Psychiatry Research 178 (2010) 270–275

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Psychiatry Research
j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

Visual processing, social cognition and functional outcome in schizophrenia
Philip Brittain a,⁎, Dominic H. ffytche b, Allison McKendrick c, Simon Surguladze a

Affective Neuroscience Group, Section of Cognitive Neuropsychiatry, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London SE5 8AF, UK
Section of Old Age Psychiatry and Centre for Neuroimaging Sciences, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London SE5 8AF, UK
Department of Optometry & Vision Sciences, The University of Melbourne, Parkville, 3010, Australia

a r t i c l e

i n f o

Article history:
Received 16 July 2009
Received in revised form 8 September 2009
Accepted 22 September 2009
Contrast sensitivity
Visual masking
Global motion
Biological motion
Social perception
Functional status

a b s t r a c t
Visual processing deficits are well recognised in schizophrenia and have potentially important clinical
implications. First, the pattern of deficits for different visual tasks may help understand the underlying
pathophysiology of the visual dysfunction. Second, several studies report deficits correlating with functional
outcomes, suggesting that outcome improvement is possible through visual remediation strategies. We
investigated these issues in a group of 64 schizophrenia patients and matched controls with a battery of
visual tasks targeting different points along the visual pathways and by examining direct and indirect
relationships (via a potential mediator) of such deficits to functional outcome. The schizophrenia group was
significantly worse on the visual tasks overall, with the deficit constant for low- and high-level processing.
Zero-order correlations suggested minimal association between vision and outcome, however, correlations
between three visual tasks and ‘social perceptual’ ability were found which in turn correlated with functional
outcome; path analysis confirmed a significant but small and indirect effect of ‘biological motion’ processing
ability on functional outcome mediated by ‘social perception’. In conclusion, the pathophysiology of visual
dysfunction affects low- and high-level visual areas similarly and the relationship between deficits and
outcome is small and indirect.
© 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
A large body of research indicates that individuals with schizophrenia experience visual deficits (see Butler et al., 2005). The deficits
are found in relation to a variety of tasks, particularly those related to
the magnocellular/dorsal stream, a pathway from retina to visual
cortex and beyond linked to visual motion processing and conveying
signals related to low-spatial frequencies (large scale visual detail),
low contrast, and high temporal frequencies. The parvocellular/ventral system, which conveys color and high spatial frequency information, appears relatively spared. The deficits are of potential clinical
interest as they may provide clues as to the underlying pathophysiology of the visual dysfunction; different visual perceptual abilities
are resolved at varying points along the visual pathways so that the
overall pattern of deficits may point to particular cortical locations
and processes. Most previous studies have focussed on ‘low-level’
processing, i.e., those resolved early-on in the visual pathways,
although ‘higher-level’ visual deficits have also been reported,
revealing problems in cortical-level visual processing. Thus, deficits
have been found for abilities such as ‘luminance-flicker sensitivity’
(Slaghuis and Bishop, 2001) static ‘contrast sensitivity’ (Keri et al.,
2002) and ‘visual masking’ (Rassovsky et al., 2005) that involve early,

⁎ Corresponding author. Tel.: +44 207848 5228.
E-mail address: (P. Brittain).
0165-1781/$ – see front matter © 2009 Elsevier Ireland Ltd. All rights reserved.

low-level visual processing and higher-level deficits have been
reported for tasks such as ‘global motion’ (Chen et al., 2003), requiring
the integration of information across the visual field, and ‘biological
motion’, requiring the extraction of walking figure contours (Kim
et al., 2005). No studies, however, have examined a range of low- and
high-level tasks within the same subjects and testing session. If visual
deficits increase in magnitude from low- to high-levels of processing,
as has recently been suggested (Butler et al., 2005), this would point
to a mechanism affecting each level of the visual hierarchy or a lowlevel deficit amplified by transmission through the increasingly
specialised components of the visual pathways. Alternatively, if the
deficit remains constant across each level of the visual hierarchy, this
would suggest a mechanism primarily affecting the earlier stages of
A second potential area of clinical interest is the relation of visual
deficits to functional outcomes, with a number of studies reporting
significant correlations between these variables in schizophrenia. This
raises the possibility that perceptual training techniques may improve
the poor functional outcomes often seen in schizophrenia. However,
the potential of this approach is unclear, as the few reports available
disagree as to how strong the correlation might be. For example, Kim
et al. (2005) found that 50% of the variance in a functional outcome
measure was accounted for by perceptual ability (r = 0.71), Butler et al.
(2005) reported figures of between 14 and 25% (r = 0.37–0.50) and
Sergi et al. (2006) reported lower figures still of between <1% and 11%
(r = 0.03 to r = 0.33). Other studies have measured the relationship

at least partially. 2002b). two mixed). 1975).1. The orientation of the gap varies on each trial. visual masking (MASK. down.2. The luminance contrast of the figure against the background varies until threshold is approximated. although presented visually. we have studied the relationship between vision and functional outcome in schizophrenia and attempted to address the question of why previous studies have found varying strengths of association. Subjects gave written consent and were paid for their participation.86°/s.03° of visual angle from the fixation cross. This theory is based in part on the link between neurocognition and social cognition (Bozikas et al. 2002a) was used to check for lifetime presence of psychotic illness. 2.5 cycles/°. micro-expressions or subtle gestures. 120 Hz) and Half-PONS (HP. The variation in reported correlation strengths between visual processing and functional outcome might reflect the fact that different studies have probed different levels of the visual system. Here. The duration of the target was 12. in the patient group. Stimuli and procedure Tasks were presented on a 21 inch gamma corrected ViewSonic G220f monitor in a dimly lit room (10–12 lx). Contrast sensitivity (CS). A battery of visual tests probing different levels of the visual hierarchy was undertaken by a cohort of patients and control subjects together with measures of social perception and. biological motion (BM. Methods 2. 800 ⁎ 600. The figure subtended 5. 2.. and for the visual tasks was kept constant with a chin rest. Each target subtended 0. 100 Hz). given the previous evidence of this channels dysfunction in schizophrenia (Butler and Javitt. biological motion stimulus. The patient group were recruited from outpatient and longterm assisted living settings in South London.1. . Higher values indicated better sensitivity to contrast. The highest level of visual processing was assessed using a test of biological motion perception. defined with the Michelson contrast (Lmax − Lmin)/(Lmax + Lmin). 2) were those used by Green et al.1. social perception and social knowledge (Green et al. 1).2. right). 1998).27° of visual angle and was located 1. Visual tasks We focussed on tasks with sensitivity to magnocellular/dorsal stream function. 2004) and between social cognition and functional outcome (Penn et al. 160 Hz). global motion (GM. A ‘no-mask’ condition was randomly interspersed within the masking trials and the observed equal performance between groups suggested that attentional problems in the patient group would not account for any deficit on this task.1.6. an identifiable neurological condition and having bestcorrected visual acuity below 0. 12 trials were presented for each SOA and the four possible locations of the target were counterbalanced (an SOA of 0 where mask and target are displayed simultaneously was also presented but was not used in the analysis). this could be a path through which visual deficits impact on functional outcome in schizophrenia. thereby inflating the apparent strength of relation between vision and function. All tasks were viewed binocularly and were presented in a random order with the exception of the contrast sensitivity task which was performed during an initial visual acuity screening session. The Freiburg Contrast Test version 5. The psychotic screening subsection from the SCID Non-patient edition (First et al. Another explanation might be the effect of certain high-level visual tasks such as biological motion perception inadvertently tapping into another. 2007). One study thus far has found evidence for this causal chain (Sergi et al. Threshold is estimated with a ‘Best PEST’ (‘parameter estimation by sequential testing’) algorithm and an adaptive-staircase procedure. Percentage correct rates for each of the six backward and six forward making SOAs were averaged and used as the masking performance score. related to outcome. Global motion (GM).2. e. fourth edition (DSM-IV) diagnosis of schizophrenia and 65 control subjects were recruited.3. ‘social cognition’. Viewing distance for the MASK...7° of visual angle and the gap had an equivalent spatial frequency of 0. All but five of the patients were taking antipsychotic medication (50 atypical. The following resolutions and frame rates were applied: contrast sensitivity (CS. For each trial.. The monitor's mean luminance was 87. 1994). The experimental protocol was approved by the Institute of Psychiatry ethics committee.1 (Bach.e.. / Psychiatry Research 178 (2010) 270–275 between functional outcome and ‘visual’ measures within large-scale neurocognitive batteries. measured using the Freiburg Visual Acuity test (Bach. A percentage of the dots moved upwards or downwards (signal dots) at 2. Intermediate-level visual processing was examined using a test of global motion perception. The ‘stimulus onset asynchrony’ (SOA) is the time between the onset of the stimulus and the onset of the mask. 2007) was used to assess contrast detection thresholds. 1024 ⁎ 768. Second. 2002) and it seems plausible that if visual deficits produce a relative inability to pick up socially important visual cues. seven typical. as analysis revealed there was no differential performance between groups on the forward versus backward trials. Subjects gave their responses by speaking aloud and the test administrator entered responses on the computer. Twelve SOAs ranging from − 75 (forward masking) to 75 ms (backward masking) were presented in randomized fashion.2.5 cycles/° (Legge. A ‘Landolt C’ optotype is used where the gap of the ‘C’ can have one of four orientations (Fig. we have studied the pattern of visual deficits in individuals with schizophrenia compared to controls across different levels of visual processing in tasks which. lower left. The CS task was run from a Mac Tower. the subjects were asked to state the location of the target. 1. i. The ‘mask’ consisted of a 4 × 4 array of adjacent boxes (a 2 × 2 array in each quadrant) that appeared together in the same spatial locations as the target could appear.. a dorsal stream area (Ungerleider and Haxby. The ‘target’ was a square with a small gap in one of its sides (the gap was irrelevant for the version of the task used here). Fig. 1024 ⁎ 768. This produces a grey scale value called the ‘critical stimulus intensity’ at which all subjects can see the unmasked target on approximately 84% of trials. Higher values indicated better performance.5 ms and the duration of the mask was 25 ms. The stimulus was a 10° of visual angle circular area containing 100 moving dots.. 2.1. which was presented 400 ms before each target presentation for 300 ms. upper right. (2006) using a low-level visual masking paradigm found lower correlations. 800 ⁎ 600. Furthermore.5 min arc in diameter. The ‘contrast sensitivity’ result is the logarithmized inverse of the threshold contrast. functional outcome.7 cd/m2. unmeasured factor. target and mask were superimposed in one of the quadrants. Tests of low-level visual processing included contrast detection and visual masking. whilst the remaining dots (noise dots) moved in random 2. The GM and BM tasks were run from a Centrex PC through a VSG 2/5 graphics card. the ‘location’ masking task used here is thought to further increase magnocellular involvement (Cadenhead et al. 1024 ⁎ 768. 2005). Diagnosis was confirmed by their treating clinician. 2006). such studies tend to use tasks that. 85 Hz). All tasks were forced choice procedures and were preceded by a practise period. Illustration of ‘Landolt C’ figures used in contrast sensitivity testing. Furthermore. Visual masking (MASK). the degraded-stimulus continuous performance task. Subjects were required to name the orientation (up. Magnocellular neurons have lower contrast thresholds (Livingstone and Hubel. This might explain why studies such as Kim et al. lower right).e. recruit the magnocellular/dorsal stream. Control subjects with no self-reported history of psychiatric illness were recruited from the community. Some of these studies have reported significant correlations (Bowen et al. and has been proposed to act as an intermediary variable between several classes of neurocognition (including vision) and functional outcome (Brekke et al.. The square could appear in any one of four locations on the screen (upper left. First. Subjects Sixty-four persons with a Diagnostic and Statistical Manual of Mental Disorders.. Social cognition includes varied domains such as emotion perception. left. Potential control subjects were excluded if any of their first-degree relatives had a history of psychotic illness. Each dot was 8. Magnocellular neurons are sensitive to transient stimuli (Breitmeyer and Julesz. Exclusion criteria applied to both groups included: current drug or alcohol dependency. (2005) which used a high-level..1. 2005). (2002).P.2. BM and HP tasks was 100 cm. involve other processes such as ‘sustained attention’. 1988) and preferentially activate to low-spatial frequency stimuli below about 1. i.. GM.. 1975) and have short latencies (Breitmeyer. The masking procedures and stimuli (Fig. 1988). 1994) whilst others have not (Vauth et al. a reading or sensory disability. chart review and the psychotic symptoms subsection of the Structured Clinical Interview for DSM-IV (SCID) Patient Edition (First et al. There were 28 trials. 2.. Each section below initially details the aspect of the magnocellular/dorsal stream targeted by the visual task. 2004). 271 85 Hz). we set out to address the above issues. found a strong association whilst studies such as Sergi et al. 2005a). The CS task viewing distance was 200 cm and no chin rest was used. Global motion is determined in cortical area V5/MT (Newsome and Paré.g. Tasks probing low-level visual processing may be less directly linked to functional outcome than tasks probing higher levels. 2. The MASK and HP tasks were run from a Dell laptop. 1978).80 decimal. Brittain et al. The target's contrast was set for each subject with a thresholding procedure.2.

The figure moved at a velocity of 4. Different dots are chosen to be signal or noise on each frame in order to limit the availability of local motion cues. The mean percentage of signal dots at the last four reversals (two from each staircase) was taken as the global motion perception threshold. two or three of these social cues.24)⁎ (0/60/4) 13.2.95) 5. one of which was correct.18) – – – – – Decimal scale. The design was a three-alternative procedure whereby the subject responded that the figure moved to the left.36) 17. Three different screen shots are shown from left to right.61) 18. Each dot was 6. 3. which consists of the first 110 scenes of the Profile of Nonverbal Sensitivity (Rosenthal et al.79) 41. Age Gender Education in years Visual acuitya WASI IQ scoreb Handedness (L/R/Ambi) PANSSc Positive PANSS Negative CPZ equivalentd Illness duration in years Role Functioning Scale subscales and total Working productivity Independent living.0 = 6:6 acuity.70 (P < 0.5°/s.66 (1..26) 461. Fig. the number of randomly moving ‘noise dots’ in the next trial increased by used a Bootstrap approximation with 1000 iterations.76) 4. d Chlorpromazine dose equivalent (mg/day).41 (10. There was no significant difference in the number of ‘didn't see’ responses in the patient and control groups (P > 0.49) (0/62/3) – – – – 3. A 1-down. Each presentation lasted 3500 ms.22) 107. Fig. The four scores can be totalled to create a Global Role Functioning Index (GFI) with scores ranging from 4 to 28.14) 1. The two appear separately. down in this example) or move randomly. list-wise deletion would have resulted in omitting 16% of subjects. A z-score of − 1 indicates a decrease in performance equivalent to one standard deviation of the mean control groups scores on that task. Before each clip the subject was presented with a card detailing two possible answers (e. the direction of the signal dots (up or down) was chosen at random. Correct identification by the subject resulted in the signal strength being degraded by replacing signal dots with noise dots. 4) walking. Functional outcome rating scale (RFS) Functional outcome in the patient group only was assessed with the Role Functioning Scale (Goodman et al. 1979) was used to assess social perception. Dots (shown as arrows indicating their direction of movement) either move in a common direction (‘signal direction’ down or up. 2. although so close together in time that the presence of the mask disrupts the perception of the target. based on agreements with the ratings of an Institute of Psychiatry expert diagnostician. directions (Fig. a type of social cognition (Green et al. higher values indicated better performance. Subjects were required to name the direction of the signal dots.91 (15. To allow comparison between tasks.22) 101.90 (3. The initial number of dots was 50. The P-value required for classification of statistical significance was 0. 2005a). All patient z-scores are negative (indicating a deficit away from the control group). therefore missing values were replaced using an expectation–maximisation method.20 (3. self care Immediate social network relationships Extended social network relationships Global functioning index (GFI) a Patient group (N = 64) Control group (N = 65) 41.8 min arc in diameter.70 (5. Biological motion (BM).29 (9... Schematic illustration of a point-light walker. indirect (via another variable) and total (direct + indirect) affects of variables in the model together with their associated P-values and 95% confidence intervals. The mask (middle) is four composite squares made of four smaller squares.36 (5. Biological motion perception is dependent on ‘downstream’ areas of the dorsal stream.52 (4..89 (11. Social cognition–‘social perception’ (HP) The Half-Profile of Nonverbal Sensitivity (Ambady et al. This was transformed into a sensitivity measure with the formula: 1/threshold.272 P.1.. 1-up staircase procedure which terminated after four reversals. 1995).24) 4. Each scene contains either one.3. Path analysis with AMOS 7. data was converted into z-scores based on the means and standard deviations of the control group. or that the subject had not seen the figure.05). 12 signal dots moved in such a way as to represent a human body (Fig. b c .31 (0. ordering food in a restaurant or threatening someone). Three different levels of signal-to-noise ratio are shown here.05).11 (1. so that like the other visual tasks.05) M = 34 14. An array of randomly moving dots appeared within a 10° of visual angle square area. Higher values indicated better biological motion perception.05. 100% coherence (left). usually resulting in a ‘fused’ image (far right). Illustration of the visual masking task with fixation cross in the centre.8 (1. / Psychiatry Research 178 (2010) 270–275 Fig.4. A higher score indicates better functioning. the observer needs to integrate the motion cues across the movie sequence to determine the signal direction of motion and cannot determine it by tracking individual dots. This resulted in 2% of test data missing and for the analysis of variance (ANOVA) and path analysis.3. Table 1 Mean and standard deviation subject characteristics for the patient and control groups. If the response was incorrect or ‘didn't see’ the number of noise dots in the next trial decreased by 10. 4.g. 1993) which assesses functional status in four domains (see Table 1) on subscales ranging from 1 (severely impaired) to 7 (optimal) based on a semi-structured interview. Lines joining dots are for illustration only. Higher scores indicated better social perception. Statistical analysis Raw data was transformed where necessary to meet normality assumptions. 2.37 (13. 1-up staircase procedure was used and continued for 42 trials. Raters were trained on the RFS to meet minimum intraclass correlation coefficients for total ratings of 0. 3). Some subjects were unable to complete all of the battery for a variety of reasons including fatigue or the inability to reach a minimum threshold for the visual masking target. but may also be subserved by ventral stream components (Vaina et al. After 2000 ms. Schematic illustration of the global motion dot stimuli. 2. 1. 75% coherence (middle). either to the left or to the right.. reducing to 10 after the first reversal. When the ‘figure dots’ move the percept of a human walking is apparent.51) 14. to the right.57) M = 35 14. Brittain et al. The ratio of signal dots began at 100% and used a 3-down. An incorrect response increased the number of signal dots. The mean number of dots in trials 32–42 was used as the biological motion perception threshold.95 (381. ⁎ P < 0.14 (1. The ‘target’ (far left) is a square with a small gap in one of the sides. The initial step-size was 8% which halved after the first two reversals.05 unless stated otherwise.33 (0. All analysis was undertaken with these z-scores. Wechsler Abbreviated Scale of Intelligence (2 subtest version). Increasing numbers of moving distracter dots (middle and right) eventually make the human figure imperceptible. 50% coherence (right). Immediately afterwards the subject was required to choose which description best described the presented clip.18) 1. If the subject responded correctly.2. Positive and Negative Syndrome Scale. Pilot work indicated that this was a sufficient number of trials to reach a performance plateau. 2001). The ‘Half-PONS’ consists of a series of 2-s video clips containing the facial expressions. Hence. Two staircases were interleaved and ran simultaneously. 2. 2. voice intonations and/or bodily gestures of a Caucasian female acting a variety of social situations. The duration of each trial was 400 ms. producing direct. For each trial.

The indirect path remained significant when positive or negative symptoms were added to the model. We then compared the patients z-scores on the CS task and the BM task (the tasks producing the least and the greatest deficit) using a paired t-test.000 (0. Nor were there any significant total effects (indirect + direct.11) (0. None of these visual measures had significant zero-order associations with the new composite functional measure. Both symptom scales correlated with the GFI.10 0.32⁎⁎ 0.059 186.12 0.57 2.13) (14.04 0.32 − 0. Only the three visual tasks correlating with social perception were included (MASK. 3.048 0.98) (4.13 0.01.636) indicating that. Visual tasks 1.2. The schizophrenia group performed worse on the visual tasks but impairments were greatest on the social perception task. partial eta2 = 0.32⁎⁎ 0.001).54⁎⁎ 0. self care 8.58⁎⁎ 0. Social perception was significantly correlated with three of the four RFS subscales (better social perception associated with better function) and the GFI.127) = 11.61⁎⁎ 0. / Psychiatry Research 178 (2010) 270–275 273 Table 2 Data from the four visual tasks (CS. social perception and functional outcome measures for the schizophrenia group ⁎P < 0.D. the RFS composite scores improved by 0.02 0. 3.20 48. Global motion (GM) 4.31 − 0. 5). Visual performance. N = 64. Neither positive nor negative symptom scores significantly correlated with any visual tasks nor the HP.36⁎⁎ 0.476.11 0. We explored possible indirect pathways between vision and functional outcome with path analysis to reveal associations otherwise obscured in zero-order correlations.000. A negative z-score of 1 indicates a decrease in performance of one standard deviation of the mean control group scores on that task.36⁎⁎ – – – – – 0. P = 0.01 0.11 0. the half-PONS (HP).59.62⁎⁎ 0.81⁎⁎ – – 0.10) (1.) P values Contrast Sensitivity in Log units (CS) Masking (MASK) Global motion (GM) Biological motion (BM) Half-PONS (HP) 2.24 − 0. ⁎⁎P < 0.52⁎⁎ 0. MASK. Results Subject characteristics and the functional outcome measurements are reported in Table 1. Working productivity 7.D.44⁎⁎ 0.56) (7.071. Brittain et al. Half-PONS (HP) Role Functioning Scale (RFS) 6.08 0. The initial model allowed for all possible direct and indirect (via social perception) paths between the three visual tasks and the functional composite score.27) (0.04 0.97) (0. although the z-scores and post hoc t-tests (Table 2) suggest a greater deficit at the highest compared to the lowest levels of the visual system.09 – 0.78) (0.06. These results suggest the visual deficit in schizophrenia is constant across the visual processing hierarchy for the tests used here.968.P. A composite score from the three RFS subscales significantly associated with social perception was created for the analysis.37 − 0. Noticeably. Independent living.47⁎⁎ – – – – – – – – – – – – – – – – – – – – – – – – 0. P = 0. Positive/GFI = −0.076 0. GM. P < 0. 3. P = 0. The task by group interaction was not significant.16 of a standard deviation respectively.020 <0.19 0.96) (1.20 0.04) suggesting that lower-levels of visual processing are less associated than higher levels with social perception. equivalent to the zero-order correlation). only 1 showed a significant correlation (better performance associated with better functional outcome). df = 63. Masking (MASK) 3. social perception and functional outcome measures in the schizophrenia group.08 – 0.09 .49⁎⁎ 0. BM.05. When BM z-scores increased by one standard deviation.24 53. Global functioning index (GFI) 1 2 3 4 5 6 7 8 9 – 0. Five commonly used model fit indices were used to test the Table 3 Pearson correlation coefficients between visual tasks.001.42⁎⁎ – – – 0.97 0.) Patient group mean z-scores (S.42) Mean and standard deviation raw scores for the control group and patient group.07 0.86⁎⁎ – – – 0.081).32⁎ 0.30.D.017). GM and BM) were significantly correlated with the HP (better visual performance associated with better social perception). the increase in deficit is not statistically significant. there remained a significant indirect path from BM to the outcome composite (Fig. suggesting the deficit did not vary across the visual hierarchy (Greenhouse–Geisser corrected F (3.086 0. social perception and functional outcome Table 3 shows the zero-order correlation matrix for the visual tasks. Contrast sensitivity (CS) 2. The main between-group was significant (F (1.06 0.04 0. putatively ordered from low-level to high-level visual processing) and the social perception task. Biological motion (BM) Social perception 5.11 0.03 − 0. Of the 20 combinations of visual performance and functional outcome subscales and totals examined.36⁎⁎ 0. MASK. P = 0.55) (1. Three visual tasks (MASK. Task differences between groups The mean raw scores for each task are presented in Table 2 together with the z-transformed data. however (Negative/GFI R = −0. P = 0. GM. Task Control group mean raw scores (S.34⁎⁎ – 0. CS. the interaction effect being equivalent to the main within-subjects effect of task type due to the control z-scores being based on their own means and standard deviations.1. GM and BM). indicating an overall worse performance by the patient group on the visual tasks.05 0.) Patient group mean raw scores (S.029) (62. The MASK and GM tasks had similar strength relationships with the HP task but the correlation coefficients of CS/HP and BM/HP were significantly different (z = −2. This difference remained significant after co-varying for IQ.09 0.68) (0.41 − 0. P-values are equivalent for raw scores and z-scores. z-scores are for the patient group only. There were no significant direct effects of BM on outcome.32 0. The patient group had a significantly lower mean IQ than the control group. Immediate social relationships 9. BM).95 84. To further examine the visual deficits in schizophrenia we performed a mixed model ANOVA with a two-level between group factor (patient or control) and a four-level within group factor (visual task.21 – – 0. partial eta2 = 0. MASK and GM were removed from the final model because of no significant paths either to HP or to the RFS composite.14) (15. Extended social relationships 10.82⁎⁎ 0.25 79.11 0.068 211.74 − 0.381) = 0. This was not significant (t = 0.028) (60.31⁎ 0.77⁎⁎ – – – – 0.239.

of the control group's performance and only two of the tasks individually showed a statistically significant deficit with post hoc testing.13 compared to 0.6. did not suggest an increase in the strength of association for higher. As well. ‘social cognition’.951. which found a very strong association between vision and function (r = 0.compared to lowerlevels of the visual hierarchy. when the model was re-run with only either the MASK or GM tasks.5% (standardised beta = 0. equivalent to a Cohen's d of nearly 0.. Brittain et al. both groups were able to see the stimuli equivalently in terms of visual acuity.. social perception and functional status in schizophrenia. biological motion perception.g.. In the final model 19. with regard to the CS test.799.. the different thresholding techniques used) determined whether the deficit reached significance or not. the main between-group effect from the ANOVA which encompasses all visual tasks produces an eta2 value of 0. vision–social perception and social perception to function. indirect path beta weights were 0. the MASK and GM tasks add no increased predictive ability over the BM task. Values suggested the model fit the data well: X2 = 0. As such. The second mechanism was the role of a potential mediating variable. Taken as a whole. may tap in to social cognitive processes and thus inflate the apparent association between vision and functional outcome through the association between social cognition and the latter.000. However. / Psychiatry Research 178 (2010) 270–275 Fig. With the exception of 1 association from 20. RMSEA = 0.377.01. With regard to the pattern of deficits across the visual hierarchy. such as the biological motion task used by Kim et al. Our version of this task involved just a walking figure. In fact. it may be that the differing psychometric properties of the tests (e. thus. had a significant and positive but indirect effect. Discussion Our study examined visual processing deficits in schizophrenia and their relationship to functional outcome.44) of the variance in social perception is explained by biological motion and 13. indirectly accounts for just 3% (standardised beta = 0. NFI =0. Regarding the relationship between the visual processing measures and the functional outcome measure. For this second question we focussed on two hypotheses. recent neuroimaging data (Green et al.42. AGFI = 0. performance was worse on the masking task than on the global motion task even though the former is most often described as being an ‘early-visual’ task (Sergi and Green. whilst mostly non-significant.. the other to the role of a third variable. Kim et al. via social perceptual ability.e. considering the trend-level performance difference on these two tasks and the consistent overall deficit.71). a slight but non-significant accumulation or amplification occurring between the lowest and highest levels. However. Also. the interaction of group by task on performance was not significant and the difference in patient performance between the CS and the BM tasks was not significant. here. the path analysis suggests that an increase in association strength for higher levels of the hierarchy might be found within the indirect pathway. df = 1 P = 0. The z-scores showed that even on the task producing the largest deficit (biological motion). equivalent to Cohen's d effect sizes of between −0.081. 5. Attentional problems were also unlikely to have caused the recorded deficits. The zero-order correlations between vision and outcome here.000. (2005) study. This was also reflected in the greater association between the BM and HP tasks than between the CS and HP tasks. However.16 for the BM task. It is not clear why the CS and GM tasks individually did not produce significant group differences as found in many previous studies.967. mean performance in the patient group fell within 0. These results indicate a perceptual dysfunction beginning with early- visual areas with the faulty signal propagating from one level of the visual hierarchy to the next. (2005).30 and − 0. The coefficient for the indirect path refers to both segments. 2005b) suggests that masking may recruit subcortical thalamic regions and several ‘down-stream’ cortical visual areas including the lateral occipital area. CFI = 1. We postulated that some high-level visual tasks. Although the z-scores suggest that deficits worsen from the lowest to the highest level of processing. The Kim et al. The visual deficits. However.5% (standardised beta = 0. the visual deficit in total should be considered as more substantial than that suggested by the individual tasks. ⁎⁎P < 0. The indirect path revealed in our analysis suggests that biological motion perception is significantly associated with functional outcome via social cognition but that the zero-order correlation between a more ‘pure’ measure of biological motion perception and outcome is non-significant. .37) of the variance in functional status is explained by social perception. The only significant visual processing predictor found. on a functional outcome composite measure (better visual performance associated with better functional outcome). 2005). Our study design allowed us to consider two possible mechanisms which might underlie the differences found in previous studies reporting zero-order visual processing and functional outcome associations.5 S. As in previous studies. These issues will be discussed in turn.05. another study (Keri et al. they did not replicate the levels of correlation seen in some earlier studies (Butler et al. Standardised path coefficients (beta) are noted above each path.274 P. groups differed in terms of visual perceptual processing ability. the strength of the zeroorder correlations was weak in this patient group. First. i. robustness of the model. masking may recruit a broader array of processing capacities and be more sensitive to any underlying deficit. The first of these was the impact of the visual processing level studied. throwing and high-levels of visual processing. our results are in general agreement with previous findings of visual dysfunction in schizophrenia. A subsequent path analysis revealed that the ability of patients on one of the visual tasks. we investigated whether visual deficits in schizophrenia accumulated or remained constant from low. whilst the lower-level MASK and GM tasks were removed. suggest a modest impairment when individual visual abilities are considered. it appears the level of processing may influence the strength of association between vision and outcome and it is possible that this effect contributes to the variation in reported zero-order correlations found in previous studies.. 1988). ‘social cognition’. In our study this was assessed with a ‘social perception’ task. Our study supports this. in tasks tapping different levels of the visual hierarchy and involving the magnocellular/dorsal stream. we investigated the association between vision and outcome and considered why the strength of any relationship might have varied widely in previous reports. suggests that any significant indirect path from vision to outcome runs from the highest level of visual processing. ⁎P < 0. The fact that the highlevel BM task was retained in the path model. 2002) showed that temporal modulation at this spatial frequency can be necessary to observe a significant deficit. Path model showing significant direct (solid lines) and indirect (dashed lines) paths between visual processing. 4. For indirect paths. Second. Effectively. used a biological motion task which involved potentially socially relevant motor acts such as kicking. These facts suggest that future studies investigating these associations should ensure any biological motion measures have as little socially relevant content as possible to avoid the association with outcome conflating with social cognitive processes.16) of the variance in the functional composite. 2003) whereas the latter is thought to be resolved cortically in area V5/MT (Newsome and Paré. 2005.D. one related to the level of visual processing measured.

. Janka. 1996)... K. 233–241. Therefore. Newsome. Sergi. Our study had several methodological weaknesses. Engel. First. 2002. Wirtz. B. Green.J. the size of the visual processing deficit in schizophrenia is modest but consistent regardless of where within the visual pathways it is measured. the different thresholding techniques used) so that performance across tasks may not be directly comparable.and negative-symptom schizophrenia. This indicates a perceptual dysfunction beginning with early-visual areas which propagates through the visual hierarchy. Structured Clinical Interview for DSM-IV-TR Axis I Disorders... Sabb.L. J. may yield more benefits in functional outcome. A. 2201–2211.. 69–81. J.. 2005... S. actual performance probably reflecting activity in several areas. C.W. S. Lutzker. Journal of Personality and Social Psychology 69.. focussing on the remediation of social cognitive processes directly. Finally. such as social or emotional perception.A. 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