cortex 45 (2009) 566574

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Research report

Do you remember what you did on March 13, 1985?

A case study of confabulatory hypermnesia
Gianfranco Dalla Barbaa,b,c,d,* and Caroline Decaixe
a

Inserm U. 610, Paris, France

Universite Pierre et Marie Curie-Paris 6, Paris, France
c
AP-HP, Hopital Henri Mondor, Service de Neurologie, Creteil, France
d
Dipartimento di Psicologia, Universita` di Trieste, Trieste, Italy
e
AP-HP, Hopital Saint Antoine, Service de Neurologie, Paris, France
b

article info

abstract

Article history:

We report on a patient, LM, with a Korsakoffs syndrome who showed the unusual ten-

Received 8 March 2007

dency to consistently provide a confabulatory answer to episodic memory questions for

Reviewed 25 May 2007

which the predicted and most frequently observed response in normal subjects and in con-

Revised 7 January 2008

fabulators is I dont know. LMs pattern of confabulation, which we refer to as confabula-

Accepted 11 March 2008

tory hypermnesia, cannot be traced back to any more basic and specific cognitive deficit and

Action editor Michael Kopelman

is not associated with any particularly unusual pattern of brain damage. Making reference

Published online 5 June 2008

to the Memory, Consciousness and Temporality Theory MCTT (Dalla Barba, 2002), we propose that LM shows an expanded Temporal Consciousness TC, which overflows the limits

Keywords:

of time (Do you remember what you did on March 13, 1985?) and of details (Do you re-

Confabulation

member what you were wearing on the first day of summer in 1979?) that are usually re-

Episodic memory

spected in normal subjects and in confabulating patients.

2008 Elsevier Srl. All rights reserved.

Semantic memory
Temporal consciousness

1.

Introduction

Confabulation is a symptom observable in some patients with

memory impairment. At a general level, confabulation can be
referred to as a symptom observable in amnesic patients who
are unaware of their memory deficit, and which consists of actions and verbal statements that are unintentionally incongruous to the patients history, background, present and
future situation (Dalla Barba, 1993a).
This rather infrequent disorder is classically described in
Korsakoffs syndrome (Benson et al., 1996; Bonhoeffer, 1904;
Cermak et al., 1980; Dalla Barba et al., 1990; Korsakoff, 1889;

Mercer et al., 1977; Schnider et al., 1996a, 1996b; Talland,

1961; Wyke and Warrington, 1960). But confabulation is also
seen in patients suffering from ruptured aneurisms of the anterior communicating artery, subarachnoid haemorrhage or
encephalitis (Alexander and Freedman, 1984; Dalla Barba
et al., 1997a, 1997b; Delbecq-Derouesne et al., 1990; Irle et al.,
1992; Kapur and Coughlan, 1980; Kopelman et al., 1995; Luria,
1976; Moscovitch, 1989, 1995; Papagno and Muggia, 1996;
Schnider et al., 1996a, 1996b; Stuss et al., 1978), head injury
(Baddeley and Wilson, 1986; Dalla Barba, 1993b; Schnider
et al., 1996a, 1996b; Weinstein and Lyerly, 1968), Binswangers
Encephalopathy (Dalla Barba, 1993a), Alzheimers disease and

* Corresponding author. INSERM U. 610, 47 boulevard de lHopital, Paris F-75013, France.

E-mail address: dallabarba@chups.jussieu.fr (G. Dalla Barba).
0010-9452/$ see front matter 2008 Elsevier Srl. All rights reserved.
doi:10.1016/j.cortex.2008.03.009

cortex 45 (2009) 566574

frontotemporal dementia (Dalla Barba et al., 1999; Kern et al.,

1992; Nedjam et al., 2000, 2004) and aphasia (Sandson et al.,
1986). Confabulation may also be observed, on occasion, in
normal subjects (Burgess and Shallice, 1996; Dalla Barba
et al., 2002; Kopelman, 1987).
Within confabulatory behaviour some distinctions have
been proposed. Berlyne (1972), following Bonhoeffer (1904),
distinguished between momentary and fantastic confabulation. According to Berlyne (1972), momentary confabulation, which invariably must be provoked, is autobiographical
in content, refers to the recent past and consists of true memories displaced in their time context. In contrast, fantastic
confabulation is spontaneous and it is autobiographical,
but entirely invented. The principal content is invariably grandiose and seems to be related to wish fulfilment and prestige
seeking (Berlyne, 1972, p. 33). Subsequently Kopelman (1987)
argued that Berlynes description was inadequate because it
failed to isolate the distinguishing features of the two types
of confabulation and proposed to focus on the modality of appearance by referring to provoked and spontaneous confabulation. Provoked confabulation would reflect a normal
response to a faulty memory, whereas spontaneous confabulation would reflect the production of an incoherent and context-free retrieval of memories and associations (Kopelman,
1987, p. 1482) resulting from the superimposition of frontal
dysfunction on an organic amnesia. Schnider et al. (1996a,
1996b) have suggested that the term spontaneous confabulator should only be attributed to patients who show the tendency to act on their confabulations, since, they argue,
action is the only observable symptom that cannot be directly
provoked by the researcher or some other external trigger.
However, the distinction between spontaneous and provoked
confabulation has not gone unchallenged. In fact it has been
shown that spontaneous confabulations are not necessarily
fantastic and grandiose (Dalla Barba, 1993a; Dalla Barba
et al., 1997a, 1997b) and that provoked confabulations can be
fantastic and incoherent (Dalla Barba, 1993b; Dalla Barba
et al., 1998). Accordingly, the line drawn between spontaneous
and provoked confabulations often appears to be quite an arbitrary decision. Some authors, in fact, argue that it is not
meaningful to impose a dichotomy, and that confabulation
should be regarded as a continuous variable, ranging from minor distortions to the more fantastical (Dalla Barba, 1993b;
Fischer et al., 1995; Kapur and Coughlan, 1980).
As far as the mechanisms of confabulation are concerned,
three major approaches have been proposed.
(1) Johnson argued that confabulation reflects poor source
monitoring, or reality monitoring, i.e., deciding whether
a memory is a trace of something that actually happened
to you or is a memory of an imagined event (Johnson,
1991). Damage to frontal/executive functions would result
in an impairment of judgment processes involved in reality monitoring and so in confabulation. This interpretation
of confabulation is consistent with the idea that confabulation is a form of source amnesia (Moscovitch, 1989;
Schacter et al., 1984) combined with misattribution of temporal and spatial context (Schacter, 1987). However, in
a more recent paper, Johnson et al. (1997) demonstrated
that reality monitoring, or source monitoring, was equally

567

disrupted in a confabulatory patient, and in non-confabulating patients with frontal lobe damage. The latter findings lead Johnson and colleagues to propose that a reality
monitoring, or source monitoring, deficit may occur with
confabulation but is not the only factor involved in the
genesis of confabulation (Johnson, 1997).
(2) Moscovitch (1989, 1995), Moscovitch and Melo (1997) and
Gilboa et al. (2006) have proposed that confabulation is
the result of a deficit of strategic retrieval. They propose
a distinction between two components of retrieval. One,
associative retrieval, is relatively automatic and independent from frontal functions. The other, strategic retrieval,
is self-initiated, goal-directed, effortful and intelligent.
Within strategic retrieval processes, two further components are hypothesised. The first involves organising
a memory search that uses whatever knowledge is available, whether semantic or episodic. Once knowledge is recovered, a second strategic process is involved in
monitoring the output of the memory search and checking
whether it is consistent with other information in semantic and episodic memory. When strategic retrieval is disrupted, following damage in the ventromedial and
orbitofrontal cortex (Gilboa et al., 2006; Moscovitch, 1982),
both semantic and episodic confabulations should occur
if the demands on the strategic retrieval of episodic versus
semantic information are matched. Burgess and Shallices
(1996) model is consistent with Moscovitchs proposal that
confabulation is associated with deficits in strategic retrieval, which implicate defective search and monitoring.
These hypotheses that emphasise the role of a frontal/
executive dysfunction and of the disruption of monitoring
processes in the origin of confabulation are challenged by
several types of observations: (a) two patients have been
described with a confabulatory syndrome where there were
spared executive functions and no frontal pathology (Dalla
Barba, 1993a; Dalla Barba et al., 1990); (b) the confabulating patient described by Delbecq-Derouesne et al. (1990) had a documented frontal lobe lesion but performed normally on tasks
supposed to be sensitive to frontal lesion; (c) the confabulating
patient described by Dalla Barba et al. (1997a, 1997b) showed
impaired executive functions without any evidence of structural or functional damage to the frontal lobe; (d) in some
patients confabulation affects the performance on episodic
memory tasks but not on semantic memory tasks (Dalla
Barba, 1993a; Dalla Barba et al., 1997a, 1997b, 1990), even
when demands on the strategic retrieval of episodic versus
semantic information are matched (Dalla Barba et al., 1997a,
1997b, 1999). It is also well known that only a relatively small
proportion of patients with ventromedial and orbitofrontal
lesions confabulate. Retrieval models of confabulation propose that it is a very specific set of cognitive functions that
are not measured by traditional frontal/executive tests that
is disrupted in confabulation. However, these models dont
predict what would be a good measure of the set of frontal/executive functions supposed to be involved in strategic retrieval and monitoring.
(3) The third approach concerning the mechanisms involved
in confabulation predicts that confabulations are the

568

cortex 45 (2009) 566574

result of a disrupted personal temporality (Dalla Barba,

1997a, 1997b, 1999, 2000, 2001, 2002). Based on clinical
and experimental, evidence, this hypothesis assumes
that in confabulating patients the knowledge of time is
preserved, in that they are aware of a past, present and future. However, they are unable to distinguish between personal habits, repeated events and routines and true
episodic memories or true personal plans. In spite of
some important differences, this theory is not incompatible with the theory proposed by Schnider and co-workers,
which posits that confabulators fail to suppress inappropriate memory traces, resulting in all active traces appearing to relate to the present (but see Dalla Barba, 2000, 2001,
2002 for a critique of the concept of memory trace).
This paper describes the study of a patient, LM, with a Korsakoffs syndrome who developed an extraordinary form of
confabulatory syndrome, which we refer to as confabulatory
hypermnesia, i.e., the tendency to provide a confabulatory answer to questions for which the predicted and most frequently
observed response in normal subjects and in confabulators is
I dont know.
The aims of this study are to elucidate as fully as possible
the nature of the impairment of patient LM by trying to find
answers to the following questions:
Can LMs confabulatory hypermnesia be traced back to
a specific cognitive deficit?
What distinguish LM from other confabulating patients
who do not confabulate answering questions for which the
expected answer is I dont know?

2.

Case report

2.1.

History

LM, retired warehouseman of an airways company, is a 68year-old right-handed man with 8 years of education. He is
married and has five children.
He has a history of heavy drinking which lasted more than
30 years and was stopped approximately 3 months before the
present evaluation.
Following the abrupt onset of temporo-spatial disorientation and memory loss, LM was referred to the Memory Clinic
of the Charles Foix hospital in Ivry-sur-Seine for neuropsychological evaluation. The physical, neurological and psychiatric
examination was normal. An MRI brain-scan showed a mild
diffuse cortical atrophy without evidence of any focal lesion.
The patients history of heavy drinking and the clinical picture
suggested a diagnosis of Korsakoffs syndrome.

2.2.

impaired on some tests considered sensitive to executive dysfunction. He performed pathologically on the Trail Making
Test (Davies, 1968) [Trail Marking Test part A 120 sec, 25/25,
<10 percentile; Trail Marking Test part B 4 min, 17/25, <10 percentile] and on the Digit Symbol subtest of the Wechsler Adult
Intelligence Scale Revised (Wechsler, 1981) raw score 17. His
performance on Letter Fluency and on Category Fluency was
also defective, producing an average of 6 and 12 words, respectively. In contrast, he performed normally on both direct
(7) and reverse (4) digit span.

2.2.1.

Clinical tests of memory

On the Free and Cued Selective Reminding Test (Buschke,

1984; see Table 1) LM showed a massive deficit in free recall,
whereas cued recall and recognition were relatively better
preserved. On the Logical Memory subtest of the Wechsler
Memory Scale III (Wechsler, 1997; see Table 1), he showed
very poor free recall and impaired recognition. In addition,
his performance on this test was contaminated by many confabulations. The patient also had great difficulty in retrieving
autobiographical episodes and showed very poor knowledge
of famous facts and famous people.

2.3.

Examination of confabulation

LM produced most of his confabulations in informal conversation, when answering specific questions and spontaneously,
mainly referring to autobiographical episodic memory. Confabulation was always plausible and semantically appropriate
so that an hypothetical observer not familiar with LMs history, background and present situation could hardly tell
whether LMs reports were confabulatory or not. For example
he would claim that on the previous day he had a soup for dinner and then he watched the news on television. In such
a case it would be impossible to tell whether this was a confabulatory report unless one knew that he didnt have soup for
dinner and that he didnt watch television because there
was no television in the ward where he was hospitalised.

2.4.

Confabulation Battery

To further examine LMs confabulation, we submitted him to

a new version of the Confabulation Battery (Dalla Barba,
1993a). The Confabulation Battery involves the retrieval of
various kinds of information and consists of 165 questions,
15 for each of the following domains:

Table 1 Memory test results

LM

Neuropsychological examination

The patients collaboration during the testing sessions was

good. On direct questioning he was disoriented and confabulated in time and space. He scored 15/30 on the Mini Mental
State Examination (Folstein et al., 1975). On tests of oral expression, understanding of oral language, neglect, ideational,
ideomotor and constructional apraxia, and short-term memory the patient was judged to be normal. LM showed to be

Free and Cued

Immediate cued recall 13/16
Selective
Total free recall
6/48
Reminding Test Recognition
13/16
Logical Memory

Immediate recall
Delayed recall
Recognition

11/75
6/50
16/30

NCs
means
(standard
deviation, SD)
15.2 (1.4)
28.9 (6.8)
15.7 (.5)

569

cortex 45 (2009) 566574

(1) Personal Semantic Memory (age, date of birth, current address, number of children, etc.).
(2) Episodic Memory. Episodic, autobiographical questions.
(3) Orientation in Time and Place.
(4) Linguistic Semantic Memory. Items 1630 of the Wechsler
Adult Intelligence Scale vocabulary subtest were selected
for a word definition task.
(5) Recent General Semantic Memory. Knowledge of facts
and people, which have been repeatedly reported in the
news during the last 10 years. For example, Who is Ben
Laden?
(6) Contemporary General Semantic Memory. Knowledge of
famous facts and famous people from 1940 to 1990. For
example, What happened in Paris in May 1968?
(7) Historical General Semantic Memory. Knowledge of famous facts and famous people before 1900. For example,
What happened in 1789?
(8) Semantic Plans. Knowledge of issues and events likely to
happen in the next 10 years. For example, Can you tell
me what you think will be the most important medical
breakthrough likely to take place in the next 10 years?
(9) Episodic Plans. Personal events likely to happen in the future. For example, What are you going to do tomorrow?
(10) I dont know Semantic. These were questions tapping
semantic knowledge and constructed so as to receive
the response I dont know from normal subjects. For
example, What did Marilyn Monroes father do?
(11) I dont know Episodic. These questions tapped episodic
memory and were constructed so as to receive the response I dont know by normal subjects. For example,
Do you remember what you did on March 13, 1985?

Since there is no sufficiently acceptable external criterion capable of defining confabulation, for its detection an arbitrary
decision necessarily had to be made. In order to distinguish
between a wrong response and a confabulation a clear-cut decision was adopted only for answers to questions probing orientation in time. In this case the most strict criterion was
chosen: answers to questions regarding the current year, season, month, day of the month, day of the week and hour of the
day were judged to be confabulations only if erring for more
than 5 years, 1 season, 2 months, 10 days, 3 days or 4 h, respectively. Answers to the other questions of the Confabulation
Battery were independently rated as correct, wrong, and
confabulation by four different raters, and interrater reliability was 100%. It must be emphasised that the decision as to
whether an answer was wrong or confabulatory was never
puzzling, although it may have been made on an arbitrary or
subjective basis. As far as questions concerning personal
and semantic plans are concerned, it might be argued that
any possible answer is a confabulation, since, by definition,
the future is only probable and there is in principle no correct answer to questions about the future. Yet, answers concerning the future can be definitely confabulatory when they
show a marked discrepancy or a real contradiction with
what a predicted future event might be, in view of the present
situation. For example, although he was hospitalised and despite the fact that there wasnt any television in the ward, to
the question What are you going to do to night?, LM answered Ill have dinner with my wife and then watch the
news at the television.

3.
2.4.1.

Procedure

Results

LMs and NCs performance on the Confabulation Battery is

reported in Table 2.

Questions from the 11 domains were randomised and presented to the patient and to 10 age and education matched
normal controls (NCs). Responses were scored as correct,
wrong, I dont know, and confabulation. For episodic
memory, responses were scored correct when they
matched information obtained from the patients relatives.
Correct responses were self-evident for semantic memory
questions. For I dont know questions, both Semantic and
Episodic, an I dont know response was scored as correct.

3.1.

Correct responses

LM produced significantly fewer correct responses than NC to

questions probing Personal Semantic Memory, Episodic Memory, Orientation in Time and Place, Recent Seneral Semantic
Memory [t(9) 15, p < .001; estimated percentage of normal
subjects falling below LMs scores .0%], Contemporary

Table 2 LMs and NCs performance (%) on the confabulation battery

Correct

Personal Semantic Memory

Episodic Memory
Orientation in Time and Place
Linguistic Semantic Memory
Recent General Semantic Memory
Contemporary General Semantic Memory
Historical General Semantic Memory
Semantic Plans
Episodic Plans
I dont know Semantic
I dont know Episodic

Confabulation

LM

NC

LM

73
33
53
66
33
73
53
80
33
66
7

100
100
100
81.4 (15.7)
96.5 (3.7)
93.2 (7.7)
73.2 (28.9)
95.9 (6.5)
98 (6.3)
99.3 (2.2)
100

20
53
13
0
40
7
13
7
33
33
93

NC
0
0
0
0
.7 (2.2)
0
.7 (2.2)
0
0
.7 (2.2)
0

Wrong
LM

NC

0
7
33
33
27
13
20
0
27
0
0

0
0
0
9.9 (9.9)
.7 (2.2)
1.3 (4.1)
13.3 (27)
1.4 (3)
0
0
0

IDK
LM

NC

7
0
7
0
0
0
0
8.7 (7.3)
0
2.1 (3.4)
7
5.5 (6.2)
13 13.2 (10.3)
13
2 (6.3)
7
2 (6.3)
66 99.3 (2.2)
7 100

Total recall
LM

NC

93
93
100
100
100
93
86
87
93
33
93

100
100
100
91.3 (5.6)
97.9 (3.3)
94.5 (6.1)
86.8 (4.5)
97.3 (6.4)
98 (6.3)
0
0

570

cortex 45 (2009) 566574

General Semantic Memory [t(9) 2.3, p < .05; estimated percentage of normal subjects falling below LMs scores 2%],
Semantic Plans [t(9) 2.5, p < .05; estimated percentage of normal subjects falling below LMs scores 1.5%], Episodic Plans
[t(9) 10.3, p < .001; estimated percentage of normal subjects
falling below LMs scores .0%], and to I dont know Semantic [t(9) 14.4, p < .001; estimated percentage of normal subjects falling below LMs scores .0%], and I dont know
Episodic questions (Crawford and Garrthwaite, 2002; Crawford
and Howell, 1998). LM produced fewer correct responses than
NC to questions probing Linguistic Semantic Memory and Historical Semantic Memory, but this effect was not significant.
The estimated percentage of normal subjects falling below
LMs scores was 19.7% for Linguistic Semantic Memory and
27.3% for Historical Semantic Memory.
LM produced significantly fewer correct responses, i.e., I
dont know, to I dont know Episodic questions than to
any other type of question (all p < .0001; estimated percentage
of normal subjects exhibiting a difference more extreme than
LM .0, Crawford and Garrthwaite, 2002; Crawford and
Howell, 1998). Episodic Memory, Recent General Semantic
Memory and Episodic Plans were also significantly affected
compared to Orientation in Time and Place and Historical
General Semantic Memory (all p < .0001; estimated percentage
of normal subjects exhibiting a difference more extreme than
LM .0), which in turn were impaired compared to Personal
Semantic Memory, Linguistic Semantic Memory, Contemporary General Semantic Memory, Semantic Plans, and I dont
know Semantic questions (all p < .0001; estimated percentage of normal subjects exhibiting a difference more extreme
than LM .0, Crawford and Garrthwaite, 2002; Crawford and
Howell, 1998).
NC produced significantly fewer correct responses to questions probing Linguistic Semantic Memory and Historical General Semantic Memory than to any other type of question (all
p < .05) except for questions probing Contemporary General
Semantic Memory.
To summarise, compared to NC, LM performed poorly
across the board on the Confabulation Battery, with his performance being relatively better preserved in Personal Semantic Memory, Linguistic Semantic Memory, Contemporary
Semantic Memory and Semantic Plans. He was particularly
impaired in answering I dont know Episodic questions
where he correctly answered I dont know only 1 out of 15
times.

3.2.

Confabulations

NC produced virtually no confabulations. In fact, only one

subject produced one confabulation in Recent General Semantic Memory and one in Historical General Semantic Memory.
A Chi-square test revealed a global significant effect of the
type of questions on LMs confabulations [c2 (10) 246,9,
p < .001]. LM did not confabulate in response to Linguistic
Semantic Memory questions. He produced significantly more
confabulations to I dont know Episodic questions than to
any other type of question (Chi-square test, all p < .001). He
also produced significantly more confabulations to Episodic
Memory, Recent General Semantic Memory, Episodic Plans
and I dont know Semantic questions than to questions

probing Personal Semantic Memory, Orientation in Time and

Place, Contemporary General Semantic Memory, Historical
General Semantic Memory and Semantic Plans (Chi-square
test, all p < .05).
To summarise, LM produced an impressive percentage of
confabulations in response to I dont know Episodic questions. He also produced more confabulations to questions involving episodic recall and episodic plans compared to
questions involving recall from semantic memory.

3.3.

Examples of LMs confabulation for each domain

3.3.1.

Personal Semantic Memory

Q. What is your brothers job?

A. Remy is an artist. He works in variety shows. LM confuses his brother with his son (Patrik) who actually works as
an artist in variety shows.

3.3.2.

Episodic Memory

Q. Do you remember the last time a doctor examined you?

A. Well, he examined me without really examining me,
because my doctor lives near me, so I see him quite often.
The last time. not so long ago in any case.

3.3.3.

Orientation in Time and Place

Q. What month is it?

A. End of December. In fact it was the end of April.

3.3.4.

Recent General Semantic Memory

Q. What does the Mir station remind you of?

A. Its a metros station in the 15th arrondissement in
Paris.

3.3.5.

Contemporary General Semantic Memory

Q. What happened in May 1968?

A. It was the beginning of the workmens revolution; the
government opposed Africa.

3.3.6.

Historical General Semantic Memory

Q. What does the Dreyfus affaire remind you of?

A. Its the story of a poisoning and of a murder.

3.3.7.

Semantic Plans

Q. What do you think will be the most important advancements in the exploration of space in the next 10 years?
A. We will land on the Moon and see if somebody lived
there, if it is habitable.

3.3.8.

Episodic Plans

Q. What are you going to do the day after tomorrow?

A. Ill go shopping, as usual, and then watch television.

3.3.9.

I dont know Semantic

Q. Who won the Palme dOr at the Canne Festival in 1980?

A. Fernandel.

3.3.10. I dont know Episodic

Q. Do you remember what you had for dinner on Tuesday
two weeks ago?
R. Steak with French fries.

cortex 45 (2009) 566574

Q. Do you remember what you were wearing on the first

day of summer in 1979?
R. A short and a T-shirt.
Q. Do you remember what you did on March 13, 1985?
A. We spent the day at the Senart Forest (a place where
LM used to go often with his family).
Q. Do you remember what you did for your 27th
birthday?
R. Wait a minute. I came back from the army when I was
23, so the 27th birthday. I think. Yes! I had dinner at my future wifes place.

4.

Discussion

The patient we have described suffers from a relatively pure

amnesic syndrome, in the sense that the memory impairment
is not associated with other cognitive impairments likely to
interfere with memory performance. Although he performs
poorly on the Mini Mental State Examination, mainly due to
his disorientation, LM doesnt show a general deterioration
of intellectual and attentional abilities, and he scores normally on tests of short-term memory. His amnesia involves
memory for both personal and public events, as well as learning of new information as shown in his poor performance on
the Free and Cued Selective Reminding Test and on the Logical
Memory subtest of the Wechsler Memory Scale. LM confabulates both spontaneously and on direct questioning. His confabulations are always plausible and never show the bizarre,
fantastic (Baddeley and Wilson, 1986) or semantically
anomalous (Dalla Barba, 1993b) content described in some
confabulating patients.
On the Confabulation Battery, LM produced fewer correct
responses than NCs to all types of questions, although he performed relatively better in Personal Semantic Memory, Linguistic Semantic Memory, Contemporary Semantic Memory
and Semantic Plans than in other domains. This result is similar to the pattern of performance of other amnesic patients
on the Confabulation Battery (Dalla Barba, 1993b; Dalla Barba
et al., 1997a, 1997b; Fotopoulou et al., 2004). In LM, like in other
patients, semantic memory and semantic plans are better preserved than episodic memory and episodic plans. However,
unlike other confabulators, LM produced only one correct I
dont know, response to I dont know Episodic questions.
To this type of question, 14 out of 15 times he produced
a confabulation.
LM confabulated in response to all types of questions, with
the exception of Linguistic Semantic Memory. However, he
produced significantly more confabulations in Episodic Memory, Recent Semantic Memory and Episodic Plans compared to
the other types of questions. Like in other confabulators (Dalla
Barba, 1993a, 1993b; Dalla Barba et al., 1997a, 1997b), LM
showed confabulations with a pattern of selectivity, affecting
the episodic domain more than the semantic domain. He also
confabulated in Recent General Semantic Memory, which may
represent a grey area between semantic and episodic memory
(Shallice, 1988), and in I dont know Semantic questions. But
the most striking aspect of LMs confabulations is his tendency to confabulate 3 times as much with episodic memory
questions that are usually answered I dont know by normal

571

subjects and which produce confabulations, but less florid

than LMs, in other confabulating patients (Dalla Barba,
1993a; Dalla Barba et al., 1998).
As far as total recall is concerned, i.e., the sum of correct responses, errors and confabulations, LM and NC showed a similar pattern of performance. They both showed the tendency
to provide an answer, correct or not, rather than an I dont
know response to all types of questions with the exception
of I dont know questions where LM was always productive,
whereas NC always correctly answered I dont know.
From LMs performance on the Confabulation Battery
emerges a previously unreported phenomenon, which we refer to as confabulatory hypermnesia, i.e., the tendency to provide
a confabulatory answer to questions for which the predicted
and most frequently observed response in normal subjects
and in confabulators is I dont know. It might be argued
that LMs specific pattern of performance reflects a methodological bias, in that I dont know Semantic questions may be
more difficult or less likely to elicit confabulations than I
dont know Episodic questions. Confabulations in response
to I dont know questions, both semantic and episodic,
have been reported in some confabulating patients (Dalla
Barba, 1993b; Dalla Barba et al., 1998; Fotopoulou et al., 2004,
2007; Kopelman et al., 1997), whereas other patients do not
confabulate at all to these questions (Box et al., 1999; Dalla
Barba, 1993a; Dalla Barba et al., 1997a, 1997b). However,
none of the reported cases confabulated as much as LM to I
dont know Episodic questions, and in none of these cases
was there such a clear dissociation between confabulations
to I dont know Episodic and I dont know Semantic questions. Actually some patients confabulated slightly more to I
dont know Semantic than to I dont know Episodic questions (Fotopoulou et al., 2007). So, although some patients confabulate to I dont know Episodic questions, none of them
show the specific pattern of performance described in LM.
This pattern of performance, that we call confabulatory hypermnesia, doesnt seem to simply reflect differences in task
difficulty. This leads us to address the problem of the origin
of confabulatory hypermnesia. By asking the following questions: Why does LM confabulate when answering episodic
memory questions for which the expected answer is I dont
know? and What is the difference between LM and confabulating patients who do not confabulate so floridly with I
dont know questions?
It has been argued that confabulation reflects poor source
monitoring. Source monitoring refers to the set of processes
involved in making a decision about the origin of different information (see Metcalf et al., 2007, for a review). A related concept is reality monitoring, which refers to the ability to
discriminate between internally and externally generated information (e.g., imagination vs veridical perception). According to this view, confabulation is the result of mistaking
imagined events for truly experienced events (Johnson,
1991). This kind of explanation, however, does not account
for the fact that confabulation, as in the present case and in
other studies (Dalla Barba, 1993a, 1993b; Dalla Barba et al.,
1990, 1997a, 1997b; Delbecq-Derouesne et al., 1990), is absent
or significantly less frequent in tasks that require retrieval of
non-episodic information. In fact, if a disruption of reality
monitoring were responsible for confabulation, confusion

572

cortex 45 (2009) 566574

between truly experienced and imagined events and information should not be limited to episodic retrieval but should extend across all memory domains. Moreover, if we consider the
examples of LMs confabulations in I dont know Episodic
questions, there is no evidence that he is mistaking imagined
events for really experienced events. Most of his confabulations to I dont know Episodic questions reflect the retrieval
of personal habits or semantic information rather than retrieval of imagined events: the Senart Forest is a place where
he used to go often with his family, steak and French fries
are a very common meal in France, in summer many people
wear shorts and T-shirts.
The retrieval of personal habits and semantic information
in LMs confabulations could be traced back to a deficit of strategic retrieval (Moscovitch, 1989, 1995; Moscovitch and Melo,
1997). In the presence of such a deficit, only associative retrieval is possible and this might be reflected by the type of
confabulations produced by LM. A deficit of strategic retrieval
applies equally across all domains of memory. In other words,
confabulation should equally affect episodic and semantic
memory if both episodic and semantic memory tasks require
the involvement of strategic retrieval processes. However, this
hypothesis has difficulties in accounting for cases in which
confabulations are confined to the domain of episodic memory (Dalla Barba, 1993b; Dalla Barba et al., 1990, 1997a,
1997b), also when both episodic and semantic memory tasks
require the involvement of strategic retrieval processes (Dalla
Barba et al., 1997a, 1997b, 1999). As far as LMs case is concerned, a strategic retrieval deficit account predicts that if I
dont know Semantic and I dont know Episodic questions
make equal demands on strategic retrieval processes then
confabulations should occur both for I dont know Semantic
and I dont know Episodic questions, which is not what was
actually observed. As discussed above, there is no reason to
consider one type of I dont know question more difficult
or more likely to elicit confabulation than the other type. Since
there is no specific available measure of the amount of strategic retrieval involved in a task, it is impossible to know
whether I dont know Episodic questions are more demanding in terms of strategic retrieval processes than I dont
know Semantic questions. However, there is clear evidence
that LM was engaged in an active search when answering
both I dont know Episodic questions (see his answer to
the question Do you remember what you did for your 27th
birthday?) and I dont know Semantic questions, as clearly
emerges from the following example:
Q. What is the first name of Jimmy Carters wife?
R. Her first name?.(search); no; no though I should know
it because she is well known;
To this type of questions, normal subjects dont even attempt
to search and immediately produce an I dont know response,
even when they are explicitly asked to make a plausible guess.
We have argued (Dalla Barba, 2000, 2001; Dalla Barba et al.,
1997a, 1997b, 1999) that confabulation can be interpreted
within the framework of the MCTT (Dalla Barba, 2002), The
MCTT, that is schematised in the model presented in Fig. 1,
holds that (1) consciousness is not a unitary and generic dimension that passively receives what comes from outside,
but is the set of distinct and original modes for addressing
the object. Among the modes of consciousness there is

Fig. 1 A hypothesis concerning the relation between

memory, consciousness and temporality. NS [ nervous
system; X and Y [ patterns of organisation and activation
of the nervous system; TC [ temporal consciousness;
KC [ knowing consciousness; U [ uniqueness; and
M [ multiplicity.

knowing consciousness KC and temporal consciousness TC. (2)

KC describes the mode of addressing the object in order to
know it. (3) TC describes the mode of consciousness that temporalises its object according to the subordinate structures of
temporality, the past, the present and the future. (4) Consciousness must necessarily always be consciousness of
something. Every type of consciousness is consciousness
of an object. The object of consciousness represents a determination and a indetermination, a Uniqueness and a Multiplicity.
Lets consider this point closer. This pen on the desk is both
a pen and the pen. In the first case it is an undetermined pen,
something that belongs to the category of pens, an object
that I recognize and use appropriately because I recognize it.
On the contrary, in the second case the pen is a determined
object, is exactly this pen in front of me, the pen I bought yesterday and that I will be using tomorrow. So, the pen reveals
a uniqueness and a multiplicity, the multiplicity of being
a pen and not a different object of the object in front of me,
the uniqueness of being precisely this pen and not another pen.
Within the framework of the MCTT, we have proposed that
confabulation in episodic memory and in personal future planning tasks, as in LMs case and in other patients (Dalla Barba
et al., 1997a, 1997b, 1999), can be interpreted as the result of a condition in which TC remains but, in order to remember the personal past and plan the personal future, addresses Multiplicity
as Uniqueness. This condition is schematised in Fig. 2. In other

Fig. 2 Confabulation: TC addresses M as U.

cortex 45 (2009) 566574

terms, this is a condition in which TC is still working but is no longer able to accomplish its usual task, i.e., to distinguish between
Multiplicity and Uniqueness in order to set up a personal temporal workspace. What TC does instead in this condition is to address Multiplicity of the object as Uniqueness, so that the
result is that not only unique personal episodes, but also habits
or personal semantic information are considered in a personal
temporal framework. When asked what they did the previous
day or what they are going to do the following day, confabulating
patients of this type typically answer reporting as memories and
plans what they usually do in their daily life. Although admitted
to the hospital, they will say, for example, that the previous day
they went out shopping and that the following day will be visiting
some friends, acts that presumably were part of their routine life.
This kind of interpretation, however, still doesnt explain
why, unlike other confabulators, LM confabulates to I dont
know Episodic questions. The analysis of total recall shows
that, with the exception of I dont know questions, LM and
NC have the same performance, a mean of 94% and 95% of responses, respectively. This indicates that both LM and NC have
answers to almost all the questions, although in LM the answer
is often confabulatory, especially in the episodic domain. It also
indicates that, according to the MCTT, in both NC and LM, KC
and TC are working, although the latter is working in an abnormal way in LM. However, while in NC, KC and TC respect the
boundary of I dont know questions, in LM this boundary is
overstepped. What is the nature of this boundary? Why NC
and most confabulators promptly respond I dont know to
I dont know questions, whereas LM confabulates?
One possibility is that LM may have always been a cognitive
outlier, in the sense that, even premorbidly, he may have
used unusual cognitive strategies and that his confabulatory
hypermnesia is a continuation of the use of such strategies.
However, no evidence in this sense emerged from questioning
the patients wife. So, although this possibility cannot be excluded, there is no specific evidence favouring a premorbid
personality account of LMs disorder.
LMs confabulatory hypermnesia doesnt seem to be correlated to any specific pattern of brain damage. The MRI brainscan showed a mild diffuse cortical atrophy, which is an
unremarkable finding. LMs cognitive profile was also unremarkable. In particular, he didnt show an especially severe
impairment of executive functions, compared to other confabulators. Accordingly, LMs confabulatory hypermnesia
cannot be traced back to any specific pattern of brain damage
or of cognitive impairment. From a merely descriptive point of
view, and making reference to the MCTT, LM, compared to
normal subjects and to other confabulators, shows an expanded TC, which overflows the limits of time (Do you remember what you did on March 13, 1985?) and of details
(Do you remember what you were wearing on the first day
of summer in 1979?) that are usually respected in normal
subjects and in confabulating patients.

5.

Conclusions

We have described a previously unreported phenomenon,

confabulatory hypermnesia, arguing that it reflects an expansion of TC beyond its normal limits. Although we believe that

573

our interpretation best accounts for the LMs confabulatory

hypermnesia, other interpretations of this phenomenon cannot be completely dismissed since a clear double dissociation
between I dont know Semantic and Episodic questions has
not been yet reported. Be that as it may, this leaves us with
a number of open questions: What are the cognitive and neural correlates of confabulatory hypermnesia? How are the
boundaries of TC normally determined? What is the cause of
their breakdown? What would be the critical test or set of evidence that would confirm or disprove this hypothesis? Answers to these questions would shed light on confabulatory
hypermnesia and on the organisation of TC in general. In
the absence of further experimental evidence these remain
unanswered, indeed I dont know questions.

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