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Neuropsychoanalysis: An Interdisciplinary Journal
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A Cognitive Neuroscience Perspective on
Confabulation: Commentary by Jorge Canestri

Jorge Canestri

Via Sesto Rufo 23, 00136 Rome, Italy, e-mail: . or
Published online: 09 Jan 2014.

To cite this article: Jorge Canestri (2000) A Cognitive Neuroscience Perspective on Confabulation: Commentary by
Jorge Canestri (Rome), Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences, 2:2,
144-148, DOI: 10.1080/15294145.2000.10773297
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NY 10023 A Cognitive Neuroscience Perspective on Confabulation Commentary by Jorge Canestri (Rome) DeLuca's paper presents the psychoanalyst with several interesting points: an accurate examination of a pathological phenomenon (confabulation) whose definition. what is essential is to note the implicit general concept: in a complex system the global level of functioning of the system cannot legitimately be explained by reference to the "atomic" elements only. Dreaming "accidentally" of Harold Pinter: The interplay of metaphor and metonymy in dreams. 21 :53-63. B. which excuses me from describing the fundamental principles of the Freudian topographical model of the mind (Freud.. D. E. & Frith. P. Dreaming. Psycholog. New York: Columbia University Press. & Caan. Psychosurgery and the Self. O.. which could be significant for the neurosciences also.. Confabulation following brain injury: Its analogues and sequelae. ed. (1998). but above all to find meaning in the manifestations of psychic life. Perthshire. The neurosciences can offer to psychoanalysis some tools that allow one to verify the biological plausibility of certain psychoanalytic hypotheses and to find confirmation or refutation of them in the experimental field. Moscovitch. Memory in Mind and Brain: What Dream Imagery Reveals. and the possibility of comparison with psychoanalytic theories. 35:1017-1034. Severe Personality Disorders.D. 5:229-245." If." in consonance with the Freudian model of the mind. an alternative model constructed on the cognitive neuroscience perspective emphasizing the differences between the various forms of confabulation. A deficit (in these cases due to an organic lesion) must be interpreted also as a function of the overall response of the system. 1951. J. Brain. Gen. From sensation to cognition. Szalita. Confabulation in schizophrenia. Rolls. (1958). Regression and perception in psychotic states. Amer. It is therefore clear that while DeLuca will put the accent on the deficit. 134:1335-1348.McCarley. & Freeman. The brain as a dream state generator: An activation-synthesis hypothesis of the dream process. New York: Basic Books. Psychiatry. and causality are still under discussion.-M.. there are "underlying wishes. uniqueness. Mesulam. Solms highlights what is essential to the Freudian task: the problem of the psychoanalyst is not only to construct a causal hypothesis.. 1915). specifically relative to this phenomenon as well as in a wider sense concerning the verisimilitude of certain statements of Freudian metapsychology. Arch. R. B. As we know. (1977). Dream-Life. C.. Rapaport. Freud constructed a hypothetical model of a "mental apparatus. W. 145 Central Park West New York. Scotland: Clunie Press. Med. Visual neurones responsive to faces in the monkey temporal cortex. It might perhaps be useful to dwell for a while on this difference in the general line of thinking. Brain Res. E. Schilder. States. D. pp. Studies concerning the psychology and symptomatology of general paresis. 121:1013-1052.Downloaded by [Gazi University] at 22:50 18 August 2014 144 . Meltzer. D. In these brief notes I will try to illustrate this viewpoint. (1984). 47:329-342. W. New Haven. Psychiatry. & Melo. Experiment. & Lyerly. Neuropsychologia. M.. New York: Grone & Stratton. 1911. This is evidenced by the different consideration that the symptoms merit in DeLuca's work and in the discussion by Solms. CT: Yale University Press. Kernberg. (1954). (1997). (1982). This is true at the physical level as well as at the level of "mental life.. (1930)." Setting aside for the time being the verisimilitude of his construction. we consider the (some- . M.. 519-580. W. Nathaniel-James. D.. 18:348-354. Psychiatry. My task in presenting these notes is greatly facilitated by Mark Solms's comment. Perrett. M. With the addition of examples taken from his clinical experience with bilateral ventromesial frontal lesioned patients. Mark Blechner. In: Organization and Pathology of Thought. Strategic retrieval and the frontal lobes: Evidence from confabulation and amnesia. Jorge Canestri Robinson. Ph. 1900. M. A. (1990). (1984). Reiser. (1995). for example. O. (1968). (1996). while psychoanalysis can supply the neurosciences with a heuristic potential that cannot be underestimated. 26:391-399. The latter emphasizes the fact that behind the "positive" (or "productive' ') manifestations of the organic lesions. Weinstein. the psychoanalyst will also emphasize the "productive" aspect of the symptom and its meaning.

regularly works in the same way." This leads him to observe. Subsequently the concept broadened to include the "reconciliation" of the three mental agencies (ego. but rather that in splitbrain patients the left hemisphere contains a mechanism (the Interpreter) that in any case tries to interpret information in a plausible manner. Luria constantly emphasized that the classical "basic concepts" of neuropsychology needed to be reexamined. if Gazzaniga is right. What I would say. and not necessarily or only as a response to embarrassment or feelings of inadequacy. whether he was analyzing attention disorders or memory disorders (in patients with ventromesial frontal lesions). 1979). through the deformations of the ego and the 145 use of different defense mechanisms. This has already been effectively pointed out by Solms when he quotes Luria. the entire system seeks states of equilibrium (which mayor may not be pathological) and this brings into consideration all the elements of the system.. especially those concerning the function of attention. The concept emerges for the first time in Freud's analysis of the Schreber case but reappears in other texts by Freud. we can see how the right hemisphere almost completely takes over all the functions of the other hemisphere. Mental life operates no differently (and it could not be otherwise). from a psychological point of view. many of Freeman's examples. I would like to recall a Freudian concept that has been somewhat forgotten (Canestri. Mental life at the level of dreams (secondary elaboration). privileging those higher functions that are essential from the adaptive point of view. including those of schizophrenia and chronic brain syndrome. even if it is not correct. and superego) in Freud's structural model. demonstrate the value in studying confabulation in a broad rather than a narrow sense. the narrative rewriting of one's own history. In these disorders Freeman identifies a failure of selective attention (described by many authors. would result in the essential feature: In the chronic brain syndrome reality has largely lost its value.. In conclusion. too exciting (Katan. The clinical phenomena suggest other causes for the break with reality-namely the disorder of selective attention and the amnesic phenomena. that the symptomatology of his patients is in consonance with the fundamental principles of the Freudian topographical model of the mind. This is not the occasion for a detailed study of its uses and applications. Luria in particular) that." is pertinent to our topic.. as is postulated in the case of schizophrenias. 1952). . In the same way. thus modifying its original meaning.Downloaded by [Gazi University] at 22:50 18 August 2014 Commentary on Confabulation times astonishing) cases of extensive malformations of one hemisphere requiring early radical hemispherectomy (I recall a case with follow-up of left hemispherectomy in a 2-year-old child). Gazzaniga's observations (1998. Even though DeLuca expressly leaves aside confabulatory psychopathology of psychiatric origin. are congruent with some central aspects of Freudian metapsychology. Luria's conceptualizing of the structures within the ventromesial frontal region of the brain as being an executive system with the task of organizing the available subroutines at lower hierarchical levels. Thus. Freeman's (1992) paper "Psychiatric Perspectives on Freud's Metapsychology. hated (Bion. 1989) and that could prove useful in this context. The loss of reality has not occurred because it had become too frightening (Rosenfeld. but I would only like to mention that the concept in question-reconciliation (Versohnung)-was subsequently transformed by Melanie Klein into reparation. as Solms also recommends." from the symptom to the collapse of the system in its entirety. is that this is a function of the system as a whole. Solms insists on the fact that "mature cognitive functions (like the function that DeLuca described as 'strategical retrieval'-which we would classify as an executive 'ego' function) are built upon the foundations of more primitive mental functions." from single abilities to "systemic organization. 1959). Attention can no longer be purposely directed to thoughts and percepts although they have achieved mental registration [po 498]. In my opinion. This justifies considering the gap filling produced by the lesions in question as a function of the mind (as a system). id. but I would like to return to some particular aspects. What did Freud mean by reconciliation? The Schreber case dealt with the fact that the patient could "reconcile himself" with his homosexual fantasy because he was not able to eliminate it. quoted by DeLuca) can be viewed from the same angle: the point is not so much in deciding whether this is confabulation from unawareness or not. rightly. the general outline of Luria's work (1973) in relation to confabulation is similar to the one I have attempted to describe here. In fact. from the concept of "function" we pass to the notion of whole "functional systems." from the cerebral zones to the articulation and hierarchical organization of "complex functional systems.

rather it was enriched by the intersection of organic symptoms and psychiatric symptoms. and compensatory efforts by the patient (pseudo-explanations. the extent of which amazed everybody as it was difficult to imagine how the patient could have led quite a "normal life" (at least from the neurological point of view) considering the extent of the cortical atrophy. while the elementary forms not only remain intact but may actually be increased.-Cs. If what I briefly mentioned above. another metapsychological concept not always taken sufficiently into account.. The excessive deficits that ensued led to the suspicion of a second pathology.) to reconcile himself to his state. requires that the Pcpt. but they also reveal the striving toward a "reconciliation" with the new condition of the entire mental apparatus. Returning to the Freudian hypothesis." it also implies an adequate control and filtering of these functions in the development of higher cognitive capacities. confabulations. an increase in elementary forms of arousal). What happens with pathology of the vetromesial frontal region of the brain? Luria and others emphasize that the "voluntary" or selective attention-arousal systems of the brain are defective. this is attributed to absence of the' 'countercathectic barrier" that protects the operations linked to voluntary attention from undesirable interference (or restated in terms of primary and secondary processes: protects thought from continuous invasion by the procedural forms of the primary process). The accompanying distractibility occurs because of the cathectic depletion of the barriers which protect consciousness from excessive stimuli . on the one hand.-and therefore to the secondary process (and the reality principle) in general. One of my patients with severe cyclical pathology... there also appears to be a deficit in the' 'filtering" of information and in its regulation. as Luria describes (i. This implies that unconscious mental processes (wishes) have to make contact with preconscious verbal representations to find conscious expression.-Cs. etc. regarding the brain and the mental apparatus as a complex system. A surgical intervention to clear the carotid (endartorectomy) brought the situation back to the stato quo ante. in turn. The definition of denial by Prigatano and Klonoff (1998. but the following months of analysis provided a good opportunity to observe a complex and articulated assemblage of productive symptoms. had a partial occlusion of the carotid. In the same way as the functioning of the mental apparatus presupposes the constant and simultaneous presence of "primitive functions.-Cs. rationalizations. Radiological investigations revealed diffuse atrophy of the cortex. 499). The psychiatric pathology did not disappear. we are brought back to what Solms clearly explained when he writes that: [A] defining property of the deficit in question must be that it deprives the mental apparatus of something that is fundamental to the whole mode of functioning of the system Pcs. Jorge Canestri In Freeman's words: As the Pes contents are hypercathected. quoted by DeLuca) could be applied to some manifestations of this point: "denial after brain injury reflects the individual's attempt . In Freudian language. What is specifically interesting in this case is that Freeman (and also Solms) resorts to the Freudian theory of attention. deficits. system should have an adequate "cathexis" (activation).. In terms of Freud's theory (1900). formed with the help of language.. This implies that structures within the ventromesial frontal region of the brain subserve functions that are prerequisite for the secondary process mode of functioning that characterizes the system Pcs. at a certain point in the analysis. Freeman's synopsis of the Freudian theory of attention highlights the fact that' 'selective attention is a function of the ego system Pcpt-Cs which acts as a sense organ" (p. and this. a countercathectic barrier arises simultaneously to insulate directed thinking and perceiving from extraneous and internal stimuli .e. This is consistent with Luria's observations (quoted by Solms) concerning a "sharp decrease in cortical tone" and with the statements of Solms (and psychoanalysis in general) on the importance of considering not only the deficit but also the' 'productive" aspects of pathology. adding that the frontal lesion disturbs only the higher cortical forms of such activation. the loss of functions served by the system Pcpt-Cs leads to the appearance of an elementary form of cognition (primary process) [po 499]. then these aspects simultaneously reveal the work of the primary process in terms of wishful states. is plausible. On the other hand. patients suffering from chronic brain syndrome cannot voluntarily recall preconscious ideas and percepts because the system Pcpt-Cs is deprived of that (bound) cathexis which would enable it to bring these representations to consciousness.Downloaded by [Gazi University] at 22:50 18 August 2014 146 I will later return to the problem of the (associated) role that certain defense mechanisms-denial or disavowal (Verleunung)-----ean also play in these pathologies.

while his approach is to emphasize them-to consider only neurogenic confabulation and to set aside psychiatric pathology." But how do we trace a clear dividing line between denial of illness and unawareness of illness? Although it may be reasonable to try to differentiate between anosognosia and functional "denial of illness. the case reported by Wheatly and McGrath (1997. misrecognition). consequent distortion of the perception of reality. From the DeLuca's viewpoint. the productive aspects of the illness. rather than memory content itself. are compromised (Damasio. Here we must take account of the fact that denial (in the Freudian sense of disavowal. this operation clearly shows how the needs of the primary process (realization of a desire through its opposite. necessarily produces a confabulatory amnesia. alongside distortions of the ego and alteration of its functions. and Kassel. and it is mainly this (temporal order) that is altered in memory confabulation. Eslinger. with a perspective that must continuously take into consideration the phenomena of meaning as well as the phenomena of deficit. connected to the ventromesial portion of the frontal lobes. 54).." as Solms says. We could therefore hypothesize that the maintenance of temporal order is one of the executive functions of the frontal cortex and that the "amnesia. (1) preconscious appraisal of danger or trauma." DeLuca adheres to the third model. and others.. I do not think. and (4) screen behavior. not to take into account the premobid personality features. on the other hand. in other words. as it were. misidentification. In his section reviewing the "Neurobehavioral Models of Confabulation. Psychoanalysis. Damasio. In my opinion the argument remains open to further study and is of considerable interest from the neuroscientific and psychoanalytic point of view. i. I think it will seem obvious to DeLuca that all these observations invite a "nuancing" of the differences. some contradictory cases could be found." This definition coincides with the above hypothesis on the function of "reconciliation. for example. Such cases indicate that other nearby structures. 1985). Moreover. It is difficult." thus associating himself with the second model. the proposal DeLuca illustrates in Figure 1 could be useful. (2) painful affect. is only the inevitable consequence. that a "special type of executive disorder . Moreover. Graff-Redford. however.Downloaded by [Gazi University] at 22:50 18 August 2014 Commentary on Confabulation to use previous coping strategies to deal with impairments that are only partially recognized. works with a wider vision of subjective phenomena. including substitution of one reality with another. a radical separation between all these phenomena can risk impoverishing our understanding of the overall functioning of the mental apparatus as well as of the brain itself.e. Ptak and Schnider's (1999) observations (quoted by DeLuca in support of the third model) seem to lead in the direction proposed by Solms. provided that DeLuca also accepts that although it is useful in neurological practice. From this point of view. I have already mentioned how psychoanalysis can have heuristic value for the neurosciences. From the neurologist's viewpoint. etc. describes how "cognitive arrest concerning the painful object and the need to adapt to the dangerous or traumatic situation stimulates the need to create a cover story or screen to hide. Theo Dorpat (1983).. to discriminate confabulation in a narrow sense from that in a broad sense. the effects of which can produce total unawareness (rather than mere altered awareness). (3) cognitive arrest. ." neutralization of the trauma. the search for clarity in definitions and for precision in delimiting the field is paramount." to me it seems unsatisfactory to state (following the American Psychiatric Association's definition) that the difference must be sought in the fact that denial of illness presupposes merely altered self-awareness rather than actual unawareness. and would be contradictory from the analyst's point of view.) are articulated alongside those of the entire system (' 'need to adapt. the gap caused by the preceding phase." as DeLuca does in the section of his paper entitled "Confabulation and Awareness. to differentiate unawareness from denial of illness. quoted by DeLuca) of confabulation in a non-ACoA patient with executive dysfunction and impaired memory secondary to a diencephalic lesion. in hypothesizing four phases of denial. This different orientation partly reflects a disparity between the disciplines. However. in fact Ptak and Schnider attribute a core role to the orbitofrontal cortex in the maintenance of temporal order in memory. The cognitive arrest is usually followed by some kind of screen behaviour the content of which is often the opposite from what has just been negated" (p.. " Solms on the other hand thinks that the memory disorder is an executive disorder. Denial involves a cognitive alteration that can be very serious. that these two orientations need necessarily be incompatible. screen behavior. Verleunung or Verweifung) is a very powerful defense mechanism. it probably is not really accurate when one deals with confabulatory phenomena as a whole. hypothesizing that the expression of confabulation requires "both amnesia and executive dysfunction. and the fact that they 147 express unconscious tendencies. of necessity. and with a viewpoint that must confront the mental apparatus in its totality alongside each of its manifestations.

Damasio.. and the like. Many disciplines-psychoanalysis among them-are based on the accurate. (1983). London: Hogarth Press. (1998). J. Psychiatric perspectives on Freud's metapsychology.(1915). Formulations on the two principles of mental function. .. Neuropsychol.ormc4958@mclink. From this point of view. S. Freeman. they are not in themselves less scientific by definition than experimental data. 1953. Psycho-Anal. for the reason that it possesses an overarching model of the mental apparatus still lacking in neuroscience. Berkeley: University of California Press.(1911). T. Riparazione. the known causes? Do we know the anatomy of the lesion(s) causing them? Why do they occur? What are the associated features? What Are They? Dr. & Kassel. T. 1957. Florida. (1999). . The Interpretation of Dreams. Co-occurrence of executive impairment and amnestic syndrome following subarachnoid haemorrhage: A case study.. P. Damasio. Department of Neurology. Internat. The cognitive arrest hypothesis of denial. A Cognitive Neuroscience Perspective on Confabulation Commentary by Neill Graff-Radford (Jacksonville. With these articles in mind. 12:56-67. 5:243-250.. 61. Eslinger. & McGrath. Amnesia following basal forebrain lesions. The Mind's Past. J. H. (1998). (1985). P. H. Luria. such as the difference between bound and freely mobile energy. Psychoanalysis in its turn could receive valuable help from the neurosciences in order to test the empirical and experimental probity of its hypothetical and sometimes speculative concepts.. & Schnider. and intersubjectively controlled collection of empirical data. Gazzaniga. to reject as nonscientific the descriptive data resulting from subjective experience. 42:263-271.. In: 11 Piccolo Hans. A. A clinician's rating scale for evaluating impaired self-awareness and denial of disability after brain damage. L.. Freud. Mayo Clinic.. from the neuroscientific point of view. it is important to ask the following questions about confabulations: What are they? What are Professor Graff-Radford is Chair. Internat. Spontaneous confabulation after orbitofrontal damage: The role of temporal context confusion and Canestri... John DeLuca has written a scholary review of the cognitive neuroscience perspective of confabulation. Ptak. 4&5. derived from a particular experience in the treatment of mental illness. First.. The Working Brain: An Introduction to Neuropsychology. N. Dorpat. Restauro. U. and from a pragmatic point of view. FL) Dr.. J. Cortex. primary process and secondary process. J. References Jorge Canestri Via Sesto Rufo 23 00136 Rome.. M. DeLuca's work provides an excellent opportunity for reconsidering some basic concepts of Freudian metapsychology. J. & Klonoff. (1992).it. 14: 159-204..Downloaded by [Gazi University] at 22:50 18 August 2014 148 Neill Graff-Radford Moreover. (1900). Rev. and the entire Freudian concept of attention. and this does not exclude them from the field of empirical science. Vol. (1997). A. Riconciliazione. R. S. Clin. Italy e-mail: canestri@mclink." This is an all-inclusive definition and fits with the model in his Figure 1. Psycho-Anal. Milan: Media Press. while Dr.. (1973). P. or epistemologically correct. Jacksonville. Mark Solms has made a compelling case that many of the features characterizing confabulation are found in Freud's model of the unconscious mind. Wheatly. Harmondsworth. (1989). Neurocase.: Penguin Books. London: Hogarth Press. R. 12:213-226. G. R. 1958. 33:711-721. Neurol. programmed. I do not believe it is useful. London: Hogarth Press. Prigatano.K. But Solms has already commented on these aspects. Standard Edition. Arch.. The neurosciences could receive useful information from psychoanalysis relative to the complexity of the phenomena to be studied. The unconscious. Standard Editon. 19:497-502. S. Standard Edition. Graff-Radford. DeLuca has used the Moscovitch and Melo (1997) definition of "statements or actions that involve unintentional but obvious distortions. . A. 64:47-57.