NEUROCASE V p Psychology Press

2012, 18(5). 366-376 X Taylor & Francis Group

Perseverations and non-verbal confabulations on the

Rey-Osterrieth Complex Figure Test
in a fronto-temporal dementia single case study

A. SeddaS S. PassonP, and G. Bottini^'^

' Psychology Department, University of Pavia, Pavia, Italy
^Cognitive Neuropsychology Center, Niguarda Ca' Granda Hospital, Milan, Italy

We describe the case of a patient with late onset fronto-temporal dementia (FTD), who presented with typi-
cal personality changes, but also perseverative and confabulatory behaviors while performing the Rey-Osterrieth
Complex Figure Test. We hypothesize that the progressive atrophy of orbitobasal, medial, and dorsolateral frontal
cortices may give rise to both confabulations and perseverations in the non-verbal domain. In agreement with
previous studies, reporting atypical profiles, this case report underlines the clinical heterogeneity of FTD.

Keywords: Confabulations; Rey-Osterrieth Complex Figure Test; Fronto-temporal dementia; Perseveration; Non-
verbal confabulation.

Perseverations and confabulations have been des-
cribed in association with a variety of neurolog-
ical disorders (Hotz & Helm-Estabrooks, 1995a;
Kern, Van Gorp, Cummings, Brown, & Osato,
1992; Metcalf, Langdon, & Coltheart, 2007).
Perseverations are frequently reported after right
brain damage (Bottini et al., 2009). Patients with
left unilateral neglect, for example, may add unre-
quested writings or drawings on the right half
of the sheet, while performing cancellation tasks
(Bottini, Bisiach, Sterzi, & Vallar, 2002; Gainotti
& Tiacci, 1970). According to the classification
of Sandson and Albert (1984), perseverations can
present as 'stuck-in-set', when a current task cate-
gory or framework is inappropriately maintained;
'recurrent', when there is an unintended repetition
of a previous response to a subsequent stimulus;
and 'continuous', when a response is inappropri-
ately repeated without interruption. Although the
taxonomy widely varies among studies (Hotz &
Helm-Estabrooks, 1995a), perseverations can be
broadly defined as the incapacity to inhibit the rep-
etition of either all or part of a previous response.
It has been suggested that the frontal lobes and
their associated white-matter pathways may play
a prominent role in perseveration (Hotz & Helm-
Estabrooks, 1995a), although there is also evidence
that other brain areas such as the basal ganlia
(Bottini et al., 2009) may also give rise to this
disorder.
Confabulations, occurring in a variety of brain
disorders such as traumatic brain injury (Dalla
Barba, 1993), dementia (Nedjam, Dalla Barba, &
Pillon, 2000), and KorsakofTs syndrome (Dalla
Barba, Cipollotti, & Denes, 1990), may be defined
as statements or actions that involve distortion of
reality (Metcalf et al., 2007). Although initially
these behaviors were described in terms of memory
failure (Berlyne, 1972), over the years the concept
has evolved leading to new hypotheses, suggesting

Address correspondence to A. Sedda, Psychology Department, University of Pavia, piazza Botta 6, Pavia 27100, Italy. (E-mail:
sedda.anna@gmail.com).
Authors declare that they have no conflicts of interest.
© 2012 Psychology Press, an imprint ofthe Taylor & Francis Group, an Informa business
http://www.psypress.com/neurocase http://dx.doi.org/10.1080/13554794.2011.608368
 CONFABULATIONS IN AN FTD SINGLE CASE ON THE ROCF
a role of executive control impairments in the gen-
eration of confabulations (Burgess & McNeil, 1999;
Metcalf et al., 2007; Turner, Cipolotti, Yousry,
& Shallice, 2008). Specifically, it has been sug-
gested that confabulations may be generated due to
an impairment in the processes required in mem-
ory retrieval (Burgess & McNeil, 1999; Metcalf
et al., 2007), attributable to a failure in execu-
tive control and reality monitoring (Turner et a l ,
2008). Several neuroimaging studies localized these
strategic retrieval processes in the prefrontal cor-
tex (Gilboa & Moscovitch, 2002; Rugg & Wilding,
2000; Shallice, 2001,2006).
While perseverations are generally reported
across various domains (Hotz & Helm-Estabrooks,
1995a, 1995b), confabulations are mainly described
in the verbal domain (Dalla Barba, 1993; Metcalf
et al., 2007; Moscovitch & Meló, 1997). Although
confabulations received fewer attention in the non-
verbal domain (Kern et al., 1992), two past studies
described these phenomena (Joslyn, Grundvig, &
Chamberlain, 1978; Kern et al., 1992). In par-
ticular, visuo-spatial or non-verbal confabulations
have been defined as embellishments of abstract
drawings and they have been proposed as linked
to verbal confabulations, independently from the
diagnosis of the patients (Joslyn et al., 1978; Kern
et al., 1992). These embellishments have also been
defined as over-elaboration of the figure details
(addition of extra details not present in the orig-
inal figure), which is more frequent in fronto-
temporal dementia (FTD) than in Alzheimer dis-
ease (Thompson, Stopford, Snowden, & Neary,
2005a). Overall, the key feature of non-verbal
confabulations seems to be a preserved spatial con-
figuration, in which unrequired details are embed-
ded.
Probably due to the progression of the atrophy of
the frontal structures (Hodges, 2001), FTD patients
frequently present with both confabulatory syn-
dromes (Nedjam et al., 2000) and perseverations
(Neary & Snowden, 1996).
Here we report the case of BM, diagnosed with
a probable FTD, the clinical course of whom we
had the opportunity to monitor over 2 years. BM
showed both confabulations and perseverations at
a number of non-verbal neuropsychological tasks,
mainly at the delayed recall of the Rey-Osterrieth
Complex Figure Test (ROCF) (Osterrieth, 1944;
Rey, 1941). Although with regard to a non-verbal
test, BM's output was associated with a spe-
cific and consistent semantic content. His pat-
tern of confabulation and perseveration on the
ROCF became progressively more evident, possibly
367
highlighting the progression of atrophy from ven-
tromedial to other frontal areas.
CASE REPORT
BM is a 75-year-old right-handed man, with
11 years of education. He worked as a painter/
decorator, and he was retired at the time of the
evaluation. He came to our attention through his
family doctor, due to relevant behavioral changes
because he became more and more irritable, and
due to generic complaint of memory loss over the
previous 2 years. His past medical history was oth-
erwise unremarkable except for a benign prostatic
hyperpiasia, which was treated with Dutasteride.
Basic neurological examination was normal. The
patient was not taking any other drug, and had not
undergone previous treatment. There was no family
history of note.
BM, now divorced, reported that he had been
married, that he has a daughter, and that he was
not having a relationship at the time of evaluation,
saying he was 'free'. The patient's daughter was not
present at the examination, neither had she agreed
for a face-to-face interview in the future. We were
able to contact her by phone, and she only reported
sporadic aggressive episodes and alcohol abuse of
her father in the past. However, given no other
relatives were available to gather collateral infor-
mation, we were not able to verify his daughter's
statements.
Written informed consent was obtained from
BM for all the cognitive evaluations. Neuro-
psychological assessment comprised:
• The Mini Mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975; Measso
et al., 1993), a 30-point screening test, which is
used to assess the severity of cognitive impair-
ment, sampling various functions such as mem-
ory and orientation. The cut-off for the Italian
population is 24/30 (Measso et al., 1993).
• The Raven Coloured Progressive Matrices
(Caffarra, Vezzadini, Zonato, Copelli, &
Venneri, 2003; Court & Raven, 1995) is a mul-
tiple choice test of abstract reasoning, in which
the score is the number of correct responses
given in 30 minutes.
• The Letter Fluency Test and the Categories
Fluency Test (Novelli et al., 1986), the first
involving executive functions, while the sec-
ond relates more to semantic memory access
(Baldo, Schwartz, Wilkins, & Dronkers, 2006).
368 SEDDA ET AL.
The score of each test is given by the number of
elements produced in 1 minute.
• The Short Story Recall (Spinnler & Tognoni,
1987) assesses long-term episodic verbal
memory. The number of elements recalled from
a short article-like story gives the score. Recall
is assessed immediately and after a 10-minute
delay.
• The Corsi block-tapping task (Corsi, 1972;
Orsini et al., 1987) assesses short-term visuo-
spatial memory span. The score is given by
the number of blocks in the longer sequence
identified correctly.
• The Digit Span Forward Task (Orsini et al.,
1987) is a common measure of short-term mem-
ory verbal span, in which the score is given by
the longest list of digits repeated correctly.
• In the Rey-Osterrieth Complex Figure Test
(ROCF) (Osterrieth, 1944; Rey, 1941), subjects
are asked to reproduce a complex and abstract
line drawing, first copying it and then drawing
it from memory after a delay of some minutes.
This test involves not only constructional abili-
ties but also planning and programming (exec-
utive functions), visuo-spatial abilities, mem-
ory and attention. For the administration and
scoring procedure we referred to Caffarra,
Vezzadini, Dieci, Zonato, and Venneri (2002).
The original ROCF was used. The delay inter-
val between the copy and the reproduction
from memory was 10 minutes (Caffarra et al.,
2002), with a verbal distracting task in the mid-
dle. In the scoring, 2 points are given when
the element is correctly reproduced, 1 point
when the reproduction is distorted, incom-
plete but placed properly, or complete but
placed poorly; a 0.5 point is credited when
the element is distorted or incomplete and
placed poorly. A zero score is given when the
unit is absent or not recognizable (Caffarra
et al., 2002). The ROCF includes 18 units,
thus the maximum raw score for each of
the two tasks (direct and delayed copying) is
36.
• The Attentional Matrices (Spinnler & Tognoni,
1987) are used to assess subjects' ability to detect
visual targets among distracters. The test is com-
posed by 3 matrices of numbers, in which the
targets have to be crossed out as fast as possi-
ble. The score is given by the overall number of
targets crossed out within 45 seconds.
• The Trail Making Test ~ parts A and B
(Giovagnoli et al., 1996; Reitan, 1958), is a
measure of different cognitive components, such
as attentional skills, visuo-motor planning, sus-
tained attention, and working memory. Part A
requires the patient to join numbers, from 1 to
25, randomly distributed in space, while in part
B the subject is asked to alternately join a set of
numbers (from 1 to 13) and a set of letters (from
A to L). The time taken to complete each part
of the test is used as score.
• The Frontal Assessment Battery (AppoUonio
et al., 2005; Dubois, Slachevsky, Litvan, &
Pillon, 2000) is a short but reliable battery for
the assessment of executive functions. It consists
of 6 subtests investigating conceptualization,
mental flexibility, motor programming, sensi-
tivity to interference, inhibitory control, and
environmental autonomy. Maximum total score
is 18 and higher scores indicate a better perfor-
mance.
• The Cornell Depression Scale (Alexopoulos,
Abrams, Young, & Shamoian, 1988) assesses
signs and symptoms of major depression. Cut-
off for depression is 9 (Italian validation of the
scale for demented patients, Gruppo di Ricerca
Geriatrica di Brescia, http://www.grg-bs.it).
For all the tests, we applied the Italian published
norms. Scores have been corrected for age and edu-
cational levels and, when possible, transformed in
equivalent scores.
26 September 2006 - First cognitive
evaluation
At this time BM showed a performance in the nor-
mal range on all neuropsychological tests apart
from the Semantic Fluency (Table 1, first evalua-
tion). Moreover, he performed poorly (below the
25th percentile) on the FAB and on the ROCF
recall. In detail, BM was impaired in the motor
programming (Luria's series) and inhibition control
(interference sensitivity) sections of the FAB, result-
ing in an equivalent score of 2. His ROCF copy-
ing was normal, although he spontaneously repro-
duced part of the geometrical elements (triangles)
of the ROCF itself in the space surrounding the
copied ROCF (Figure la). However, BM's delayed
figure recall was impaired (equivalent score of 1):
although he was still able to reproduce most of
the individual elements of the figure, he was inca-
pable to preserve the global geometric pattern
(Figure lb). During the clinical interview he pre-
sented with tangential speech. Neither visuo-spatial
(Corsi Span) (Spimiler & Tognoni, 1987) nor verbal
 CONFABULATIONS IN AN FTD SINGLE CASE ON THE ROCF 369

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370 SEDDA ET AL.
Figure 1. ROCF copy (a) and delayed reproduction (b) (first evaluation). Geometrical insertions are evident below the figure in the copy
condition.
memory (Short Story Recall) (Novelli et a l , 1986)
deficits emerged at this time.
First follow-up (17/03/2008) - Second
cognitive evaluation
Eighteen months after the first evaluation, BM's
behavioral symptoms worsened, although he
appeared to be less aware of this, not complaining
anymore of memory losses or other cognitive
disturbances. On direct questioning the patient
reported that his memory was as good as it ever
had been. He was confabulating about his auto-
biographical information, claiming not to have
enough time to complete the assessment, because
he had an appointment with his brother (he has no
relatives except his daughter). Moreover, he stated
to have a degree in architecture and a broken right
arm, which were false information.
At the neuropsychological testing, the patient
showed a general worsening, most of the tests
now being outside the normal range (Table 1,
second evaluation). Moreover, he produced many
perseverations on the Phonemic and Semantic fiu-
encies (Novelli et a l , 1986). A dense perseverative
behavior was also evident at the copy of a geometric
pattern (Figure 2).
Figure 2. Copy of a geometric pattern. The initial task is lost
and original elements are substituted with spontaneous and
unrequested productions.
At the Raven Coloured Progressive Matrices
(Court & Raven, 1995), BM stated that he could
not see well and that 'These are as table cloths
burnt by an iron', and refused to perform the test.
On the ROCF, although clearly instructed to copy
all the details, he 're-interpreted' the original pat-
tern as a fish. Furthermore, he gave a rich verbal
description, commenting on all the elements of the
original figure as possible parts of the drawn fish,
with the exception of the 'cross' that he could not
fit in, as it was not coherent with the rest. He stated
as follows: 'I do not understand how a cross can fit
in a fish! However, I will copy it as these are your
instructions'. He finally completed the 'fish' adding
a number of new elements, such as the tail and
the fins (Figure 3a). On the ROCF delayed recall.
 CONFABULATIONS IN AN FTD SINGLE CASE ON THE ROCF
Figure 3. ROCF copy (a) and delayed reproduction (b) (second evaluation). Geometrical insertions are no longer present and the patient
completely substitutes the original ROCF with a fish, both during the copy and the delayed reproduction.
when asked to reproduce the figure, he said: 'Oh
yes, the fish with the cross that does not fit in at all,
I will draw a fish again but now it will be a shark'
(Figure 3b).
When tested with the practice trials of the Trail
Making Test (Reitan, 1958), instead of simply
connecting the numbers, BM added some graphic
elements in order to make the pattern looking like a
fish (Figure 4). On the MMSE, he said an incorrect
year (2006) and he interpreted the sentence 'No
ifs, ands or buts' as 'there is no total traffic light'.
Moreover, his spontaneous written sentence was
incomplete and indicative of disinhibition: 'hospi-
tal evaluation only troubles'. On the Attentional
Matrices, BM read aloud all the numbers he
crossed, although being advised not to do it. His
Figure 4. Trail Making Test - part A; practice trials. Instead of
performing the requested conjunctions, BM draws a fish, using
as landmarks the Trail Making circles.
371
behavior did not allow him to perform a more
exhaustive neuropsychological evaluation. At this
stage, BM has been diagnosed as FTD following the
Lund and Manchester groups diagnostic criteria
(1994). Moreover, given the absence of a caregiver,
we required the intervention of a social worker.
Second follow up (7/04/2008) - Third
cognitive evaluation
One month after the second evaluation, we found a
clear persistence of the 'fish' behavior while copy-
ing the ROCF (Figure 5), and the patient clearly
remembered to have drawn a fish before. Pointing to
the different parts ofthe figure, he commented: 'The
cross that does not fit in at all'. At this time, BM was
even more productive: he drew more fish and added
new elements to the original pattern (Figure 5a).
In the delayed recall the patient drew a number of
small circles at the bottom of the sheet, saying that
they were eggs the fish being pregnant (Figure 5b).
BM was cheerful and satisfied of how his memory
was functioning, as he was able to remember the
fish with all its details.
At this time, we tried to administer the patient
with other cognitive tests, but he was unable to
follow the instructions and started confabulating
about the stimuli. For instance, on the Raven
Matrices BM interpreted each item in terms of
familiar objects (A3: a table suite; AB 10 n.5:
372 SEDDA ET AL.
í/
Figure 5. ROCF copy (a) and delayed reproduction (b) during the last follow-up (third evaluation). The fish pattern is still present.
Moreover, other confabulatory items, related to the fish, are added to the picture, during the copy and the delayed reproduction.
Pharmacy sign; Al, N.3: the flag when Schumacher
wins; A7, N. 5: the Swedish flag) claiming that none
of the available choices was the correct one. He was
able to complete only one stimulus, scoring 1 of 36.
DISCUSSION
Confabulations and perseverative behaviors may
be typical disorders of FTD when compared to
other dementias (Rozzini, Lussignoli, Padovani,
Bianchetti, & Trabucchi, 1997; Thompson,
Stopford, Snowden, & Neary, 2005b). We had the
opportunity to monitor the neuropsychological
symptoms of BM, a patient diagnosed as probable
FTD.
Interestingly, our patient presented with a dense
non-verbal confabulation, starting from his second
neuropsychological evaluation. BM's performance
on the ROCF initially showed an intrusion of geo-
metrical shapes (first evaluation. Figure 1) devel-
oping in the following controls a more complex
re-interpretation of the original pattern (the ROCF)
as a fish (second and third evaluations. Figures 2
and 3). Moreover, this flsh pattern persisted enough
to spread across the Trail Making Test, the stim-
uli of which have been re-interpreted as a fish as
well.
Initially BM's performance may be described as
a visual perseveration, as he repeats part of the geo-
metrical elements (triangles) of the ROCF in the
space surrounding the copied figure (Sandson &
Albert, 1984). The repetition of the fish pattern in
the third evaluation and on the Trail Making Test
may be seen as well as a perseveration of the fish
visuo-spatial confabulation. Similarly, in the third
evaluation the patient adds more little fish, which
can be a perseveration focused on the visuo-spatial
confabulation he had previously produced.
However, at the second assessment, BM's per-
formance on the ROCF suites the definition of
visuo-spatial confabulation (Figures 2 and 3), as he
develops a meaningful embellished figure, related
to the ROCF original abstract drawing, rather than
simply adding perseverative strokes or repeating the
same elements of the figure. He adds details to the
abstract pattern of the ROCF, drawing a fish, but
maintains the original spatial configuration (i.e., the
fish has the same orientation of the ROCF, of which
part of the original elements are elaborated), in
agreement with non-verbal confabulations descrip-
tions from previous studies (Joslyn et al., 1978;
Kernetal., 1992).
We believe that BM presents a mix of non-verbal
confabulation and perseveration, which we can
speculate is related to the disease progression and
 CONFABULATIONS IN AN FTD SINGLE CASE ON THE ROCF
possibly to the anatomical involvement of different
frontal areas. Our hypothesis is that the progressive
atrophy of orbitobasal, medial, and dorsolateral
frontal cortices may give rise to both confabulations
and perseverations. FTD has been reported to ini-
tially involve the ventromedial and orbitobasal por-
tions of the frontal cortices, implying emotional
dysfunctions, dishinibition, poor impulse control,
and stereotypes (Hodges, 2001; Neary, Snowden,
& Mann, 2005). With the disease progression, dor-
solateral frontal cortices are affected as well, and
planning, organization, executive functions in gen-
eral are also compromised (Hodges, 2001). In sup-
port of this view, BM initially showed a perse-
verative behavior, and his confabulations increased
together with the worsening of his executive func-
tions. It was only during the second evaluation that
tests other than the FAB showed a clear impairment
of executive control. BM's personality changed dur-
ing the follow-ups, from a mildly impulsive behav-
ior to an increasing irritability, passing through
a depressive mood.
FTD is known to be characterized by a strong
clinical heterogeneity: each patient experiences dif-
ferent symptoms, depending on the frontal and
temporal areas of the brain initially involved in the
atrophy (Graham et al., 2005). Typically, during
the initial stages, personality and behavior may be
compromised, while memory is still intact. Patients
may become extroverted and lose their inhibition or
alternatively they may manifest apathy and become
withdrawn. Patients may also develop fixed and
obsessive routines and change their food prefer-
ences towards sweet tastes. However, otherwise typ-
ical cases of FTD have already been reported in
the literature. For instance, Graham et al. (2005)
even evaluated FTD patients with memory dis-
turbance as the presenting feature. Manes et al.
(2010) described the case of a FTD patient, whose
initial feature was a pathological gambling behav-
ior. Based on clinical experience, absence of 'early,
severe amnesia' as an exclusion criterion for the
diagnosis of FTD has been recently questioned: sev-
eral studies demonstrated that patients with FTD
may complain of memory loss and memory under-
performance (Binetti, Locascio, Corkin, Vonsattel,
& Growdon, 2000; Graham et al., 2005). It is
still debated if these memory problems are a 'pure
storage' deficit (Hodges, 2001) or an impairment
in strategic retrieval (Turner et al., 2008). In our
patient, confabulations and cognitive dysfunctions
were in parallel; however, it is very difficult to
373
establish the primary causal role. As highlighted
by his neuropsychological profile, both his ver-
bal and graphical confabulations increased together
with the executive control decline. At the second
evaluation, in fact, when BM's 'fish' behavior
became more apparent, his performance at a num-
ber of frontal tests (FAB, Verbal Fluency, and
Attentional Matrices; Spinnler & Tognoni, 1987)
became impaired together with a decline of his
memory functions as shown by the Digit and the
Corsi Span scores. Curiously enough, his perfor-
mance on the Short Story Recall was nearer to
the normal range, possibly suggesting a greater role
of executive control rather than memory storage
impairments per se in arising BM's confabulations
(Metcalf et al., 2007; Turner et al., 2008).
Independently from the mechanism responsi-
ble for the impairment, the strict application of
clinical criteria in FTD diagnosis may be mis-
leading in some atypical cases in which memory
impairment or other peculiar deficits are present,
just because of the well-known heterogeneity of
FTD (Graham et a l , 2005). BM himself may rep-
resent a typical case of FTD, as he presented
with classical personality and behavioral changes
during its initial stages. However, he also pre-
sented with perseverations and confabulations in
the non-verbal domain and initially complained
about memory impairments, partially confirmed by
his performance on the Semantic Fluency Test.
Moreover, his disease onset was late in life. For
FTD, the age of onset has been established typ-
ically between 45 and 65 years, although rarely
onset can occur after 75 years of age (Manes et al.,
2010).
It is puzzling that, despite the general tendency
of our patient to confabulate, he actually did not
confabulate while recalling the short story, unlike
previously reported FTD patients (Nedjam et al.,
2000; Nedjam, Devouche, & Dalla Barba, 2004;
Thompson et al., 2005b). It may also be possible
that BM produces 'spatial' confabulations referring
to a semantic domain (fish) to facilitate his recall
process using this re-interpretation of an unfa-
miliar geometric pattern as a known object. The
attempt to refer the individual components of the
ROCF rather than to the global pattern is typi-
cally observed in brain-damaged patients (Trojano
et al., 2004). This 'piecewise approach' (Trojano
et al., 2004) may facilitate the interpretation of
the single elements as more familiar things such
as a house or a cross. To store information in
374 SEDDA ET AL.
long-term memory, consolidation processes, allow-
ing reorganization within representations of stored
information, have been shown to be important
(Shin, Park, Park, Seol, & Kwon, 2006). Executive
functions help to organize diverse materials into a
meaningful cluster, so that the memory consolida-
tion can be facilitated. Organizing the ROCF into
a meaningful perceptual unit, during the Copy con-
dition, has been shown to enhance its subsequent
recall from memory (Shin et al., 2006). Thus, BM's
better performance on the delayed recall in the sec-
ond evaluation (equivalent score 2; first evaluation,
equivalent score 1) may be explained thanks to the
fish pattern, which is, in fact, a helpful, meaningful
perceptual gestalt. We think that BM's peculiarity is
that his productive behavior is strongly centered on
a unique semantic cue ('fish'), consistently replac-
ing the original stimulus in two neuropsychological
tests. This new representation consolidated so much
in time so as to actually predominate over the pre-
sentation of the original pattern and manifested as
a perseveration.
The ROCF aims to evaluate different cognitive
abilities related to the visuo-spatial domain, such
as attention, planning, and memory (Osterrieth,
1944; Rey, 1941). FTD patients have been reported
to copy the ROCF poorly, because of impulsive-
ness or impoverished strategy formation (Hodges,
2001). However, other visuo-spatial tests such as the
Visual and Objects Space Perception (Warrington
& James, 1991) have been reported to be strikingly
well carried out by these patients even in advanced
stages of the disease (Hodges, 2001; Neary et al.,
2005). Our patient's performance demonstrates that
the ROCF may be a good test to evaluate the
presence of confabulations and perseverations in
FTD. BM, in fact, while performing the task at
the second and third evaluations, clearly remem-
bered the task instructions, but reproduced the fish
rather than the requested original pattern, suggest-
ing an impairment in executive control of memory
retrieval and failure of inhibition (Metcalf et al.,
2007; Turner et al., 2008). This is also supported
by the fact that BM reproduces the original spatial
configuration of the ROCF, elaborating it instead
of simply missing parts of the figure (Neary et a l ,
2005).
Non-verbal confabulations have been scarcely
reported in previous studies, but they may be a
relevant feature for some FTD cases. Therefore,
we think that it may be worthwhile to investigate
further non-verbal confabulations and their asso-
ciation with perseverations in FTD and generally
in frontal lobe lesions. Previous studies (Joslyn
et al., 1978; Kern et al., 1992) on non-verbal
confabulations, although limited, are meaningful.
Non-verbal confabulations, nicely revealed by the
ROCF, may be a relevant part of the clinical profile
of FTD and a distinctive sign useful for a differen-
tial diagnosis from Alzheimer's disease.
Original manuscript received 17 November 2010
Revised manuscript accepted 24 July 2011
First published online 6 December 2011
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