Self-reported face recognition is highly valid, but alone is not highly discriminative of prosopagnosia-level performance on objective assessments

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.

Investigating people's metacognitive insight into their own face abilities

Within the domain of face processing, researchers have been interested in quantifying the relationship between objective (i.e., performance on laboratory tests of recognition and matching) and subjective measures of ability (typically, self-report questionnaires). Put simply, do people show high levels of metacognitive insight into their own abilities with faces? Although several studies have suggested that the association between these two types of measures may only be moderate, there remain several important issues that require consideration before this question can be sensibly investigated. First, specificity is needed regarding both objective and subjective measurements because both tend to span a wide range of potentially separable abilities. Second, experimental tasks appear to focus on different contexts to those tapped in self-report questionnaire items. Third, recent issues with statistical approaches and visualisation can result in numerical artefacts and misinterpretations. Finally, the sizes of population-level insights suggested by recent work provide only limited information regarding individuals within these populations, and so researchers aiming to identify people at the extremes of ability must be careful when drawing conclusions. Taken together, we argue that more attention to these issues is needed when attempting to investigate metacognitive insight within this domain.

Autistic adults have insight into their relative face recognition ability

The PI20 is a self-report questionnaire that assesses the presence of lifelong face recognition difficulties. The items on this scale ask respondents to assess their face recognition ability relative to the rest of the population, either explicitly or implicitly. Recent reports suggest that the PI20 scores of autistic participants exhibit little or no correlation with their performance on the Cambridge Face Memory Test-a key measure of face recognition ability. These reports are suggestive of a meta-cognitive deficit whereby autistic individuals are unable to infer whether their face recognition is impaired relative to the wider population. In the present study, however, we observed significant correlations between the PI20 scores of 77 autistic adults and their performance on two variants of the Cambridge Face Memory Test. These findings indicate that autistic individuals can infer whether their face recognition ability is impaired. Consistent with previous research, we observed a wide spread of face recognition abilities within our autistic sample. While some individuals approached ceiling levels of performance, others met the prevailing diagnostic criteria for developmental prosopagnosia. This variability showed little or no association with non-verbal intelligence, autism severity, or the presence of co-occurring alexithymia or ADHD.

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

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

The neuropsychological evaluation of face identity recognition

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

A new approach to diagnosing and researching developmental prosopagnosia: Excluded cases are impaired too

Developmental prosopagnosia is characterized by severe, lifelong difficulties when recognizing facial identity. Unfortunately, the most common diagnostic assessment (Cambridge Face Memory Test) misses 50-65% of individuals who believe that they have this condition. This results in such excluded cases' absence from scientific knowledge, effect sizes of impairment potentially overestimated, treatment efficacy underrated, and may elicit in them a negative experience of research. To estimate their symptomology and group-level impairments in face processing, we recruited a large cohort who believes that they have prosopagnosia. Matching prior reports, 56% did not meet criteria on the Cambridge Face Memory Test. However, the severity of their prosopagnosia symptoms and holistic perception deficits were comparable to those who did meet criteria. Excluded cases also exhibited face perception and memory impairments that were roughly one standard deviation below neurotypical norms, indicating the presence of objective problems. As the prosopagnosia index correctly classified virtually every case, we propose it should be the primary method for providing a diagnosis, prior to subtype categorization. We present researchers with a plan on how they can analyze these excluded prosopagnosia cases in their future work without negatively impacting their traditional findings. We anticipate such inclusion will enhance scientific knowledge, more accurately estimate effect sizes of impairments and treatments, and identify commonalities and distinctions between these different forms of prosopagnosia. Owing to their atypicalities in visual perception, we recommend that the prosopagnosia index should be used to screen out potential prosopagnosia cases from broader vision research.

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

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

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

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

The rise and fall of face recognition awareness across the life span

A core component of metacognition is cognitive awareness, insight into how one's cognitive abilities compare with others. Previous studies of cognitive awareness have focused on basic aspects of perception, memory, and learning. Further, studies of the awareness of one's social-cognitive abilities have been limited to examining awareness of others' thinking (i.e., theory of mind). The current study characterizes awareness of one's own social-cognitive abilities, specifically face recognition awareness, and examines its change across the life span. We used a large, web-based sample (N = 4,143) with a broad age range (ages 10-70), administering well-validated measures of objective (Cambridge Face Memory Test 3) and self-reported (Cambridge Face Memory Questionnaire) face recognition. We found a robust overall association between objective and self-reported face recognition (r = .42 in females, r = .36 in males). While we found that face recognition ability peaked in the early- to mid-30s, face recognition awareness peaked in the early- to mid-20s, was relatively stable throughout the 20s-40s, and declined in the 50s-60s. Relative subjective versus objective face recognition bias measures demonstrated that 10- to 18- and 51- to 70-year-olds overestimated their self-reported face recognition abilities in comparison with 19- to 50-year-olds. Finally, compared with males, females had greater face recognition awareness and a bias to relatively underestimate their face recognition abilities. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evaluating the Reliability and Validity of the Famous Faces Doppelgangers Test, a Novel Measure of Familiar Face Recognition

Face recognition assessments that use images of celebrities require not only face recognition ability but also pop-culture knowledge and successful recall of identifying information. Here, we introduce a task designed to measure face recognition more specifically: the Famous Faces Doppelgangers Test (FFDT). Participants (N = 57,407) identified 40 celebrities paired with lookalike doppelgangers, allowing face recognition ability to be assessed without requiring information recall. In addition, participants reported whether they were familiar with each celebrity, allowing poor face recognition ability to be differentiated from low pop-culture knowledge. FFDT performance was reliable (r_xx = .80), similar across participants of different racial and ethnic groups, and more highly correlated with memory for faces (r = .50) and self-reported face recognition ability (r = .48) than processing speed ability (r = .10). Thus, the FFDT is a reliable, valid, and specific measure of the ability to identify familiar faces, making it a promising new tool for assessing face recognition ability.

Is It Just Face Blindness? Exploring Developmental Comorbidity in Individuals with Self-Reported Developmental Prosopagnosia

Developmental prosopagnosia (DP)—or ‘face blindness’—refers to life-long problems with facial recognition in the absence of brain injury. We know that neurodevelopmental disorders tend to co-occur, and this study aims to explore if individuals with self-reported DP also report indications of other neurodevelopmental disorders, deficits, or conditions (developmental comorbidity). In total, 115 individuals with self-reported DP participated in this online cross-sectional survey. Face recognition impairment was measured with a validated self-report instrument. Indications of difficulties with navigation, math, reading, or spelling were measured with a tailored questionnaire using items from published sources. Additional diagnoses were measured with direct questions. We also included open-ended questions about cognitive strengths and difficulties. Results: Overall, 57% reported at minimum one developmental comorbidity of interest, with most reflecting specific cognitive impairment (e.g., in memory or object recognition) rather than diagnostic categories (e.g., ADHD, dyslexia). Interestingly, many participants reported cognitive skills or strengths within the same domains that others reported impairment, indicating a diverse pattern of cognitive strengths and difficulties in this sample. The frequency and diversity of self-reported developmental comorbidity suggests that face recognition could be important to consider in future investigations of neurodevelopmental comorbidity patterns.

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

Numerous neurological, developmental, and psychiatric conditions demonstrate impaired face recognition, which can be socially debilitating. These impairments can be caused by either deficient face perception or face memory mechanisms. Though there are well-validated, sensitive measures of face memory impairments, it currently remains unclear which assessments best measure face perception impairments. A sensitive, validated face perception measure could help with diagnosing causes of face recognition deficits and be useful in characterizing individual differences in unimpaired populations. Here, we compared the computerized Benton Face Recognition Test (BFRT-c) and Cambridge Face Perception Test (CFPT) in their ability to differentiate developmental prosopagnosics (DPs, N = 30) and age-matched controls (N = 30). Participants completed the BFRT-c, CFPT, and two additional face perception assessments: the University of Southern California Face Perception Test (USCFPT) and a novel same/different face matching test (SDFMT). Participants were also evaluated on objective and subjective face recognition tasks including the Cambridge Face Memory Test, famous faces test, and Prosopagnosia Index-20. We performed a logistic regression with the perception tests predicting DP vs. control group membership and used multiple linear regressions to predict continuous objective and subjective face recognition memory. Our results show that the BFRT-c performed as well as, if not better than, the CFPT, and that both tests clearly outperformed the USCFPT and SDFMT. Further, exploratory analyses revealed that face lighting-change conditions better predicted DP group membership and face recognition abilities than viewpoint-change conditions. Together, these results support the combined use of the BFRT-c and CFPT to best assess face perception impairments.

The Twenty Item Prosopagnosia Index (PI20) provides meaningful evidence of face recognition impairment

The Twenty Item Prosopagnosia Index (PI20) is a self-report questionnaire used for quantifying prosopagnosic traits. This scale is intended to help researchers identify cases of developmental prosopagnosia by providing standardized self-report evidence to complement diagnostic evidence obtained from objective computer-based tasks. In order to respond appropriately to items, prosopagnosics must have some insight that their face recognition is well below average, while non-prosopagnosics need to understand that their relative face recognition ability falls within the typical range. There has been considerable debate about whether participants have the necessary insight into their face recognition abilities to respond appropriately. In the present study, we sought to determine whether the PI20 provides meaningful evidence of face recognition impairment. In keeping with the intended use of the instrument, we used PI20 scores to identify two groups: high-PI20 scorers (those with self-reported face recognition difficulties) and low-PI20 scorers (those with no self-reported face recognition difficulties). We found that participant groups distinguished on the basis of PI20 scores clearly differed in terms of their mean performance on objective measures of face recognition ability. We also found that high-PI20 scorers were more likely to achieve levels of face recognition accuracy associated with developmental prosopagnosia.

Forgetting faces over a week: investigating self-reported face recognition ability and personality

Background

Although face recognition is now well studied, few researchers have considered the nature of forgetting over longer time periods. Here, I investigated how newly learned faces were recognised over the course of one week. In addition, I considered whether self-reported face recognition ability, as well as Big Five personality dimensions, were able to predict actual performance in a recognition task.

Methods

In this experiment (N = 570), faces were learned through short video interviews, and these identities were later presented in a recognition test (using previously unseen images) after no delay, six hours, twelve hours, one day, or seven days.

Results

The majority of forgetting took place within the first 24 hours, with no significant decrease after that timepoint. Further, self-reported face recognition abilities were moderately predictive of performance, while extraversion showed a small, negative association with performance. In both cases, these associations remained consistent across delay conditions.

Discussion

The current work begins to address important questions regarding face recognition using longitudinal, real-world time intervals, focussing on participant insight into their own abilities, and the process of forgetting more generally.

Associations between self-reported and objective face recognition abilities are only evident in above- and below-average recognisers

The 20-Item Prosopagnosia Items (PI-20) was recently introduced as a self-report measure of face recognition abilities and as an instrument to help the diagnosis of prosopagnosia. In general, studies using this questionnaire have shown that observers have moderate to strong insights into their face recognition abilities. However, it remains unknown whether these insights are equivalent for the whole range of face recognition abilities. The present study investigates this issue using the Mandarin version of the PI-20 and the Cambridge Face Memory Test Chinese (CFMT-Chinese). Our results showed a moderate negative association between the PI-20 and the CFMT-Chinese. However, this association was driven by people with low and high face recognition ability, but absent in people within the typical range of face recognition performance. The implications of these results for the study of individual differences and the diagnosis of prosopagnosia are discussed.

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.

Metacognition of average face perception

Individuals have the ability to extract summary statistics from multiple items presented simultaneously. However, it is unclear yet whether we have insight into the process of ensemble coding. The aim of this study was to investigate metacognition about average face perception. Participants saw a group of four faces presented for 2 s or 5 s, and then they were asked to judge whether the following test face was present in the previous set (Experiment 1), or whether the test face was the average of the four member faces (Experiment 2). After each response, participants rated their confidence. Replicating previous findings, there was substantial endorsement for the average face derived from the four member faces in Experiment 1, even though it was not present in the set. When judging faces that had been presented in the set, confidence correlated positively with accuracy, providing evidence for metacognitive awareness of previously studied faces. Importantly, there was a negative confidence-accuracy relationship for judging average faces when duration was 2 s, and a near-zero relationship when duration was 5 s. By contrast, when the average face had to be identified explicitly in Experiment 2, performance was above chance level and there was a positive correlation between confidence and accuracy. These results suggest that people have metacognitive awareness about average face perception when averaging is required explicitly, but they lack insight into the averaging process when member identification is required.

Diagnosing developmental prosopagnosia: repeat assessment using the Cambridge Face Memory Test

Developmental prosopagnosia (DP) is a cognitive condition characterized by a relatively selective impairment in face recognition. Currently, people are screened for DP via a single attempt at objective face-processing tests, usually all presented on the same day. However, several variables probably influence performance on these tests irrespective of actual ability, and the influence of repeat administration is also unknown. Here, we assess, for the first known time, the test-retest reliability of the Cambridge Face Memory Test (CFMT)-the leading task used worldwide to diagnose DP. This value was found to fall just below psychometric standards, and single-case analyses revealed further inconsistencies in performance that were not driven by testing location (online or in-person), nor the time-lapse between attempts. Later administration of an alternative version of the CFMT (the CFMT-Aus) was also found to be valuable in confirming borderline cases. Finally, we found that performance on the first 48 trials of the CFMT was equally as sensitive as the full 72-item score, suggesting that the instrument may be shortened for testing efficiency. We consider the implications of these findings for existing diagnostic protocols, concluding that two independent tasks of unfamiliar face memory should be completed on separate days.

People have modest, not good, insight into their face recognition ability: a comparison between self-report questionnaires

Whether people have insight into their face recognition ability has been intensely debated in recent studies using self-report measures. Although some studies showed people’s good insight, other studies found the opposite. The discrepancy might be caused by the difference in the questionnaire used and/or the bias induced using an extreme group such as suspected prosopagnosics. To resolve this issue, we examined the relationship between the two representative self-report face recognition questionnaires (Survey, N = 855) and then the extent to which the questionnaires differ in their relationship with face recognition performance (Experiment, N = 180) in normal populations, which do not include predetermined extreme groups. We found a very strong correlation (r = 0.82), a dominant principal component (explains > 90% of the variance), and comparable reliability between the questionnaires. Although these results suggest a strong common factor underlying them, the residual variance is not negligible (33%). Indeed, the follow-up experiment showed that both questionnaires have significant but moderate correlations with actual face recognition performance, and that the correlation was stronger for the Kennerknecht’s questionnaire (r =  − 0.38) than for the PI20 (r =  − 0.23). These findings not only suggest people’s modest insight into their face recognition ability, but also urge researchers and clinicians to carefully assess whether a questionnaire is suitable for estimating an individual’s face recognition ability.

Gender Differences in Familiar Face Recognition and the Influence of Sociocultural Gender Inequality

Are gender differences in face recognition influenced by familiarity and socio-cultural factors? Previous studies have reported gender differences in processing unfamiliar faces, consistently finding a female advantage and a female own-gender bias. However, researchers have recently highlighted that unfamiliar faces are processed less efficiently than familiar faces, which have more robust, invariant representations. To-date, no study has examined whether gender differences exist for familiar face recognition. The current study addressed this by using a famous faces task in a large, web-based sample of  > 2000 participants across different countries. We also sought to examine if differences varied by socio-cultural gender equality within countries. When examining raw accuracy as well when controlling for fame, the results demonstrated that there were no participant gender differences in overall famous face accuracy, in contrast to studies of unfamiliar faces. There was also a consistent own-gender bias in male but not female participants. In countries with low gender equality, including the USA, females showed significantly better recognition of famous female faces compared to male participants, whereas this difference was abolished in high gender equality countries. Together, this suggests that gender differences in recognizing unfamiliar faces can be attenuated when there is enough face learning and that sociocultural gender equality can drive gender differences in familiar face recognition.

Objective Patterns of Face Recognition Deficits in 165 Adults with Self-Reported Developmental Prosopagnosia

In the last 15 years, increasing numbers of individuals have self-referred to research laboratories in the belief that they experience severe everyday difficulties with face recognition. The condition “developmental prosopagnosia” (DP) is typically diagnosed when impairment is identified on at least two objective face-processing tests, usually involving assessments of face perception, unfamiliar face memory, and famous face recognition. While existing evidence suggests that some individuals may have a mnemonic form of prosopagnosia, it is also possible that other subtypes exist. The current study assessed 165 adults who believe they experience DP, and 38% of the sample were impaired on at least two of the tests outlined above. While statistical dissociations between face perception and face memory were only observed in four cases, a further 25% of the sample displayed dissociations between impaired famous face recognition and intact short-term unfamiliar face memory and face perception. We discuss whether this pattern of findings reflects (a) limitations within dominant diagnostic tests and protocols, (b) a less severe form of DP, or (c) a currently unrecognized but prevalent form of the condition that affects long-term face memory, familiar face recognition or semantic processing.

Progress in perceptual research: the case of prosopagnosia

Prosopagnosia is an impairment in the ability to recognize faces and can be acquired after a brain lesion or occur as a developmental variant. Studies of prosopagnosia make important contributions to our understanding of face processing and object recognition in the human visual system. We review four areas of advances in the study of this condition in recent years. First are issues surrounding the diagnosis of prosopagnosia, including the development and evaluation of newer tests and proposals for diagnostic criteria, especially for the developmental variant. Second are studies of the structural basis of prosopagnosia, including the application of more advanced neuroimaging techniques in studies of the developmental variant. Third are issues concerning the face specificity of the defect in prosopagnosia, namely whether other object processing is affected to some degree and in particular the status of visual word processing in light of recent predictions from the "many-to-many hypothesis". Finally, there have been recent rehabilitative trials of perceptual learning applied to larger groups of prosopagnosic subjects that show that face impairments are not immutable in this condition.