Eye tracking dysfunction in schizophrenia: characterization of component eye movement abnormalities, diagnostic specificity, and the role of attention

Towards Clinically Relevant Oculomotor Biomarkers in Early Schizophrenia

In recent years, psychiatric research has focused on the evaluation and implementation of biomarkers in the clinical praxis. Oculomotor function deviances are among the most consistent and replicable cognitive deficits in schizophrenia and have been suggested as viable candidates for biomarkers. In this narrative review, we focus on oculomotor function in first-episode psychosis, recent onset schizophrenia as well as individuals at high risk for developing psychosis. We critically discuss the evidence for the possible utilization of oculomotor function measures as diagnostic, susceptibility, predictive, monitoring, and prognostic biomarkers for these conditions. Based on the current state of research we conclude that there are not sufficient data to unequivocally support the use of oculomotor function measures as biomarkers in schizophrenia.

BIOMARKERS AND NEUROBEHAVIORAL DIAGNOSIS

Our current diagnostic methods for treatment planning in Psychiatry and Neurodevelopmental Disabilities leave room for improvement, and null results in clinical trials in these fields may be a result of insufficient tools for patient stratification. Great hope has been placed in novel technologies to improve clinical and trial outcomes, but we have yet to see a substantial change in clinical practice. As we examine attempts at biomarker validation within these fields, we find that it may be the diagnoses themselves that fall short. We now need to improve neuropsychiatric nosologies with a focus on validity based not solely on behavioral features, but on a synthesis that includes genetic and biological data as well. The eventual goal is diagnostic biomarkers and diagnoses themselves based on distinct mechanisms, but such an understanding of the causal relationship across levels of analysis is likely to be elusive for some time. Rather, we propose an approach in the near-term that deconstructs diagnosis into a series of independent, empiric and clinically relevant associations among a single, defined patient group, a single biomarker, a single intervention and a single clinical outcome. Incremental study across patient groups, interventions, outcomes and modalities will lead to a more interdigitated network of knowledge, and correlations in metrics across levels of analysis will eventually give way to the causal understanding that will allow for mechanistically based diagnoses.

The coordinate system of endogenous spatial attention during smooth pursuit

A central question in vision is whether spatial attention is represented in an eye-centered (retinotopic) or world-centered (spatiotopic) reference-frame. Most previous studies on this question focused on how coordinates are modulated across saccades. In the present study, we investigated the reference-frame of attention across smooth pursuit eye-movements using a goal-directed saccade task. In two experiments, participants were asked to pursue a moving target while attending to one or two grating stimuli. On each trial, one stimulus was constant in its retinal position and the other was constant in its spatial position. Upon detection of a slight change in stimulus orientation, participants were asked to stop pursuing and perform a fast saccade toward the modified stimulus. In the focused attention condition, they attended one, predefined, stimulus, and in the divided attention condition they attended both. In Experiment 1 the angle of the orientation change marking the target event was constant across participants and conditions. In Experiment 2, the angle was individually adapted to equate performance across participants and conditions. Findings of the two experiments were consistent and showed that the enhancement of mean visual sensitivity in the focused relative to the divided attention condition was similar in magnitude for both retinotopic and spatiotopic targets. This indicates that during smooth pursuit, endogenous attention was proportionally divided between targets in retinotopic and spatiotopic frames of reference.

Saccade reaction time asymmetries during task-switching in pursuit tracking

We investigate how smooth pursuit eye movements affect the latencies of task-switching saccades. Participants had to alternate their foveal vision between a continuous pursuit task in the display center and a discrete object discrimination task in the periphery. The pursuit task was either carried out by following the target with the eyes only (ocular) or by steering an on-screen cursor with a joystick (oculomanual). We measured participants' saccadic reaction times (SRTs) when foveal vision was shifted from the pursuit task to the discrimination task and back to the pursuit task. Our results show asymmetries in SRTs depending on the movement direction of the pursuit target: SRTs were generally shorter in the direction of pursuit. Specifically, SRTs from the pursuit target were shorter when the discrimination object appeared in the motion direction. SRTs to pursuit were shorter when the pursuit target moved away from the current fixation location. This result was independent of the type of smooth pursuit behavior that was performed by participants (ocular/oculomanual). The effects are discussed in regard to asymmetries in attention and processes that suppress saccades at the onset of pursuit.

Efference copy failure during smooth pursuit eye movements in schizophrenia

Abnormal smooth pursuit eye movements in patients with schizophrenia are often considered a consequence of impaired motion perception. Here we used a novel motion prediction task to assess the effects of abnormal pursuit on perception in human patients. Schizophrenia patients (n = 15) and healthy controls (n = 16) judged whether a briefly presented moving target ("ball") would hit/miss a stationary vertical line segment ("goal"). To relate prediction performance and pursuit directly, we manipulated eye movements: in half of the trials, observers smoothly tracked the ball; in the other half, they fixated on the goal. Strict quality criteria ensured that pursuit was initiated and that fixation was maintained. Controls were significantly better in trajectory prediction during pursuit than during fixation, their performance increased with presentation duration, and their pursuit gain and perceptual judgments were correlated. Such perceptual benefits during pursuit may be due to the use of extraretinal motion information estimated from an efference copy signal. With an overall lower performance in pursuit and perception, patients showed no such pursuit advantage and no correlation between pursuit gain and perception. Although patients' pursuit showed normal improvement with longer duration, their prediction performance failed to benefit from duration increases. This dissociation indicates relatively intact early visual motion processing, but a failure to use efference copy information. Impaired efference function in the sensory system may represent a general deficit in schizophrenia and thus contribute to symptoms and functional outcome impairments associated with the disorder.

"To see or not to see: that is the question." The "Protection-Against-Schizophrenia" (PaSZ) model: evidence from congenital blindness and visuo-cognitive aberrations

The causes of schizophrenia are still unknown. For the last 100 years, though, both “absent” and “perfect” vision have been associated with a lower risk for schizophrenia. Hence, vision itself and aberrations in visual functioning may be fundamental to the development and etiological explanations of the disorder. In this paper, we present the “Protection-Against-Schizophrenia” (PaSZ) model, which grades the risk for developing schizophrenia as a function of an individual's visual capacity. We review two vision perspectives: (1) “Absent” vision or how congenital blindness contributes to PaSZ and (2) “perfect” vision or how aberrations in visual functioning are associated with psychosis. First, we illustrate that, although congenitally blind and sighted individuals acquire similar world representations, blind individuals compensate for behavioral shortcomings through neurofunctional and multisensory reorganization. These reorganizations may indicate etiological explanations for their PaSZ. Second, we demonstrate that visuo-cognitive impairments are fundamental for the development of schizophrenia. Deteriorated visual information acquisition and processing contribute to higher-order cognitive dysfunctions and subsequently to schizophrenic symptoms. Finally, we provide different specific therapeutic recommendations for individuals who suffer from visual impairments (who never developed “normal” vision) and individuals who suffer from visual deterioration (who previously had “normal” visual skills). Rather than categorizing individuals as “normal” and “mentally disordered,” the PaSZ model uses a continuous scale to represent psychiatrically relevant human behavior. This not only provides a scientific basis for more fine-grained diagnostic assessments, earlier detection, and more appropriate therapeutic assignments, but it also outlines a trajectory for unraveling the causes of abnormal psychotic human self- and world-perception.

Psychosis in children: diagnosis and treatment

The diagnosis of childhood psychosis raises a host of unresolved problems, despite the Diagnostic and Statistical Manual Of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) giving identical symptoms and definitions for children, adolescents, and adults. The fantasy lives of children, and issues of developing language and cognition (including retardation), all impair diagnostic accuracy, particularly when differentiating between childhood-onset schizophrenia (COS) (≤12 years), bipolar affective disorder, major depressive disorder, and even obsessive-compulsive disorder and attention-deficit/hyperactivity disorder: the catch-all classification, psychosis not otherwise specified (PNOS), is always available for conundra that prove unsolvable. Typical if nonpathognomonic features include neurocognitive difficulties. Multiple screening instruments and specialized versions of semistructured diagnostic interviews are available. Although smooth-pursuit eye-tracking movements may prove a genetic marker for COS, etiologies are likely to be oligogenetic rather than related to a single gene. No specific biological markers or neuroimages have been identified. As such, psychoses may be indicative of a more general pattern of brain dysfunction. Drug treatments are largely based on the adult literature because of a dearth of controlled data below age 18. There are still no rigorous studies of psychosocial treatments and psychotherapy specific to childhood psychosis.

The biology of schizophrenia

Schizophrenia is an illness where the clinical signs and symptoms, course, and cognitive characteristics are well described. Successful pharmacological treatments do exist, even though they are likely palliative. However, this broad knowledge base has not yet led to the identification of its pathophysiology or etiology The risk factors for schizophrenia are most prominently genetic and scientists anticipate that contributions from the new genetic information in the human genome will help progress towards discovering a disease mechanism. Brain-imaging techniques have opened up the schizophrenic brain for direct inquiries, in terms of structure, neurochemisiry, and function. New proposals for diagnosis include grouping schizophrenia together with schizophrenia-related personality disorders into the same disease entity, and calling this schizophrenia spectrum disorder. New hypotheses of pathophysiology do not overlook dopamine as playing a major role, but do emphasize the participation of integrative neural systems in the expression of the illness and of the limbic system in generating symptoms. Critical observations for future discovery are likely to arise from molecular genetics, combined with hypothesis-generating experiments using brain imaging and human postmortem tissue.

Flexibility of foveal attention during ocular pursuit

Smooth pursuit of natural objects requires flexible allocation of attention to inspect features. However, it has been reported that attention is focused at the fovea during pursuit. We ask here if foveal attention is obligatory during pursuit, or if it can be disengaged. Observers tracked a stimulus composed of a central dot surrounded by four others and identified one of the dots when it dimmed. Extinguishing the center dot before the dimming improved task performance, suggesting that attention was released from it. To determine if the center dot automatically usurped attention, we provided the pursuit system with an alternative sensory signal by adding peripheral motion that moved with the stimulus. This also improved identification performance, evidence that a central target does not necessarily require attention during pursuit. Identification performance at the central dot also improved, suggesting that the spatial extent of the background did not attract attention to the periphery; instead, peripheral motion freed pursuit attention from the central dot, affording better identification performance. The results show that attention can be flexibly allocated during pursuit and imply that attention resources for pursuit of small and large objects come from different sources.

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

Background

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

Methods

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

Results

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

Conclusion

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

Differential activation patterns of occipital and prefrontal cortices during motion processing: evidence from normal and schizophrenic brains

Visual motion perception is normally mediated by neural processing in the posterior cortex. Focal damage to the middle temporal area (MT), a posterior extrastriate region, induces motion perception impairment. It is unclear, however, how more broadly distributed cortical dysfunction affects this visual behavior and its neural substrates. Schizophrenia manifests itself in a variety of behavioral and perceptual abnormalities that have proved difficult to understand through a dysfunction of any single brain system. One of these perceptual abnormalities involves impaired motion perception. Motion processing provides an opportunity to clarify the roles of multiple cortical networks in both healthy and schizophrenic brains. Using fMRI, we measured cortical activation while participants performed two visual motion tasks (direction discrimination and speed discrimination) and one nonmotion task (contrast discrimination). Normal controls showed robust cortical activation (BOLD signal changes) in MT during the direction and speed discrimination tasks, documenting primary processing of sensory input in this posterior region. In patients with schizophrenia, cortical activation was significantly reduced in MT and significantly increased in the inferior convexity of the prefrontal cortex, an area that is normally involved in higher level cognitive processing. This shift in cortical responses from posterior to prefrontal regions suggests that motion perception in schizophrenia is associated with both deficient sensory processing and compensatory cognitive processing. Furthermore, this result provides evidence that in the context of broadly distributed cortical dysfunction, the usual functional specificity of the cortex becomes modified, even across the domains of sensory and cognitive processing.

Effects of second-generation antipsychotic medication on smooth pursuit performance in antipsychotic-naive schizophrenia

CONTEXT

Analyses of smooth pursuit eye movement parameters in patients with schizophrenia provide information about the integrity of neural networks mediating motion perception, sensorimotor transformation, and cognitive processes such as prediction. Although pursuit eye tracking deficits have been widely reported in schizophrenia, the integrity of discrete components of pursuit responses and the effect of second-generation antipsychotic medication on them are not well established.

OBJECTIVE

To examine different components of smooth pursuit performance in antipsychotic-naive patients with schizophrenia before and after treatment with second-generation antipsychotic medication.

DESIGN, SETTING, AND PARTICIPANTS

Thirty-three antipsychotic-naive patients with schizophrenia performed 3 different smooth pursuit paradigms designed to evaluate specific components of the pursuit response. All of the patients were retested after 6 weeks of treatment with risperidone or olanzapine. Testing was also performed with 39 matched healthy individuals. Thirteen patients and 21 healthy participants were retested after 26 and 52 weeks.

MAIN OUTCOME MEASURES

Pursuit initiation, maintenance gain (ratio of eye velocity over target velocity), and frequency of catch-up saccades during pursuit maintenance.

RESULTS

Prior to treatment, pursuit gain when tracking less predictable ramp targets tended to be reduced, latency of pursuit initiation was speeded, and catch-up saccade frequency was increased during predictive pursuit. After antipsychotic treatment initiation, pursuit gain decreased with ramp targets, indicating treatment-emergent impairments in sensorimotor processing. No changes were observed for predictive pursuit. Exploratory analyses in the subgroup with follow-up to 1 year revealed that these effects continued through long-term follow-up with some partial normalization at 1 year. Deficits were unrelated to drug dosage and clinical ratings.

CONCLUSIONS

Impaired sensorimotor function was observed after initiation of second-generation antipsychotic medications, which may be explained by their serotonergic antagonism of brainstem sensorimotor systems. Predictive mechanisms supported by frontostriatal-cerebellar circuitry were not affected by treatment initiation and appear able to compensate for treatment-emergent sensorimotor impairments during predictive tracking.

Weakened center-surround interactions in visual motion processing in schizophrenia

Schizophrenia is often accompanied by a range of visual perception deficits, with many involving impairments in motion perception. The presence of perceptual abnormalities may impair neural processes that depend on normal visual analysis, which in turn may affect overall functioning in dynamic visual environments. Here, we examine the integrity of suppressive center-surround mechanisms in motion perception of schizophrenic patients. Center-surround suppression has been implicated in a range of visual functions, including figure-ground segregation and pursuit eye movements, visual functions that are impaired in schizophrenia. In control subjects, evidence of center-surround suppression is found in a reduced ability to perceive motion of a high-contrast stimulus as its size increases. This counterintuitive finding is likely a perceptual correlate of center-surround mechanisms in cortical area MT. We now show that schizophrenic patients exhibit abnormally weak center-surround suppression in motion, an abnormality that is most pronounced in patients with severe negative symptoms. Interestingly, patients with the weakest surround suppression outperformed control subjects in motion discriminations of large high-contrast stimuli. This enhanced motion perception of large high-contrast stimuli is consistent with an MT abnormality in schizophrenia and has a potential to disrupt smooth pursuit eye movements and other visual functions that depend on unimpaired center-surround interactions in motion.

Prepulse inhibition of the acoustic startle reflex and oculomotor control

Prepulse inhibition and the suppression of reflexive saccades on the antisaccade task are thought to tap inhibitory function. Reports of a lack of association between these measures suggest that they reflect different facets of inhibition. This study aimed to reexamine this relationship in a large sample and investigate the association of prepulse inhibition with oculomotor tasks that require inhibition of a reflexive saccade with lower concurrent processing demands than antisaccades, namely the oculomotor delayed response and fixation with distractors tasks. One hundred and seven healthy volunteers took part. Prepulse inhibition was uncorrelated with oculomotor performance. The error rate was highest for antisaccades, intermediate for the delayed response task, and lowest for fixation with distractors, and was correlated across tasks. These findings provide no evidence of a relationship between prepulse inhibition and oculomotor inhibition. Failure in suppressing reflexive saccades toward a peripheral target may represent a common inhibitory component underlying these oculomotor tasks.

Smooth-pursuit eye movement and directional motion-contrast sensitivity in schizophrenia

Although the occurrence of visual processing and eye-movement disorders in schizophrenia have been widely recognized, their relationship with the symptoms of schizophrenia is less well understood. In two experiments the relationship between directional-motion processing and smooth-pursuit eye movement was investigated in normal observers and in groups with positive and negative symptoms in schizophrenia. The first experiment measured linear smooth-pursuit eye movement at six target velocities from 5.0 to 30.0 degrees s(-1) and the second experiment measured directional motion-contrast sensitivity at three spatial (1.0, 4.0 and 8.0 c/deg) and five temporal (0.75, 3.0, 6.0, 12.0 and 18.0 Hz) frequencies in the same groups of observers. No significant differences were found between the control and positive-symptom group in directional motion-contrast sensitivity and smooth-pursuit eye movements. In comparison, a relationship was found between a significant reduction in directional motion-contrast sensitivity and significantly reduced smooth-pursuit eye movement in the negative-symptom group and serves to further cleave the distinction between positive and negative symptoms in schizophrenia. The relationship between visual motion processing and pursuit eye movement in the negative-symptom group was explained by a disorder in directional motion processing that fails to fully engage the pursuit eye movement system and reduces smooth pursuit eye-velocity gain.

The effects of dividing attention on smooth pursuit eye tracking

Attentional processes have traditionally been closely linked to the production of saccadic eye movements, but their role in the control of smooth pursuit eye movements remains unclear. In two experiments we used dual task paradigms to vary the attentional resources available for pursuit eye tracking. In both experiments we found that attentionally demanding secondary tasks impaired smooth pursuit performance, resulting in decreased velocity and increased position error. These findings suggest that attention is important for the maintenance of accurate smooth pursuit, and do not support the hypothesis that pursuit is a relatively automatic function that proceeds optimally in the absence of attentional control. These results add weight to the suggestion that a similar functional architecture underlies both pursuit and saccadic eye movements.

Saccades to moving targets in schizophrenia: evidence for normal posterior cortex functioning

People diagnosed with schizophrenia have abnormalities of smooth pursuit eye movement initiation that could be attributable to dysfunction of posterior cortical areas and/or the smooth pursuit regions of frontal cortex. To evaluate whether schizophrenia patients' pursuit initiation performance is most consistent with pre- or postrolandic neuropathology, 25 schizophrenia patients and 25 nonpsychiatric individuals were presented step-ramp stimuli moving either away from or toward the fovea. Schizophrenia and nonpsychiatric individuals did not differ on position error of saccades to moving targets, suggesting that the schizophrenia patients did not have general difficulty with motion perception. During the initial 100 ms of smooth pursuit, however, schizophrenia patients had significantly slower eye velocities than did nonpsychiatric individuals. These results suggest that schizophrenia patients' smooth pursuit abnormalities are not associated with neuropathology of posterior cortical areas.

Timing and amplitude of saccades during predictive saccadic tracking in schizophrenia

Schizophrenia patients have ocular motor abnormalities. It has been hypothesized that these abnormalities are associated with frontal eye field pathology. If so, schizophrenia patients should have difficulties decreasing saccadic reaction times in response to predictably moving targets. To evaluate the frontal eye field hypothesis, 25 schizophrenic and 26 nonpsychiatric subjects completed predictive saccadic tracking tasks. The groups demonstrated equivalent decreases in saccadic reaction times over consecutive trials. Schizophrenia patients, however, had faster reaction times and shorter amplitude saccades than nonpsychiatric subjects. The shorter amplitude saccades were made regardless of reaction time, perhaps an antipsychotic medication effect. The reaction time results are unlikely to be an effect of treatment with antipsychotic medication and are inconsistent with the hypothesis that schizophrenia patients have frontal eye field pathology.