Confabulation: Damage to a specific inferior medial prefrontal system

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.

Confabulations in a teenager with a right frontal hemispherotomy: Possible underlying mechanisms

Objective: Confabulations, i.e. false memories without intention to deceive, can be observed in adults with frontal brain damage. Confabulations are typically associated with episodic memory and/or executive disorders although the severity of these impairments is highly variable. Confabulations may also be associated with emotional/motivational particularities, as a positive bias seems to prevail in such situations. Several distinct cognitive and socio-affective processes may account for the various types of confabulations and these issues remain open. Method: We present the case of a teenager with an early acquired frontal damage, referred for "strange lies." Besides a standard neuropsychological assessment, we explored (1) source memory, using a reality-monitoring task, (2) episodic autobiographical memory, including both the recollection of the past memories and the ability to imagine future personal events, with an episodic future thinking task (EFT), (3) the sense of self, with questionnaires targeting self-representations, self-esteem and self-competence. Results: The results showed the expected source memory deficits and poor episodic future thinking, whereas episodic autobiographical memory was preserved, contrary to the episodic memory dysfunction usually evidenced in adult confabulators. The confabulations produced by this teenager displayed a clear positive bias, seemed to fit to personal/social goals and to wishful ideations, and were associated with an above average self-esteem and self-representation. Conclusions: These results support the hypothesis of self-identity and emotional regulatory roles of the confabulations. Although the literature on confabulating children/teenagers is nearly non-existent, a more systematic screening of confabulations should be conducted in order to avoid false interpretation to strange discourse or behavior.

Observations on the Clinical Features of the Wernicke-Korsakoff Syndrome

This paper begins with a short case report of florid, spontaneous confabulation in a 61-year-old man with an alcohol-induced Wernicke-Korsakoff syndrome. His confabulation extended across episodic and personal semantic memory, as well as orientation in time and place, as measured on Dalla Barba's Confabulation Battery. Five other brief case summaries will then be presented, followed by a summary of the clinical, neurological, and background neuropsychological findings in three earlier series of Korsakoff patients. These observations will be considered in light of Wijnia's recent and my own, earlier reviews of the Korsakoff syndrome. Taken together, they indicate the need for a multi-faceted approach (clinical, neurological, neuropsychological, and neuroimaging) to the assessment and diagnosis of the disorder.

Impaired attention mechanisms in confabulating patients: A VLSM and DWI study

Attention is one of the most studied cognitive functions in brain-damaged populations or neurological syndromes, as its malfunction can be related to deficits in other higher cognitive functions. In the present study, we aimed at delimiting the attention deficits of a sample of brain-injured patients presenting confabulations by assessing their performance on alertness, spatial orienting, and executive control tasks. Confabulating patients, who present false memories or beliefs without intention to deceive, usually show memory deficits and/or executive dysfunction. However, it is also likely that attention processes may be impaired in patients showing confabulations. Here, we compared confabulating patients' attention performance to a lesion control group and a healthy control group. Confabulating patients' mean overall accuracy was lower than the one of healthy and lesion controls along the three experimental tasks. Importantly, confabulators presented a greater Simon congruency effect than both lesion controls and healthy controls in the presence of predictive spatial cues, besides a lower percentage of hits and longer RTs in the Go-NoGo task, demonstrating deficits in executive control. They also showed a higher reliance on alerting and spatially predictive orienting cues in the context of a deficient performance. Grey and white matter analyses showed that patients' percentage of hits in the Go-NoGo task was related to damage to the right inferior frontal gyrus (pars triangularis and pars opercularis), whereas the integrity of the right inferior fronto-occipital fasciculus was negatively correlated with their alertness effect. These results are consistent with previous literature highlighting an executive dysfunction in confabulating patients, and suggest that some additional forms of attention, such as alertness and spatial orienting, could be selectively impaired in this clinical syndrome.

Substance abuse and susceptibility to false memory formation: a systematic review and meta-analysis

Background

Substance abuse has an impact on various cognitive domains, including memory. Even though this impact has been extensively examined across different subdomains, false memory has been sparsely studied. This systematic review and meta-analysis seek to synthesize the current scientific data concerning false memory formation in individuals with a history of substance abuse.

Methods

PubMed, Scopus, the Cochrane Library, Web of Science, and PsycINFO were searched to identify all experimental and observational studies in English, Portuguese, and Spanish. Studies were then examined by four independent reviewers and, if they met the inclusion criteria, assessed for their quality. The Cochrane Risk of Bias Tool for randomized controlled trials (RCT) and the Joanna Briggs Institute (JBI) critical appraisal checklists for quasi-experimental and analytic cross-sectional studies were used to assess the risk of bias.

Results

From the 443 screened studies, 27 (and two more from other sources) were considered eligible for full-text review. A final 18 studies were included in the present review. Of these, 10 were conducted with alcoholics or heavy drinkers, four focused on ecstasy/polydrug users, three were done with cannabis users and one focused on methadone maintenance patients with current cocaine dependence. Regarding false memory type, 15 studies focused on false recognition/recall, and three on provoked confabulation.

Conclusions

None but one of the studies considering false recognition/recall of critical lures found any significant differences between individuals with a history of substance abuse and healthy controls. However, most of the studies taking into account false recognition/recall of related and unrelated events found that individuals with a history of substance abuse showed significantly higher rates of false memories than controls. Future research should continue to consider different types of false memories as well as their potential association with relevant clinical variables.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266503, identifier: CRD42021266503.

Interventions for confabulation: A systematic literature review

OBJECTIVE

Confabulations are false memories which are expressedwithout the intention to deceive and arise following brain damage or psychological dysfunction. Confabulations can become a barrier to effective neuropsychological rehabilitation and consequently, intervention is required.The current review aimed to provide a detailed evaluative account of existing interventions for confabulation and their relative effectiveness.

METHOD

The search process found 11 studies conducive with the inclusion and exclusion criteria. A methodological quality assessment was then carried out and the majority of included studies demonstrated poor methodological quality.

RESULTS

Ten types of interventions were identified and the majority of theseled to a reduction or elimination of confabulations.

CONCLUSION

Since methodological quality of many included studies was deemed unsatisfactory, further large-scale experimental research and standardised measures are necessary to adequately compare the relative effectiveness of these interventions. Further research and clinical implications are also highlighted.

Fetal alcohol spectrum disorder and confabulation in psycholegal settings: A beginner's guide for criminal justice, forensic mental health, and legal interviewers

Fetal alcohol spectrum disorders (FASD) are neurodevelopmental/neurobehavioral conditions caused by prenatal alcohol exposure (PAE). Impairments caused by PAE contribute to the over-representation of individuals with FASD in the United States juvenile and adult criminal justice systems. These same impairments can equally impact on individuals with FASD who are witnesses to or victims of crime who also have to navigate the complexities of the criminal justice system. Difficulties include increased susceptibility to confabulation throughout the legal process that, in turn, can contribute to increased rates of poor outcomes including false confessions and wrongful convictions. Individuals with FASD are particularity at risk of confabulation when they are subjected to tactics, such as stressful and anxiety-provoking situations, threats, and leading, suggestive, or coercive questioning. Many professionals in the forensic context are unfamiliar with FASD or related confabulation risk and may unintentionally utilize tactics that intensify impacts of pre-existing impairment. This article serves as a beginner's guide for professionals working in criminal justice settings by (a) providing research-based overviews of FASD and confabulation, (b) describing how FASD may lead to confabulation, and (c) suggesting ways that professionals can modify protocols when interacting with individuals with FASD. Suggestions in this article hold the potential to decrease the risk of confabulation in the criminal justice system and decrease problematic outcomes, such as false confessions and wrongful convictions among individuals with FASD.

Understanding, Explanation, and Active Inference

While machine learning techniques have been transformative in solving a range of problems, an important challenge is to understand why they arrive at the decisions they output. Some have argued that this necessitates augmenting machine intelligence with understanding such that, when queried, a machine is able to explain its behaviour (i.e., explainable AI). In this article, we address the issue of machine understanding from the perspective of active inference. This paradigm enables decision making based upon a model of how data are generated. The generative model contains those variables required to explain sensory data, and its inversion may be seen as an attempt to explain the causes of these data. Here we are interested in explanations of one's own actions. This implies a deep generative model that includes a model of the world, used to infer policies, and a higher-level model that attempts to predict which policies will be selected based upon a space of hypothetical (i.e., counterfactual) explanations-and which can subsequently be used to provide (retrospective) explanations about the policies pursued. We illustrate the construct validity of this notion of understanding in relation to human understanding by highlighting the similarities in computational architecture and the consequences of its dysfunction.

The Role of the Ventromedial Prefrontal Cortex and Basal Forebrain in Relational Memory and Inference

The ventromedial prefrontal cortex (vmPFC) is involved in diverse cognitive operations, from inhibitory control to processing of semantic schemas. When accompanied by damage to the basal forebrain, vmPFC lesions can also impair relational memory, the ability to form and recall relations among items. Impairments in establishing direct relations among items (e.g., A is related to B, B is related to C) can also hinder the transitive processing of indirect relationships (e.g., inferring that A and C are related through direct relations that each contain B). Past work has found that transitive inference improves when the direct relations are organized within an existing knowledge structure, or schema. This type of semantic support is most effective for individuals whose relational memory deficits are mild (e.g., healthy age-related decline) rather than pronounced (e.g., hippocampal amnesia, amnestic mild cognitive impairment). Given that vmPFC damage can produce both relational memory and schema processing deficits, such damage may pose a particular challenge in establishing the type of relational structure required for transitive inference, even when supported by preexisting knowledge. To examine this idea, we tested individuals with lesions to the mPFC on multiple conditions that varied in pre-experimental semantic support and explored the extent to which they could identify both previously studied (direct) and novel transitive (indirect) relations. Most of the mPFC cases showed marked transitive inference deficits and even showed impaired knowledge of preexisting, direct, semantic relations, consistent with disruptions to schema-related processes. However, one case with more dorsal mPFC damage showed preserved ability to identify direct relations and make novel inferences, particularly when pre-experimental knowledge could be used to support performance. These results suggest that damage to the mPFC and basal forebrain can impede establishment of ad hoc relational schemas upon which transitive inference is based, but that appealing to prior knowledge may still be useful for those neurological cases that have some degree of preserved relational memory.

Confabulations in Cases of Dementia: Atypical Early Sign of Alzheimer’s Disease or Misleading Feature in Dementia Diagnosis?

Confabulations, also known as false memories, have been associated with various diseases involving mainly the frontal areas, such as Wernicke–Korsakoff syndrome or frontal epilepsy. The neuropsychological dysfunctions underlying mechanisms of confabulation are not well known. We describe two patients with memory impairment and confabulations at the onset speculating about neuropsychological correlates of confabulations and self-awareness. Both patients, a 77-year-old woman and a 57-years-old man, exhibited confabulations as first symptom of cognitive decline. She later developed memory impairment without awareness of her memory deficits and her cognitive and imaging profile suggested an amnesic mild cognitive impairment due to Alzheimer’s disease (AD). Unlike her, he developed a prevalent involvement of frontal functions despite a clear consciousness of his cognitive deficits. However, the clinical diagnostic hypothesis of behavioral variant of frontotemporal dementia was not supported by imaging findings, which suggested AD. Both patients underwent neuropsychological evaluation including the Confabulation Battery. Despite that the exact anatomical correlation of confabulations is still not defined, imaging data shown by our patients is consistent with recent theories according to which at the origin of confabulatory tendency in AD there is an impairment of the connections between crucial hubs in frontal and mediotemporal areas, mainly involving the right hemisphere. Besides, it would be reasonable to hypothesize that self-awareness and confabulations should not be considered as necessarily associated dimensions.

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.

Anomalies of Autobiographical Memory

OBJECTIVES

In this paper, I review three 'anomalies' or disorders in autobiographical memory: neurological retrograde amnesia (RA), spontaneous confabulation, and psychogenic amnesia.

METHODS

Existing theories are reviewed, their limitations considered, some of my own empirical findings briefly described, and possible interpretations proposed and interspersed with illustrative case-reports.

RESULTS

In RA, there may be an important retrieval component to the deficit, and factors at encoding may give rise to the relative preservation of early memories (and the reminiscence bump) which manifests as a temporal gradient. Spontaneous confabulation appears to be associated with a damaged 'filter' in orbitofrontal and ventromedial frontal regions. Consistent with this, an empirical study has shown that both the initial severity of confabulation and its subsequent decline are associated with changes in the executive function (especially in cognitive estimate errors) and inversely with the quantity of accurate autobiographical memories retrieved. Psychogenic amnesia can be 'global' or 'situation-specific'. The former is associated with a precipitating stress, depressed mood, and (often) a past history of a transient neurological amnesia. In these circumstances, frontal control mechanisms can inhibit retrieval of autobiographical memories, and even the sense of 'self' (identity), while compromised medial temporal function prevents subsequent retrieval of what occurred during a 'fugue'. An empirical investigation of psychogenic amnesia and some recent imaging studies have provided findings consistent with this view.

CONCLUSIONS

Taken together, these various observations point to the importance of frontal 'control' systems (in interaction with medial temporal/hippocampal systems) in the retrieval and, more particularly, the disrupted retrieval of 'old' memories.

Believing in dopamine

Midbrain dopamine signals are widely thought to report reward prediction errors that drive learning in the basal ganglia. However, dopamine has also been implicated in various probabilistic computations, such as encoding uncertainty and controlling exploration. Here, we show how these different facets of dopamine signalling can be brought together under a common reinforcement learning framework. The key idea is that multiple sources of uncertainty impinge on reinforcement learning computations: uncertainty about the state of the environment, the parameters of the value function and the optimal action policy. Each of these sources plays a distinct role in the prefrontal cortex-basal ganglia circuit for reinforcement learning and is ultimately reflected in dopamine activity. The view that dopamine plays a central role in the encoding and updating of beliefs brings the classical prediction error theory into alignment with more recent theories of Bayesian reinforcement learning.

Memory Dysfunction

PURPOSE OF REVIEW

This article reviews the current understanding of memory system anatomy and physiology, as well as relevant evaluation methods and pathologic processes.

RECENT FINDINGS

Our understanding of memory formation advances each year. Successful episodic memory formation depends not only on intact medial temporal lobe structures but also on well-orchestrated interactions with other large-scale brain networks that support executive and semantic processing functions. Recent discoveries of cognitive control networks have helped in understanding the interaction between memory systems and executive systems. These interactions allow access to past experiences and enable comparisons between past experiences and external and internal information. The semantic memory system is less clearly defined anatomically. Anterior, lateral, and inferior temporal lobe regions appear to play a crucial role in the function of the semantic processing system. Different but tightly interconnected cortical regions, such as the prefrontal region, may play a controlling role in this system. The presentation of clinical disease affecting memory is the result of the selective vulnerability of the memory system. An understanding of current concepts of memory anatomy, physiology, and evaluation plays a central role in establishing an accurate diagnosis.

SUMMARY

Different memory systems rely on separate but overlapping distributed brain networks. Certain pathologic processes preferentially affect memory systems. An understanding of memory formation stages will enable more accurate diagnosis.

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.

The Neural Dynamics of Novel Scene Imagery

Retrieval of long-term episodic memories is characterized by synchronized neural activity between hippocampus and ventromedial prefrontal cortex (vmPFC), with additional evidence that vmPFC activity leads that of the hippocampus. It has been proposed that the mental generation of scene imagery is a crucial component of episodic memory processing. If this is the case, then a comparable interaction between the two brain regions should exist during the construction of novel scene imagery. To address this question, we leveraged the high temporal resolution of MEG to investigate the construction of novel mental imagery. We tasked male and female humans with imagining scenes and single isolated objects in response to one-word cues. We performed source-level power, coherence, and causality analyses to characterize the underlying interregional interactions. Both scene and object imagination resulted in theta power changes in the anterior hippocampus. However, higher theta coherence was observed between the hippocampus and vmPFC in the scene compared with the object condition. This interregional theta coherence also predicted whether imagined scenes were subsequently remembered. Dynamic causal modeling of this interaction revealed that vmPFC drove activity in hippocampus during novel scene construction. Additionally, theta power changes in the vmPFC preceded those observed in the hippocampus. These results constitute the first evidence in humans that episodic memory retrieval and scene imagination rely on similar vmPFC–hippocampus neural dynamics. Furthermore, they provide support for theories emphasizing similarities between both cognitive processes and perspectives that propose the vmPFC guides the construction of context-relevant representations in the hippocampus.

SIGNIFICANCE STATEMENT Episodic memory retrieval is characterized by a dialog between hippocampus and ventromedial prefrontal cortex (vmPFC). It has been proposed that the mental generation of scene imagery is a crucial component of episodic memory processing. An ensuing prediction would be of a comparable interaction between the two brain regions during the construction of novel scene imagery. Here, we leveraged the high temporal resolution of MEG and combined it with a scene imagination task. We found that a hippocampal–vmPFC dialog existed and that it took the form of vmPFC driving the hippocampus. We conclude that episodic memory and scene imagination share fundamental neural dynamics and the process of constructing vivid, spatially coherent, contextually appropriate scene imagery is strongly modulated by vmPFC.

Remote Memory and the Hippocampus: A Constructive Critique

The hippocampus is known to be recruited during the recall of experiences from our distant past, despite evidence that memory traces in this region vanish over time. Extant theories of systems-level consolidation have yet to accommodate both phenomena. We propose that the hippocampus reconstructs remote memories in the absence of the original trace. It accomplishes this by assembling consolidated neocortical elements into spatially coherent scenes that form the basis of unfolding memory events. This reconstruction is likely facilitated by input from the ventromedial prefrontal cortex. This process-oriented approach to hippocampal recruitment during remote recollection is consistent with its increasingly acknowledged role in constructing mental representations beyond the domain of memory.

Enhanced brain activity associated with memory access in highly superior autobiographical memory

Brain systems underlying human memory function have been classically investigated studying patients with selective memory impairments. The discovery of rare individuals who have highly superior autobiographical memory (HSAM) provides, instead, an opportunity to investigate the brain systems underlying enhanced memory. Here, we carried out an fMRI investigation of a group of subjects identified as having HSAM. During fMRI scanning, eight subjects with HSAM and 21 control subjects were asked to retrieve autobiographical memories (AMs) as well as non-AMs (e.g., examples of animals). Subjects were instructed to signal the "access" to an AM by a key press and to continue "reliving" it immediately after. Compared with controls, individuals with HSAM provided a richer AM recollection and were faster in accessing AMs. The access to AMs was associated with enhanced prefrontal/hippocampal functional connectivity. AM access also induced increased activity in the left temporoparietal junction and enhanced functional coupling with sensory cortices in subjects with HSAM compared with controls. In contrast, subjects with HSAM did not differ from controls in functional activity during the reliving phase. These findings, based on fMRI assessment, provide evidence of interaction of brain systems engaged in memory retrieval and suggest that enhanced activity of these systems is selectively involved in enabling more efficient access to past experiences in HSAM.

Nonmonotonic recruitment of ventromedial prefrontal cortex during remote memory recall

Systems-level consolidation refers to the time-dependent reorganisation of memory traces in the neocortex, a process in which the ventromedial prefrontal cortex (vmPFC) has been implicated. Capturing the precise temporal evolution of this crucial process in humans has long proved elusive. Here, we used multivariate methods and a longitudinal functional magnetic resonance imaging (fMRI) design to detect, with high granularity, the extent to which autobiographical memories of different ages were represented in vmPFC and how this changed over time. We observed an unexpected time course of vmPFC recruitment during retrieval, rising and falling around an initial peak of 8–12 months, before reengaging for older 2- and 5-year-old memories. This pattern was replicated in 2 independent sets of memories. Moreover, it was further replicated in a follow-up study 8 months later with the same participants and memories, for which the individual memory representations had undergone their hypothesised strengthening or weakening over time. We conclude that the temporal engagement of vmPFC in memory retrieval seems to be nonmonotonic, revealing a complex relationship between systems-level consolidation and prefrontal cortex recruitment that is unaccounted for by current theories.

Our past experiences are captured in autobiographical memories that allow us to recollect events from our lives long after they originally occurred. A part of the brain’s frontal lobe, called the ventromedial prefrontal cortex (vmPFC), is known to be important for supporting autobiographical memories, especially as memories become more remote. The precise temporal profile of the vmPFC’s involvement is unclear, yet this information is vital if we are to understand how memories change over time and the mechanisms involved. In this study, we sought to establish the time course of vmPFC engagement in the recollection of autobiographical memories while participants recalled memories of different ages during functional magnetic resonance imaging (fMRI). Using a method that detects the brain activity patterns associated with individual memories, we found that memory-specific neural patterns in vmPFC became more distinct over the first few months after a memory was formed, but then this initial involvement of vmPFC subsided after 1 year. However, more remote memories (2 years and older) appeared to reengage vmPFC once again. This temporal profile is difficult to accommodate within any single existing theory. Consequently, our results provoke a rethink about how memories evolve over time and the role played by the vmPFC.

Human lesion studies of ventromedial prefrontal cortex

Studies of neurological patients with focal lesions involving ventromedial prefrontal cortex (vmPFC) have demonstrated a critical role for this brain area in various aspects of cognition, emotion, and behavior. In this article, we review the key themes, methods, and findings from neuropsychological research on vmPFC lesion patients. Early case studies demonstrated profound disruptions in personality and behavior following vmPFC damage, including blunted affect, poor decision-making, and inappropriate social behavior. Subsequent laboratory investigations with groups of vmPFC lesion patients have revealed deficits in a host of interrelated functions, such as value-based decision-making, future and counterfactual thinking, physiological arousal to emotional stimuli, emotion recognition, empathy, moral judgment, and memory confabulation. The compendium of findings described here demonstrates that vmPFC is crucial for diverse aspects of adaptive function.

Psychosis in parkinsonism: an unorthodox approach

Psychosis in Parkinson's disease (PD) is currently considered as the occurrence of hallucinations and delusions. The historical meaning of the term psychosis was, however, broader, encompassing a disorganization of both consciousness and personality, including behavior abnormalities, such as impulsive overactivity and catatonia, in complete definitions by the International Classification of Diseases-10 (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Our review is aimed at reminding that complex psychotic symptoms, including impulsive overactivity and somatoform disorders (the last being a recent controversial entity in PD), were carefully described in postencephalitic parkinsonism (PEP), many decades before dopaminergic treatment era, and are now described in other parkinsonisms than PD. Eminent neuropsychiatrists of the past century speculated that studying psychosis in PEP might highlight its mechanisms in other conditions. Yet, functional assessments were unavailable at the time. Therefore, the second part of our article reviews the studies of neural correlates of psychosis in parkinsonisms, by taking into account both theories on the narrative functions of the default mode network (DMN) and hypotheses on DMN modulation.

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.

Confabulation in children with autism

Some children with high-functioning autistic spectrum conditions (ASC) have been noted clinically to produce accounts and responses akin to confabulations in neurological patients. Neurological confabulation is typically associated with abnormalities of the frontal lobes and related structures, and some forms have been linked to poor performance on source monitoring and executive function tasks. ASC has also been linked to atypical development of the frontal lobes, and impaired performance on source monitoring and executive tasks. But confabulation in autism has not to our knowledge previously been examined experimentally. So we investigated whether patterns of confabulation in autism might share similarities with neurologically-based confabulation. Tests of confabulation elicitation, source monitoring (reality monitoring, plus temporal and task context memory) and executive function were administered to four adolescents with ASC who had previously been noted to confabulate spontaneously in everyday life. Scores were compared to a typically developing (TD) and an ASC control group. One confabulating participant was significantly impaired at reality monitoring, and one was significantly worse at a task context test, relative to both the ASC and TD controls. Three of the confabulators showed impairment on measures of executive function (Brixton test; Cognitive Estimates test; Hayling Test B errors) relative to both control groups. Three were significantly poorer than the TD controls on two others (Hayling A and B times), but the ASC control group was also significantly slower at this test than the TD controls. Compared to TD controls, two of the four confabulating participants produced an abnormal number of confabulations during a confabulation elicitation questionnaire, where the ASC controls and TD controls did not differ from each other. These results raise the possibility that in at least some cases, confabulation in autism may be less related to social factors than it is to impaired source memory or poor executive function.

Medio-dorsal thalamus and confabulations: Evidence from a clinical case and combined MRI/DTI study

The Medio-Dorsal Nuclei (MDN) including the thalamic magnocellular and parvocellular thalamic regions has been implicated in verbal memory function. In a 77 year old lady, with a prior history of a clinically silent infarct of the left MDN, we observed the acute onset of spontaneous confabulations when an isolated new infarct occurred in the right MDN. The patient and five age-matched healthy subjects underwent Magnetic Resonance Imaging (MRI) and Diffusion Tensor Imaging (DTI). The thalamic lesions were localized by overlapping Morel Thalamic Atlas with structural MRI data. DTI was used to assess: i) white matter alterations (Fractional Anisotropy, FA) within fibers connecting the ischemic areas to cortex; ii) the micro-structural damage (Mean Diffusivity) within the thalamic sub-regions defined by their structural connectivity to the Anterior Cingulate Cortex (ACC) and to the temporal lobes. These target regions were chosen because their damage is considered associated with the appearance of confabulations. Thalamic lesions were localized within the parvocellular regions of the right and left MDNs. The structural connectivity study showed that the fiber tracts, connecting the bilaterally damaged thalamic regions with the frontal cortex, corresponded to the anterior thalamic radiations (ATR). FA within these tracts was significantly lower in the patient as compared to controls. Mean diffusivity within the MDNs projecting to Broadman area (BA) 24, BA25 and BA32 of ACC was significantly higher in the patient than in control group. Mean diffusivity values within the MDN projecting to temporal lobes in contrast were not different between patient and controls. Our findings suggest the involvement of bilateral MDNs projections to ACC in the genesis of confabulations and help provide clarity to the longstanding debate on the origin of confabulations.

Fantastic confabulation in right frontal lobe epilepsy

Background

Interictal behavioral symptoms in frontal lobe epilepsy (FLE) are variable and often difficult to discriminate from other localization-related epilepsies.

Methods and results

We report two female patients with right FLE who exhibited fantastic confabulations. One of the patients had a 14-year history of hypermotor seizures, and the other had a 10-year history of dyscognitive seizures with automatism. Their fantastic confabulations arose in the context of moderate-to-severe cognitive impairment and of a variety of behavioral abnormalities, including emotional withdrawal and compulsive behaviors.

Conclusion

Fantastic confabulations are rare but may be a relatively specific behavioral marker for FLE-associated psychosis.

Self-representation in delusional misidentification and confabulated "others"

In some instances the ostensibly false narratives produced by patients with delusional misidentification syndromes (DMS) or confabulation may - unbeknownst to the patient - contain some authentic self-referential information. In this review, extracted from a video library or verbatim transcripts of approximately 50 clinical cases with either delusional misidentification or some variety of confabulation, we identified four cases (Feinberg, 2001, 2009, 2010; Feinberg & Shapiro, 1989) with either DMS for persons or confabulations about "phantom" persons, who showed prominent "self-referential" (SR) narratives. The presence of self-referential narratives was judged by: 1) the misidentification or confabulation was generally consistent and repeatable, e.g., the narrative was repeated on more than one occasion and not variably "provoked," 2) the content of the delusional misidentifications or confabulations were facts, feelings, or motivations that were true of the patients themselves either by history obtained from collateral sources (medical records, family, friends, etc.) or by admission by the patients themselves, but were attributed to a "double" of confabulated person, 3) these facts or feelings attributed to the "double" or confabulated "other" were either denied by the patients or admitted but also attributed to the "other." For purposes of comparison we also selected from the original group of 50 patients four "comparison" cases with delusional misidentification for persons and/or confabulation who based on these same criteria for self-referential material, were judged not to show self-referential (SR) aspects (Comparison cases 1-4). The neuroanatomy and neurocognitive features of these cases are reviewed and compared, the possible role of psychological defense in the self-referential cases is considered, and a model that integrates the neuroanatomical, neuropsychological and dynamic psychological aspects of these self-related disorders is offered. We propose that an appreciation of these self-related productions could have significant clinical and therapeutic implications.

The Doors and People Test: The effect of frontal lobe lesions on recall and recognition memory performance

OBJECTIVE

Memory deficits in patients with frontal lobe lesions are most apparent on free recall tasks that require the selection, initiation, and implementation of retrieval strategies. The effect of frontal lesions on recognition memory performance is less clear with some studies reporting recognition memory impairments but others not. The majority of these studies do not directly compare recall and recognition within the same group of frontal patients, assessing only recall or recognition memory performance. Other studies that do compare recall and recognition in the same frontal group do not consider recall or recognition tests that are comparable for difficulty. Recognition memory impairments may not be reported because recognition memory tasks are less demanding.

METHOD

This study aimed to investigate recall and recognition impairments in the same group of 47 frontal patients and 78 healthy controls. The Doors and People Test was administered as a neuropsychological test of memory as it assesses both verbal and visual recall and recognition using subtests that are matched for difficulty.

RESULTS

Significant verbal and visual recall and recognition impairments were found in the frontal patients.

CONCLUSION

These results demonstrate that when frontal patients are assessed on recall and recognition memory tests of comparable difficulty, memory impairments are found on both types of episodic memory test.

Disturbance of time orientation, attention, and verbal memory in amnesic patients with confabulation

Confabulation is often observed in amnesic patients after brain damage. However, evidence regarding the relationship between confabulation and other neuropsychological functions is scarce. In addition, previous studies have proposed two possibilities of the relationship between confabulation and false memory, in which patients with confabulation are likely to retrieve false memories, or confabulations are relatively independent of false memories. The present study investigated how confabulation is related to various cognitive functions, including orientation, attention, frontal lobe function, memory, and mental status, and to false memories, as assessed by the Deese-Roediger-Mcdermott (DRM) paradigm. Patients with organic amnesia participated, and confabulations were evaluated using the Confabulation Battery. Amnestic patients were classified into two groups: confabulating (CP) and nonconfabulating patients (NCP). The CP group was significantly impaired in time orientation, attention, and verbal memory, compared to the NCP group and age-matched healthy controls (HC). Results of the DRM paradigm revealed no significant difference in false memory retrieval induced by critical lures across CP, NCP, and HC groups. Confabulating responses in organic amnesia could be in part induced by disturbance of time consciousness and attention control in severe impairment of verbal memories, and confabulation and false memory could be modulated by different cognitive systems.

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.

Schema representation in patients with ventromedial PFC lesions

Human neuroimaging and animal studies have recently implicated the ventromedial prefrontal cortex (vmPFC) in memory schema, particularly in facilitating new encoding by existing schemas. In humans, the most conspicuous memory disorder following vmPFC damage is confabulation; strategic retrieval models suggest that aberrant schema activation or reinstatement plays a role in confabulation. This raises the possibility that beyond its role in schema-supported memory encoding, the vmPFC is also implicated in schema reinstatement itself. If that is the case, vmPFC lesions should lead to impaired schema-based operations, even on tasks that do not involve memory acquisition. To test this prediction, ten patients with vmPFC damage, four with present or prior confabulation, and a group of twelve matched healthy controls made speeded yes/no decisions as to whether words were closely related to a schema (a visit to the doctor). Ten minutes later, they repeated the task for a new schema (going to bed) with some words related to the first schema included as lures. Last, they rated the degree to which stimuli were related to the second schema. All four vmPFC patients with present or prior confabulation were impaired in rejecting lures and in classifying stimulus belongingness to the schema, even when they were not lures. Nonconfabulating patients performed comparably to healthy adults with high accuracy, comparable reaction times, and similar ratings. These results show for the first time that damage to the human vmPFC, when associated with confabulation, leads to deficient schema reinstatement, which is likely a prerequisite for schema-mediated memory integration.

Ventromedial prefrontal cortex supports affective future simulation by integrating distributed knowledge

Although the future often seems intangible, we can make it more concrete by imagining prospective events. Here, using functional MRI, we demonstrate a mechanism by which the ventromedial prefrontal cortex supports such episodic simulations, and thereby contributes to affective foresight: This region supports processes that (i) integrate knowledge related to the elements that constitute an episode and (ii) represent the episode's emergent affective quality. The ventromedial prefrontal cortex achieves such integration via interactions with distributed cortical regions that process the individual elements. Its activation then signals the affective quality of the ensuing episode, which goes beyond the combined affective quality of its constituting elements. The integrative process further augments long-term retention of the episode, making it available at later time points. This mechanism thus renders the future tangible, providing a basis for farsighted behavior.

Imaging autobiographical memory

Autobiographical memory (AM) defines the memory systems that encode, consolidate, and retrieve personal events and facts, AM is strongly related to self-perception and self representation. We review here the neural correlates of AM retrieval. AM retrieval encompasses a large neural network including the prefrontal, temporal, and parietal cortex, and limbic structures. All these regions subserve the cognitive processes (episodic remembering, cognitive control, self-processing, and scene construction) at play during memory retrieval. We emphasize the specific role of medial prefrontal cortex and precuneus in self-processing during autobiographical memory retrieval. Overall, these data call for further studies in psychiatric patients, to investigate the neural underpinnings of autobiographical memory and self-representation in mental disorders.

Insights into human behavior from lesions to the prefrontal cortex

The prefrontal cortex (PFC), a cortical region that was once thought to be functionally insignificant, is now known to play an essential role in the organization and control of goal-directed thought and behavior. Neuroimaging, neurophysiological, and modeling techniques have led to tremendous advances in our understanding of PFC functions over the last few decades. It should be noted, however, that neurological, neuropathological, and neuropsychological studies have contributed some of the most essential, historical, and often prescient conclusions regarding the functions of this region. Importantly, examination of patients with brain damage allows one to draw conclusions about whether a brain area is necessary for a particular function. Here, we provide a broad overview of PFC functions based on behavioral and neural changes resulting from damage to PFC in both human patients and nonhuman primates.

Psychosis, agnosia, and confabulation: an alternative two-factor account

INTRODUCTION

Theories of delusions which rely on a combination of abnormal experience and defective belief evaluation and/ or cognitive bias are the subject of an emerging consensus. This paper challenges the validity of these theories and constructs a two factor alternative.

METHODS

The paper starts by identifying the difficulty the current theories have explaining the complex delusions of schizophrenia and then, by considering, first, the aetiology of somatopsychotic symptoms, and second, the literature on the relationship between confabulation and allopsychotic symptoms, demonstrates that the natural solution is to retain the experiential factor whilst replacing the second factor with confabulation.

RESULTS

The paper is then able to demonstrate that the resultant two-factory theory can clarify recent work on the aetiological role of autonoetic agnosia and on the relationships between confabulation, delusion, and thought disorder.

CONCLUSIONS

The theory supersedes currently available theories in terms of its simplicity, fruitfulness, scope and conservatism and represents an advance in the search for unified theory of psychosis.

Perseverations and non-verbal confabulations on the Rey-Osterrieth Complex Figure Test in a fronto-temporal dementia single case study

We describe the case of a patient with late onset fronto-temporal dementia (FTD), who presented with typical personality changes, but also perseverative and confabulatory behaviors while performing the Rey-Osterrieth Complex Figure Test. We hypothesize that the progressive atrophy of orbitobasal, medial, and dorsolateral frontal cortices may give rise to both confabulations and perseverations in the non-verbal domain. In agreement with previous studies, reporting atypical profiles, this case report underlines the clinical heterogeneity of FTD. Authors declare that they have no conflicts of interest.

On the Imposition of Torture, an Extreme Stressor State, to Extract Information From Memory

There is a widespread and popularly-held belief that the imposition of extreme stressor states (torture) is efficacious at facilitating the release of intentionally-withheld information from (human) memory. Here, I explore why this belief is so widespread. I examine the folk model of the brain and behavior that underpins this belief, and show that this folk model is utterly inconsistent with what we currently know about the effects of extreme stressor states on the brain systems that support memory and executive function. Scientific evidence on how repeated and extreme stress and pain affect memory and executive functions (such as planning or forming intentions) suggests that subjecting individuals to such states is unlikely to do anything other than the opposite of what is intended by coercive or “enhanced” interrogation. Coercive interrogations involving imposition of extreme stressor states are unlikely to facilitate the release of veridical information from long-term memory, given our current cognitive neurobiological knowledge. On the contrary, these techniques cause severe, repeated, and prolonged stress, which compromises brain tissue supporting memory and executive function. The fact that the detrimental effects of these techniques on the brain are not visible to the naked eye makes them no less real.

When Rey-Osterrieth's Complex Figure Becomes a Church: Prevalence and Correlates of Graphic Confabulations in Dementia

Verbal confabulation (VC) has been described in several pathological conditions characterized by amnesia and has been defined as 'statements that involve distortion of memories'. Here we describe another kind of confabulation (graphic confabulation, GC), evident at the recall of the Rey-Osterrieth complex figure (ROCF). In a retrospective study of 267 patients with mild-to-moderate dementia, 14 patients (4.9 %) recalled the abstract ROCF as drawings with recognizable semantic meaning. VC was evident at the story recall test in 19.8% of the study participants. VC and GC were homogeneously distributed among the different types of dementia. VC has been proposed to originate from complex interactions of amnesia, motivational deficit and dysfunction of monitoring systems. On the contrary, GC seems to be the result of a deficit in visual memory replaced by the semantic translation of isolated parts of the ROCF along with a source monitoring deficit.