Improving Visual Attention to Social Stimuli in Individuals With Schizophrenia
Phase: NA
Conditions: Schizophrenia, Schizoaffective Disorder
Sponsor: The University of Texas at Dallas

IMPROVING VISUAL ATTENTION IN SCHIZOPHRENIA 
 
 
 
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Improving Visual Attention to Social Stimuli in Individuals with Schizophrenia. 
Hans Klein 
The University of Texas at Dallas 
ID 19-58 
Approved: January 22, 2019 
 
 
 
 

IMPROVING VISUAL ATTENTION IN SCHIZOPHRENIA 
 
 
 
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Current Research Program 
 
It is unclear what causes the social cognitive deficits that are observed in schizophrenia, 
but one promising theory suggests that abnormal visual attention may prevent accurate 
understanding of social information, cascading into more complex social dysfunction. 
Specifically, we propose that faulty modulation of the rTPJ, which is possibly responsible for 
updating internal models with appropriate and salient external information, leads to abnormal 
visual attention in the form of abnormal scanning and fixations when viewing both social and 
nonsocial stimuli. The failure to attend to salient visual stimuli may then prevent accurate social 
cognitive processes that are intrinsically tied to functional outcomes. As these social deficits are 
tied to daily functioning, it is of interest to parse out this relationship and determine if abnormal 
neural modulation underlies visual attention abnormalities. Novel neurostimulation techniques 
provide a viable method for addressing this question as they allow for the experimental 
manipulation of neural regions that can extend to neural networks, resulting in a range of 
observable effects in both healthy individuals and clinical populations.  
The current research program therefore seeks to experimentally manipulate the neural 
mechanism that potentially underlies the automatic behavioral process of visual attention. 
Through the use of novel neurostimulation techniques (i.e., anodal tDCS to rTPJ) and eye 
tracking technology, we aim to directly assess how rTPJ impacts visual attention to social 
stimuli.  
Considerations 
One consideration for this study is to address whether any observed changes are specific 
to stimulation of the TPJ. In order to address these concerns, we will use an alternate stimulation 
site as a comparator. The dorsal medial prefrontal cortex (dmPFC) may act as a suitable alternate 

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stimulation site, as it has a role in controlled integration of information within the social brain 
network1. However, unlike the TPJ, the dmPFC should not directly be involved in reorienting 
visual attention to salient cues. Comparing stimulation of rTPJ to that of dmPFC should therefore 
allow examination of the dissociable role of stimulus driven attention via the rTPJ vs. cognitive 
control over social cognition via dmPFC. To limit practice effects on our social cognitive tasks, 
we will not require participants to undergo active and sham stimulation conditions to both brain 
regions. Instead, after pairing participants on key demographic factors (i.e. age, race, and, when 
possible, years of education), we will randomly assign participants to receive active and sham 
conditions over either the TPJ or dmPFC and use stimulation site as a between subject’s factor.  
Aims and Hypothesis. 
The current research program investigates the role of the TPJ, specifically the right TPJ, 
in visual attention and how this may act as one potential mechanism for social cognitive 
impairments in individuals with schizophrenia. Primarily, we seek to utilize anodal tDCS to 
stimulate the rTPJ in order to increase the proportion of time spent attending to salient visual 
social stimuli compared to sham stimulation as measured via eye-tracking.  
In order to support the overarching idea that abnormal visual attention stems from 
dysregulated neural systems, we hypothesize the following: 
1. Participants will better regulate their eye movements (i.e. show a higher percentage of 
fixations in designated areas of interest) after anodal stimulation of the rTPJ relative to 
sham, and compared to stimulation of the dmPFC.  
Should improvements in visual attention occur only after anodal stimulation to the rTPJ, we will 
have demonstrated that visual attention to socially salient stimuli can be impacted by tDCS based 

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upon increased electrical activation in this region. We expect to see no significant increase in 
visual attention after stimulation of our comparator site, the dmPFC.  
Methods 
Participants. This study will recruit participants diagnosed with schizophrenia or 
schizoaffective disorder (DSM-5 codes 295.9 and 295.7) between the ages of 18 and 65. Upon 
entry into the study, participants will be randomly assigned to one of the two stimulation location 
groups, the TPJ stimulation group and the dmPFC stimulation group.  
 
Patients will be recruited from a laboratory database of past participants, as well as 
through mental health agencies servicing the Dallas- Fort Worth metroplex. Psychiatric 
diagnoses will be confirmed through the administration of two gold standard diagnostic 
assessments, Mini International Neuropsychiatric Interview (MINI)2 and Structured Clinical 
Interview for DSM Disorders - Psychosis Module (SCID-P)3. Prescribed medications will be 
assessed via patient self-report as well as medical and pharmacy records as available, and 
participants will be asked to remain on stable dose of medication throughout their participation in 
the study.  
 
Participants will be deemed ineligible for this study if they meet any of the following 
additional criteria: i) the presence or history of a pervasive developmental disorder or mental 
retardation as defined by a premorbid IQ < 70, ii) presence or history of medical or neurological 
disorders in which neural stimulation would be contraindicated (e.g. presence of epilepsy or 
history of seizures, iii) presence of sensory limitations, including visual or hearing impairments 
that interfere with assessment, iv) history of electroconvulsive therapy, v) not proficient in 
English, vi) presence of substance abuse in the past one month or dependence not in remission in 
the past six months. Participants will be matched in pairs based upon key demographic factors, 

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specifically age (within 5 years of age) and race, as well as years of education when able. Paired 
participants are not expected to complete the study at the same time, but instead will act as 
comparators for the two stimulation locations. Each member of the participant pair will be 
assigned to one of the two identified tDCS stimulation locations (i.e. either the TPJ or the 
dmPFC) prior to enrollment and assessment.  
Procedure/ Design. Participants will be asked to complete two visits with 7 to 10 days between 
the two visits to allow for any tDCS effects from the first visit to dissipate. At the initial visit, 
and prior to any study specific tasks, written informed consent will be obtained from the 
participant. Participants will complete two diagnostic interviews to confirm psychiatric 
diagnosis. The MINI and SCID-P will be administered as needed for all subjects whose 
psychiatric diagnosis have not previously been confirmed by a trained member of the research 
team in a previous lab study.  
Stimulation procedure. Following diagnostic and symptom assessment interviews, subjects will 
begin the neurostimulation procedure using neuroConn’s programable Direct Current stimulator. 
 
During the neurostimulation procedure, electrodes will be affixed to the subject’s head in 
order to target the assigned stimulation location. Placement will be determined for each 
individual using international 10-20 EEG placement system with Modified Combinatorial 
Nomenclature. For those assigned to the target TPJ region, the anode will be placed between P6 
and CP6, which will target the posterior portion of the TPJ. Although the electrodes are too large 
to target specific sub regions of the rTPJ, this placement should sufficiently stimulate the 
posterior portion of the rTPJ that may be associated with social cognitive function, as well as 
attentional reorientation. The cathode for this montage will be placed extra-cortically on the left 

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shoulder. Placing the cathode contralaterally will draw the current across the midline, ensuring 
full stimulation of the targeted region.  
 
For those assigned to the dmPFC target location, the anode will be placed at AFz, with 
the cathode placed on the opposite side of the skull, on the participant’s neck, approximately 1 
cm below Iz. This location is desired to ensure the current flows through the targeted dmPFC 
region.  
 
For all participants, active and sham stimulation will be counterbalanced, so that each 
participant will have an equal likelihood of receiving either active or sham stimulation at their 
first visit, and the alternate at their second. NeuroConn machine’s preprogrammed “study mode” 
will be used to administer either active or sham stimulation in a double-blinded fashion. This is 
accomplished through the use of preprogrammed, 5-digit stimulation codes that the administrator 
will manually enter into the device prior to each stimulation procedure that indicates whether that 
condition is to be active or sham. These 5-digit codes will be paired, one active code and one 
sham code, prior to study start so that a single participant cannot inadvertently be assigned to two 
active or two sham conditions. Codes entered into the machine at each visit will be recorded for 
unblinding after study completion. A master list that identifies which condition relates to each 
code will be accessible only by the lab director during the duration of the study in the event the 
blind needs to be broken in real time.  
 
The total stimulation procedure time will be 20 minutes and 30 seconds for both active 
and sham stimulation. The active stimulation will consist of active current at 2mA, ramping up 
over 15 seconds, sustaining for 20 minutes, and then ramping down for an additional 15 seconds. 
In the pre-programmed sham condition, the procedure will consist of a brief active current that 
will follow the same ramping procedure as the active condition, 15 seconds ramping up and 15 

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seconds ramping down. Unlike the active condition, the participant will only receive 30 seconds 
of direct current before the ramp down occurs. The machine will continue to perform impedance 
control checks during the remainder of the 20-minute assessment so that the participant and the 
administrator are unaware of which condition the machine is administering.   
 
Following the neurostimulation procedure, the participant will be asked to wait quietly 
and read through a selection of magazines for 30 minutes to allow for tDCS effects to work 
through the neural network. Participants will then complete the remaining behavioral measures 
with concurrent eye movements recorded via Gazepoint desktop eye tracker. Gazepoint is an eye 
tracking system that can easily be attached to the bottom of a computer monitor, and angled 
toward the participant’s eyes in order to capture visual attention to stimuli shown on the 
computer screen.   
Post-stimulation assessments. Following the stimulation procedures, subjects will complete a 
series of three social cognitive tasks and a visual fixation task. Poststimulation tasks will be 
counterbalanced to reduce the impact of practice or order effects on our results. The same tasks 
will be administered following both active and sham stimulation. 
Social cognitive tasks. Descriptions for each of the social cognitive tasks are listed below. Eye 
tracking will be utilized to measure the primary variable, the proportion of time attending to 
researcher identified socially and contextually important cues in the social cognition tasks. The 
method for identification of socially and contextually important cues discussed in the statistical 
plan below and examples of these important areas of interest (AOIs) are discussed in the task 
descriptions.  
• Emotion Recognition 40 (ER-40)4. Participants will be shown 40 color photographs of 
faces expressing 4 basic emotions (i.e. happiness, sadness, anger, or fear) and neutral 

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expressions, one at a time, and asked to identify the emotion expressed on each face. 
Socially important AOIs for this task will be core features of the faces shown, namely the 
eyes, nose, and mouth of the actors exhibiting the emotions.  
• Bell Lysaker Emotion Recognition Task (BLERT)5. Participants will view 21 ten second 
video clips of a male actor expressing one of seven emotional states (i.e. happiness, 
sadness, fear, disgust, surprise, anger, and no emotion). In this task, socially important 
AOIs will be similar to static faces in the ER40, namely the core features of the actor’s 
face, in addition to the actor’s body movement during the video.  
• The Awareness of Social Inferences Test (TASIT)6. Participants will view 16 video 
vignettes of complex social situations in which actors either use lies or sarcastic 
responses to relay information to the other actors in the scene. For this task, both socially 
and contextually important AOIs will be identified. Socially important AOIs will be 
similar to the previous two tasks, namely core features of the actors’ faces and bodies. 
Contextually important AOIs will be specific to each scene, but include specific clues 
embedded in the scene that are needed to understand the intent of the main actor in each 
scenario. Examples of these contextually important cues include childlike scribbles in a 
book, an empty wallet, or an incomplete crossword puzzle.  
Non-Social Eye Movement task. Following research that identifies both scanpath abnormalities 
on freeviewing tasks and unstable fixations on directed tasks as potential markers of 
schizophrenia,7 this task will be included as a supplementary assessment to characterize the 
extent to which stimulation of our targeted areas affects visual abnormalities observed in the 
disorder. Since the rTPJ is believed to be responsible for reorienting attention only when stimuli 
is behaviorally or contextually relevant, it is hypothesized that participants should have better 

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stability of visual attention post TPJ stimulation relative to sham and compared to dmPFC 
stimulation as distractors will not be behaviorally relevant. 
• Fixation task. (Adapted from Benson et al., 2015)7 Participants will be instructed to focus 
on a single fixation cross presented in the middle of the screen for a 5 second interval. 
The fixation cross will either be presented alone in the center of the screen, or with 
flanking distractor fixation crosses presented on either the left or right side of the screen, 
totaling three conditions. Each condition will be presented in random order two times, for 
a total of six fixation assessments. Eye tracking software will be utilized to measure eye 
drift from the center fixation cross during each of the conditions to calculate fixation 
stability.  
Statistical plan. To test this study’s primary hypothesis, which predicts that anodal stimulation 
of the TPJ will increase the proportion of time spent attending to salient visual stimuli, we will 
first identify and mark salient areas of interest (AOI) on the social cognitive tasks as discussed in 
the task descriptions above. For all tasks,  AOI’s will be determined based upon consensus 
review of each stimulus/scene by expert researchers (HK and AEP). Should the researchers fail 
to agree on specific AOIs, a third opinion will be solicited from a researcher in the field with 
experience administering the task. A two-thirds majority opinion will determine any contested 
AOI.  
Once primary eye tracking values are obtained, we will run three separate 2x2 mixed 
ANOVAs on the proportion of time spent attending to researcher defined regions of interest on 
static faces (ER-40), dynamic videos (BLERT), and social situations (TASIT), with location 
(TPJ vs dmPFC) as a between subjects’ factor and stimulation condition (active versus sham 
stimulation) as a within subject factor. No direct comparisons between tasks will be performed as 

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we do not have any hypotheses regarding if the effect will be larger for one social cognitive task 
versus any other. We hope to observe simple main effects for region (TPJ > dmPFC) and 
stimulation type (active > sham), but expect that if these main effects are observed, they will be 
accounted for by interaction effects between location and stimulation condition. Specifically, 
should active stimulation on the TPJ increase proportion of time attending to AOIs compared to 
all other conditions, this interaction effect would support our hypothesis that TPJ activation has a 
unique effect on visual attention during all tasks. To adjust for multiple comparisons, a 
Bonferroni correction will be applied, with significant alpha = 0.017 for each of the tests run. 
 
 
 
 
 

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