Disorientation, confabulation, and extinction capacity: clues on how the brain creates reality

It's not a lie … If you believe it: Narrative analysis of autobiographical memories reveals over-confidence disposition in patients who confabulate

Humans perceive their personal memories as fundamentally true, and although memory is prone to inaccuracies, flagrant memory errors are rare. Some patients with damage to the ventromedial prefrontal cortex (vmPFC) recall and act upon patently erroneous memories (spontaneous confabulations). Clinical observations suggest these memories carry a strong sense of confidence, a function ascribed to vmPFC in studies of memory and decision making. However, most studies of the underlying mechanisms of memory overconfidence do not directly probe personal recollections and resort instead to laboratory-based tasks and contrived rating scales. We analyzed naturalistic word use of patients with focal vmPFC damage (N = 18) and matched healthy controls (N = 23) while they recalled autobiographical memories using the Linguistic Inquiry and Word Count (LIWC) method. We found that patients with spontaneous confabulation (N = 7) tended to over-use words related to the categories of 'certainty' and of 'swearwords' compared to both non-confabulating vmPFC patients (N = 11) and control participants. Certainty related expressions among confabulating patients were at normal levels during erroneous memories and were over-expressed during accurate memories, contrary to our predictions. We found no elevation in expressions of affect (positive or negative), temporality or drive as would be predicted by some models of confabulation. Thus, erroneous memories may be associated with subjectively lower certainty, but still exceed patients' report criterion because of a global proclivity for overconfidence. This may be compounded by disinhibition reflected by elevated use of swearwords. These findings demonstrate that analysis of naturalistic expressions of memory content can illuminate global meta-mnemonic contributions to memory accuracy complementing indirect laboratory-based correlates of behavior. Memory accuracy is the result of complex interactions among multiple meta-mnemonic processes such as monitoring, report criteria, and control processes which may be shared across decision-making domains.

Anatomical and functional predictors of disorientation after first-ever brain damage

BACKGROUND AND OBJECTIVES

Disorientation is a frequent consequence of acute brain injury or diffuse disorders, such as confusional states or dementia. Its anatomical correlates are debated. Impaired memory as its commonly assumed mechanism predicts that disorientation is associated with medial temporal damage. The alternative is that disorientation reflects defective orbitofrontal reality filtering (ORFi) - a specific failure to identify whether thoughts or memories refer to present reality or not. The latter is a function of the posterior orbitofrontal cortex and connected structures. This study examined the mechanisms and anatomical basis of disorientation in an unselected group of patients with first-ever subacute brain injury.

METHODS

Participants hospitalized for neurorehabilitation were asked to participate in this observational cohort study if they had first-ever organic hemispheric brain dysfunction as evident in a localizable brain lesion or verbal amnesia (often without localizable brain damage). Orientation to time, place, situation and person was tested with a 20-items questionnaire. To identify the mechanisms of disorientation, we determined its correlations with executive tasks, verbal episodic memory, and ORFi in all patients. ORFi was examined with a continuous recognition task, which measures learning and item recognition in the first run, and ORFi as reflected in the increase of false positive responses in the second run (temporal context confusion). Lesions of patients having localizable brain damage were manually delineated and normalized before entering multivariate lesion-symptom-mapping (LSM) to determine anatomical predictors of orientation.

RESULTS

Eighty-four patients (61.1 ± 14.4 years, 29 women) were included. Among measures of memory and executive functioning, a step-wise regression retained temporal context confusion (R = -0.71, p < 0.0001), item recognition (R = 0.67, p < 0.0001) and delayed free recall (R = 0.63, p < 0.0001) as significant predictors of orientation. LSM was possible in 67 participants; it revealed an association of disorientation with damage of the right OFC and the bilateral head of the caudate nucleus.

CONCLUSION

Disorientation in non-confused, non-demented patients with first-ever brain damage is associated with impaired orbitofrontal reality filtering and memory dysfunction, but not with executive dysfunction. Its main anatomical determinant is damage to the orbitofrontal cortex and its subcortical relay, the head of the caudate.

Rehabilitation of Memory Disorders

Memory disorders are common in clinical practice. This review focuses on the rehabilitation of anterograde amnesia, the inability to learn and retrieve new information, in non-degenerative brain disease. Diverse mnemonic strategies may be helpful in learning specific pieces of information. Their success also depends on the severity of associated cognitive failures, in particular, executive dysfunction. However, unless transfer to everyday activities is specifically trained, such strategies are of limited value in promoting independence in daily life. External memory aids are often necessary to allow for independent living. Learning to use them requires intact capacities such as procedural learning or conditioning. This review further discusses the rehabilitation of confabulation, that is, the emergence of memories of events that never happened. The rehabilitation of memory disorders needs to be tailored to patients’ individual capacities and needs.

Flexible adjustment of anticipations in human outcome processing

To sense whether thoughts refer to current reality or not, a capacity called orbitofrontal reality filtering, depends on an orbitofrontal signal when anticipated outcomes fail to occur. Here, we explored the flexibility and precision of outcome processing in a deterministic reversal learning task. Healthy subjects decided which one of two colored squares hid a target stimulus. Brain activity was measured with high-density electroencephalography. Stimuli resembling, but not identical with, the target stimuli were initially processed like different stimuli from 210 to 250 ms, irrespective of behavioral relevance. From 250 ms on, they were processed according to behavioral relevance: If they required a subsequent switch, they were processed like different stimuli; if they had been declared potential targets, they were treated like true targets. Stimuli requiring a behavioral switch induced strong theta activity in orbitofrontal, ventromedial, and medial temporal regions. The study indicates flexible adaptation of anticipations but precise processing of outcomes, mainly determined by behavioral relevance.

Distinct outcome processing in deterministic and probabilistic reversal learning

Anticipations that fail to happen are important drivers of behavioral adaptation. Their processing appears to depend on the context. In a deterministic environment, where a stimulus unequivocally predicts the outcome, processing of absent outcomes involves the posterior orbitofrontal cortex (OFC). Failure has been linked to reality confusion with confabulations and disorientation. In a probabilistic environment, absent outcomes appear to be processed by the anterior cingulate cortex (ACC) rather than the OFC. Failure has been associated with poor decision making and schizophrenia. These data suggest different mechanisms depending on the context. Here, healthy human subjects made two formally similar reversal learning tasks, but one with deterministic, the other with probabilistic instructions. Brain activity was monitored using high-density electroencephalography. We found that in the deterministic task, negative outcomes, which unequivocally call for a behavioral switch, induced a distinct frontal potential at 200-300 msec. Computational modeling indicated a strong association of evoked potentials with prediction error, surprise, and behavioral adaptation. In the probabilistic task, where behavioral adaptation follows the cumulated processing of outcomes, negative outcomes evoked potentials that were associated with prediction error and surprise, but had a weak link with subsequent behavior. Outcome processing in the probabilistic task induced stronger activation than the deterministic task of an extended network including the ACC, OFC and striatum at 300-400 msec. In both tasks, negative outcomes were processed differently from positive outcomes at 400-600 msec, possibly reflecting updating of the outcome record. We conclude that the brain disposes of at least two distinct systems processing outcomes with unequivocal or ambiguous behavioral significance. These systems differ along behavioral, clinical, electrophysiological and anatomical dimensions.

Get real: Orbitofrontal cortex mediates the ability to sense reality in early adolescents

INTRODUCTION

Orbitofrontal reality filtering (ORFi) is a memory mechanism that distinguishes whether a thought is relevant to present reality or not. In adults, it is mediated by the orbitofrontal cortex (OFC). This region is still not fully developed in preteenagers, but ORFi is already active from age 7. Here, we probe the neural correlates of ORFi in early adolescents, hypothesizing that OFC mediates the sense of reality in this population.

METHODS

Functional magnetic resonance images (fMRI) were acquired in 22 early adolescents during a task composed of two runs: run 1 measuring recognition capacity; run 2 measuring ORFi; each containing two types of images (conditions): distractors (D: images seen for the first time in the current run) and targets (T: images seen for the second time in the current run). Group region of interest (ROI) analysis was performed in a flexible factorial design with two factors (run and condition) using SPM12.

RESULTS

We found significant main effects for the experimental run and condition. The bilateral OFC activation was higher during ORFi than during the first run. Additionally, the OFC was more active while processing distractors than targets.

CONCLUSION

These results confirm, for the first time, the role of OFC in reality filtering in early adolescents.

Confabulations in Alcoholic Korsakoff's Syndrome: A Factor Analysis of the Nijmegen-Venray Confabulation List

Confabulations generally refer to the emergence of memories of experiences and events that, in reality, never took place, and which are unintentionally produced. They are frequently observed in alcoholic Korsakoff's syndrome. The aim of the current study was to validate the Nijmegen-Venray Confabulation List (NVCL), an observation scale for quantifying both spontaneous and provoked confabulations. The NVCL was completed for 252 patients with alcoholic Korsakoff's syndrome. Exploratory and confirmatory factor analyses were conducted to test three- and four-factor models of the NVCL structure. A four-factor model (provoked confabulations, spontaneous confabulations, severity of spontaneous confabulations, and distorted sense of reality) fitted the data better than the initially proposed three-factor model (provoked confabulations, spontaneous confabulations, memory, and orientation). The new instrument is therefore referred to as the NVCL-R. We encourage clinicians to include the assessment of confabulations in the neuropsychological examination, and to do so with validated instruments such as the NVCL-R.

Beyond a rod through the skull: A systematic review of lesion studies of the human ventromedial frontal lobe

Neuropsychological studies from the past century have associated damage to the ventromedial frontal lobes (VMF) with impairments in a variety of domains, including memory, executive function, emotion, social cognition, and valuation. A central question in the literature is whether these seemingly distinct functions are subserved by different sub-regions within the VMF, or whether VMF supports a broader cognitive process that is crucial to these varied domains. In this comprehensive review of the neuropsychological literature from the last two decades, we present a qualitative synthesis of 184 papers that have examined the psychological impairments that result from VMF damage. We discuss these findings in the context of several theoretical frameworks and advocate for the view that VMF is critical for the formation and representation of schema and cognitive maps.

Negative expectations influence behavioral and ERP responses in the subsequent recognition of expectancy-incongruent neutral events

Previous studies have shown that expectancy incongruence in emotional stimuli influences the encoding (i.e., the first stage of memory processing) of the stimuli. However, it is unknown about whether expectancy incongruence influences later stages of memory processing, such as recognition. To this end, expectancy cues were presented prior to emotional pictures. Most often, the cues accurately indicated the emotional consequences of the pictures, but in some cases the consequence was incongruent with the expectations, and a picture from another emotional category was presented. Afterward, participants completed an unexpected recognition task in which old and novel pictures were not preceded by expectancy cues. The results showed that, in the encoding phase, expectancy incongruence reduced response accuracy when categorizing pictorial emotions, and the effect was smaller for neutral pictures than for negative pictures. ERP results showed stronger and weaker responses to expectancy incongruent pictures compared to congruent pictures in time ranges related to the encoding-related early and middle late positive potential (LPP), respectively. In the subsequent recognition phase, d' scores were higher for incongruent neutral pictures than for congruent ones. Expectancy incongruence enlarged the P2 response but reduced the recognition-related early LPP response for neutral pictures. However, effects of expectancy incongruence were not seen for negative pictures. Therefore, the findings in the present study indicate that negative expectations influence the later recognition of expectancy incongruent neutral events, whereas negative events are more resistant to the effects of expectation incongruence.

Frontolimbic affective bias and false narratives from brain disease

Since the nineteenth century, clinicians and investigators have systematically evaluated the origin of delusions and psychotic thinking. One major clue to understanding the neurobiological underpinnings of delusions is the emergence of false narratives from brain disease. In addition to delusions themselves, there are a range of other false narratives not due to deliberate lying and resulting from neurological disorders, including provoked confabulations, fantastic confabulations, false memories, magical thinking, dream delusions, and "fantastic thinking". A comparison of their characteristics, similarities, and differences suggest a hypothesis: despite different sources for their false narrative experiences, such as unusual thoughts or perceptions, all false narratives from brain disease involve erroneous or mismatched "affective biases" applied to the experiences. Affective labels usually signal the sense of rightness, sense of familiarity, and the external vs. internal origin of an experience, and they can be altered by limbic neuropathology. The location and involvement of neuropathology that facilitates false narratives involves frontolimbic regions and their connections, particularly on the right. Future investigations can focus on frontolimbic mechanisms involved in the provision of the intrinsically-linked affective biases, which indicate the nature and external/internal origin of experiences.

Neural correlates of reality filtering in schizophrenia spectrum disorder

BACKGROUND

A false sense of reality is a characteristic of schizophrenia spectrum disorders (SSD). Reality confusion may also emanate from posterior orbitofrontal cortex (OFC) lesions, as evident in confabulations that patients act upon and disorientation. This confusion can be measured by repeated runs of a continuous recognition task (CRT): patients increase their false positive rate from the second run on, failing to realize that an item is not a repetition within the current run. Correct handling of these stimuli, a faculty called orbitofrontal reality filtering (ORFi), induces a distinct frontal potential at 200-300 ms, the "ORFi potential". Patients with schizophrenia have been reported to fail in this task, too. Here, we explored the electrophysiology of ORFi in SSD.

METHODS

Evoked potentials, source, and connectivity analyses derived from high-density electroencephalograms of 17 patients with SSD and 15 age-matched healthy controls performing two runs of a CRT.

RESULTS

Although the patients obtained normal performance, they did not normally express the frontal potential typical of ORFi between 200 and 300 ms. Coherence analysis demonstrated virtually absent functional connectivity in the theta band within the memory network in this period. Source analysis showed increased activity in left medial temporal and prefrontal regions in patients.

CONCLUSIONS

SSD patients appear to invoke compensatory resources to handle the challenges of reality filtering. An abnormal ORFi potential may be an early biomarker of SSD.

Context Memory in Alzheimer's Disease: The "Who, Where, and When"

Objective

Context memory, a component of episodic system, refers to the ability to retrieve conditions under which an event has occurred, such as who was present during that event and where and when it occurred. Context memory has been found to be compromised in older adults, an issue that we investigated in Alzheimer's disease (AD).

Methods

Thirty-one participants with AD and 35 older adults were asked to generate three autobiographical events. Afterward, they were asked to remember the names of all people who were evoked during the events, and the names for any location that was mentioned during the events. Participants were also asked to remember the year, season, month and day of the week when the events occurred.

Results

Compared to older adults, participants with AD showed lower memory for "who" (p < .001), "where" (p < .05), and "when" (p < .01). Compared to "who" and "where", both participants with AD and older adults showed pronounced difficulties in remembering the "when".

Conclusion

these findings highlight difficulties in remembering temporal information as an indication of context memory decline in AD. The difficulties in retrieving temporal information are discussed in terms of timing failures and hippocampal degenerations in AD.

Simultaneous Reality Filtering and Encoding of Thoughts: The Substrate for Distinguishing between Memories of Real Events and Imaginations?

Any thought, whether it refers to the present moment or reflects an imagination, is again encoded as a new memory trace. Orbitofrontal reality filtering (ORFi) denotes an on-line mechanism which verifies whether upcoming thoughts relate to ongoing reality or not. Its failure induces reality confusion with confabulations and disorientation. If the result of this process were simultaneously encoded, it would easily explain later distinction between memories relating to a past reality and memories relating to imagination, a faculty called reality monitoring. How the brain makes this distinction is unknown but much research suggests that it depends on processes active when information is encoded. Here we explored the precise timing between ORFi and encoding as well as interactions between the involved brain structures. We used high-density evoked potentials and two runs of a continuous recognition task (CRT) combining the challenges of ORFi and encoding. ORFi was measured by the ability to realize that stimuli appearing in the second run had not appeared in this run yet. Encoding was measured with immediately repeated stimuli, which has been previously shown to induce a signal emanating from the medial temporal lobe (MTL), which has a protective effect on the memory trace. We found that encoding, as measured with this task, sets in at about 210 ms after stimulus presentation, 35 ms before ORFi. Both processes end at about 330 ms. Both were characterized by increased coherence in the theta band in the MTL during encoding and in the orbitofrontal cortex (OFC) during ORFi. The study suggests a complex interaction between OFC and MTL allowing for thoughts to be re-encoded while they undergo ORFi. The combined influence of these two processes at 200-300 ms may leave a memory trace that allows for later effortless reality monitoring in most everyday situations.

Effectiveness of a neuropsychological treatment for confabulations after brain injury: A clinical trial with theoretical implications

Confabulators consistently generate false memories without intention to deceive and with great feelings of rightness. However, to our knowledge, there is currently no known effective treatment for them. In order to fill this gap, our aim was to design a neuropsychological treatment based on current theoretical models and test it experimentally in 20 confabulators sequentially allocated to two groups: an experimental and a control group. The experimental group received nine sessions of treatment for three weeks (three sessions per week). The sessions consisted of some brief material that participants had to learn and recall at both immediate and delayed time points. After this, patients were given feedback about their performance (errors and correct responses). Pre- and post-treatment measurements were recorded. Confabulators in the control group were included in a waiting list for three weeks, performed the pre- and post- measurements without treatment, and only then received the treatment, after which a post-treatment measurement was recorded. This applied to only half of the participants; the other half quit the study prematurely. Results showed a significant decrease in confabulations and a significant increase in correct responses in the experimental group; by contrast, patients in the control group did not improve during the waiting list period. Only control group patients who subsequently received the treatment after serving as controls improved. The effects of the treatment were generalized to patients’ everyday lives, as reported by relatives, and persisted over time. This treatment seems to be effective and easy to implement and consequently of clinical interest. Moreover, it also has theoretical implications regarding the processes related to the genesis and/or maintenance of confabulations. In particular, results point to a deficit in early stages of memory retrieval with the preservation of later strategic monitoring processes. Specifically, some of the processes involved may include selective attention or early conflict detection deficits. Future research should test these hypotheses.

No Influence of Positive Emotion on Orbitofrontal Reality Filtering: Relevance for Confabulation

Orbitofrontal reality filtering (ORFi) is a mechanism that allows us to keep thought and behavior in phase with reality. Its failure induces reality confusion with confabulation and disorientation. Confabulations have been claimed to have a positive emotional bias, suggesting that they emanate from a tendency to embellish the situation of a handicap. Here we tested the influence of positive emotion on ORFi in healthy subjects using a paradigm validated in reality confusing patients and with a known electrophysiological signature, a frontal positivity at 200-300 ms after memory evocation. Subjects made two continuous recognition tasks ("two runs"), composed of the same set of neutral and positive pictures, but arranged in different order. In both runs, participants had to indicate picture repetitions within, and only within, the ongoing run. The first run measures learning and recognition. The second run, where all items are familiar, requires ORFi to avoid false positive responses. High-density evoked potentials were recorded from 19 healthy subjects during completion of the task. Performance was more accurate and faster on neutral than positive pictures in both runs and for all conditions. Evoked potential correlates of emotion and reality filtering occurred at 260-350 ms but dissociated in terms of amplitude and topography. In both runs, positive stimuli evoked a more negative frontal potential than neutral ones. In the second run, the frontal positivity characteristic of reality filtering was separately, and to the same degree, expressed for positive and neutral stimuli. We conclude that ORFi, the ability to place oneself correctly in time and space, is not influenced by emotional positivity of the processed material.

[Formula: see text]Children's sense of reality: The development of orbitofrontal reality filtering

Orbitofrontal reality filtering denotes a memory control mechanism necessary to keep thought and behavior in phase with reality. In adults, it is mediated by the orbitofrontal cortex and subcortical connections and its failure induces reality confusion, confabulations, and disorientation. Here we investigated for the first time the development of this mechanism in 83 children from ages 7 to 11 years and 20 adults. We used an adapted version of a continuous recognition task composed of two runs with the same picture set but arranged in different order. The first run measures storage and recognition capacity (item memory), the second run measures reality filtering. We found that accuracy and reaction times in response to all stimulus types of the task improved in parallel across ages. Importantly, at no age was there a notable performance drop in the second run. This means that reality filtering was already efficacious at age 7 and then steadily improved as item memory became stronger. At the age of 11 years, reality filtering dissociated from item memory, similar to the pattern observed in adults. However, performance in 11-year-olds was still inferior as compared to adults. The study shows that reality filtering develops early in childhood and becomes more efficacious as memory capacity increases. For the time being, it remains unresolved, however, whether this function already depends on the orbitofrontal cortex, as it does in adults, or on different brain structures in the developing brains of children.

Memory, Decision-Making, and the Ventromedial Prefrontal Cortex (vmPFC): The Roles of Subcallosal and Posterior Orbitofrontal Cortices in Monitoring and Control Processes

The ventromedial prefrontal cortex (vmPFC) prominently and separately features in neurobiological models of decision-making (e.g., value-encoding) and of memory (e.g., automatic veracity-monitoring). Recent decision-making models propose value judgments that inherently comprise of second-order confidence estimates. These demonstrate quadratic relationships with first-order judgments and are automatically encoded in vmPFC activity. Memory studies use Quantity-Accuracy Profiles to capture similar first-order and second-order meta-mnemonic processes, suggesting convergence across domains. Patients with PFC damage answered general knowledge questionnaires under 2 conditions. During forced report, they chose an answer and rated the probability of it being correct (first-order "monitoring"). During free report, they could choose to volunteer or withhold their previous answers (second-order "control") to maximize performance. We found quadratic relationships between first-order and second-order meta-mnemonic processes; voxel-based lesion-symptom mapping demonstrated that vmPFC damage diminished that relationship. Furthermore, damage to subcallosal vmPFC was specifically associated with impaired monitoring and additional damage to posterior orbitofrontal cortex led to deficient control. In decision-making, these regions typically support valuation and choice, respectively. Persistent spontaneous confabulation (false memory production) confirmed the clinical relevance of these dissociations. Compared with patients with no confabulation history, patients who currently confabulate were impaired on both monitoring and control, whereas former confabulators demonstrated impaired monitoring but intact control.

An Electrophysiological Dissociation between Orbitofrontal Reality Filtering and Context Source Monitoring

Memory influences behavior in multiple ways. One important aspect is to remember in what precise context in the past a piece of information was acquired (context source monitoring). Another important aspect is to sense whether an upcoming thought, composed of fragments of memories, refers to present reality and can be acted upon (orbitofrontal reality filtering). Whether these memory control processes share common underlying mechanisms is unknown. Failures of both have been held accountable for false memories, including confabulation. Electrophysiological and imaging studies suggest a dissociation but used very different paradigms. In this study, we juxtaposed the requirements of context source monitoring and reality filtering within a unique continuous recognition task, which healthy participants performed while high-resolution evoked potentials were recorded. The mechanisms dissociated both behaviorally and electrophysiologically: Reality filtering induced a frontal positivity, absence of a specific electrocortical configuration, and posterior medial orbitofrontal activity at 200–300 msec. Context source monitoring had no electrophysiological expression in this early period. It was slower and less accurate than reality filtering and induced a prolonged positive potential over frontal leads starting at 400 msec. The study demonstrates a hitherto unrecognized separation between orbitofrontal reality filtering and source monitoring. Whereas deficient orbitofrontal reality filtering is associated with reality confusion in thinking, the behavioral correlates of deficient source monitoring should be verified with controlled experimental exploration.

Orientation and disorientation: lessons from patients with epilepsy

Orientation in time, space, and person is a fundamental cognitive faculty and the bedrock of neurological and psychiatric mental status examination. Nevertheless, research in orientation and disorientation is neglected in both cognitive science and neuropsychiatry. Specifically, it is still unclear whether disorientations in time, space, and person represent a failure of the same system or merely share a common nomenclature and whether these three domains of orientation depend on different psychological and neural systems. Here, we analyzed descriptions of patients with specific orientation failures associated with circumscribed cortical lesions, with a primary focus on epilepsy. The form of disorientation is analyzed according to its specific domain, the underlying neuropsychiatric disorder, and its anatomical correlate. Disorientations in the different domains are classified as self-referenced (incorrect self-localization) or nonself-referenced (incorrect localization or knowledge of other places, events, and people). Analysis of the cognitive and neural systems disturbed in these patients suggests that disorientation in one or several domains may be related to a failure in a specific brain mechanism localized mostly in the right hemisphere, partially overlapping with the default mode network (mostly the medial and lateral parietal, medial temporal, and lateral prefrontal cortices), which processes essential self-related cognitive faculties such as orientation.

Dreams, reality and memory: confabulations in lucid dreamers implicate reality-monitoring dysfunction in dream consciousness

INTRODUCTION

Dreams might represent a window on altered states of consciousness with relevance to psychotic experiences, where reality monitoring is impaired. We examined reality monitoring in healthy, non-psychotic individuals with varying degrees of dream awareness using a task designed to assess confabulatory memory errors - a confusion regarding reality whereby information from the past feels falsely familiar and does not constrain current perception appropriately. Confabulatory errors are common following damage to the ventromedial prefrontal cortex (vmPFC). Ventromedial function has previously been implicated in dreaming and dream awareness.

METHODS

In a hospital research setting, physically and mentally healthy individuals with high (n = 18) and low (n = 13) self-reported dream awareness completed a computerised cognitive task that involved reality monitoring based on familiarity across a series of task runs.

RESULTS

Signal detection theory analysis revealed a more liberal acceptance bias in those with high dream awareness, consistent with the notion of overlap in the perception of dreams, imagination and reality.

CONCLUSIONS

We discuss the implications of these results for models of reality monitoring and psychosis with a particular focus on the role of vmPFC in default-mode brain function, model-based reinforcement learning and the phenomenology of dreaming and waking consciousness.

Memory consolidation in humans: new evidence and opportunities

We are endlessly fascinated by memory; we desire to improve it and fear its loss. While it has long been recognized that brain regions such as the hippocampus are vital for supporting memories of our past experiences (autobiographical memories), we still lack fundamental knowledge about the mechanisms involved. This is because the study of specific neural signatures of autobiographical memories in vivo in humans presents a significant challenge. However, recent developments in high-resolution structural and functional magnetic resonance imaging coupled with advanced analytical methods now permit access to the neural substrates of memory representations that has hitherto been precluded in humans. Here, I describe how the application of 'decoding' techniques to brain-imaging data is beginning to disclose how individual autobiographical memory representations evolve over time, deepening our understanding of systems-level consolidation. In particular, this prompts new questions about the roles of the hippocampus and ventromedial prefrontal cortex and offers new opportunities to interrogate the elusive memory trace that has for so long confounded neuroscientists.

Orbitofrontal reality filtering

Decades of research have deepened our understanding of how the brain forms memories and uses them to build our mental past and future. But how does it determine whether an evoked memory refers to the present and can be acted upon? The study of patients who confuse reality, as evident from confabulation and disorientation, has opened ways to explore this vital capacity. Results indicate that the brain recurs to a phylogenetically old faculty of the orbitofrontal cortex - extinction - and structures of the reward system to keep thought and behavior in phase with reality.

Isolated prospective confabulation in Wernicke-Korsakoff syndrome: a case for reality filtering

A 57-year-old man suffered severe amnesia and disorientation, accompanied by content-specific confabulation, due to an alcoholic Wernicke-Korsakoff syndrome. For months, he was deeply concerned about a single obligation that he thought he had to respond to, but which he had already assumed 20 years previously. This monothematic, prospective confabulation was associated with failures of reality filtering as previously documented in behaviorally spontaneous confabulation and disorientation: the patient failed to suppress the interference of currently irrelevant memories and to abandon anticipations that were no longer valid (impaired extinction capacity). Magnetic resonance imaging showed damage to the mamillary bodies and the dorsomedial thalamic nucleus. Positron emission tomography (FDG-PET) showed extended orbitofrontal hypometabolism. We suggest that isolated prospective confabulation shares the core feature (acts and thoughts based on currently irrelevant memory), mechanism (failure of reality filtering), and anatomical basis (orbitofrontal dysfunction) with behaviorally spontaneous confabulations.

Dissociable roles for lateral orbitofrontal cortex and lateral prefrontal cortex during preference driven reversal learning

One of the archetypal task manipulations known to depend on frontal-lobe function is reversal learning, where a dominant response must be overridden due to changes in the contingencies relating stimuli, responses, and environmental feedback. Previous studies have indicated that the lateral prefrontal cortex (LPFC), the lateral orbitofrontal cortex (LOFC), the anterior cingulate cortex (ACC), and the caudate nucleus (CN) all contribute to reversal learning. However, the exact contributions that they make during this cognitively complex task remain poorly defined. Here, using functional magnetic resonance imaging, we examine which of the cognitive processes that contribute to the performance of a reversal best predicts the pattern of activation within distinct sub-regions of the frontal lobes. We demonstrate that during reversal learning the LOFC is particularly sensitive to the implementation of the reversal, whereas the LPFC is recruited more generally during attentional control. By contrast, the ACC and CN respond when new searches are initiated regardless of whether the previous response is available, whilst medial orbitofrontal cortex (MOFC) activity is correlated with the positive affect of feedback. These results accord well with the hypothesis that distinct components of adaptable behaviour are supported by anatomically distinct components of the executive system.

Human processing of behaviorally relevant and irrelevant absence of expected rewards: a high-resolution ERP study

Acute lesions of the posterior medial orbitofrontal cortex (OFC) in humans may induce a state of reality confusion marked by confabulation, disorientation, and currently inappropriate actions. This clinical state is strongly associated with an inability to abandon previously valid anticipations, that is, extinction capacity. In healthy subjects, the filtering of memories according to their relation with ongoing reality is associated with activity in posterior medial OFC (area 13) and electrophysiologically expressed at 220-300 ms. These observations indicate that the human OFC also functions as a generic reality monitoring system. For this function, it is presumably more important for the OFC to evaluate the current behavioral appropriateness of anticipations rather than their hedonic value. In the present study, we put this hypothesis to the test. Participants performed a reversal learning task with intermittent absence of reward delivery. High-density evoked potential analysis showed that the omission of expected reward induced a specific electrocortical response in trials signaling the necessity to abandon the hitherto reward predicting choice, but not when omission of reward had no such connotation. This processing difference occurred at 200-300 ms. Source estimation using inverse solution analysis indicated that it emanated from the posterior medial OFC. We suggest that the human brain uses this signal from the OFC to keep thought and behavior in phase with reality.

The false memory syndrome: experimental studies and comparison to confabulations

False memories, or recollections that are factually incorrect but strongly believed, remain a source of confusion for both psychiatrists and neurologists. We propose model for false memories based on recent experimental investigations, particularly when analyzed in comparison to confabulations, which are the equivalent of false memories from neurological disease. Studies using the Deese/Roedinger-McDermott experimental paradigm indicate that false memories are associated with the need for complete and integrated memories, self-relevancy, imagination and wish fulfillment, familiarity, emotional facilitation, suggestibility, and sexual content. In comparison, confabulations are associated with the same factors except for emotional facilitation, suggestibility, and sexual content. Both false memories and confabulations have an abnormal sense of certainty for their recollections, and neuroanatomical findings implicate decreased activity in the ventromedial frontal lobe in this certainty. In summary, recent studies of false memories in comparison to confabulations support a model of false memories as internally-generated but suggestible and emotionally-facilitated fantasies or impulses, rather than repressed memories of real events. Furthermore, like confabulations, in order for false memories to occur there must be an attenuation of the normal, nonconscious, right frontal "doubt tag" regarding their certainty.

Behaviorally spontaneous confabulation in limbic encephalitis: the roles of reality filtering and strategic monitoring

Behaviorally spontaneous confabulation is characterized by a confusion of reality evident in currently inappropriate acts that patients justify with confabulations and in disorientation. Here, we describe a 38-year-old woman lawyer hospitalized because of non-herpetic, presumably autoimmune, limbic encephalitis. For months, she considered herself at work and desperately tried to respect her falsely believed professional obligations. In contrast to a completely erroneous concept of reality, she did not confabulate about her remote personal past. In tasks proposed to test strategic retrieval monitoring, she produced no confabulations. As expected, she failed in tasks of reality filtering, previously shown to have high sensitivity and specificity for behaviorally spontaneous confabulation and disorientation: she failed to suppress the interference of currently irrelevant memories and she had deficient extinction capacity. The observation underscores the special status of behaviorally spontaneous confabulation among confabulatory phenomena and of reality filtering as a thought control mechanism. We suggest that different processes may underlie the generation of false memories and their verbal expression. We also emphasize the need to present theories of confabulation together with experimental tasks that allow one to empirically verify the theories and to explore underlying physiological mechanisms.

Cognitive rehabilitation of episodic memory disorders: from theory to practice

Memory disorders are among the most frequent and most debilitating cognitive impairments following acquired brain damage. Cognitive remediation strategies attempt to restore lost memory capacity, provide compensatory techniques or teach the use of external memory aids. Memory rehabilitation has strongly been influenced by memory theory, and the interaction between both has stimulated the development of techniques such as spaced retrieval, vanishing cues or errorless learning. These techniques partly rely on implicit memory and therefore enable even patients with dense amnesia to acquire new information. However, knowledge acquired in this way is often strongly domain-specific and inflexible. In addition, individual patients with amnesia respond differently to distinct interventions. The factors underlying these differences have not yet been identified. Behavioral management of memory failures therefore often relies on a careful description of environmental factors and measurement of associated behavioral disorders such as unawareness of memory failures. The current evidence suggests that patients with less severe disorders benefit from self-management techniques and mnemonics whereas rehabilitation of severely amnesic patients should focus on behavior management, the transmission of domain-specific knowledge through implicit memory processes and the compensation for memory deficits with memory aids.

Dopaminergic modulation of rapid reality adaptation in thinking

Dopamine has long held a prominent role in the interpretation of schizophrenia and other psychoses. Clinical studies on confabulation and disorientation, disorders marked by a confusion of reality in thinking, indicated that the ability to keep thinking in phase with reality depends on a process suppressing the interference of upcoming memories that do not refer to ongoing reality. A host of animal studies and a recent clinical study suggested that this suppression might correspond to the phasic inhibition of dopaminergic neurons in response to the absence of expected outcomes. In this study, we tested healthy subjects with a difficult version of a memory paradigm on which confabulating patients had failed. Subjects participated in three test sessions, in which they received in double-blind, randomized fashion L-dopa, risperidone, or placebo. We found that l-dopa, in comparison with risperidone, impaired performance in a highly specific way, which corresponded to the pattern of patients with reality confusion. Specifically, they had an increase of false positive responses, while overall memory performance and reaction times were unaffected. We conclude that dopaminergic transmission influences the ability to rapidly adapt thinking to ongoing reality.

Neural response to the behaviorally relevant absence of anticipated outcomes and the presentation of potentially harmful stimuli: A human fMRI study

Adaptive behavior requires the ability to react to potentially harmful stimuli, characterized by high negative inherent emotional salience (iES) (e.g., spiders, snakes), and to the unexpected non-occurrence of anticipated events. When presented simultaneously, threatening stimuli and unexpected absence of anticipated outcomes induce distinct electrocortical responses in different time periods. In this study, we used fMRI to test whether processing of the absence of anticipated outcomes (prediction errors) was anatomically dissociated from the processing of iES or whether iES simply modulated activity of areas processing the non-occurrence of anticipated outcomes. Participants saw two alternating pairs of faces and indicated for each pair which one would have a declared target stimulus on its nose. Depending on the condition, the target stimulus was either a spider (high iES stimulus) or a disk (low iES stimulus). The target stimulus switched to the other face after several consecutive correct responses, with the switch being indicated by the appearance of the alternative stimulus (disk when the spider was the declared target; spider when the disk was the declared target). We found that the spider induced stronger activation in visual areas than the disk. By contrast, the absence of anticipated outcomes specifically activated the orbitofrontal cortex (OFC), irrespective of the iES of the outcome stimulus. The findings support a generic role of the OFC in outcome monitoring.