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7/25/2019 10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)
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Confabulation: Response to Commentaries JohnDeLuca, (Newark, NJ)John DeLuca Ph.D.
a
aNeuropsychology 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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7/25/2019 10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)
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Confabulation
Confabulation: Response to Commentaries
John
DeLuca, (Newark, NJ)
I am grateful for the responses to my article on confab
ulation 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 ad
dress the major issues.
In the presentation
of
the psychoanalytic perspec
tive on confabulation, MarkSolmsprovides an intrigu
ing argument for viewing confabulation within the
framework
of
psychoanalytic theory. I was particularly
intrigued with the apparent overlap in constructs be
tween the four characteristics of
the system uncon
scious and some
of
the constructs in neuropsychology
and cognitive neuroscience, to describe confabulation.
The characteristic of tolerance of mutual contradic
tion, whereby two incompatible ideas can exist side
by side, can be analogous to neuropsychological con
cepts
of
unawareness or impaired self-monitoring
found under the rubric
of
executive functions. Time
lessness, where mental contents are not coded in chro
nological 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
sense can be analogous to the issues of self-monitoring
in executive control systems in the brain. Dr. Solms s
examples of the first two characteristics were very in
teresting 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, al
though presumably at the unconscious level. Dr. Ners
essian refers to this as the patient having a motive
behind their distortion and that the motive stems from
Dr. DeLuca is Professor, Department of Physical Medicine and Reha
bilitation, Department of Neurosciences, UMDNJ-New Jersey Medical
School, Newark, NJ.
7
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 confabu
lates 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 persevera
tive thoughts by the patient, for which the patient is
unable to self-monitor the apparently illogical think
ing. Perhaps this can simply be viewed
as
a difficulty
in the conscious monitoring of the patient s verbal out
put. However, the psychoanalytic view does provide a
potential mechanism (perhaps too psychic for some
neuroscientists). Nonetheless, the psychoanalytic in
terpretation 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 de
scribe
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 in
deed 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
and
frontal/executive systems is necessary for confab
ulation to be observed in anterior communicating ar
tery (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 confabulat
ing, they should no longer be amnesic: this does not
occur. The amnesia remains in ACoA patients while
confabulation dissipates, arguing for two separate sys
tems. 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
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7/25/2019 10 Confabulation: Response to Commentaries John DeLuca, (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, in
sightful, and different perspective on the content
of
confabulation based on a psychoanalytic perspec
tive. The overlap between some of the constructs be
tween 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 in
formation. Cognitive neuroscience appears to prefer
to use the term un w reness or nosognosi 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 mech
anism.
Dr. Nersessian presents an interesting perspective
on memory in general. It is well known that recall
from stored memory is a reconstructive process, in
fluenced by many factors (e.g., initial learning context,
postlearning experiences, etc.). That memory recall
can be influenced by
some
real events, some fanta
sies, 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 psycho
analytic theories can be tested using cognitive neuro
science techniques.
Dr. Nersessian asks: [O]nce patients are no
longer confabulating, are they capable
of
remember
ing the events occurring at the time
of
their illness
which they could not remember while still confabulat
ing?
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 Es
posito, Alexander, Fischer, McGlinchey-Berroth, and
O Conner, 1996). It is also well established that con
fabulation diminishes with improvements in executive
John
DeLuca
functions (see DeLuca and Diamond, 1995, for a re
view). 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 Kins
bourne. 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 in
formation after the patient has recovered? Such fac
tors 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 condi
tions. While schizophrenic patients indeed confabu
late, 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 differ
ences 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
iz rre
(a term which provides little behavioral
specificity and should not be used), I have yet to expe
rience an ACoA patient with such psychotic confabu
lations (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 in
triguing, and easily fits many definitions
of
confabula
tion. However, Blechner provides some characteristics
of
dreams that do not appear in memory confabulation
(e.g., interobjects ). While neologisms are not ob
served in ACoA patients, they do occur in persons
with Wernicke s aphasia, which may be related to the
violation
of
Category Boundaries that Blechner de
scribes. Blechner presents the concept of disjunctive
cognitions, described as the disjunction between ap
pearances and identity within dreams. He presents
neuropsychological evidence for the separation
of
pro
cessing, such as prosopagnosia, and apgrass syn-
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7/25/2019 10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)
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Confabulation
drome (also known as reduplicative paramnesia). The
separation of feature perception and facial identity
recognition brings tomind (and ismentioned byKins
bourne) the work in cognitive neuroscience by Mish
kin 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 neu
roscientific constructs? In addition to the disjunctive
cognitions, , the distortion of time within dreams
overlaps markedly with that observed in memory con
fabulation.
Kinsbourne directly addresses some key ques
tions 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 vari
ous 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 confabu
lation.)
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, scien
tific 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 combina
tion of poor memory and ventromedial frontal impair
ment that evokes voiced or acted out wish
fulfillment? He suggests that faulty self-monitoring
is not sufficient. However, his notion
of
an inner
directed focus on an affectively laden issue seems to
me equally insufficient, for perhaps the same reasons.
While several commentators have pointed to the ven
tromedial frontal lobes as perhaps involved in
bind
9
in of
wish fulfillment, these remain hypotheses in
need
of
verification and testing.
But what of the confabulating patient who pres
ents 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 re
turned 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 confabulat ion 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 re
lated to confabulation. One very interesting idea is
her suggestion that narrow-sense confabulators (e.g.,
patients with bilateral occipital lesions) be asked ques
tions that have traditionally been reserved for other
narrow-sense confabulators (e.g., frontal/basal fore
brain lesioned patients). This novel idea exposes the
lack
of
standardization of assessment
of
confabulation
and lack
of
cross-talk among researchers and clini
cians 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 cogni
tive mechanisms as suggested by Johnson, but this
remains an area
of speculation that again could be a
fruitful area of collaboration between the psychoana
lyst and neuroscientist.
I concur with Johnson (also alluded to by Graff
Radford) that no single structure in the brain will ulti
mately be found to cause confabulation. The distrib
uted nature
of brain functioning continues to be
demonstrated with functional neuroimaging tech
niques. 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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7/25/2019 10 Confabulation: Response to Commentaries John DeLuca, (Newark, NJ)
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7
collaborative ideas can be applied to the study of con
fabulation. Yet, as Johnson states,
the relations be
tween cognitive and neural mechanisms largely
remain to be specified. I look forward to seeing func
tional neuroimaging techniques applied to confabula
tion, 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 cogni
tive psychology and psychoanalysis by suggesting that
reflection (the 'secondary process') involves an ac
tive inhibitory process by which instructive actions are
inhibited (or delayed), giving thought (other reflective
processes) a chance to have its influence. She sug
gests that active inhibitory processes or active
goals or agendas that activate
bias )
representa
tions 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. Per
haps 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 neuro
scientific hypotheses may have significant implica
tions for psychodynamic constructs and principles.
In closing, I have found these commentaries en
joyable, enlightening, as well
as
intellectually stimu
lating. Ultimately, an all-encompassing model
of
confabulation will need to explain confabulation from
brain damage, psychiatric conditions, and healthy in
dividuals (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, neuropsychol
ogy, 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 pro
vided in this issue will contribute to reaching such a
convergence of investigation on confabulation.
References
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of
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Berroth, R., O'Conner,
M
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Weins te in, E. A., Kahn, R. L. (1955) , Denial
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John DeLuca Ph.D.
Neuropsychology and Neuroscience Laboratory
Kessler Medical Rehabilitation
Research and Education Corporation
1199 Pleasant Valley
Way
West Orange 07052
e-mail: delucaj. @umdnj.edu