10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)

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Confabulation: Response to Commentaries John DeLuca, (Newark, NJ) John DeLuca Ph.D.

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Neuropsychology and Neuroscience laboratory, Kessler Medical Rehabilitation, Research and Education Corporation, 1199 Pleasant Valley Way, West Orange, NJ 07052, e-mail: Published online: 09 Jan 2014.

To cite this article: John DeLuca Ph.D. (2000) Confabulation: Response to Commentaries John DeLuca, (Newark, NJ), Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences, 2:2, 167-170, DOI: 10.1080/15294145.2000.10773302 To link to this article: http://dx.doi.org/10.1080/15294145.2000.10773302

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Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)

I am grateful for the responses to my article on confabulation by the commentators. They have all raised very important and stimulating questions. I am not sure I can address all of the points made, but I hope to address the major issues. In the presentation of the psychoanalytic perspective on confabulation, Mark Solms provides an intriguing argument for viewing confabulation within the framewor k of psychoanalytic theory. I was particularly intrigued with the apparent overlap in constructs between the four characteristics of the "system unconscious" and some of the constructs in neuropsychology and cognitive neuroscience, to describe confabulation. The characteristic of tolerance of mutual contradiction, whereby two incompatible ideas can exist side by side, can be analogous to neuropsychological concepts of unawareness or impaired self-monitoring found under the rubric of executive functions. Timelessness, where mental contents are not coded in chronological sequence, is very similar to the temporal order difficulties observed in ACoA confabulators. Replacement of external reality by psychical reality, where subjective mental contents predominate over objectively derived (or reality-based) contents, in some way is related to Weinstein's notion that the content of confabulation has a ' 'psychic' , basis (Weinstein and Kahn, 1955; Weinstein and Lyerly, 1968). Primary process, where the activation of ideas is unconstrained by external processes to allow for the expression of inner needs and desires, in some broader

the requirement of the mental apparatus to decrease unpleasure and optimize pleasure." Using this logic, it would be challenging to argue that a person with left hemispatial neglect and hemiplegia "confabulates" about being able to use the paretic limb because of a "wish" to use the left side, although Kinsbourne proposes this very argument. How can this be verified (see below)? Also, in the examples provided by Dr. Solms (e.g., the No Smoking sign; husband in the next bed), one could argue that these are simply perseverative thoughts by the patient, for which the patient is unable to self-monitor the apparently illogical thinking. Perhaps this can simply be viewed as a difficulty in the conscious monitoring of the patient's verbal output. However, the psychoanalytic view does provide a potential mechanism (perhaps too "psychic" for some neuroscientists). Nonetheless, the psychoanalytic interpretation is a viable alternative hypothesis that needs to be verified. Dr. Solms suggests that the "type of amnesia [I describe] ... could itself be described as an executive disorder." He suggests that the memory disorder I describe' 'is an executive disorder." Canestri appears to support Solms's position on this as well. I would agree that the notion of impaired strategic retrieval, which monitors the output from the memory system, is indeed an executive process. However, the declarative memory disorder itself is not an executive process. The available evidence (see DeLuca and Diamond, 1995) shows that damage to both the basal forebrain

sense can be analogous to the issues of self-monitoring

and frontal/executive systems is necessary for confab-

in executive control systems in the brain. Dr. Solms's examples of the first two characteristics were very interesting and provocative. In the discussion of the third and fourth unconscious characteristics, the notion of "wishes" driving the content of confabulation seems more challenging to ascribe to all of the confabulations a person may make. What Dr. Solms refers to as "wishful" has the feeling of being "intentional," although presumably at the unconscious level. Dr. Nersessian refers to this as the patient having "a motive behind their distortion and that the motive stems from

ulation to be observed in anterior communicating artery (ACoA) patients. The basal forebrain region, which presumably is responsible for the amnesia in ACoA patients, is not part of the ventromedial system, but the declarative memory system. If Solms's notion were true, then when ACoA patients stop confabulating, they should no longer be amnesic: this does not occur. The amnesia remains in ACoA patients while confabulation dissipates, arguing for two separate systems. Other evidence for separate systems include the fact that patients with executive lesions alone tend not to confabulate, and that amnesics without executive impairments themselves do not confabulate. I would agree that a "special type of executive disorder" is required, but I add that this alone is not sufficient to

Dr. DeLuca is Professor, Department of Physical Medicine and Rehabilitation, Department of Neurosciences, UMDNJ-New Jersey Medical School, Newark, NJ.

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168 produce memory confabulation. I also agree with Dr. Solms that the ventromedial portions of the frontal lobes (distribution of the anterior cerebral artery) play a critical role in memory confabulation, and eagerly await research studies that support his suggestion that this area "subserve(s) functions that are prerequisite for the secondary process mode of functioning that characterizes the system Pcs.-Cs." Dr. Solms succeeds in providing a new, insightful, and "different perspective" on the content of confabulation based on a psychoanalytic perspective. The overlap between some of the constructs between the psychoanalytic and cognitive neuroscience viewpoints is intriguing. The difference in approach perhaps lies in whether a "system unconscious" is even required (from the neuroscience perspective) for an understanding of the content of confabulation, compared to a model that suggests difficulty in the executive monitoring of the outflow of conscious information. Cognitive neuroscience appears to prefer to use the term unawareness or anosognosia when discussing aspects that do not reach consciousness, but can both camps really be speaking about the same thing? Both perspectives are viable approaches to the problem of confabulation. Ultimately, perhaps the two perspectives will be able to fuse into a single mechanism. Dr. Nersessian presents an interesting perspective on memory in general. It is well known that recall from stored memory is a reconstructive process, influenced by many factors (e.g., initial learning context, postlearning experiences, etc.). That memory recall can be influenced by "some real events, some fantasies, and some elements of a possibly traumatic event ... to create [or reconstruct] a memory ..." is consistent with current cognitive neuroscience views of memory functioning. Perhaps learning more about how subjective experience can influence the memory reconstruction process may be an area where psychoanalytic theories can be tested using cognitive neuroscience techniques. Dr. Nersessian asks: "[O]nce patients are no longer confabulating, are they capable of remembering the events occurring at the time of their illness which they could not remember while still confabulating?" This is a very good question. But the answer is likely to be very complicated. First, there is some evidence that problems in retrograde amnesia diminish with improvements in executive functioning (D'Esposito, Alexander, Fischer, McGlinchey-Berroth, and O'Conner, 1996). It is also well established that confabulation diminishes with improvements in executive

John DeLuca functions (see DeLuca and Diamond, 1995, for a review). So the answer to the question posed may be tied to some resolution of retrograde recall. But other variables may also playa significant role; for example, cognitive and personality factors outlined by Johnson, or affective and "psychic" factors discussed by Kinsbourne. The second issue regards what such patients are actually recalling when asked about events that took place around the time of their illness. Assuming one finds increased recall following the resolution of confabulation, are patients now recalling the events that were previously unavailable or are they recalling information newly learned about the time of the illness by persons (e.g., family members) providing such information after the patient has recovered? Such factors would have to be controlled to truly answer this interesting question. When I read the excellent commentary by Blechner, it reinforces my decision to exclude from my discussion confabulation from psychiatric conditions. While schizophrenic patients indeed confabulate, I would argue that the nature of the confabulations differ from say ACoA or Korsakoff patients. Nathaniel-James and Frith (1996) appear to agree with this: "The confabulations elicited appear to be of a new type, which is qualitatively different from the confabulations observed in Korsakoff's and Amnesic patients" (p. 397). The qualitative differences appear to be the psychotic features associated with the confabulation of schizophrenic patients (e.g., hallucinations, voices providing instructions, etc.) While confabulation following ACoA aneurysm can appear bizarre (a term which provides little behavioral specificity and should not be used), I have yet to experience an ACoA patient with such psychotic confabulations (e.g., Marilyn Monroe was my mother). Nonetheless, an ultimate explanation of confabulation broadly defined will have to take into account such psychotic confabulation. Envisioning dreams as confabulation is very intriguing, and easily fits many definitions of confabulation. However, Blechner provides some characteristics of dreams that do not appear in memory confabulation (e.g., "interobjects"). While neologisms are not observed in ACoA patients, they do occur in persons with Wernicke's aphasia, which may be related to the violation of Category Boundaries that Blechner describes. Blechner presents the concept of "disjunctive cognitions," described as the disjunction between appearances and identity within dreams. He presents neuropsychological evidence for the separation of processing, such as prosopagnosia, andCapgrass syn-

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Confabulation

drome (also known as reduplicative paramnesia). The separation of "feature perception and facial identity recognition" brings to mind (and is mentioned by Kinsbourne) the work in cognitive neuroscience by Mishkin and many others who talk about the distinction of the "dorsal stream" and "ventral stream" in visual perception (in both humans and primates) (Mishkin, Ungerleider, and Macko, 1983). The former has been described as the occipitoparietal perceptual system, which processes spatial information, while the latter is an occipitotemporal perceptual system involved in the processing of object characteristics. Can there be some overlap between these psychoanalytic and neuroscientific constructs? In addition to the "disjunctive cognitions,' , the distortion of time within dreams overlaps markedly with that observed in memory confabulation. Kinsbourne directly addresses some key questions regarding the nature of confabulation. While he states that "confabulation comes and goes," memory confabulation (at least in ACoA patients) comes then goes. That is, confabulation usually appears (in various degrees of severity) and usually wanes after weeks or months. But the question of "why do even severely affected patients not confabulate during much or all deliberate activity ..." is a very good question. (It should be mentioned that it appears from his examples that Kinsbourne is talking about broad-sense confabulation.) Dr. Kinsbourne argues that affective significance of the topic of confabulation is a key to answering this question. I think this is a fascinating possibility. However, one is of course immediately tempted to ask, where is the data? I have yet to see well-designed studies showing confabulated items as being those that are more affectively significant versus those which are not. There are certainly post hoc suggestions (e.g., Weinstein and Lyerly, 1968) but no systematic, scientific investigation. It sounds as if it has potential as a great collaborative project for neuroscientists and psychoanalysts. Although the role of affective coding in memory processing is well documented, its role in confabulation remains to be systematically evaluated. Kinsbourne asks, "What is it about the combination of poor memory and ventromedial frontal impairment that evokes voiced or acted out wish fulfillment?" He suggests that faulty self-monitoring is not sufficient. However, his notion of an "innerdirected focus on an affectively laden issue" seems to me equally insufficient, for perhaps the same reasons. While several commentators have pointed to the ventromedial frontal lobes as perhaps involved in "bind-

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ing" of wish fulfillment, these remain hypotheses in need of verification and testing. But what of the confabulating patient who presents inconsistent or opposite positions within the same session (which is not infrequent)? For instance, after I asked a recent ACoA patient about the scar on his head (from the surgery), the patient soon thereafter reported that his mother recently had an aneurysm and a scar on her head. Later in the same session, I returned to this issue and he denied that his mother had any medical problems, and explicitly denied that his mother had an aneurysm or a head scar when I asked him directly. Perhaps the initial response by this ACoA patient was nothing more than a perseverative response to my initially explaining to him that his scar was a result of surgery for his cerebral aneurysm. I would have expected an affectively driven hypothesis to have yielded a consistent confabulation in such a case. However, inconsistency is fairly consistent among ACoA confabulators. Johnson provides a very informative, thoughtful, and thought-provoking discussion on several topics related to confabulation. One very interesting idea is her suggestion that narrow-sense confabulators (e.g., patients with bilateral occipital lesions) be asked questions that have traditionally been reserved for other narrow-sense confabulators (e.g., frontal/basal forebrain lesioned patients). This novel idea exposes the lack of standardization of assessment of confabulation and lack of cross-talk among researchers and clinicians studying confabulation from their own patient populations. I agree with Johnson that we need to learn more about confusional states and confabulatory experiences, not only in neuroanatomical terms, but also in the content of confabulation. Delusions and hallucinations mayor may not involve similar cognitive mechanisms as suggested by Johnson, but this remains an area of speculation that again could be a fruitful area of collaboration between the psychoanalyst and neuroscientist. I concur with Johnson (also alluded to by GraffRadford) that no single structure in the brain will ultimately be found to cause confabulation. The distributed nature of brain functioning continues to be demonstrated with functional neuroimaging techniques. Anterior cerebral structures (e.g., ventromedial frontal regions, anterior cingulate) are sure to play a critical role in memory confabulation. Her detailed analysis from the cognitive psychology literature on the multiple cognitive, personality, and emotional variables that contribute to memory distortions and beliefs provides an excellent springboard from which

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collaborative ideas can be applied to the study of confabulation. Yet, as Johnson states, "the relations between cognitive and neural mechanisms largely remain to be specified." I look forward to seeing functional neuroimaging techniques applied to confabulation, with neuroscientists and psychoanalysts working in concert. At this point, I would like to return to the example of the "irresolvable conflict" raised by Kinsbourne of the patient with left hemispatial hemiplegia, neglect, and anosognosia, who denies problems with his left side. Kinsbourne states that "the confabulation is a psychodynamic reaction to an organic problem. ' , Johnson attempts to interweave the work from cognitive psychology and psychoanalysis by suggesting that "reflection (the 'secondary process') involves an active inhibitory process by which instructive actions are inhibited (or delayed), giving thought (other reflective processes) a chance to have its influence." She suggests that "active inhibitory processes" or "active goals or agendas" that activate ("bias") representations or action plans can circumvent "instinctive, or habitual, or prepotent responses." With these points in mind, perhaps one can ask the following: does the right parietal lesion resulting in hemispatial neglect and hemiplegia somehow inhibit (or disinhibit) the "instinctive" monitoring (by the right hemisphere) of the "Interpreter" (Gazzaniga, 1998) within the left hemisphere? Recall that the role of the Interpreter is to interpret information both internally and externally to logically explain the events in the environment. Perhaps it is this lack of access to the Interpreter that results in the confabulations observed in such patients. It seems to me that the investigation of such neuroscientific hypotheses may have significant implications for psychodynamic constructs and principles. In closing, I have found these commentaries enjoyable, enlightening, as well as intellectually stimulating. Ultimately, an all-encompassing model of confabulation will need to explain confabulation from brain damage, psychiatric conditions, and healthy individuals (e.g., dreams, false memories). In agreement with Dr. Johnson, the only way to accomplish this

John DeLuca

ultimate goal is for research and theory from among the disciplines of cognitive psychology, neuropsychology, cognitive neuroscience, and psychoanalysis to come together in a convergence of investigation. Such a wide "gaze" as Blechner refers to it, can only be achieved with such convergence. It is within this spirit that I proposed a model of broad- and narrow-sense confabulation. For those of us who cast a "narrow" net, there is much to learn from the other disciplines. But the widest "gaze" can only be achieved with work across disciplines. I hope that the discussion provided in this issue will contribute to reaching such a convergence of investigation on confabulation.

References DeLuca, J., & Diamond, B. J. (1995), Aneurysm of the anterior communicating artery: A review of neuroanatomical and neuropsychological sequelae. J. Clin. Experiment. Neuropsychol., 17:100-121. D'Esposito, M., Alexander, M. P., Fischer, R., McGlincheyBerroth, R., & O'Conner, M. (1996), Recovery of memory and executive function following anterior communiInternat. cating artery aneurysm rupture. J. Neuropsychol. Soc., 2(6):565-570. Gazzaniga, M. S. (1998), The Mind's Past. Berkeley: University of California Press. Mishkin, M., Ungerleider, L., & Macko, K. (1983), Object vision and spatial vision: Two cortical pathways. Trends in Neurosci., 6:41~17. Nathaniel-James, D. A., & Frith, C. D. (1996), Confabulation in schizophrenia: Evidence of a new form. Psycholog. Med., 26:391-399. Weinstein, E. A., & Kahn, R. L. (1955), Denial of Illness. Springfield, IL: Charles C. Thomas. - - - Lyerly, O. G. (1968), Confabulation following brain injury: Its analogues and sequelae. Arch. Gen. Psychiatry, 18:348-354. John DeLuca, Ph.D. Neuropsychology and Neuroscience Laboratory Kessler Medical Rehabilitation Research and Education Corporation, 1199 Pleasant Valley Way West Orange, NJ 07052 e-mail: delucaj. @umdnj.edu