and quickly, even when it requires fine-grained analysis to individualize these objects. He is also capable of perceiving objects and faces as integrated wholes, as indicated by normal Navon effect, 3D-figures perception and perception of Mooney and Arcimboldo face stimuli. However, the patient could not perceive individual faces holistically, showing no inversion, composite, or whole-part advantage effects for faces. We conclude that an occipito-temporal right hemisphere lesion may lead to a specific impairment of holistic perception of individual items, a function that appears critical for normal face recognition but not for object recognition.

Specific impairment of face-processing abilities in children with autism spectrum disorder using the Let's Face It! skills battery

Although it has been well established that individuals with autism exhibit difficulties in their face recognition abilities, it has been debated whether this deficit reflects a category-specific impairment of faces or a general perceptual bias toward the local-level information in a stimulus. In this study, the Let's Face It! Skills Battery [Tanaka & Schultz, 2008] of developmental face- and object-processing measures was administered to a large sample of children diagnosed with autism spectrum disorder (ASD) and typically developing children. The main finding was that when matched for age and IQ, individuals with ASD were selectively impaired in their ability to recognize faces across changes in orientation, expression and featural information. In a face discrimination task, ASD participants showed a preserved ability to discriminate featural and configural information in the mouth region of a face, but were compromised in their ability to discriminate featural and configural information in the eyes. On object-processing tasks, ASD participants demonstrated a normal ability to recognize automobiles across changes in orientation and a superior ability to discriminate featural and configural information in houses. These findings indicate that the face-processing deficits in ASD are not due to a local-processing bias, but reflect a category-specific impairment of faces characterized by a failure to form view-invariant face representations and discriminate information in the eye region of the face.

Infants' Processing of Featural and Configural Information in the Upper and Lower Halves of the Face

Three- to 4-month-old and 6- to 7-month-old infants were administered an infant version of the Face Dimensions Test that has been used with adults (e.g., Bukach, Le Grand, Kaiser, Bub, & Tanaka, 2008). Infants were familiarized with a photograph of a woman's face and then tested with the familiar face paired with a face differing in the (a) distance separating the eyes (a configural/eyes change), (b) distance between the nose and mouth (configural/mouth change), (c) size of the eyes (featural/eyes change), and (d) size of the mouth (featural/mouth change). Infants were shown to be more sensitive to (a) configural than featural change, and (b) change around the eyes versus the mouth. Implications for the development of face processing are discussed.