Successful life outcome and management of real-world memory demands despite profound anterograde amnesia

A case of severe anterograde amnesia in the era of smartphone technology

A.V. is a young herpes simplex encephalitis (HSE) survivor who suffered extensive bilateral damage to the medial temporal lobe (MTL) leading to a severe and pervasive form of anterograde amnesia. Structural Magnetic Resonance Imaging (MRI) revealed lesions that encompass the hippocampus and amygdala in both hemispheres and that extend more laterally in the right temporal lobe. At the same time, detailed neuropsychological testing showed that the disparity between A.V.'s preserved intellectual functioning (Full Scale IQ: 115) and severe memory deficit (Delayed Memory Index: 42) is one of the largest on record. Despite this deficit, A.V. has regained a higher level of functioning and autonomy compared to previously documented amnesic cases with major bilateral MTL lesions. As a millennial, one advantage which A.V. has over prior amnesic cases is fluency with digital technology - particularly the smartphone. The analysis of his phone and specific app usage showed a pattern that is consistent with the strategy to offload cognitive tasks that would normally be supported by the MTL. A.V.'s behavior is significant in terms of rehabilitation and may have broader implications at the societal level and for public health given the ubiquity of smartphone technology and its potential to become integrated with neural mnemonic functions.

Amygdala but not hippocampal damage associated with smaller social network size

Social network size has been associated with complex socio-cognitive processes (e.g., memory, perspective taking). Supporting this idea, recent neuroimaging studies in healthy adults have reported a relationship between social network size and brain volumes in regions related to memory and social cognition (e.g., hippocampus, amygdala). Lesion-deficit studies in neurological patients are rare and have been inconclusive due to differences in participant sampling and measurement. The present study uses a multiple case study approach. We investigated patients with focal damage to the hippocampus and/or amygdala (two neural structures thought to be critical for social networks), and examined the patients' social network size, loneliness, and life satisfaction relative to a non-injured comparison group. Patients with amygdalar damage had smaller social networks and reported higher levels of loneliness and lower life satisfaction, on average, than comparison participants. Patients with damage to the hippocampus reported more friends than the comparison participants, but did not differ in their ratings of loneliness or life satisfaction. This lesion study offers new evidence that the amygdala is critical for social networks, life satisfaction, and reduced loneliness.

The Value of Patient Registries to Advance Basic and Translational Research in the Area of Traumatic Brain Injury

The number of individuals affected by traumatic brain injury (TBI) is growing globally. TBIs may cause a range of physical, cognitive, and psychiatric deficits that can negatively impact employment, academic attainment, community independence, and interpersonal relationships. Although there has been a significant decrease in the number of injury related deaths over the past several decades, there has been no corresponding reduction in injury related disability over the same time period. We propose that patient registries with large, representative samples and rich multidimensional and longitudinal data have tremendous value in advancing basic and translational research and in capturing, characterizing, and predicting individual differences in deficit profile and outcomes. Patient registries, together with recent theoretical and methodological advances in analytic approaches and neuroscience, provide powerful tools for brain injury research and for leveraging the heterogeneity that has traditionally been cited as a barrier inhibiting progress in treatment research and clinical practice. We report on our experiences, and challenges, in developing and maintaining our own patient registry. We conclude by pointing to some future opportunities for discovery that are afforded by a registry model.

Who Are You? The Study of Personality in Patients With Anterograde Amnesia

Little is known about the role of declarative memory in the ongoing perception of one's personality. Seven individuals who developed a rare and severe type of anterograde amnesia following damage to their medial temporal lobes were identified from our neurological patient registry. We examined the stability of their personality ratings on the Big Five Inventory over five retest periods and assessed the accuracy of their ratings via analyses of self-caregiver agreement. The patients portrayed a stable sense of self over the course of 1 year. However, their self-ratings differed from those provided by the caregivers. Intriguingly, these discrepancies diminished when caregivers retrospectively rated the patients' personalities prior to their brain injury, suggesting that patients' perceptions of themselves were stuck in the past. We interpret our findings to indicate that the ability to form new declarative memories is not required for maintaining a stable sense of self but may be important for updating one's sense of self over time.

Gesture height reflects common ground status even in patients with amnesia

When we communicate, we alter our language and gesture based on the mutually shared knowledge - common ground - that we have with our listener. How memory supports these alterations remain unclear. We asked healthy adults and patients with hippocampal amnesia to engage in a referential communication task. Previous work suggests that common ground can be encoded by distinct memory systems; Amnesic patients show normal learning and referential label use as common ground increases, but inconsistently mark these labels with definite determiners (e.g., the vs. a windmill). Which memory systems support the ability to mark common ground via hand gesture? We found that gestures of both healthy participants and amnesic patients reflected common ground status. Both groups produced high gestures when common ground was lacking, and were less likely to do so as common ground increased. These findings suggest that gesture can reflect common ground status during conversation, potentially via non-declarative memory.

Comparing and Contrasting the Cognitive Effects of Hippocampal and Ventromedial Prefrontal Cortex Damage: A Review of Human Lesion Studies

The hippocampus and ventromedial prefrontal cortex (vmPFC) are closely connected brain regions whose functions are still debated. In order to offer a fresh perspective on understanding the contributions of these two brain regions to cognition, in this review we considered cognitive tasks that usually elicit deficits in hippocampal-damaged patients (e.g., autobiographical memory retrieval), and examined the performance of vmPFC-lesioned patients on these tasks. We then took cognitive tasks where performance is typically compromised following vmPFC damage (e.g., decision making), and looked at how these are affected by hippocampal lesions. Three salient motifs emerged. First, there are surprising gaps in our knowledge about how hippocampal and vmPFC patients perform on tasks typically associated with the other group. Second, while hippocampal or vmPFC damage seems to adversely affect performance on so-called hippocampal tasks, the performance of hippocampal and vmPFC patients clearly diverges on classic vmPFC tasks. Third, although performance appears analogous on hippocampal tasks, on closer inspection, there are significant disparities between hippocampal and vmPFC patients. Based on these findings, we suggest a tentative hierarchical model to explain the functions of the hippocampus and vmPFC. We propose that the vmPFC initiates the construction of mental scenes by coordinating the curation of relevant elements from neocortical areas, which are then funneled into the hippocampus to build a scene. The vmPFC then engages in iterative re-initiation via feedback loops with neocortex and hippocampus to facilitate the flow and integration of the multiple scenes that comprise the coherent unfolding of an extended mental event.

Targeted activation of the hippocampal CA2 area strongly enhances social memory

Social cognition enables individuals to understand others' intentions. Social memory is a necessary component of this process, for without it, subsequent encounters are devoid of any historical information. The CA2 area of the hippocampus, particularly the vasopressin 1b receptor (Avpr1b) expressed there, is necessary for memory formation. We used optogenetics to excite vasopressin terminals, originating from the hypothalamic paraventricular nucleus, in the CA2 of mice. This markedly enhanced their social memory if the stimulation occurred during memory acquisition, but not retrieval. This effect was blocked by an Avpr1b antagonist. Finally, this enhanced memory is resistant to the social distraction of an introduced second mouse, important for socially navigating populations of individuals. Our results indicate the CA2 can increase the salience of social signals. Targeted pharmacotherapy with Avpr1b agonists or deep brain stimulation of the CA2 are potential avenues of treatment for those with declining social memory as in various dementias.

Thin Versus Thick Description: Analyzing Representations of People and Their Life Worlds in the Literature of Communication Sciences and Disorders

PURPOSE

Evidence-based practice relies on clinicians to translate research evidence for individual clients. This study, the initial phase of a broader research project, examines the textual resources of such translations by analyzing how people with acquired cognitive-communication disorders (ACCD) and their life worlds have been represented in Communication Sciences and Disorders (CSD) research articles.

METHOD

Using textual analysis, we completed a categorical analysis of 6,059 articles published between 1936 and 2012, coding for genre, population, and any evidence of thick representations of people and their life worlds, and a discourse analysis of representations used in 56 ACCD research articles, identifying thin and thick representations in 4 domains (derived from the International Classification of Functioning, Disability, and Health) and across article sections.

RESULTS

The categorical analysis identified a higher percentage of ACCD articles with some evidence of thick representation (30%) compared with all CSD articles (12%) sampled. However, discourse analysis of ACCD research articles found that thick representations were quite limited; 34/56 articles had thin representational profiles, 19/56 had mixed profiles, and 3/56 had thick profiles.

CONCLUSIONS

These findings document the dominance of thin representations in the CSD literature, which we suggest makes translational work more difficult. How clinicians translate such evidence will be addressed in the next research phase, an interview study of speech-language pathologists.

Navigating life

The discoveries of "place cells" in the hippocampus and "grid cells" in the entorhinal cortex are landmark achievements in relating behavior to neural activity, permitting analysis of a powerful system for spatial representation in the brain. The contributions of this work include not only the empirical findings but also the approach this work pioneered of examining neural activity in complex behaviors with real ecological validity in freely moving animals, and of attempting to place the findings in the larger context of how the neural representations of space are used in service of real-world behavior, namely what the Nobel committee described as permitting us to "navigate our way through a complex environment." These discoveries and approaches have had far-ranging impact on and implications for work in human cognitive neuroscience, where we see (1) confirmation in humans that the hippocampus and overlying MTL cortex are critically engaged in supporting a relational representation of space, and that it can be used for flexible spatial navigation and (2) evidence that these regions are also critically involved in aspects of relational memory not limited to space, and in the flexible use of hippocampal memory extending beyond spatial navigation. Recent work, using tasks that emphasize the requirement for the active use of memory in online processing, just as spatial navigation has long placed such a requirement on rodents, suggests that the hippocampus and related MTL cortex can support the navigating of environments even more complex than what is needed in spatial navigation. It allows us to use memory in guiding upcoming actions and choices to act optimally in and on the world, permitting us to navigate life in all its beautiful complexity.

The role of the hippocampus in flexible cognition and social behavior

Successful behavior requires actively acquiring and representing information about the environment and people, and manipulating and using those acquired representations flexibly to optimally act in and on the world. The frontal lobes have figured prominently in most accounts of flexible or goal-directed behavior, as evidenced by often-reported behavioral inflexibility in individuals with frontal lobe dysfunction. Here, we propose that the hippocampus also plays a critical role by forming and reconstructing relational memory representations that underlie flexible cognition and social behavior. There is mounting evidence that damage to the hippocampus can produce inflexible and maladaptive behavior when such behavior places high demands on the generation, recombination, and flexible use of information. This is seen in abilities as diverse as memory, navigation, exploration, imagination, creativity, decision-making, character judgments, establishing and maintaining social bonds, empathy, social discourse, and language use. Thus, the hippocampus, together with its extensive interconnections with other neural systems, supports the flexible use of information in general. Further, we suggest that this understanding has important clinical implications. Hippocampal abnormalities can produce profound deficits in real-world situations, which typically place high demands on the flexible use of information, but are not always obvious on diagnostic tools tuned to frontal lobe function. This review documents the role of the hippocampus in supporting flexible representations and aims to expand our understanding of the dynamic networks that operate as we move through and create meaning of our world.

Memory as social glue: close interpersonal relationships in amnesic patients

Memory may be crucial for establishing and/or maintaining social bonds. Using the National Social life, Health, and Aging Project questionnaire, we examined close interpersonal relationships in three amnesic people: K.C. and D.A. (who are adult-onset cases) and H.C. (who has developmental amnesia). All three patients were less involved than demographically matched controls with neighbors and religious and community groups. A higher-than-normal percentage of the adult-onset (K.C. and D.A.) cases’ close relationships were with family members, and they had made few new close friends in the decades since the onset of their amnesia. On the other hand, the patient with developmental amnesia (H.C.) had forged a couple of close relationships, including one with her fiancé. Social networks appear to be winnowed, but not obliterated, by amnesia. The obvious explanation for the patients’ reduced social functioning stems from their memory impairment, but we discuss other potentially important factors for future study.

Long-term neuropsychological, neuroanatomical, and life outcome in hippocampal amnesia

Focal bilateral hippocampal damage typically causes severe and selective amnesia for new declarative information (facts and events), a cognitive deficit that greatly impacts the ability to live a normal, fully independent life. We describe the case of 1846, a 48-year-old woman with profound hippocampal amnesia following status epilepticus and an associated anoxic episode at age 30. Patient 1846 has undergone extensive neuropsychological testing on many occasions over the 18 years since her injury, and we present data indicating that her memory impairment has remained severe and stable during that time. New, high-resolution, structural MRI studies of 1846's brain reveal substantial bilateral hippocampal atrophy resembling that of other well-known amnesic patients. In spite of severe amnesia 1846 lives a full and mostly independent adult life, facilitated by an extensive social support network of family and friends. Her case provides an example of a rare and unlikely positive outcome in the face of severe memory problems.

The use of definite references signals declarative memory: evidence from patients with hippocampal amnesia

Language function in patients with impaired declarative memory presents a compelling opportunity to investigate the inter-dependence of memory and language in referential communication. We examined amnesic patients' use of definite references during a referential communication task. Discursively, definite references can be used to mark a referent as situationally unique (e.g., "the game," as in the case of a recently publicized game) or as shared information (e.g., "the game," as in one discussed previously). We found that despite showing normal collaborative learning after repeated referring-as indexed by consistent and increasingly efficient descriptive labels for previously unfamiliar tangram figures-amnesic patients did not consistently use definite references in referring to those figures. The use of definite references seems to be critically dependent on declarative memory, and the engagement of such memory is signaled by language.

Detestable or marvelous? Neuroanatomical correlates of character judgments

As we learn new information about the social and moral behaviors of other people, we form and update character judgments of them, and this can profoundly influence how we regard and act towards others. In the study reported here, we capitalized on two interesting neurological patient populations where this process of complex "moral updating" may go awry: patients with bilateral damage to ventromedial prefrontal cortex (vmPFC) and patients with bilateral damage to hippocampus (HC). We predicted that vmPFC patients, who have impaired emotion processing, would exhibit reduced moral updating, and we also investigated how moral updating might be affected by severe declarative memory impairment in HC patients. The vmPFC, HC, and brain-damaged comparison (BDC) participants made moral judgments about unfamiliar persons before and after exposure to social scenarios depicting the persons engaged in morally good, bad, or neutral behaviors. In line with our prediction, the vmPFC group showed the least amount of change in moral judgments, and interestingly, the HC group showed the most amount of change. These results suggest that the vmPFC and hippocampus play critical but complementary roles in updating moral character judgments about others: the vmPFC may attribute emotional salience to moral information, whereas the hippocampus may provide necessary contextual information from which to make appropriate character judgments.

Hippocampal amnesia disrupts verbal play and the creative use of language in social interaction

BACKGROUND: While the neural substrates and cognitive components of creativity have received considerable attention in cognitive neuroscience, the creative use of language in social interaction has been less well studied. As part of a broader program of research on language-and-memory-in-use in individuals with hippocampal amnesia, we analyzed verbal play, a creative use of language that is pervasive in everyday communicative interaction. AIMS: To identify instances of creative uses of language in the protocols of social and collaborative interactions, to characterize the qualitative nature, and to determine the frequency of these interactions initiated by participants with hippocampal amnesia vs. comparison participants in order to ascertain whether amnesia impairs this aspect of social communication. METHODS AND PROCEDURES: This study uses quantitative group comparisons and detailed discourse analysis to analyze verbal play in the interactional discourse sessions of 4 participants with hippocampal amnesia and 4 healthy (demographically matched) comparison participants, each interacting with a familiar partner while completing a collaborative referencing task and with a researcher between task trials. RESULTS: All participants used verbal play. However, significantly fewer episodes were initiated in sessions with amnesia participants (312) and by participants with amnesia themselves (187) than in sessions with comparison participants (572) and by comparison participants (395). No significant group differences were observed for interactional forms, resources, or functions. Qualitative differences were also observed in amnesia sessions (e.g., more rotely produced episodes, lack of thematically linked episodes). CONCLUSIONS: These findings suggest that hippocampal amnesia disrupts the creative use of language in social interaction and accord with our previous work pointing to impairments in language-and-memory-in-use more broadly. These findings highlight the interdependence of language and memory especially in the interactional aspects of communication.