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

The similar eye movement dysfunction between major depressive disorder, bipolar depression and bipolar mania

OBJECTIVE

To find eye movement characteristics in patients with affective disorders.

METHOD

The demographic and clinical evaluation data of patients with major depressive disorder (MDD), bipolar disorder (BPD), and healthy control (HC) were collected. EyeLink 1000 eye tracker was used to collect eye movement data. Chi-squared test and independent sample t-test were used for demographics and clinical characteristics. The Mann-Whitney U-test was used to compare the eye movement variables among four groups, and the FDR method was used for multiple comparison correction. Pearson correlation analysis was used to analyse the relationship between clinical symptoms and eye movement variables.

RESULTS

Patients with affective disorders showed smaller saccade amplitude under free-viewing task, more fixations and saccades, shorter fixation duration, longer saccade duration under fixation stability and smooth pursuit tasks (all, p < 0.05) when compared to HC, but there was no significant difference in all eye movement variables among patients in the three groups. Also, all eye movement variables under the three paradigms had no significant correlation with clinical scale scores.

CONCLUSION

Patients with major depression, bipolar depression and bipolar mania share similar eye movement dysfunction under free-viewing, fixation stability and smooth pursuit tasks.

An opportunity for primary prevention research in psychotic disorders

An opportunity has opened for research into primary prevention of psychotic disorders, based on progress in endophenotypes, genetics, and genomics. Primary prevention requires reliable prediction of susceptibility before any symptoms are present. We studied a battery of measures where published data supports abnormalities of these measurements prior to appearance of initial psychosis symptoms. These neurobiological and behavioral measurements included cognition, eye movement tracking, Event Related Potentials, and polygenic risk scores. They generated an acceptably precise separation of healthy controls from outpatients with a psychotic disorder. METHODS: The Bipolar and Schizophrenia Network on Intermediate Phenotypes (B-SNIP) measured this battery in an ancestry-diverse series of consecutively recruited adult outpatients with a psychotic disorder and healthy controls. Participants include all genders, 16 to 50 years of age, 261 with psychotic disorders (Schizophrenia (SZ) 109, Bipolar with psychosis (BPP) 92, Schizoaffective disorder (SAD) 60), 110 healthy controls. Logistic Regression, and an extension of the Linear Mixed Model to include analysis of pairwise interactions between measures (Environmental kernel Relationship Matrices (ERM)) with multiple iterations, were performed to predict case-control status. Each regression analysis was validated with four-fold cross-validation. RESULTS AND CONCLUSIONS: Sensitivity, specificity, and Area Under the Curve of Receiver Operating Characteristic of 85%, 62%, and 86%, respectively, were obtained for both analytic methods. These prediction metrics demonstrate a promising diagnostic distinction based on premorbid risk variables. There were also statistically significant pairwise interactions between measures in the ERM model. The strong prediction metrics of both types of analytic model provide proof-of-principle for biologically-based laboratory tests as a first step toward primary prevention studies. Prospective studies of adolescents at elevated risk, vs. healthy adolescent controls, would be a next step toward development of primary prevention strategies.

Positive and Negative Symptoms Are Associated with Distinct Effects on Predictive Saccades

The predictive saccade task is a motor learning paradigm requiring saccades to track a visual target moving in a predictable pattern. Previous research has explored extensively anti-saccade deficits observed across psychosis, but less is known about predictive saccade-related mechanisms. The dataset analysed came from the studies of Crawford et al, published in 1995, where neuroleptically medicated schizophrenia and bipolar affective disorder patients were compared with non-medicated patients and control participants using a predictive saccade paradigm. The participant groups consisted of medicated schizophrenia patients (n = 40), non-medicated schizophrenia patients (n = 18), medicated bipolar disorder patients (n = 14), non-medicated bipolar disorder patients (n = 18), and controls (n = 31). The current analyses explore relationships between predictive saccades and symptomatology, and the potential interaction of medication. Analyses revealed that the schizophrenia and bipolar disorder diagnostic categories are indistinguishable in patterns of predictive control across several saccadic parameters, supporting a dimensional hypothesis. Once collapsed into predominantly high-/low- negative/positive symptoms, regardless of diagnosis, differences were revealed, with significant hypometria and lower gain in those with more negative symptoms. This illustrates how the presentation of the deficits is homogeneous across diagnosis, but heterogeneous when surveyed by symptomatology; attesting that a diagnostic label is less informative than symptomatology when exploring predictive saccades.

Deficits in generalized cognitive ability, visual sensorimotor function, and inhibitory control represent discrete domains of neurobehavioral deficit in psychotic disorders

Psychotic disorders are characterized by impaired cognition, yet some reports indicate specific deficits extend beyond reduced general cognitive ability. This study utilized exploratory and confirmatory factor analytic methods to evaluate the latent structure of a broad neurocognitive battery used in the Bipolar-Schizophrenia Network of Intermediate Phenotypes (B-SNIP) study, which included neuropsychological and neurophysiological measures in psychotic disorder probands and their unaffected first-degree relatives. Findings indicate that the factor structure of data from this set of assessments is more complex than the unitary factor of global cognitive ability underlying the Brief Assessment of Cognition in Schizophrenia (BACS). In addition to assessing generalized cognitive ability, two other factors were identified: visual sensorimotor function and inhibitory behavioral control. This complex cognitive architecture, derived in controls, generalized to patients across the psychosis spectrum and to their unaffected relatives. These findings highlight the need for a more differentiated assessment of neurobehavioral functions in studies designed to test for diagnostically specific biomarkers, endophenotypes for gene discovery and beneficial effects of therapeutics on cognitive function.

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.

Smooth pursuit eye movement deficits as a biomarker for psychotic features in bipolar disorder-Findings from the PARDIP study

OBJECTIVES

Smooth pursuit eye movement deficits are an established psychosis biomarker across schizophrenia, schizoaffective and psychotic bipolar disorder (BPwP). Whether smooth pursuit deficits are also seen in bipolar disorder without psychosis (BPwoP) is unclear. Here we present data from the Psychosis and Affective Research Domains and Intermediate Phenotypes (PARDIP) study comparing bipolar patients with and without psychotic features.

METHODS

Probands with BPwP (N = 49) and BPwoP (N = 36), and healthy controls (HC, N = 71) performed eye tracking tasks designed to evaluate specific sensorimotor components relevant for pursuit initiation and pursuit maintenance.

RESULTS

While BPwoP did not differ from either BPwP or HC on initial eye acceleration, they performed significantly better than BPwP on early (P < .01) and predictive (P = .02) pursuit maintenance measures, both without differing from HC. BPwP were impaired compared to HC on initial eye acceleration, and on early and predictive pursuit maintenance (all P < .01). In contrast to the three pursuit measures, BPwP and BPwoP were both impaired on general neurocognitive assessments in relation to HC (both P < .001), without a significant difference between the two bipolar patient groups.

CONCLUSIONS

Our findings support the model that impairments of sensorimotor and cognitive processing as required for early and later predictive smooth pursuit maintenance are relatively specific to those bipolar patients with a history of psychosis. This suggests that the neural circuitry for developing feed-forward predictive models for accurate pursuit maintenance is associated with the occurrence of psychotic features in bipolar patients. In contrast, generalized neuropsychological impairments did not differentiate the two bipolar patient groups.

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.

Genome-wide association studies of smooth pursuit and antisaccade eye movements in psychotic disorders: findings from the B-SNIP study

Eye movement deviations, particularly deficits of initial sensorimotor processing and sustained pursuit maintenance, and antisaccade inhibition errors, are established intermediate phenotypes for psychotic disorders. We here studied eye movement measures of 849 participants from the Bipolar-Schizophrenia Network on Intermediate Phenotypes (B-SNIP) study (schizophrenia N=230, schizoaffective disorder N=155, psychotic bipolar disorder N=206 and healthy controls N=258) as quantitative phenotypes in relation to genetic data, while controlling for genetically derived ancestry measures, age and sex. A mixed-modeling genome-wide association studies approach was used including ~4.4 million genotypes (PsychChip and 1000 Genomes imputation). Across participants, sensorimotor processing at pursuit initiation was significantly associated with a single nucleotide polymorphism in IPO8 (12p11.21, P=8 × 10-11), whereas suggestive associations with sustained pursuit maintenance were identified with SNPs in SH3GL2 (9p22.2, P=3 × 10-8). In participants of predominantly African ancestry, sensorimotor processing was also significantly associated with SNPs in PCDH12 (5q31.3, P=1.6 × 10-10), and suggestive associations were observed with NRSN1 (6p22.3, P=5.4 × 10-8) and LMO7 (13q22.2, P=7.3x10-8), whereas antisaccade error rate was significantly associated with a non-coding region at chromosome 7 (P=6.5 × 10-9). Exploratory pathway analyses revealed associations with nervous system development and function for 40 top genes with sensorimotor processing and pursuit maintenance (P=4.9 × 10-2-9.8 × 10-4). Our findings suggest novel patterns of genetic variation relevant for brain systems subserving eye movement control known to be impaired in psychotic disorders. They include genes involved in nuclear trafficking and gene silencing (IPO8), fast axonal guidance and synaptic specificity (PCDH12), transduction of nerve signals (NRSN1), retinal degeneration (LMO7), synaptic glutamate release (SH3GL2), and broader nervous system development and function.

Eye Movement in Unipolar and Bipolar Depression: A Systematic Review of the Literature

BACKGROUND

The analysis of eye movements (EM) by eye-tracking has been carried out for several decades to investigate mood regulation, emotional information processing, and psychomotor disturbances in depressive disorders.

METHOD

A systematic review of all English language PubMed articles using the terms "saccadic eye movements" OR "eye-tracking" AND "depression" OR "bipolar disorders" was conducted using PRISMA guidelines. The aim of this review was to characterize the specific alterations of EM in unipolar and bipolar depression.

RESULTS

Findings regarding psychomotor disturbance showed an increase in reaction time in prosaccade and antisaccade tasks in both unipolar and bipolar disorders. In both disorders, patients have been reported to have an attraction for negative emotions, especially for negative pictures in unipolar and threatening images in bipolar disorder. However, the pattern could change with aging, elderly unipolar patients disengaging key features of sad and neutral stimuli. METHODological limitations generally include small sample sizes with mixed unipolar and bipolar depressed patients.

CONCLUSION

Eye movement analysis can be used to discriminate patients with depressive disorders from controls, as well as patients with bipolar disorder from patients with unipolar depression. General knowledge concerning psychomotor alterations and affective regulation strategies associated with each disorder can also be gained thanks to the analysis. Future directions for research on eye movement and depression are proposed in this review.

Association of variants in DRD2 and GRM3 with motor and cognitive function in first-episode psychosis

Similar smooth pursuit eye tracking dysfunctions are present across psychotic disorders. They include pursuit initiation and maintenance deficits that implicate different functional brain systems. This candidate gene study examined psychosis-related genotypes regulating dopamine and glutamate neurotransmission in relation to these pursuit deficits. One hundred and thirty-eight untreated first-episode patients with a psychotic disorder were genotyped for four markers in DRD2 and four markers in GRM3. The magnitude of eye movement abnormality in patients was defined in relation to performance of matched healthy controls (N = 130). Eighty three patients were followed after 6 weeks of antipsychotic treatment. At baseline, patients with a -141C deletion in DRD2 rs1799732 had slower initiation eye velocity and longer pursuit latency than CC insertion carriers. Further, GRM3 rs274622_CC carriers had poorer pursuit maintenance than T-carriers. Antipsychotic treatment resulted in prolonged pursuit latency in DRD2 rs1799732_CC insertion carriers and a decline in pursuit maintenance in GRM3 rs6465084_GG carriers. The present study demonstrates for the first time that neurophysiological measures of motor and neurocognitive deficits in patients with psychotic disorders have different associations with genes regulating dopamine and glutamate systems, respectively. Alterations in striatal D2 receptor activity through the -141C Ins/Del polymorphism could contribute to pursuit initiation deficits in psychotic disorders. Alterations in GRM3 coding for the mGluR3 protein may impair pursuit maintenance by compromising higher perceptual and cognitive processes that depend on optimal glutamate signaling in corticocortical circuits. DRD2 and GRM3 genotypes also selectively modulated the severity of adverse motor and neurocognitive changes resulting from antipsychotic treatment.

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.

Effects of methylphenidate on basic and higher-order oculomotor functions

Eye movements are sensitive indicators of pharmacological effects on sensorimotor and cognitive processing. Methylphenidate (MPH) is one of the most prescribed medications in psychiatry. It is increasingly used as a cognitive enhancer by healthy individuals. However, little is known of its effect on healthy cognition. Here we used oculomotor tests to evaluate the effects of MPH on basic oculomotor and executive functions. Twenty-nine males were given 20mg of MPH orally in a double-blind placebo-controlled crossover design. Participants performed visually-guided saccades, sinusoidal smooth pursuit, predictive saccades and antisaccades one hour post-capsule administration. Heart rate and blood pressure were assessed prior to capsule administration, and again before and after task performance. Visually-guided saccade latency decreased with MPH (p<0.004). Smooth pursuit gain increased on MPH (p<0.001) and number of saccades during pursuit decreased (p<0.001). Proportion of predictive saccades increased on MPH (p<0.004), specifically in conditions with predictable timing. Peak velocity of predictive saccades increased with MPH (p<0.01). Antisaccade errors and latency were unaffected. Physiological variables were also unaffected. The effects on visually-guided saccade latency and peak velocity are consistent with MPH effects on dopamine in basal ganglia. The improvements in predictive saccade conditions and smooth pursuit suggest effects on timing functions.

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.

Abnormal visual motion processing in schizophrenia: a review of research progress

Motion processing represents a perceptual domain in which dynamic visual information is encoded to support the perception of movement. Research over the last decade has found a variety of abnormalities in the processing of motion information in schizophrenia. The abnormalities span from discrimination of basic motion features (such as speed) to integration of spatially distributed motion signals (such as coherent motion). Motion processing involves visual signals across space and time and thus presents a special opportunity to examine how spatial and temporal information is integrated in the visual system. This article surveys the behavioral and neuroimaging studies that probe into the spatial integration of motion information in schizophrenia. An emerging theme from these studies points to an imbalanced regulation of spatial interaction processes as a potential mechanism mediating different levels of abnormal motion processing in schizophrenia. The synthesis of these mechanism-driven studies suggests that further investigation of the neural basis and functional consequences of this abnormal motion processing are needed in order to render a basic biomarker for assessment and intervention of cognitive dysfunction in this mental disorder.

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.

Eye movement deficits in schizophrenia: investigation of a genetically homogenous Icelandic sample

BACKGROUND

Deficits in antisaccade (AS) and smooth pursuit eye movements (SPEM) are promising endophenotypes in genetic studies of schizophrenia. The Icelandic population lends itself ideally to genetic studies due to its ethnic homogeneity and well-documented genealogy. The primary aim of this study was to assess AS and SPEM performance in a large Icelandic sample. Additional aims were to investigate the relationship between AS and SPEM task performance and to assess internal consistency, within-session performance changes and effects of SPEM target velocity on performance.

METHOD

Patients with schizophrenia (N = 118) and healthy controls (N = 109) matched for age and gender underwent infrared oculographic assessment of AS and SPEM (at target velocities of 12 degrees , 24 degrees and 36 degrees /s).

RESULTS

On the AS task patients displayed significantly more reflexive errors, longer latency, increased intra-individual latency variability, and reduced amplitude gain compared to controls. On the SPEM task, patients had significantly lower velocity gain and more frequent saccades during pursuit at all velocities, but group differences in velocity gain increased with increasing target velocity. Internal consistency of performance was high for all variables in both groups (Cronbach's alpha >0.77 for AS and >0.85 for SPEM) except for AS spatial error in patients (alpha = 0.38). A moderate association was found between AS and SPEM performance. By and large, patients and controls showed similar patterns of systematic within-session performance changes.

CONCLUSIONS

Our findings confirm the existence of robust eye movement deficits in schizophrenia in a large sample. These measures may be studied as endophenotypes in future studies of potential schizophrenia risk genotypes in the genetically homogenous Icelandic population.

Cognitive task fulfilment may decrease gaze control performances

Human cognitive processing limits can lead to difficulties in performing two tasks simultaneously. In this respect, the mobilization of attentional resources seems to be more important in voluntary than in reflexive visuo-oculomotor movements. With this in mind, this study aimed to determine the differentiated effects of carrying out cognitive tasks on reflexive and voluntary movements generated by the visuo-oculomotor system. Eye movements were recorded with a videonystagmography system in 20 healthy adults. Prosaccade and antisaccade latency and accuracy were determined, as was the gain of regular smooth pursuit. The cognitive tasks comprised a backward counting task in steps of seven or thirteen and were carried out during the three oculomotor tasks. Whatever the backward counting, the cognitive tasks caused an increase in latency and a decrease in accuracy in the prosaccades and antisaccades as well as a drop in smooth pursuit gain. Despite a high degree of prosaccade, antisaccade and pursuit predictability, the oculomotor parameters were altered during dual-task fulfilment, and voluntary movements were more vulnerable than reflexive movements. Cognitive task achievement during oculomotor tasks requires greater attentional resource mobilization, and the reduction in visuo-oculomotor performance is even greater since the oculomotor task places more demand on the cognitive resources. Attention is thus a crucial cognitive process for the maintenance of adequate reflexive and voluntary oculomotor performance. Concurrently performing tasks have broader implications in motor coordination degradation understanding in situations like handheld phone when driving or in management of organisational and environmental constraints in occupational activities.

Low frequency rTMS over posterior parietal cortex impairs smooth pursuit eye tracking

The role of the posterior parietal cortex in smooth pursuit eye movements remains unclear. We used low frequency repetitive transcranial magnetic stimulation (rTMS) to study the cognitive and neural systems involved in the control of smooth pursuit eye movements. Eighteen participants were tested on two separate occasions. On each occasion we measured smooth pursuit eye tracking before and after 6 min of 1 Hz rTMS delivered at 90% of motor threshold. Low frequency rTMS over the posterior parietal cortex led to a significant reduction in smooth pursuit velocity gain, whereas rTMS over the motor cortex had no effect on gain. We conclude that low frequency offline rTMS is a potentially useful tool with which to explore the cortical systems involved in oculomotor control.

“Dark Nights of the Soul”: Phenomenology and Neurocognition of Spiritual Suffering in Mysticism and Psychosis

Phenomenological, clinical, and neurocognitive levels of analysis are combined to understand the cognitive bases of spirituality and spiritual suffering. In particular, the “dark night of the soul” in classical mysticism, with its painful “metapathological” loss of felt meaning is compared with the anhedonias central to the negative symptoms of schizophrenia and schizotypicality. Paul Schilder's early understanding of instabilities in the body image, as our core sense of self, offers a key to both the disorganized hallucinatory syndromes of psychosis and to the relative enhancements of body image/ecological self in spirituality. Expanded versus deleted felt presence/embodiment, as outwardly indexed in measures of physical balance and spatial abilities, becomes the general dimension underlying integrative versus disintegrative transformations of consciousness. “Dark night” suffering can be seen as a semantic satiation leading to a relative deletion of experienced presence in the context of its previous enhancement, a focalized version of the more general anhedonic despair shared by clinical schizotypy and aspects of a larger secularized culture.

Bipolar and schizophrenic patients differ in patterns of visual motion discrimination

BACKGROUND

Since Kraepelin's early distinction between bipolar disorder and schizophrenia, it has been assumed that these disorders represent two different pathophysiological processes, although they share many clinical symptoms. Previous studies showed that velocity discrimination, a sensitive psychophysiological measure of the visual motion system, is deficient in schizophrenia. Here we examined whether the motion processing impairment found in schizophrenia also occurs in bipolar disorder.

METHODS

We compared 16 bipolar patients, 25 schizophrenic patients, and 25 normal controls on a velocity discrimination task. We measured the psychophysical threshold for velocity discrimination and contrast detection (as a control task) in all subjects.

RESULTS

Bipolar patients showed normal velocity discrimination thresholds at intermediate velocities, the range in which velocity cues dominate velocity discrimination, and at low velocities. Schizophrenic patients, however, showed elevated velocity discrimination thresholds at intermediate and low velocities. At higher velocities, both bipolar and schizophrenic patients showed elevated thresholds. All subjects showed normal contrast detection thresholds.

CONCLUSIONS

Normal velocity discrimination in the intermediate range of velocity indicates unimpaired motion processing in bipolar disorder. The abnormal velocity discrimination of both schizophrenic and bipolar patients at higher velocities may reflect impaired temporal processing rather than impaired motion processing per se. These results suggest that the pathophysiological processes of bipolar disorder and schizophrenia diverge at the stage of visual motion processing, a sensory component mediated primarily in the extrastriate cortex.

The antisaccade task as a research tool in psychopathology: a critical review

The antisaccade task is a measure of volitional control of behavior sensitive to fronto-striatal dysfunction. Here we outline important issues concerning antisaccade methodology, consider recent evidence of the cognitive processes and neural mechanisms involved in task performance, and review how the task has been applied to study psychopathology. We conclude that the task yields reliable and sensitive measures of the processes involved in resolving the conflict between volitional and reflexive behavioral responses, a key cognitive deficit relevant to a number of neuropsychiatric conditions. Additionally, antisaccade deficits may reflect genetic liability for schizophrenia. Finally, the ease and accuracy with which the task can be administered, combined with its sensitivity to fronto-striatal dysfunction and the availability of suitable control conditions, may make it a useful benchmark tool for studies of potential cognitive enhancers.

Functional magnetic resonance imaging studies of eye movements in first episode schizophrenia: smooth pursuit, visually guided saccades and the oculomotor delayed response task

Schizophrenia patients show eye movement abnormalities that suggest dysfunction in neocortical control of the oculomotor system. Fifteen never-medicated, first episode schizophrenia patients and 24 matched healthy individuals performed eye movement tasks during functional magnetic resonance imaging studies. For both visually guided saccade and smooth pursuit paradigms, schizophrenia patients demonstrated reduced activation in sensorimotor areas supporting eye movement control, including the frontal eye fields, supplementary eye fields, and parietal and cingulate cortex. The same findings were observed for an oculomotor delayed response paradigm used to assess spatial working memory, during which schizophrenia patients also had reduced activity in dorsolateral prefrontal cortex. In contrast, only minimal group differences in activation were found during a manual motor task. These results suggest a system-level dysfunction of cortical sensorimotor regions supporting oculomotor function, as well as in areas of dorsolateral prefrontal cortex that support spatial working memory. These findings indicate that a generalized rather than localized pattern of neocortical dysfunction is present early in the course of schizophrenia and is related to deficits in the sensorimotor and cognitive control of eye movement activity.

Saccadic eye movement task identifies cognitive deficits in children with schizophrenia, but not in unaffected child relatives

BACKGROUND

The delayed oculomotor response (DOR) task requires response inhibition followed by movement of gaze towards a known spatial location without a current stimulus. Abnormalities in response inhibition and in the spatial accuracy of the eye movement are found in individuals with schizophrenia and in many of their relatives, supporting the use of these saccadic abnormalities as endophenotypes in genetic studies. It is unknown whether school-age children, either with psychosis or as relatives of a schizophrenic proband, can be included.

METHOD

One hundred eighty-seven children, ages 5.8-16.0 years - 45 children with childhood-onset schizophrenia, 64 children with a first-degree relative with schizophrenia, and 84 typically developing children - completed DOR tasks with 1 and 3 second delays.

RESULTS

Children with childhood-onset schizophrenia demonstrated impaired response inhibition and impaired spatial accuracy compared to both relatives and typicals; however, relatives and typicals did not differ from each other.

CONCLUSIONS

Children with childhood-onset schizophrenia have saccadic abnormalities similar to those found in adults with schizophrenia, supporting the continuity of executive function deficits in childhood-onset with adolescent and adult-onset schizophrenia. However, saccadic tasks are not sensitive to genetic risk in non-psychotic children and 6-15-year-old children should not be included in genetic studies utilizing this endophenotype.

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.

Antisaccade and smooth pursuit performance in positive- and negative-symptom schizotypy

Schizophrenic patients have well-documented abnormalities in smooth pursuit eye movements and antisaccade performance. In populations at risk for schizophrenia, smooth pursuit abnormalities are also well documented. Antisaccade deficits have been replicated in high-risk populations as well, but the findings are more variable and the reasons for the variability are not clear. Some evidence suggests that antisaccade deficits increase in high-risk populations in relation to the presence of positive symptoms. Whether antisaccade deficits increase in relation to negative symptoms in high-risk populations is relatively uninvestigated. We evaluated antisaccade and pursuit performance in "psychometric schizotypes" who had elevated scores on either the Perceptual Aberration Scale (PerAb; i.e., positive symptoms) or the Physical Anhedonia Scale (PhysAnh; i.e., negative symptoms) but not both, and in normal controls. We used the standard version of the antisaccade task, for which results in positive-symptom schizotypes have previously been reported, and investigated performance on a gap and overlap version. We replicated the finding that a significantly larger percentage of positive-symptom schizotypes than controls have elevated antisaccade error rates on the standard antisaccade task (P=0.03); the percentage of negative-symptom schizotypes with elevated antisaccade error rates did not differ from that of control subjects. Neither schizotypal group was impaired on the gap or overlap versions of the task. On the pursuit task, a higher percentage of positive- and negative-symptom schizotypes were classified as having deviant performance than control subjects (both Ps<0.04). These findings suggest that antisaccade deficits may be better at identifying high-risk subjects with positive symptoms. Pursuit deficits identified both positive- and negative-symptom schizotypes, but was better at identifying the latter.

Handedness in schizophrenia: a quantitative review of evidence

OBJECTIVE

The prevalence of various anomalous handedness subtypes in schizophrenia patients remains ambiguous. Although current literature favours the notion that the shift in lateral preferences seen is because of an increase of mixed-handedness, several studies suggest that exclusive left handedness is more prevalent than in the general population.

METHOD

Over 40 studies with reported prevalence data on various handedness subtypes in a schizophrenia population were evaluated by meta-analysis. Combined odds ratios for the three common handedness subtypes (left, mixed, and right) were separately calculated.

RESULTS

Each of the three atypical hand dominance patterns were significantly greater in schizophrenia patients than in control subjects, showing that the leftward shift in handedness distribution is not entirely because of an increase in mixed-handedness alone.

CONCLUSION

An increase of exclusive left-handedness is at variance with the prevailing assertion that the handedness shift in schizophrenia patients is because of a diffuse and bilateral hemispheric insult.

Visual motion integration in schizophrenia patients, their first-degree relatives, and patients with bipolar disorder

Many schizophrenia patients show degraded detection of coherent motion. This visual deficit may (1) be a consequence of having a specifically schizophrenic psychosis, (2) be a non-specific effect of suffering from a severe illness (i.e., "generalized deficit"), or (3) reflect properties of the visual motion processing system that play an antecedent, possibly causal role in the pathophysiology of a disposition to schizophrenia. To distinguish among these possibilities, we measured the accuracy of detecting the direction of coherent motion in 29 schizophrenia patients, 20 first-degree relatives of schizophrenia patients, 19 patients with bipolar disorder and 33 normal controls. The task requires the integration of dynamic signals from stochastic random dot patterns in order to discern the direction of their motion. Schizophrenia patients, as a group, showed significantly elevated thresholds for detecting the direction of coherent motion, but relatives of schizophrenia patients and patients with bipolar disorder did not differ from normal controls on this task. The results indicate that visual motion integration, normally mediated in motion-sensitive brain areas such as the Middle Temporal Area, is impaired in patients with a clinically manifest schizophrenic psychosis, but is intact in patients with a non-schizophrenic psychosis (bipolar disorder) and in the relatives of schizophrenia patients. Our findings suggest that deficiencies in integrating motion signals, while specific for schizophrenia, do not seem to be a co-familial trait.

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.

Effects of procyclidine on eye movements in schizophrenia

Smooth pursuit eye movement (SPEM) and antisaccade deficits are observed in the schizophrenia spectrum and have been used to study the pathophysiology as well as the genetic basis of this condition. The neurotransmitter acetylcholine has been implicated in a number of cognitive processes thought to underlie SPEM and antisaccade performance. This study investigates effects on eye movements of procyclidine, an anticholinergic drug often administered to schizophrenic patients. A total of 13 patients completed a double-blind placebo-controlled crossover design, receiving 15 mg procyclidine and placebo. Seven participants received procyclidine first and placebo second, six participants were tested in the reverse order. SPEM and antisaccade (as well as fixation and prosaccade) eye movements were recorded using infrared oculography. Results showed that procyclidine overall, relative to placebo, mildly worsened SPEM performance, as indicated by nonsignificantly reduced gain (p=0.08) and increased frequency of intrusive anticipatory saccades during pursuit (p=0.06). A significant interaction of group and order of administration indicated that procyclidine increased the rate of antisaccade reflexive errors only when administered first; the opposite pattern was observed when placebo was administered first, likely due to the operation of practice effects at second assessment. These findings indicate that acute administration of a clinically relevant dose of procyclidine leads to mild impairments in eye movement performance in schizophrenic patients, suggesting the need to consider this compound in oculomotor studies in schizophrenia. The action of this anticholinergic drug on oculomotor performance is consistent with the hypothesized role of the cholinergic system in the cognitive mechanisms of attention and working memory, processes thought to underlie SPEM and antisaccade performance. Effects of order of administration and practice on the antisaccade task suggest that these factors need to be taken into consideration in future pharmacological studies.

Effects of nicotine on leading saccades during smooth pursuit eye movements in smokers and nonsmokers with schizophrenia

Several studies have shown that schizophrenic patients and their biological relatives generate a greater number of leading saccades during smooth pursuit eye movement (SPEM) tasks. This abnormality may reflect a failure of cortical and/or cerebellar areas to coordinate saccadic and pursuit eye movements during visual tracking. The pharmacology of this phenomenon is not known. Here, we sought to replicate and extend the findings of Olincy et al (1998), who found that nicotine transiently reduced the number of leading saccades during SPEMs. A total of 27 subjects with schizophrenia (17 males; 14 smokers), and 25 healthy comparison subjects (nine males; 14 smokers) completed an eye-tracking task after receiving a 1.0 mg nasal spray of nicotine and during drug-free conditions. Results confirm that nicotine reduces the number of leading saccadic eye movements during visual tracking in schizophrenic patients. Baseline impairments and the beneficial effects of nicotine were not restricted to patient smokers, as nonsmoker patients exhibited the greatest number of leading saccades in the no drug condition and exhibited the most pronounced improvements after nicotine administration. Improvement in patient nonsmokers was not a function of previous smoking history. No effect of nicotine was observed in control nonsmokers. In contrast to the previous study, nicotine appeared to improve performance in control smokers. Overall, the study results support a functional role of nACh receptors in improving eye-tracking performance, and are consistent with the hypothesis, articulated by several investigators, that nACh receptor system abnormalities are responsible for a number of schizophrenia-related neurophysiological deficits.

Components of the smooth pursuit function in deficit and nondeficit schizophrenia

The diagnosis of schizophrenia likely encompasses a heterogeneous group of disorders, complicating the search for its causes. Studies of deficit schizophrenia represent an attempt to reduce this heterogeneity by identifying biologically distinct subgroups. Supplementing clinical phenotypes with biological markers of risk (e.g., eye-tracking and sensory-gating deficits) have also been used to reduce disease heterogeneity. In this study, we examined smooth pursuit eye movements in healthy controls (n = 37), and deficit (n = 18) and nondeficit (n = 32) patients with schizophrenia to determine what aspects of abnormal smooth pursuit are associated with the two patient groups, and which, if any, specifically mark the deficit phenotype. A small sample of relatives of deficit (n = 12) and nondeficit (n = 35) patients was also examined. Positive symptoms were equally present in deficit and nondeficit patients. Subtle, psychotic-like positive traits were also equally present in the relatives of both deficit and nondeficit probands, whereas negative symptoms were significantly more prevalent among the relatives of deficit probands. Deficits in predictive pursuit were present in both patient groups and both groups of relatives. Deficit patients showed significantly lower initiation acceleration. A similar pattern of results was seen in our pilot sample of relatives of deficit patients. These findings suggest that predictive smooth pursuit abnormality is associated with positive symptoms in schizophrenia, and that initiation abnormalities may be associated with the deficit syndrome.

Reliability of smooth pursuit, fixation, and saccadic eye movements

The present study investigated the reliability and susceptibility to practice effects of oculomotor tasks. Smooth pursuit, fixation, antisaccade, and prosaccade tasks were administered to 31 healthy participants to assess internal consistency (Cronbach's alpha) and within-session practice effects. Twenty-one of these participants were retested after an average interval of 57.86 days to assess temporal stability and between-session practice effects. Internal consistencies were high for most measures, with few within-session performance changes. Test-retest reliabilities of most measures were good. Between-session practice effects were most consistently observed on the antisaccade task, indicated by reduced error rate and improved spatial accuracy at retest. Magnitude of improvement on these measures was related to performance, indicating that poor performers benefited most from repeated assessment. These findings support the trait nature of oculomotor function and point to the need to take into consideration between-session practice effects on the antisaccade task in longitudinal studies.

Commentary: eye movement research with clinical populations

The preceding set of chapters span the disciplines of neurology and psychiatry, and provide a diverse introduction to clinical eye movement research. They illustrate how oculomotor paradigms can be used to learn about acute and chronic perturbations in brain function, disturbances in brain development, disturbances in sensorimotor as well as cognitive systems, and the effects of therapeutic and illicit drugs on brain function. This commentary discusses these contributions, provides an overview of broad methodological issues involved in applying eye movement studies to psychiatric populations using the antisaccade task as an exemplar, and considers the potential of collaborations between eye movement and brain imaging researchers to advance understanding of clinical eye movement abnormalities and of what they reveal about the organization of the oculomotor system.

Pursuit and saccadic eye movement subregions in human frontal eye field: a high-resolution fMRI investigation

Recent positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) studies in humans have localized the frontal eye field (FEF) to the precentral sulcus (PCS). In macaque monkeys, low-threshold microstimulation and single unit recording studies have located a saccadic subregion of FEF in a restricted area along the anterior wall of the arcuate sulcus and a pursuit subregion located deeper in the sulcus close to the fundus. The functional organization and anatomical location of these two FEF subregions are still to be defined in humans. In the present study, we used fMRI with high spatial resolution image acquisition at 3.0 Tesla to map the saccade- and pursuit-related areas of FEF within the two walls of the PCS in 11 subjects. We localized the saccade-related area to the upper portion of the anterior wall of the precentral sulcus and the pursuit-related area to a deeper region along the anterior wall, extending in some subjects to the fundus or deep posterior wall. These findings localize distinct pursuit and saccadic subregions of FEF in humans and demonstrate a high degree of homology in the organization of these FEF subregions in the human and the macaque monkey.

Saccadic and smooth-pursuit eye movements in deficit and non-deficit schizophrenia

We have analyzed eye movement performances in schizophrenics showing primary negative or deficit symptoms (n=16) and non-deficit schizophrenics (n=55), and compared them with those of controls (n=34) in order to study the relationships between negative symptoms and eye movement abnormalities. Patients were subtyped into deficit and non-deficit subgroups using the Schedule for the Deficit Syndrome. Three oculomotor paradigms were used: smooth pursuit, a reflexive saccade paradigm and an antisaccadic task. The smooth pursuit gain was significantly decreased (and the rate of catch-up saccades increased) in schizophrenics as compared with controls, but no difference was observed between patient groups. In the reflexive saccade paradigm, no difference was found between controls and patients, except for latency in deficit patients. In the antisaccade paradigm, the number of errors and the latency of successful antisaccades were significantly increased in schizophrenics as compared with controls. The latency of successful antisaccades in both directions was significantly increased in deficit patients as compared with non-deficit patients. The latency of rightward successful antisaccades was significantly increased as compared with the latency of leftward antisaccades in deficit patients only. However, when patients were classified into negative and non-negative groups using the PANSS, no difference was found in the antisaccade paradigm. Smooth pursuit impairment does not seem to depend on the primary enduring negative symptoms.In deficit schizophrenics, the abnormalities observed in the antisaccadic task are consistent with prefrontal dysfunction, and may suggest parietal lobe dysfunction as well.

Syndromes of schizophrenia and smooth-pursuit eye movement dysfunction

There have been a number of studies on smooth pursuit eye movement (SPEM) dysfunction in schizophrenia. However, the association between SPEM dysfunction and particular clinical symptoms remains unclear. We examined SPEM dysfunction in relation to schizophrenic symptoms using both the positive/negative dichotomy and the three-syndrome model. Subjects included 78 patients with schizophrenia and 60 healthy control subjects. SPEM performance was indexed by root mean square error. Symptom profiles were assessed using the Positive and Negative Syndrome Scale (PANSS), and the three-primary syndromes were identified by factor analysis of PANSS ratings (Psychomotor poverty: deficit negative symptoms; Disorganization: defined primarily by thought disorder; and Reality distortion: hallucinations and delusions). Compared with controls, the schizophrenia group showed significant impairment in global SPEM function. The three-syndrome approach produced more specific findings than the dichotomous model. Of the three syndromes, only the Disorganization dimension showed a significant association with increased global SPEM dysfunction. The specificity of SPEM dysfunction to Disorganization was verified in comparisons among schizophrenia subgroups and the control group. By contrast, the general domains of positive and negative symptoms were both found to be modestly associated with SPEM dysfunction. The separation of positive and negative symptoms that contribute to Disorganization from those that define Reality Distortion and Psychomotor Poverty has revealed significant new associations between SPEM and schizophrenic symptoms. These findings are interpreted in light of the proposal that the Disorganization syndrome is the central form of pathology in schizophrenia.

Eye movement dysfunction as a biological marker of risk for schizophrenia

OBJECTIVE

Our aim was to review smooth pursuit eye movement (SPEM) studies in schizophrenia and groups at high risk for schizophrenia, with a view to evaluating the utility of SPEM dysfunction as a biological marker of risk for schizophrenia.

METHOD

Smooth pursuit eye movement studies, related saccade function and the unresolved issues in this area of schizophrenia research were addressed. The different perspectives on the trait marker status of SPEM dysfunction, provided by both high-risk studies and related developmental research were considered. Attention was also given to the relationship between eye movement dysfunction and symptom profiles.

RESULTS

Converging evidence points to the robust and specific nature of SPEM dysfunction in schizophrenia, and highlights the role of frontal lobe and a related network dysfunction. The vast majority of 'high risk' studies support the view that SPEM dysfunction is also genetically specific to schizophrenia, and is not simply due to the overt expression of this illness. Studies assessing SPEM in relation to symptomatology show an association with the Disorganisation syndrome in particular.

CONCLUSIONS

Evidence for the specificity of SPEM dysfunction to diagnosed schizophrenia, as well as to healthy individuals with a genetic vulnerability to schizophrenia, suggests that the SPEM task has efficacy as a test of gene carrier status in schizophrenia, and therefore as a trait marker of risk for schizophrenia. Future studies should seek to explore the relationships between SPEM and other eye movement dysfunctions (antisaccades, express saccades), in view of evidence that some of these dysfunctions also show specificity for schizophrenia.

Defining the schizophrenia phenotype

Schizophrenia is a complex disease with multifactorial etiology. The schizophrenia phenotype has been traditionally defined by chronic psychosis and functional deterioration. However, the boundary of the phenotype is likely to be more extensive than the one defined by chronic psychosis. This is highlighted by the findings of subtle, schizophrenia- like deficits in the nonschizophrenic, first-degree relatives of schizophrenic patients. Subtle clinical signs and symptoms, cognitive impairment particularly in attention and memory, and neurophysiologic deficits such as in sensory gating and smooth-pursuit eye movements all define aspects of the schizophrenia phenotype.

Smooth pursuit eye movements in schizophrenia and attentional dysfunction: adults with schizophrenia, ADHD, and a normal comparison group

BACKGROUND

Smooth pursuit eye movement (SPEM) abnormalities are found in schizophrenia. These deficits often are explained in the context of the attentional and inhibitory deficits central to schizophrenia psychopathology. It remains unclear, however, whether these attention-associated eye movement abnormalities are specific to schizophrenia or are a nonspecific expression of attentional deficits found in many psychiatric disorders. Adult attention-deficit/hyperactivity disorder (ADHD) is an alternative disorder with chronic attentional and inhibitory dysfunction. Thus, a comparison of SPEM in adult schizophrenia and adult ADHD will help assess the specificity question.

METHODS

SPEM is recorded during a 16.7 degrees per second constant velocity task in 17 adults with ADHD, 49 adults with schizophrenia, and 37 normal adults; all groups included individuals between ages 25-50 years.

RESULTS

Smooth pursuit gain and the frequency of anticipatory and leading saccades are worse in schizophrenic subjects, with normal and ADHD subjects showing no differences on these variables.

CONCLUSIONS

Many attention-associated SPEM abnormalities are not present in most subjects with ADHD, supporting the specificity of these findings to the attentional deficits seen in schizophrenia.

Quantitative characterization of eye tracking dysfunction in schizophrenia

The purpose of this study was to characterize the nature of the processes that are involved in eye tracking dysfunction (ETD). We identified a combination of quantitative measures that best distinguished qualitatively normal eye tracking from qualitatively abnormal eye tracking, using discriminant analysis. Discriminant scores distinguished schizophrenics with ETD from both schizophrenics with normal eye tracking and normal controls, but did not distinguish schizophrenics with normal eye tracking from normal controls, underscoring the heterogeneity of schizophrenic patients with respect to eye tracking. The results of the discriminant analysis indicated that ETD is a multivariate process involving a primary impairment in the smooth pursuit system characterized by increased catch-up saccades and reduced gain, and, secondarily, disinhibition of intrusive saccades, especially square-wave jerks. Quantitative characterization of ETD makes it possible to consider eye tracking as a quantitative trait in genetic investigations of a multidimensional phenotype.

Subthreshold symptoms and vulnerability indicators (e.g., eye tracking dysfunction) in schizophrenia

Subthreshold symptoms in schizophrenia can be prodromal signs of a psychotic relapse. In people without schizophrenia, similar symptoms may indicate the presence of disorders termed schizophrenia spectrum disorders. Subthreshold schizophrenia-like symptoms may indicate a genetically transmitted higher proneness to schizophrenia. Such a higher liability to develop schizophrenia is ascertained on a symptom level. In genetic studies, asymptomatic members of a pedigree are therefore classified as unaffected although they may possess the genes in question. On a biological level, eye tracking dysfunction has been shown to fulfill certain criteria for a vulnerability indicator and therefore promises to offer more information on genetically transmitted proneness to schizophrenia even in people without psychopathological symptoms. Subthreshold symptoms may warrant treatment. The database for prophylactic treatment in populations at high risk, especially those without symptoms, is currently very small.