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Neuropsychoanalysis: An Interdisciplinary Journal

for Psychoanalysis and the Neurosciences
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A Cognitive Neuroscience Perspective on

Confabulation: Commentary by Neill Graff-Radford
(Jacksonville, FL)

Neill Graff-Radford MBBCh, FRCP


Professor and Chair of the Department of Neurology, Mayo Clinic Jacksonville, 4500 San
Pablo Road, Jacksonville, FL 32256, Phone 904-953-7103, FAX 904-953-7233
Published online: 09 Jan 2014.

To cite this article: Neill Graff-Radford MBBCh, FRCP (2000) A Cognitive Neuroscience Perspective on Confabulation:
Commentary by Neill Graff-Radford (Jacksonville, FL), Neuropsychoanalysis: An Interdisciplinary Journal for
Psychoanalysis and the Neurosciences, 2:2, 148-150, DOI: 10.1080/15294145.2000.10773298
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Neill Graff-Radford

Moreover, I do not believe it is useful, or epistemologically correct, from the neuroscientific point of
view, to reject as nonscientific the descriptive data
resulting from subjective experience. First, they are
not in themselves less scientific by definition than experimental data. Many disciplines-psychoanalysis
among them-are based on the accurate, programmed, and intersubjectively controlled collection
of empirical data, and this does not exclude them from
the field of empirical science. The neurosciences could
receive useful information from psychoanalysis relative to the complexity of the phenomena to be studied,
for the reason that it possesses an overarching model
of the mental apparatus still lacking in neuroscience.
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, derived from a particular
experience in the treatment of mental illness.
From this point of view, DeLuca's work provides
an excellent opportunity for reconsidering some basic
concepts of Freudian metapsychology, such as the difference between bound and freely mobile energy, primary process and secondary process, and the entire
Freudian concept of attention, and the like. But Solms
has already commented on these aspects.

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Jorge Canestri
Via Sesto Rufo 23
00136 Rome, Italy

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A Cognitive Neuroscience Perspective on Confabulation

Commentary by Neill Graff-Radford (Jacksonville, FL)

Dr. John DeLuca has written a scholary review of the

cognitive neuroscience perspective of confabulation,
while Dr. Mark Solms has made a compelling case
that many of the features characterizing confabulation
are found in Freud's model of the unconscious mind.
With these articles in mind, and from a pragmatic
point of view, it is important to ask the following questions about confabulations: What are they? What are
Professor Graff-Radford is Chair, Department of Neurology, Mayo
Clinic, Jacksonville, Florida.

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. DeLuca has used the Moscovitch and Melo (1997)
definition of "statements or actions that involve unintentional but obvious distortions." This is an all-inclusive definition and fits with the model in his Figure 1,


in which he divides confabulations into broad sense
and narrow sense groups and the latter into memory,
neglect, Anton's syndrome, and Wernicke's aphasia.
This framework is useful in that many different neuropsychological deficits fit the above definition but do
not necessarily have the same anatomy or mechanism.
It acknowledges the similarities and differences. However, the main area to which confabulations relates
refers back to Korsakoff's original description of amnesic patients, having incorrect recollections which
they believed were true.

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What Are the Known Causes?

Referring in the narrow sense to memory-related confabulation, the two most frequently cited causes are
Korsakoff's disease and amnestic patients with anterior communication aneurysm hemorrhages. In the
broad sense, many other causes of brain damage including stroke, an-Jxia, the many causes of confusional
states, dementia, and even corpus callosum damage
may result in confabulation.

What Is the Anatomy of the Lesion(s)?

Damage to a combination of the basal forebrain and
the ventromedial frontal lobe has strong support as the
probable sites responsible. However, it is not even
clear which lesions are important in Korsakoff's disease. If we accept that amnesia and executive (frontal)
dysfunction are the crucial combination, then a combination of mammillary body, dorsomedial thalamic nuclei (which have strong projections to the frontal lobe),
and median thalamic nuclei, may be the necessary anatomical combination. This is speculative and clearly
delineates an important area to investigate. There is
no good information about how frequently either
spontaneous or provoked confabulations occur in
other amnestic syndromes, such as in anoxia, herpes
encephalitis, Alzheimer's disease, and Lewy Body Dementia. Many of these syndromes have both a memory
and frontal component to them, yet spontaneous confabulations certainly seem less frequent in such cases
than in patients with Korsakoff's disease or amnesia
related to anterior communicating aneurysms.

position to 100 years ago when Korsakoff believed

that confabulations consisted of actual events displaced temporally and Bonhoffer thought that confabulations were attempts by the patient to cover up a
disorder of which the patient was consciously aware.
However, some progress has been made.
Schnider, von Daniken, and Gutbrod (1996) showed
some experimental support for a temporal context
deficit in that confabulating amnesics confused present
and previously acquired information on a continuous
recognition task whereas nonconfabulating amnestics
did not. There is some indirect evidence that confabulations reflect a desire to fill in gaps in memory. The
right hemisphere of a split-brain patient was instructed
to get up and walk. The left hemisphere was then
asked where the person was going to and the patient
replied, to get a drink of water. While the left hemisphere was aware that it did not know why the person
was walking it decided to fill in the gap in memory.
However, this is at best very indirect support for this
theory in that the split-brain patient is clearly very
different from an amnestic patient.
Anterior communicating amnestic patients suffer
from retrieval deficits. For example, our patient was
asked if he was married and he said he was not. Then
his wife's name was raised and he then recognized he
was married and remembered his children's names.
Even if this is true, the retrieval deficit does not seem
to explain the confabulation in Korsakoff patients.
Mark Solms points out that many of the features
of confabulating amnestic patients fit with aspects of
what Freud described in the special characteristics of
the system Unconscious. These include tolerance of
mutual contradiction, timelessness, replacement of external reality by psychical reality and the primary process of mobility of cathexis. These features,
Korsakoff's belief that memory confabulation consisted of actual events displaced temporally for which
patients were unaware, and dreaming, seem to have a
lot in common. One wonders if this is an important
clue to an identification of the anatomical structures
important in dreaming and in the amnestic syndrome.

What Are the Associated Features?

DeLuca's Table 1 provides an excellent list of these.

Why Do Confabulations Occur?


From DeLuca's review we clearly do not know the

answer to this. He points out that we are in a similar

We have made little progress in the last 100 years in

our understanding of confabulations. This exercise in


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viewing the same problem from the perspective of the

two different disciplines, cognitive neuroscience and
psychoanalysis, has been useful. I find it remarkable
that Freud, from the analysis of normal individuals,
described some of the features of the mind revealed
in the confabulating amnestic syndrome. Only time
will tell if this association leads to advance in our
understanding of psychoanalysis, or the amnestic confabulation syndrome, or dreaming.

Marcia K. Johnson

Moscovitch, M., & Melo, B. (1997), Strategic retrieval and
the frontal lobes: Evidence from confabulation and amnesia. Neuropsychologia, 35:1017-1034.
Schnider, A., von Daniken, C., & Gutbrod, R. (1996), The
meaning of spontaneous and provoked confabulation.
Brain, 119:1365-1375.
Neill Graff-Radford, MBBCh, FRCP (London)
Professor and Chair of the Department of Neurology
Mayo Clinic Jacksonville,
4500 San Pablo Road,
Jacksonville, FL 32256
Phone 904-953-7103
FAX 904-953-7233

Commentary by Marcia K. Johnson (New Haven, CT)

DeLuca and his colleagues (DeLuca and Cicerone,

1991; DeLuca, 1993; DeLuca and Diamond, 1995)
have provided some of the most systematic observations of confabulating patients that we have available.
Therefore his views about our current level of understanding of this fascinating neuropsychological phenomenon are of particular interest. In the interest of
stimulating a conversation, I will focus on several areas where I think DeLuca's analysis is problematic,
needs further clarification or development, or perhaps
underestimates the progress that has been made in understanding the cognitive mechanisms of confabulation.

Is the Field Suffering from the Problem of a

Lack of a Clear Definition of Confabulation?
Most definitions of confabulation have in common the
idea that patients may make statements that are false
or engage in behaviors that reflect false memories or
beliefs, and that they do this without an intention to
deceive (e.g., Whitlock, 1981; Moscovitch, 1989;
Johnson, 1991). DeLuca adopts such a definition for
what he calls "confabulation in the broad sense," but
suggests that little progress has been made in the last
Dr. Johnson is Professor of Psychology, Department of Psychology,
Yale University, New Haven, Connecticut.
Acknowledgments. Preparation of this paper was supported by NIA
Grants AG09253 and AG 15793.

hundred years in understanding confabulation because

cognitive neuropsychologists have not come to a consensus about whether there is one type or two (or
more) distinct forms of confabulation.
A more optimistic view is that researchers have
pointed out that confabulations (even from the same
patient) differ on a number of dimensions. Confabulations differ in general content-whether they are about
current visual experience (Anton's syndrome); identity of persons (Capgras syndrome) or places (reduplicative paramensia); experiences of body parts (denial
of paralysis); or about autobiographical episodes, semantic knowledge, or beliefs. They also differ in bizarreness, whether spontaneously offered or given in
answer to questions, and whether they are acted upon.
They may also differ in the degree to which patients
are aware (at least initially, see below) that they are
embellishing. Such observations provide the beginning
of a systematic scheme for describing (i.e., coding)
patients' behavior that is more nuanced (i.e., multidimensional) than the simple dichotomous schemes that
DeLuca correctly suggests we should reject, but also
more detailed than the one he outlines.
In his Figure 1 and the accompanying discussion,
DeLuca proposes a classification scheme largely based
on general content of confabulations, which has
shown some relationship to lesion evidence. For example, confabulation about visual experience is associated with bilateral occipital brain damage;
confabulation that denies paralysis is associated with