COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8), 1005–1034

RIGHT VENTRAL FRONTAL HYPOMETABOLISM

AND ABNORMAL SENSE OF SELF IN A CASE OF
DISPROPORTIONATE RETROGRADE AMNESIA

Pascale Piolino
Inserm-Université de Caen EMI E0218, Caen and Université René Descartes-EPHE-CNRS,
UMR 8581, Paris, France
Didier Hannequin
Inserm, U614 and CHU, Rouen, France
Béatrice Desgranges
Inserm E0218-Université de Caen, France
Carole Girard
CHU, Rouen, France
Hélène Beaunieux, Bénédicte Giffard, Karine Lebreton
Inserm-Université de Caen, EMI E0218, Caen, France
Francis Eustache
Inserm-Université de Caen, EMI E0218, Caen and EPHE-CNRS-Université René Descartes,
UMR 8581, Paris, France

We report the case of a 42-year-old man (patient CL) who developed a particular profile of amnesia
with two dates of onset. At the first onset, the patient suffered a mild/moderate injury that accounts
for an initial anterograde and mild retrograde memory impairment. At the second onset, 8 months
later, he suffered a sudden and persistent loss of personal identity and severe retrograde amnesia. We
report an extensive neuropsychological investigation of his memory systems carried out 18 months
after the second onset. Results indicated mild executive dysfunction (primary memory), intact pro-
cedural skills and perceptual representational system. In accordance with Kopelman’s methodological
recommendations, we have reliably compared post- and pre-onset semantic and episodic memory
using strict matched procedures. We found that post-onset, though not pre-onset semantic (autobio-
graphical and nonautobiographical) memory was entirely preserved. Post-onset episodic autobiogra-
phical memory was not intact, however, although it was clearly less affected compared with the total
absence of the pre-onset memory. Moreover, a novel and high standard investigation of the subjec-
tive states of consciousness, which accompanied retrieval of autobiographical memories via the
Remember/Know (R/K) paradigm with a long time interval from the present, demonstrated a
deterioration of R responses compared to matched controls. Interestingly, this result showed
deficient autonoetic consciousness and suggested an underlying accelerated forgetting rate for

Correspondence should be addressed to Professor Francis Eustache, Inserm-Université de Caen, EMI E0218, Laboratoire de
Neuropsychologie, CHU Côte de Nacre, 14033 Caen Cedex, France (Email: neuropsycho@chu-caen.fr).
The authors would like to thank E. Portier for reviewing the English style, P. A. Bohu, M. J. Gaillard, and D. Leveille-Nizerolle
for their help in conducting the neuropsychological examination of the patient, and the two anonymous referees for their helpful
comments.

# 2005 Psychology Press Ltd. 1005

http://www.tandf.co.uk/journals/pp/02643294.html DOI:10.1080/02643290442000428
PIOLINO ET AL.

post-onset autobiographical episodic memories. Last, a [18F] fluorodeoxyglucose resting PET study
revealed a significant right-sided ventral frontal lobe hypometabolism in the absence of overt struc-
tural lesions. The involvement of this region is consistent with CL’s autobiographical retrograde
amnesia and his inability to re-experience information concerning the self across time. In our par-
ticular case, characterised by two dates of onset, the attribution of causality is thoroughly examined
in terms of CL’s organic and psychogenic aspects.

INTRODUCTION memory relative to semantic memory (Dalla

Apart from a few early studies by authors such as
Théodule Ribot (1881), the field of retrograde
amnesia (impaired recall of information acquired
prior to the onset of injury) has long been neg-
lected, compared with that of anterograde
amnesia (deficit in the acquisition and retention
of new information). Memory loss following
brain injury is most often characterised by both
anterograde and retrograde amnesia, although
the incidence of anterograde amnesia after cer-
ebral lesions is considerably higher than that of
retrograde amnesia (Kopelman, 2002). In recent
years, however, a growing number of reports
have described cases of pure retrograde amnesia
(for recent reviews, see Kapur, 1999, 2000;
Kopelman, 2000a, 2002). This pattern of
memory loss, labelled either isolated or focal retro-
grade amnesia (FRA; Kapur, 1993; Kapur, Young,
Bateman, & Kennedy, 1989) has stirred up a great
deal of controversy. Interest has focused on three
main areas (Kopelman, 2000a, 2000b, 2002;
Mayes, 2002): the issue of “pure” FRA; cerebral
dysfunction in FRA; and the attribution of causal-
ity in terms of organic and psychogenic factors.
The issue of “pure” FRA
A number of neuropsychological studies on
amnesia (Kopelman, 2002) have found that some
patients which present both anterograde and
retrograde amnesia recover from the former, but
not from the latter. The loss of retrograde
memory may selectively affect the retrieval of per-
sonal episodes (Dalla Barba, Mantovan, Ferruzza,
& Denes, 1997; Levine et al., 1998; Manning,
2002), disproportionately affect autobiographical
Barba et al., 1997; Hunkin et al., 1995;
O’Connor, Butters, Miliotis, Eslinger, &
Cermak, 1992; Stracciari, Ghidoni, Guarino,
Poietti, & Pazzaglia, 1994), or affect both auto-
biographical memory and aspects of general
semantic memory (De Renzi, Lucchelli, Muggia,
& Spinnler, 1995; Kapur, 1993; Lucchelli et al.,
1998; Mackenzie Ross, 2000; Yoneda,
Yamadoni, Mori, & Yamashita, 1992).
Retrograde deficits may either concern the entire
lifespan, extending as far back as childhood
(Levine et al., 1998; Mackenzie Ross, 2000;
O’Connor et al., 1992) or be temporally graded
in accordance with Ribot’s Law (Kapur, 1993;
Lucchelli, Muggia, & Spinnler, 1995; Mattiolli,
Grassi, Perani, Cappa, Miozzo, & Fazio, 1996).
However, given the existence of some anterograde
deficits, extensive reviews have indicated that most
cases of FRA, in fact, concerned cases of dispro-
portionate RA (Kopelman, 2000a, 2002),
arguing against the concept of pure FRA,
although Kapur (2000) considers that it is really
a matter of interpretation. Definitive conclusions
are difficult to establish, because apart from a
few exceptions (Manning, 2002), studies have
not compared anterograde and retrograde
memory using matched procedures. Evidence of
additional anterograde dysfunctions has come
from case studies of FRA in which standard episo-
dic memory tests were supplemented either by
procedures making it possible to identify the rela-
tive contributions of episodic and semantic pro-
cesses when testing new learning performance,
or by memory tests administered up to several
weeks apart. Their results have suggested an
abnormal sense of remembering (Levine et al.,
1998) and an accelerated forgetting rate (De

1006 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)


Renzi & Lucchelli, 1993; Kapur et al., 1996;
Lucchelli & Spinnler, 1998), arguing in favour
of additional anterograde deficits in patients
diagnosed with FRA.
The cerebral dysfunction of FRA
FRA may be associated with major cerebral path-
ology, resulting from a head injury or other aetio-
logical factors, such as encephalitic illness and
brain hypoxia, or may occur without any overt
structural lesions (documented by CT or MRI),
often following minor head injury, but in the
presence of cerebral dysfunction (revealed by
SPECT, PET, or fMRI). Studies have empha-
sised the heterogeneity of the injured sites linked
with reported cases of FRA, from bilateral
frontal, anterior temporal, and right posterior/
visual neocortical regions to a form of frontotem-
poral disconnection, due to lesioning of the
uncinate fasciculus (for reviews, see Kapur, 1997,
1999, 2000; Kopelman, 2000a, 2002; Wheeler &
McMillan, 2001). The frequent involvement of
the right hemisphere has been highlighted in
episodic FRA, especially the frontotemporal
lobe (Calabrese et al., 1996; Kroll, Markowitsch,
Knight, & Von Cramon, 1997; Markowitsch,
1995), the anterior temporal cortex (Kapur et al.,
1996; Kapur, Ellison, Smith, McLellan, &
Burrows, 1992; Rousseaux, Delafosse, Cabaret,
Lesoin, & Jomin, 1984; Sellal, Manning,
Seegmuller, Scherper, & Schoenfelder, 2002), the
frontal lobe (Levine et al., 1998; Starkstein, Sabe,
& Dorrego, 1997), and the occipital lobe
(Hunkin et al., 1995; Ogden, 1993; Rubin &
Greenberg, 1998). This heterogeneity suggests
that remote memory is widely distributed across
the brain and that all these areas play a role in
memory performance. Kapur (2000) also commen-
ted on the lack of consistency in lesion sites in
patients reported to have dense autobiographical
focal retrograde amnesia. Extensive patterns of ret-
rograde amnesia can be caused either by damage to
specific cerebral structures that subtend the neural
network involved in remote memory retrieval or
by their disconnection. The most likely candidate
for dense autobiographical FRA should be a
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
lesion profile that includes bilateral anterior tem-
poral lobe and bifrontal lobe, with a relative
sparing of the medial temporal lobe (Kapur, 2000).
Anatomical damage responsible for FRA is at
the core of the theoretical debate about the cere-
bral structures involved in the storage and retrieval
of remote memory, suggesting a relative indepen-
dence of mechanisms for retrograde and antero-
grade memory (for reviews, see Kapur, 1999;
Kopelman, 2000a, 2002; Kopelman & Kapur,
2001). FRA does indeed imply that distinct
neural networks play a role in the retrieval of
memories, according to the latter’s temporal
relationship to the onset of cerebral pathology,
as suggested by standard models of long-term
memory consolidation (Murre, 1996; Squire &
Alvarez, 1995). Low correlations observed
between the performance of the two components
of the amnesia in patients as well as comparisons
of recovery profiles from these two components
also provide evidence of their relative indepen-
dence (Kopelman, 2002).
The attribution of causality
Previous studies have shown that FRA may exist
as a purely neurological entity (De Renzi, 2002;
Lucchelli & Spinnler, 2002) as well as a purely
psychological entity (i.e., psychogenic amnesia;
Markowitsch, 1999, 2003) in the absence of any
overt structural lesion, showing that factors other
than the sites of the lesion may account for
FRA. In some cases, termed functional RA (De
Renzi et al., 1995), there is absence of any docu-
mented cerebral injury as well as seemingly any
history of psychiatric or emotional disturbances.
Although the profiles of psychogenic and
organic retrograde amnesia bear a close resem-
blance to each other, such as the detached attitude
to memory loss or affective indifference
(Markowitsch, 1996), major distinguishing fea-
tures have been drawn, based on noticeable criteria
(for reviews, see Barbarotto, Laiacona, &
Cocchini, 1996; Kapur, 1999; Kopelman, 2000a,
2000b, 2002; Kopelman & Kapur, 2001;
Kopelman, Christensen, Puffett, & Stanhope,
1994). Nevertheless, as far as organic FRA is
1007
PIOLINO ET AL.
concerned, psychological factors are generally
underestimated (Kopelman, 2000a). In particular,
it is not yet clear whether the kind of extensive
FRA following minor concussion exists as a
purely neurological entity or whether it is partially
psychological in origin (Kapur, 1999, 2000;
Kopelman, 2000a; Wheeler & McMillan, 2001).
As far as psychogenic FRA is concerned, studies
have consistently revealed the presence of
detectable cerebral dysfunction (i.e., right
frontotemporal hypometabolism) that coincides
with sites of lesions involved in organic FRA
(Markowitsch, Fink, Thöne, Kessler, & Heiss,
1997a; Markowitsch, Kessler, Russ, Frölich,
Schneider, & Maurer, 1999; Markowitsch, Thiel,
Kessler, von Stockhausen, & Heiss, 1997b;
Markowitsch, 2003). Hence, the attribution of
causality is a particularly complex issue because
there is a frequent concomitance of neurological
and psychological problems in FRA. In effect,
“the mere existence of brain lesion does not
exclude the possibility of psychological causation”
(Kopelman, 2000a) and the “presence of evidence
is not evidence of primacy” (Kapur, 2000). For
example, Kapur (2000) reported the possibility of
a psychological contribution in a previous patient
with FRA (Kapur et al., 1992), which was initially
attributed purely to brain lesion. According to
Kopelman (2000a), organic and psychogenic
FRA form points along a continuum rather than
discrete categories. For instance, three subtypes of
psychogenic amnesia may be distinguished accord-
ing to their degree of combination with neurologi-
cal aetiologies (Kapur, 1999): (1) pure psychogenic
amnesia, which corresponds to a type of FRA in the
absence of any cerebral pathology—in general, a
severe precipitating emotional or stressful event
results in a loss of personal identity and of many
autobiographical facts about oneself for the entire
lifespan; (2) psychogenic FRA, which occurs in
the presence of major cerebral pathology, but
where psychological rather than neurological
factors are likely to contribute to the severity of
the retrograde amnesia; and (3) psychogenic FRA
following a minor head injury.
We report the case of a 42-year-old man
(patient CL) who suffered a minor head injury
1008 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
and developed a particular profile of amnesia
with two dates of onset. At the first onset, the
patient suffered a mild/moderate injury that
accounts for an initial anterograde and mild retro-
grade memory impairment. At the second onset, 8
months later, he suffered a persistent total loss of
personal identity and severe RA in the context of
clinically documented good everyday memory
and normal neuroanatomical data (CT scan,
MRI). The main aim of this study was to investi-
gate in this single case the issue of “pure” FRA
(using an extended memory systems investigation
and strict post-onset and pre-onset matched pro-
cedures), and underlying brain dysfunction. We
were also interested by the issue of the attribution
of causality, but we knew there were fundamental
problems in making any assumptions in this par-
ticular case characterised by two dates of onset.
First, we began by performing an extensive
neuropsychological assessment of memory
systems, using both standardised tests and exper-
imental paradigms to depict precisely the pattern
of CL’s performances. Knowing the heterogeneity
of profiles of FRA, we were especially interested in
characterising the differential impairments of
memory systems and the dissociations between
preserved and disturbed abilities
Given that the episodic/semantic distinction is
critical in dissociating different forms of FRA
(Wheeler & McMillan, 2001), we took as our
reference the theoretical framework devised by
Tulving (1995), which proposes a hierarchical
organisation of the five memory systems, i.e.,
from the most to the least developed form of
memory—episodic memory, primary memory
semantic memory, the perceptual representation
system (PRS), and procedural memory, respect-
ively. Episodic memory enables individual to
acquire and remember their personally experi-
enced past situated in a spatio-temporal context.
Primary memory registers and retains information
for a short period of time after input. Semantic
memory makes possible the acquisition, retention,
and retrieval of general information of the world
independently of the learning context. PRS, also
referred to as perceptual priming, subserves a special
form of perceptual learning that is expressed in

enhanced identification of objects as structured
physical-perceptual entities. Procedural memory
is expressed in the form of skilled behavioural
and cognitive systems independently of any cogni-
tion. This model postulates that higher-level
systems depend on lower-level systems, though
each one has its own storage capacity. Moreover,
the nature of the relationship between episodic
and semantic memory depends on the phase of
the mnesic process under consideration: encoding
(serial), storage (parallel), and retrieval (indepen-
dent). We were specially interested in studying
the dissociations among those different forms of
memory (e.g., episodic/semantic) in the patient
CL in comparison with previous cases of FRA.
Second, in order to reliably test the issue of
pure FRA, we used tight direct comparisons of
the domains of post- and pre-onset episodic and
semantic knowledge, by means of a strict standard
matched testing procedure (like with like memory
tasks), taking into account Kopelman’s recent
methodological recommendations in order to
avoid some bias present in previous studies
(2000a, 2002). We subsequently investigated the
status of autobiographical memory, with reference
to the current definition of episodic memory,
which refers to the state of consciousness accom-
panying memory retrieval (Tulving, 1985, 2001,
2002; Wheeler, Stuss, & Tulving, 1997). The
episodic and semantic components of memory
are characterised by two different states of con-
sciousness. Autonoetic consciousness, which is
critically involved in episodic memory retrieval,
is a feeling of re-experiencing or reliving the past
and mentally travelling back in subjective time,
while noetic consciousness, which characterises
semantic memory, is the capacity that the subject
has of being aware of the information about the
world in the absence of such a recollection.
Subjective reports of autobiographical memories
can be assessed with the Remember/Know para-
digm, which allows differentiating episodic and
semantic autobiographical memory (Conway,
Gardiner, Perfect, Anderson, & Cohen, 1997;
Piolino, Desgranges, & Eustache, 2000; Piolino,
Belliard, Desgranges, Perron, & Eustache,
2003a; Piolino et al., 2003b). Remembering is
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
associated with autonoetic consciousness whereas
knowing is associated with noetic consciousness.
Consequently, we administered a novel
autobiographical memory task especially designed
to be more valid and reliable than previous
neuropsychological autobiographical test instru-
ments, assessing the contribution of episodic and
semantic memory systems to autobiographical
performance via the Remember/Know (R/K)
paradigm (Tulving, 1985) and using a timescale
of days and weeks from the present.
Last, a functional neuroimaging study using
PET measurements of resting regional cerebral
glucose utilisation (CMRGlc) was performed in
order to study possibly underlying brain dysfunc-
tion in the patient CL.
CASE REPORT
Patient CL, who was 42 years old at the time of
the study, is a right-handed man with 8 years of
schooling, who is a qualified heating specialist.
He was employed as a maintenance man in the
stationery trade between the ages of 20 and 30,
then as a furniture deliverer and assembler. He is
married with two daughters. His wife and daugh-
ters described their family life as pleasant. To the
best of their knowledge, the patient CL did not
suffer special difficulties in childhood and adoles-
cence, except for signs of dyslexia. He also suffered
from an epistaxis with brief loss of consciousness
at 26, and over the last 10 years he has been receiv-
ing treatment for high blood pressure.
First onset amnesia
On September 29, 1996, during a party celebrat-
ing the departure of a colleague, patient
CL, who was unusually drunk (alcohol level .
3g/l), fell and banged his head against a chair.
He suffered a minor closed head injury with
short loss of consciousness (less than an hour),
beginning to regain consciousness on admission
to hospital. A CT scan showed a fracture to the
left temporal region of the skull with a minor
extradural lesion, which did not require surgery.
Post-neurological follow-up was normal.
1009
PIOLINO ET AL.
From October 1996 to May 1997, the evol-
ution of the minor closed head injury of patient
CL was described as positive. However, he suf-
fered from a post-concussion syndrome with
vertigo, anosmia, headaches, and depression with
asthenia, irritability, and memory problems. He
did some activities at home, but remained off
work, asking for several prolongations of his sick
leave. He felt himself to be guilty for the episode
of drunkenness and needed some reassurance
that the evolution of his head injury was
favourable.
On May 20– 30 1997, given the absence of
amelioration, patient CL was hospitalised to
undergo an antidepressant treatment (viloxazine
400 mg/day). At this point, a neuropsychiatric
and psychometric investigation was performed.
When asked about his identity, patient CL
could supply without any difficulty his name and
date of birth, together with other personal
details ( job, family) and information about
events in his life from childhood to the present.
In contrast, his knowledge about current affairs
was poor. Moreover, patient CL complained
about a retrograde gap of approximately 6
months. For example, he could not recall any
information about his previous summer holidays
(1996), even from photographs. The psychometric
evaluation indicated that patient CL showed a
normal general intellectual level (IQ: 104) as
assessed by the PM 38 (Raven, Count, & Raven,
1998). A general memory assessment conducted
using the BEM 84 memory efficiency battery
(Batterie d’Efficience Mnésique, Signoret, 1991)
revealed a low performance (40.5) compared
with normative data (Mean + SD: 64 + 8),
especially for the recall of verbal stories and learn-
ing of a series of 12 words. Attentional abilities
evaluated via the Wechsler Memory Scale
(Wechsler, 1991) were at the lower limit (87).
The Stroop Colour-Word Test (Stroop, 1935)
confirmed attentional difficulties, with a clear
slowdown and a pathological sensitivity to
interference (inhibition score: 32). In summary,
the assessment documented a moderate post-
traumatic amnesia characterised by a deficit of
learning abilities (anterograde amnesia) and
1010 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
some elements suggestive of executive dysfunc-
tion. Structural imaging (CT scan and MRI)
and EEG were normal.
Second onset amnesia
Strangely, when he returned home on May 31
1997, patient CL thought he had been absent
for a long time. He spent the evening with his
family, who noticed nothing abnormal. On the
morning of June 1 1997, he woke up after his
wife and daughters had left to do some shopping.
Coming home later that morning, they found CL
in front of the house, distressed and crying, “in
search of his personal identity” and failing to
recognise them. He was taken to hospital,
where an initial clinical assessment (3 – 4 June)
revealed dense RA with total loss of identity
and inability to remember any personal or
famous public event that had occurred in his
entire lifespan. Furthermore, there was a loss of
general semantic information (concepts, words,
etc.) and of previously acquired skills, such as
how to use cutlery or tie up his shoelaces.
Account of the hospitalisation mentioned
“mnesic difficulties giving the impression of
being neurotic.” After this episode (June 1997),
CL’s family started patiently teaching him the
most relevant autobiographical knowledge and
episodes of his life through photographs, films,
meetings with colleagues or old friends, and
trips to different relevant places (i.e., old neigh-
bourhood, school, places of work). His family
helped him to relearn daily skills and general
knowledge, while CL also learned by himself
through dictionaries and encyclopaedias or by
doing crosswords. Moreover, he undertook train-
ing sessions with a neuropsychologist, to help him
relearn general semantic information. Gradually,
thanks to his relatively good everyday memory,
he relearned some personal information
(address, names of family members). He also
relearned certain skills (driving a car, using a
pocket calculator, soldering, hanging wallpaper),
some general semantic knowledge (dates, geogra-
phy, feast days), and vocabulary. He gradually
built up his knowledge, though he often failed

to provide the correct definition of a relearned
concept, such as season, rank, or department,
despite being able to remember exactly who had
taught him it—and where.
Six months after the onset of CL’s identity pro-
blems (December 1997), retrograde amnesia
remained severe and disproportionate, compared
with anterograde amnesia. CL also showed
several significant behavioural changes. For
example, he exhibited an affective indifference to
his family members (mother, wife, children) and
some feelings of detachment (“That’s what they
called multiplication tables”) from the world,
although he rapidly adapted to family life. In par-
ticular, he appeared unconcerned about his
mother, even though he had been very close to
her before his loss of memory. He also showed
changes in eating habits (breakfast, lunch), using
the habits of his family instead of his previous
ones (i.e., separating the vegetables from the
meat on his plate). While the patient did not
seem obviously anxious or depressed about his
state, he was afraid to meet old friends or col-
leagues, being conscious of his memory loss. His
wife waited for a trigger mechanism that would
enable her husband to recover his memory, “as
shown in films.” Before their summer holiday, it
was pointed out to CL and his wife that the anti-
depressant treatment should explain some mnesic
difficulties following the hospitalisation, but not
the striking clinical profile of CL’s amnesia. It
was suggested that CL may have been deeply
upset by his hospitalisation and therefore that his
amnesia should result from psychologic causes.
CL was encouraged by doctors to have holidays
with his family, to take part in all the activities,
and to contact his employer to regain his work
and undergo psychotherapy in September. CL
was specially concerned about the name of the
doctor who might propose him for psychotherapy.
Nevertheless, when CL returned back from holi-
days, he did not go to work and, in agreement
with his wife, declined the suggestion that he
should undergo psychotherapy or hypnotherapy,
rejecting the idea that his amnesia was the result
of a psychologic mental “block,” preferring the
idea of organic basis.
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
In December 1998, 18 months after the start
of CL’s identity problems, we undertook a
3-month series of extensive neuropsychological
examinations and a resting PET study. The
patient’s consent was obtained before the examin-
ations, after detailed information was given to
him. During the period of testing, he neither pre-
sented mood disorders nor any other psychiatric
symptoms. CL was cooperative during the
testing: While he appeared resigned to live
without memories, he hoped for a recovery.
A follow-up study of overall memory and
learning efficiency was performed using the
Wechsler Memory Scale (Table 1). The compari-
son of performances 6 months and 21 months
after the start of loss of identity indicated a
general improvement in episodic memory per-
formances. Nevertheless, the verbal memory
index on the WMS-R of 79 at 21 months post-
onset implies still quite an impairment of antero-
grade memory. There was no problem of abnormal
forgetting (normal delayed recall) and visual
memory had completely recovered. Otherwise,
some attentional difficulties persisted (WMS
attention index of 87). In total, at the second
onset, in addition to the loss of identity, there
was an initially severe anterograde memory
impairment and, subsequently, a moderate antero-
grade amnesia. Twenty-one months after the start
of his loss of identity, patient CL showed a normal
general intellectual level (IQ: 94) as assessed by
the PM 38, slightly lower than the IQ measured
6 months after his head injury (IQ: 104). At
present, 512 years after his loss of identity, patient
Table 1. Subtests of the Wechsler Memory Scale: CL’s
results 6 months (Dec 1997) and 21 months (Mar 1999)
after the onset of loss of identity
6 months post-onset 21 months post-onset
Overall memory 66 88
Verbal memory ,50 79
Visual memory 83 108
Attention 77 87
Delayed recall 83 97
Norms ¼ 100 + 15.
1011
PIOLINO ET AL.
CL has still not recovered the ability to recollect
his personal episodic past, although he has gradu-
ally relearned his personal semantic past and
semantic knowledge. He has been employed as a
garden cleaner for the last 2 years.
NEUROPSYCHOLOGICAL
INVESTIGATION OF MEMORY
SYSTEMS
Method
A cognitive examination was used to explore the
five memory systems (episodic, primary, semantic,
perceptual representational system, and procedural
memory) of Tulving’s model (1995), distinguish-
ing the phonological loop, the visual sketchpad
and the central executive within primary
memory, also referred to short-term memory or
working memory, i.e., the three components in
Baddeley’s (1996) model. We used standardised
tools and sophisticated experimental paradigms
drawn up in the light of the most recent theoreti-
cal models (Tulving, 1995, 2002; Wheeler et al.,
1997).
Episodic memory was tested with the ESR
(Encoding, Storage, Retrieval) paradigm
(Eustache et al., 1999), which was used to
attempt to separate out the different processes
involved in episodic memory impairment, based
on Tulving and Thomson’s encoding depth prin-
ciple (1973) and incidental/intentional learning
conditions. A first list of 16 words is used to test
superficial/incidental learning (subjects have to
say whether or not the first and last letters of the
word are in alphabetical order). A second list of
16 words tests deep/intentional learning and
requires some form of semantic processing (sub-
jects have to generate a sentence containing the
word). The effective encoding of the second list
is tested by means of immediate cued recall every
two words. Immediately after each list has been
processed, retrieval is assessed by means of a free
recall task and a recognition task. After 1 week,
delayed recall and recognition tests are performed
for both lists. The analysis of the score profiles
1012 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
makes it possible to determine, more precisely
than standard episodic tests, although this tech-
nique is not foolproof, whether the anterograde
amnesia is due to encoding, storage, or retrieval
problems.
Given patient CL’s obvious semantic memory
impairment, a modified version (Eustache,
Desgranges, Giffard, de la Sayette, & Baron,
2001) of Grober and Buschke’s test (1987)
enabled us to examine episodic memory, checking
the semantic integrity of words used in the learn-
ing list by means of a semantic knowledge task
beforehand (see below). The subjects learn 15
items presented 3 at a time on a card, pointing
out and naming each item when its category cue
is presented verbally. They are then asked to
perform immediate verbal cued recall. If they fail
to recall an item, the card is shown again. This
encoding phase is followed by three recall tests,
first a free recall and, if necessary, a categorical
cued recall. Each trial is preceded by 20 seconds’
interference when the subjects are asked to count
backwards. A recognition memory test is then
undertaken. After 20 minutes, delayed free and
cued recall tests are administered.
As regards primary memory, the phonological
loop was assessed by a task involving the serial rep-
etition of a series of digits (verbal span), and the
visuospatial sketchpad by the reproduction of
spatial sequences (visuopatial span), from the
Wechsler Memory Scale (Wechsler, 1991). The
central executive was assessed by backward verbal
span and visuospatial span, and a task (Eustache
et al., 1995) derived from the Brown-Peterson
paradigm (Peterson & Peterson, 1959). In the
latter, subjects have to read three monosyllabic
words per card (25 cards), arranged vertically.
Then, after turning over the card to reveal a
number, they have to count backwards in twos
from that number (counting distractor task), for
a variable amount of time (0 –18 s) and then
immediately recall the words. Central executive
was also examined using the Modified Card
Sorting Test (Nelson, 1976) and the Stroop
Colour-Word Test (Stroop, 1935), which assess
set shifting and sensitivity to interference,
respectively.

Semantic memory was assessed using explicit
and implicit memory tasks. Explicit tasks con-
sisted in a word fluency task in which the subject
was asked to produce in 2 minutes as many
words as possible which complied with certain cat-
egories (names of animals, i.e., category fluency) or
orthographic (words beginning with p, i.e., letter
fluency) criteria (Cardebat, Doyon, Puel, Goulet,
& Joanette, 1990), and a semantic knowledge
task (Giffard et al., 2001). The latter, which is
derived from Martin’s protocol (Martin et al.,
1986) and Desgranges et al. (1998; Desgranges,
Eustache, Rioux, de la Sayette, & Lechevalier,
1996), involves three components (picture
naming, categorical knowledge, and attribute
knowledge of concepts) relating to 30 concepts
belonging to four categories (animals, plants,
objects, and body parts). Subjects first have to
name 30 drawings corresponding to the 30 con-
cepts or recognise their name if they cannot do
so. They then have to answer “yes” or “no” to a
series of questions about the concepts: superordi-
nate category (“Does it occur naturally or is it
manmade?”), category membership (“Is it an
animal, plant, object or body part?”), subcategory
(“Is it a domestic or a wild animal?”) and specific
attribute—either functional (“Is it edible?”) or
perceptual (“Does it have a mane?”). Two other
explicit semantic tasks were administered: a
picture naming task (DO 80: Deloche &
Hannequin, 1997), where subjects have to name
80 black-and-white line drawings of familiar
objects, and Beauregard’s verbal automatism test
(Beauregard, 1971), which consists in completing
familiar phrases, idiomatic expressions, and pro-
verbs. Last, three supplementary explicit tasks
about public events and famous names were pro-
posed. The first of these was a French Public
Events Interview (EVE: Thomas-Antérion et al.,
1997), involving 63 famous public events
between 1920 and 1997 selected from
“Chroniques du XXème siècle.” The interview
consists of 36 questions presented verbally (i.e.,
Chernobyl), and the presentation of 27 photo-
graphs (i.e., May 1968 in Paris). For each event,
two specific questions are posed, and free recall,
recognition, and the date are assessed. Next
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
came a famous names fluency task (Piolino, 2000),
which requires subjects to supply as many items
as possible in the space of 2 minutes (French
Presidents, American Presidents). The third,
famous faces familiarity task, consisted of an easy
test of familiarity decision (Bruyer & Schweich,
1991) concerning 24 very famous French celebri-
ties (i.e., Jean-Paul Belmondo, Alain Delon).
Semantic memory was also assessed by means
of an implicit memory task using a tachistoscopic
identification task (semantic priming effects task,
Lebreton, Desgranges, Landeau, Baron, &
Eustache, 2001), which consists in naming aloud
briefly flashed drawings of living/nonliving every-
day objects. In the initial study phase, subjects are
instructed to read aloud a series of 35 words (30
targets and 5 fillers) and indicate the semantic cat-
egory and specific attributes (preferentially func-
tional) of each one. In the test phase, separated
by 2 minutes from the study phase, 60 achromatic
line drawings (taken from Snodgrass &
Vanderwart, 1980) are presented very briefly to
the subjects, who must name them or say the
word “pass.” The presentation time was chosen
beforehand, on the basis of a preliminary session,
so that baseline performance was between 20%
and 40% correct naming for new items. Half the
drawings correspond to the target words (target
drawings), while the other drawings are new
(control drawings). Each drawing is presented
for 500 ms, after which a blank screen is shown
for 2.5 s. The amplitude of the priming effects cor-
responds to the number of target drawings named
minus the number of control drawings. Drawings
that patient CL could not name were not taken
into account in our measurement of priming
effects.
The perceptual representation system (PRS) was
assessed with a different version of the semantic
priming effects task described above. In this
paradigm, the stimuli retain the same symbolic
format in both the study and test phases
(drawing/drawing). In the study phase, subjects
are instructed to decide whether each drawing
in a series of 35 is shown facing right, left, or
full face. In the test phase, they must name 60
drawings or say the word “pass.” Drawings that
1013
PIOLINO ET AL.

patient CL could not name were not taken into Table 2. Results of the episodic, primary and semantic
account in our measurement of priming effects. memory assessment: Data shown are raw scores with stat-
Procedural memory was examined using a sim- istical significance according to z-scores for patient CL
plified version of the Tower of Hanoi task Memory Patient
(Beaunieux, Desgranges, Lalevée, de la Sayette, system Tests CL
Lechevalier, & Eustache, 1998), proposed by
Episodic ESR paradigm
Cohen (1984), which assesses cognitive pro- memory SIE: Free recall (/16) 3

cedural acquisition. The material consists of a Recognition (/16) 13

wooden block into which three identical vertical Delayed free recall (/16) 0

pegs are set. On one of these, four wooden discs Delayed recognition (/16) 7



of decreasing diameter are stacked. The task is DIE: Free recall (/16) 6

Recognition (/16) 16
to rebuild the pyramid of discs on another peg, Delayed free recall (/16) 2

obeying two rules: never place a larger disc on a Delayed recognition (/16) 12



smaller one and only move one disc at a time. Modified Grober and Buschke test
Three sessions (separated by intervals of 30 Immediate recall (/15) 15
mins) of five consecutive trials are held. Free recall (/15):
Trial 1 6
Performances are measured in terms of time. A Trial 2 9
decrease in the amount of time taken to reach Trial 3 11
the solution in a trial reflects the acquisition of Total recall (/15):
the procedure. Trial 1 12





Trial 2 13
Trial 3 15
Results Delayed free recall (/15) 11
Delayed total recall (/15) 15
CL’s performances on the detailed assessment of Recognition (/15) 15
the five memory systems according to Tulving’s
Primary Digit span 5
model were compared with the normative data memory Visual span 6
from age-matched controls available for each test Backward digit span 3


and reported in the original studies (see refer- Backward visual span 4

ences). Data from the episodic memory assess- MCST category number 6
ment (see Table 2) revealed some difficulties, MCST perseveration 4
Brown-Peterson 51
suggesting the presence of mild anterograde distractor test (/75)
amnesia. The performances in the ESR paradigm Stroop (inhibition) 50
indicated that retrieval processes were mainly
impaired (i.e., preservation of recognition com- Semantic Category fluency (animals) 13

memory Letter fluency (P) 4


pared to free recall using deep intentional encod- Semantic knowledge task:
ing). The comparison of performances between Total score (/236) 192



the two conditions of the learning list indicated Naming (/60) 57



that CL benefited from the deep intentional Categorical knowledge (/86) 81



encoding rather than the superficial incidental Attribute knowledge (/90) 84



Naming task (DO 80) 64



encoding. Delayed performance was also impaired Verbal automatism (/40) 1



(in free recall and recognition), indicating a
storage deficiency. Nevertheless, when the integ- ESR paradigm: SIE (Superficial Incidental Encoding), DIE
rity of the concepts used in the learning word (Deep Intentional Encoding), delayed (1 week later); MCST:
list was checked in the modified version of Modified Card Sorting Test.
Pathological score:
p , .05;

p , .01;


p , .001.
Grober and Buschke’s test, CL’s performance
was clearly better preserved. This test showed
that CL had no problem encoding and had good

1014 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)


learning ability (showing an improvement across
the trials and reaching the normal range for the
third trial), recognition, and delayed recall. This
type of score profile is indicative of preserved
learning ability with some episodic retrieval diffi-
culties of mild intensity.
His performances on the primary memory tests
(see Table 2) were preserved, i.e., the phonological
loop, the visual sketchpad, and the central execu-
tive within primary memory, except for the back-
ward spans indicating some executive problems (in
keeping with the WMS attention index of 87).
By contrast, CL’s semantic memory perform-
ances (see Table 2) showed an overall impoverish-
ment of general knowledge for concepts, ideas and
vocabulary (fluency tasks, semantic knowledge
task, naming task, and verbal automatism test) as
well as for famous people and events (see
Table 3). The results of the last of these (public
events, famous names fluency, famous faces)
were grossly impaired, whatever the testing
format (verbal/visual; free recall/recognition).
The correct responses were always associated
Table 3. Results of remote famous faces, celebrities, and
public events memory assessment: Data shown are raw
scores with statistical significance according to z-scores for
patient CL
Tests Patient CL
Public events memory test
Verbal: % total
Verbal: free recall (/36)
Verbal: recognition (/36)
Verbal: specific question (/36)
Verbal: date (/36)
Visual: % total
Visual: free recall (/27)
Visual: recognition (/27)
Visual: specific question (/27)
Visual: date (/27)
Category fluency
French Presidents
American Presidents
Famous faces familiarity test
Unknown (/24)
Known (/24)
Pathological score:
p , .05;


p , .001.
RIGHT FRONTAL HYPOMETABOLISM IN RA
with information that had recently been learned
or relearned (e.g., Lady Diana: “the princess died
recently”; Louis de Funes or Yves Montand: “I
saw him recently in a film on television”). It is
noteworthy that, impaired category fluency and
letter fluency may also indicate an executive
dysfunction (Troyer, Moscovitch, Winocur,
Alexander, & Stuss, 1998). Also, the results
(data not shown) of implicit semantic memory
task showed intact performances. The perform-
ances of PRS and procedural memory investi-
gations were preserved. The preservation of
procedural memory confirmed clinical findings
showing the recovery of old procedural skills
since the onset of dense RA in June 1997.
LIKE WITH LIKE INVESTIGATION
OF PRE- AND POST-ONSET
MEMORY
Method
Different components of pre-onset and post-onset
memory were directly investigated, comparing like
with like: first, semantic nonautobiographical
memory relating to knowledge of famous people,
and second, autobiographical memory, dis-
tinguishing between its semantic and episodic
elements.
11



2



Semantic nonautobiographical memory
8


A famous names familiarity task was administered,
1


which involves reading out to subjects a list of 120
5


unknown names, 60 famous names (12 per period
12


studied) from five decades (1990s, 1980s, 1970s,
1



5



1960s, 1950s), and 6 new famous names from
1


the last year (post-onset 1998 for CL), all in
6


random order.
2

0
Personal semantic and episodic autobiographical
memory
24
11



We asked patient CL to answer a sophisticated
experimental semistructured autobiographical
questionnaire (Piolino, Desgranges, Benali,
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8) 1015
PIOLINO ET AL.
& Eustache, 2002) based on that of Kopelman,
Wilson, and Baddeley (1989). The questionnaire
deals with the current year (post-onset 1998)
and, for subjects aged from 40 to 49, five time
periods (the 1990s, 1980s, 1970s, 1960s, 1950s).
For each period examined, from the most remote
to the most recent, subjects perform a general
information recall test (semantic), followed by a
specific event recall test (episodic).
The general information recall task is based on
four topics: the names of people, information
about school then professional environments, an
important date, and personal address. The recall
of specific events is based on four topics: a
meeting or event linked to a person, a school
and then a professional event, a trip or journey,
and a family event. Specific instructions are
given beforehand, notably defining the type of
memory requested (episode lasting less than a
day that can be relived with details). When sub-
jects fail to produce any specific memory, they
are prompted with cues and/or encouragement.
Scoring procedure. A point was given for each
piece of general information accurately recalled, 12
point when recall was partial and 0 when there
was absence of recall or when what was recalled
was not confirmed at the retest (see below).
Each autobiographical event was scored on a
fine-grained 6 half-point episodic scale based on
that of Baddeley and Wilson (1986). This scale
takes into account the specificity of the content
(single or repeated event), spatio-temporal
context (place, date, and time), and the presence
of details indicating that the subject is mentally
reliving the episode. A specific memory, situated
in time and space and with details, especially of
a phenomenological kind (i.e., emotions,
thoughts, images), is given a score of 3 points. A
specific event without detail but situated in time
and space scores 2.5 points. A repeated or
extended event scores 2 points or 1.5 points,
according to whether it is detailed or not. A
repeated or extended event that is not situated in
time and space scores 1 and a vague description
0.5. The validity of the results is assessed by check-
ing whether the subjects can recall the same
1016 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
memories by means of a retest 12 (+2) days
later and, in the particular case of patient CL,
each memory was checked out with his wife.
Three main autobiographical scores were
recorded per age period examined. The first
score was a measurement of personal semantic
memory (recall of information, max: 3  4 ¼ 12),
while the second corresponded to a measurement
of autobiographical events memory (recall of event,
max: 3  4 ¼ 12) taking into account all types of
recalls, both specific and generic. A third score
was obtained which corresponded to the number
(max: 4) of strictly episodic memories (scored 3)
using a more stringent criterion of episodicity.
Results
CL’s performances were compared with those of
13 age-matched controls (mean age + SD:
45.38 + 2.72, range 40– 49) with a mean of 13
years of education (13.54 + 1.50). None of them
had any neurological or psychiatric medical
history or symptoms of cognitive difficulties as
assessed by the MMSE (Folstein et al., 1975;
28.84 + 0.90). CL was impaired in the famous
names familiarity task whatever the time period
covered, except for the current year referring to
post-onset 1998 (Figure 1). Moreover, for the
very recent time period (within the last 3
months), the patient could recall current affairs
concerning the famous names and supply several
specific details about what had happened. A
number of times, as in the personal semantic
memory test, patient CL said that his wife had
spoken about the information requested, but con-
tinued, “I can’t remember it anymore; at the
moment, I learn things, but only things which
can be of use in daily life; knowing about public
events isn’t useful to me, so I don’t memorize
them.”
The semantic and episodic autobiographical
memory test (Figure 2) showed that personal
semantic and episodic recall was mainly restricted
to the current period referring to post-onset 1998.
While current personal semantic performances
were within a normal range, current episodic
ones were not. Indeed, the autobiographical
 RIGHT FRONTAL HYPOMETABOLISM IN RA

Figure 1. Performances of patient CL on famous names

familiarity task relative to controls: Data shown are
raw scores (% of correctly recognised famous names).
CL’s performances are significantly impaired according to
z-scores whatever the decade considered (p , .001) except
for the current time period.

event score, which took events into account what-

ever their nature, as well as the number of strictly
episodic memories, was lower than that of the age-
matched controls. Remarkably, patient CL sup-
plied absolutely no pre-onset information or
memory. He did not recall names of acquain-
tances, dates, his different jobs and addresses, or
specific events, even generic ones, namely over-
rehearsed and well-established personal verbal
scripts. The most remote autobiographical knowl-
edge dated from the end of July 1997 (2 months
after the onset of his loss of identity), consisting
of a few items of knowledge (approximate place
and date) and a very vague memory of his
summer holidays. No cue or encouragement
could help him initiate recall. By contrast, for
the current year, he was perfectly able to give per-
sonal semantic information and strictly episodic
memories. For example, on the theme of family Figure 2. Results of the semantic and episodic
autobiographical memory test: Data shown are raw scores,
events, he recalled: “When they put the chocolates
and means+SD are shown for control subjects. CL’s
outside; I was with my brothers and sisters, we had 1990s responses are post-onset memories (from July 1997);
been invited to my parents’ home, and at a certain current: 1998. CL’s performances are significantly
moment, they asked the children to go outside and impaired according to z-scores whatever the decade
search for the chocolates; I don’t know the reason! considered (p , .001) except for the semantic personal
(Q: Does this bring any specific happening to memory in the current period.
mind?) I was in the living room, and I could see

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8) 1017

PIOLINO ET AL.
them through the open window looking every-
where because the chocolates were hidden in the
flowers. They were delighted and wolfed them
down, even though they’d just had lunch. I don’t
know how they could!” By contrast, CL did not
seem familiar with any pre-onset information or
episode even during the retest. Moreover, CL’s
performances did not show any improvement by
using more specific cues (i.e., the place of his
national service) based on information provided
by his wife, apart a few exceptions where CL
said “my wife has already told me that,” but he
was unable to add any further details.
In summary, these various results show that
pre-onset nonpersonal semantic and personal
semantic and episodic memory was greatly
impaired. The data confirmed the findings of the
general neuropsychological semantic investi-
gation, clearly indicating an extreme deficit for
pre-onset semantic knowledge whatever its
nature and its remoteness, didactic knowledge
being slightly less affected. In contrast, post-
onset episodic memory was better preserved, and
post-onset semantic memory (personal or non-
personal) was intact. Nevertheless, “strictly episo-
dic” post-onset autobiographical memory was
significantly impaired.
EPISODIC AUTOBIOGRAPHICAL
MEMORY AND STATES OF
CONSCIOUSNESS
Method
In view of the gravity of CL’s impairment in the
first autobiographical assessment, we proposed a
second evaluation 2 weeks later, based on a novel
episodic autobiographical task (TEMPau task;
Piolino et al., 2003a, 2003b), in order to investi-
gate his episodic autobiographical memory in
greater depth. First, this task explored different
time periods that were more relevant to personal
life than decades. Second, it enabled us to study
post-onset memories in a more detailed way,
using a timescale of days and weeks from the
1018 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
present. Last, it addressed the issue of the state
of awareness accompanying memory retrieval.
Indeed, this second autobiographical memory
assessment relies on the current definition of epi-
sodic memory, which refers to a specific mode of
subjective experience accompanying the retrieval
of information (see Introduction). Episodic
memory is characterised by autonoetic conscious-
ness, which is associated with a sense of the self
in the past and mental reliving of an experience
(i.e., emotions and goals). Autobiographical
memory is critical in grounding and changing
the self (Conway, 2001).
The TEMPau task is based on the episodic
component of the autobiographical memory test
(see above) but with different time periods: 0– 17
years old, 18 –30 years old, more than 30 years
old except for the last 5 years (that is 31– 40
years old for CL), last 5 years except for the last
12 months, last 12 months, covering the entire
lifespan. The same four questions per period are
posed, except for the most recent period, for
which eight questions are posed, in order to
allow a chronological study of the recent
past (from the present time to the last
New Year’s Day).
For each event recalled, the subjects have to
indicate their conscious subjective experience
accompanying retrieval via the Remember/Know
paradigm (Gardiner, 1988, 2001; Tulving,
1985). Subjects must give either a “Remember”
response (R), if retrieval is accompanied by the
recollection of a specific autobiographical event
as a re-experiencing of the details from the learn-
ing context (i.e., thoughts, feelings or perceptions,
where and when), or a “Know” response (K), if
retrieval is achieved with a feeling of familiarity
in the absence of recollection of the source of
acquisition. They could also indicate if they had
simply guessed the recalled event (Mäntylä,
1993), but neither remembered nor knew it
(Gardiner & Conway, 1999).
Responses were checked and scored in the same
way that they had been in the episodic task of the
autobiographical memory test (autobiographical
events score and strictly episodic score). In
addition, further scores were recorded: a
 RIGHT FRONTAL HYPOMETABOLISM IN RA

Remember or Know score (max: 4), which corre-
sponded to the total number of R or K judgments
provided, and a justified Remember score (max:
3  4 ¼ 12), which concerned the number of R
judgments that were correctly associated with
the recollection of a specific event (scored . 2).
Each score for the last 12-month period, which
concerned eight items instead of four, was halved.
Results
CL’s performances on the TEMPau task (see
Table 4 for examples of recollections) were com-
pared with those of 12 age-matched controls
(mean age + SD: 42.12 + 2.29, range 40 –45)
who had not taken part in Experiment 1, with a
minimum of 8 years of education (mean years of
education + SD: 10 + 2). CL’s performances on
the TEMPau task did not show any improvement
compared with the first autobiographical assess-
ment. He did not give any of the post-onset mem-
ories he had recalled in the first autobiographical
test, except for the summer holidays of 1997.
CL’s performances on both autobiographical
events and strictly episodic scores were deficient
whatever the time period tested (Figure 3).
Nevertheless, the last 12-month period was less
affected, compared with the absolute deficiency
observed for the other periods, though not
normal relative to age-matched controls
(p , .001). All his memories (exactly 10) were
post-onset and came from the last 12-month
period, apart from 2 vague post-onset memories
from the last 5-year period. There was a total
absence of pre-onset memories.
As regards the R/K paradigm, the retrieval of
the last 12-month period was accompanied by as
many R responses as that of the controls (87.5%
versus 97%), though this was not true for retrieval
of memories from the last 5-year period (0%
versus 81.9%). Moreover, for latter, CL produced
significantly more K responses (50%) than the
controls (15.2%, p , .001). As far as controls
were concerned, whereas their R responses
declined over time (97%, 81.9%, 79.1%, 72.2%,
69.4% from the last 12-month period to the 0 –
17 years old period) their K responses increased
(3%, 15.2%, 20.6%, 23.6%, 27.8%). Nevertheless,
CL’s R responses provided for the last 12-month
period were not correctly justified compared with
those of the controls (p , .01) in terms of actual
specificity of memories. These data highlighted
difficulties in recollecting contextual details from
the source of acquisition of single post-onset
personal events.
The detailed data (autobiographical score and
state of consciousness response) for each of the
10 post-onset memories recalled on the
TEMPau task for the different questions are pre-
sented in Figure 4. The results indicate that, like
the controls, patient CL was able to recollect
specific detailed events that had taken place on
the day of the test and on previous days (yesterday
and 2 days ago), although he did not supply as
many details about the previous week or more
distant events. These data suggest difficulties in
remembering contextual details from post-onset

Table 4. Examples of autobiographical memories recalled by patient CL, with scoring on the TEMPau task for recent to more
distant memories
“Give details of a particular event which occurred . . .”
Last week: “Nothing, my daughter found a job, she had an appointment. (Q) No (score 1)
Summer 1998: “We went hiking. (Q) I remember a large, frozen lake with sheep all around. We took a photograph. (Q) Usually, we
left in the morning with some sandwiches, we walked, we stopped for a while, then we ate, and after we came back. After those
hikes, we were tired, we would take a shower and go to sleep. (score 2)
New Year’s Day 1998: I don’t remember it, but I suppose I was with my family. (score 0)
Christmas 1997: I remember it a little. This Christmas was very important, because it was my first Christmas. (Q) The Christmas
tree, but I don’t remember where it stood, I don’t remember anything else. (score 0.5)

Q: Does this bring back any specific happening to mind?

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8) 1019

PIOLINO ET AL.

Figure 3. Patient CL’s results on the TEMPau task compared to control subjects as a function of five lifetime periods: Data
shown are raw scores, and means+SD are shown for control subjects. CL’s performances are significantly impaired according
to z-scores whatever the lifetime period considered (p , .001).

personal events with long time interval from the
present. Indeed, post-onset autobiographical
memories lost their episodic criteria, becoming
generic instead of specific, and were reported
with a sense of knowing (or guessing) rather
than remembering. CL was unable to
remember any details about last Christmas or
New Year’s Day; he just knew or guessed he
had experienced such events. Noteworthy, at the
time of testing, his family was preparing for the
next Christmas, just 2 weeks away. When asked
about his difficulty in recalling relatively recent

1020 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)

 RIGHT FRONTAL HYPOMETABOLISM IN RA

Figure 4. Detailed scoring for each of the post-onset memories recalled by CL on the TEMPau task (from the 12 last months
period and Christmas and Summer 1997 from the 5 last years period) using a fine-grained 6 half-point episodic scale, shown
alongside controls’ results (mean rated score), from the shorter interval (today) to the most distant interval tested (Summer
1997) and CL’s subjective responses accompanying each of his recollections. Data shown are the mean rated scores for
controls from each question tested in the patient. CL’s raw scores are indicated with statistical significance according to
z-scores (pathological score:

p , .01;


p , .001).
Episodic scoring chart of event recall:
3 Specific event (isolated, stimulated in time and space) with details (thoughts, emotions, images etc.)
2,5 Specific event (isolated, stimulated in time and space) without detail
2 Detailed generic event (repeated or continuous, situated in time and space)
1,5 Generic event (repeated or continuous situated in time and space), not very detailed
1 Vague event (repeated or continuous with little detail of time or space)
0,5 Vague personal impression (content and circumstances very vague)
0 Absence of an answer or general information
The kind of responses (R: Remember; K: Know; G: Guess) accompanying CL’s memory retrieval for each recall is
indicated at the bottom of CL’s histograms.

specific events, CL replied that “time’s not the
same thing for you as it is for me/Two days are
like two months.”
In sum, these results from the TEMPau task
confirm total absence of pre-onset memories as
observed with the first autobiographical memory
test and highlight deficits of episodic autobiogra-
phical memory in its anterograde component.
Moreover, they give some evidence for accelerated
forgetting and an abnormal sense of remembering
within post-onset personal episodic memory.
RESTING PET STUDY
Method
PET method
A PET study was performed 24 months after the
minor trauma (16 months after the onset of the
loss of identity). The cerebral metabolic rate of
glucose (CMRGlc) was measured by PET in a
resting state, with eyes closed and in dimmed
light with reduced ambient noise, using [18F]

COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8) 1021

PIOLINO ET AL.
fluoro-2-deoxy-D-glucose (FDG). For this study,
we used a high-resolution 63-slice HRþ scanner,
which makes it possible to acquire a whole-brain
image (field of view ¼ 158 mm). The method is
described in detail in previous reports
(Desgranges et al., 1998). The patient was posi-
tioned parallel to the cantho-meatal line.
Following 68Ga transmission scans, 3– 5 mCi
ofFDG was injected as a bolus. Fifty to 60
minutes post-injection, 63 PET planes were
acquired without septa (volume acquisition).
The 63 18 FDG images were converted into
parametric maps of CMRGlc, in accordance
with the operational equation of Phelps et al.
(1979).
Image processing
The PET data were transferred to a SUN work-
station for image processing. The SPM 99
(Statistical Parametric Mapping; Wellcome
Department of Cognitive Neurology, London,
UK) and ANALYZE (Biodynamic Research
Unit, Mayo Clinic, Rochester, MI, USA) software
was used to reorient each PET data set onto the
MNI (Montreal National Institute) template.
Manipulations of the image matrix (stereotactic
normalisation) and statistical calculations were
carried out using MATLAB (Mathworks,
Sherborn, MA, USA). PET images were con-
verted into Talairach’s space (Talairach &
Tournoux, 1988) and filtered with a 14-mm
three-dimensional Gaussian filter in order to
Figure 5. Statistical parametric glass brain maps showing the significant hypometabolism found in CL, with z-score . 3.09,
p , .001 (uncorrected) projected in three orthogonal directions (sagittal, coronal, and transverse).
1022 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
lessen anatomical interindividual differences and
reduce noise data. In order to minimise “edge
effects” and restrict the analysis to grey matter,
only the voxels with values above 80% of the
mean of the whole brain were selected for statisti-
cal analysis.
Statistical anlaysis
The SPM 99 software was used to perform the
statistical analysis. The PET data were normalised
according to the overall metabolic value using pro-
portional scaling. An analysis was performed in
order to map CL’s hypometabolic network. This
analysis consisted in comparing the normalised
CMRGlc (nCMRGlc) values obtained in the
patient with those of an age-matched control
group, composed of 10 subjects (mean
age ¼ 43.6 + 8.3 yrs). For this analysis, we used
the standard significance threshold (p value
, .001, uncorrected).
Results
Compared with the control group, the analysis
revealed significantly decreased nCMRGlc in the
patient in the right ventral frontal gyrus (BA 11)
(see Figure 5) (size ¼ 59 voxels; 38, 38, 219, x,
y, z; Z ¼ 3.36). Even at the more liberal threshold
of p , .01, the hypometabolism was almost
entirely restricted to the right ventral frontal
cortex (BA 11/47).

DISCUSSION
In this study, we carried out a thorough investi-
gation in order to study the case of a massive retro-
grade amnesia. Given that CL’s case would be
inaccurately labeled as focal RA, we discuss “dis-
proportionate RA” (DRA), rather than FRA.
Nevertheless, we do not reject the fact that FRA
may exist. We focus on the issue of “pureness” of
retrograde amnesia (using an extended memory
systems investigation and strict post-onset and
pre-onset matched procedures), and underlying
brain dysfunction. Moreover, we discuss the
issue of the attribution of causality in the particu-
lar case of CL, making assumptions about the
possible organic and psychogenic factors.
The issue of pureness of retrograde amnesia
A few months after the total loss of retrograde
memory in patient CL, an extensive memory
systems assessment revealed that several memory
systems were intact, such as procedural skills and
PRS, whereas primary memory (executive func-
tion) was mildly impaired and semantic memory
was grossly impaired. In contrast, new learning
of episodic information was better preserved,
especially using a specific test that controlled
depth of encoding and the semantic integrity of
words of the learning list (i.e., Grober &
Buschke, 1987, revised test), but deteriorated on
the basis of the WMS-R verbal memory index.
Absence of control of encoding and requirement
of semantic verbal abilities (which were particu-
larly impaired in the case of CL) in the latter
may explain the discrepancy between the two
kinds of anterograde memory assessments. These
results, obtained via a particularly thorough assess-
ment, when compared with many previous studies
might be taken to suggest a dissociation between
relatively spared episodic memory and impaired
semantic memory. This kind of dissociation is
the mirror image of the amnesic syndrome
profile, which is characterised by disorders of epi-
sodic memory and a relative preservation of
semantic memory (Kopelman, 2002).
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
This type of episodic –semantic distinction is
incompatible with Tulving’s model (1995, 2001),
where new learning of episodic information
depends on the integrity of semantic memory.
However, that interpretation fails to distinguish
between memory systems and age of acquisition
of information (post- and pre-onset). By taking
this very issue into account, using comparable
pre- and post-onset episodic and semantic
memory tasks, we reliably demonstrated that
both memory systems were grossly impaired in
the pre-onset period, whereas in the post-onset
period, personal and nonpersonal semantic
memory was intact while episodic autobiographi-
cal memory was moderately impaired. This
profile is in accordance with Tulving’s model.
Interestingly, compared to matched controls,
post-onset autobiographical memories dating
back more than a few months rapidly lost their
richness of detail compared with those of the con-
trols. This may imply the presence of an acceler-
ated forgetting rate at very long-term intervals,
as already suggested by several authors using non-
autobiographical anterograde verbal memory tasks
(De Renzi & Lucchelli, 1993; Kapur et al., 1996;
Lucchelli & Spinnler, 1998) but where the
measurement of forgetting rates was from
“unmatched” starting points. It is worth noting
that CL’s delayed recall performances were
normal on standard episodic/anterograde
memory tests (i.e., the modified version of
Grober & Buschke’s test or the Wechsler
Memory Scale). This finding is supported by the
fact that after a period of 312 years, patient CL
no longer clearly remembered the extensive neuro-
psychological assessment reported here.
Nevertheless, some early learning difficulties may
also have contributed to this deficit in his post-
onset retrieval memory.
The study of states of consciousness showed
that patient CL manifested no pre-onset sense
of self: CL’s state of mind was “a blank” whenever
he tried to think about his pre-injury past. By con-
trast, he retained a subjective sense of remember-
ing (R responses) comparable to that of the
controls for the last 12-month period (post-
onset 1998), but not for more distant post-onset
1023
PIOLINO ET AL.
information. In addition, he was unable to justify
his remembering (justified R responses) by recol-
lecting actual contextual details to the same
extent as the controls, although his very recent
sense of remembering was correct (e.g., today,
yesterday) suggesting a deficit in autonoetic
consciousness that may be common to both pre-
onset and post-onset memory. This result
matches that of a previous case of organic DRA
(Levine et al., 1998) that also revealed a deficit
of autonoetic consciousness, showing normal
cued recall and recognition when performing an
anterograde memory task, but a bias towards pro-
ducing more K than R responses. By contrast, the
findings of Dalla Barba et al. (1997) suggested
preserved autonoetic consciousness for post-
onset, but not pre-onset, memory. However, the
latter was not based on a matched anterograde/
retrograde comparison and concerned a DRA
patient with uncertain aetiology. Our findings
suggest that CL had difficulty bringing to mind
contextual details of previous events and experi-
ences concerning a particular time or place that
included an impaired awareness of self and an
inability to project himself back into both the
remote and the recent past. This deficiency also
seemed to concern the ability to project himself
forward into the future, as clinical examinations
suggested that CL had no personal plans for the
future and did not take any active part in family
projects. CL would therefore appear to suffer
from a subjective discontinuity between present,
past, and future that disturbs his sense of personal
continuity and identity.
Taken as a whole, this series of behavioural data
seems to reveal an impairment of long-term
memory consolidation and of the sense of self in
time, which implies that underlying anterograde
abnormality is, to some extent, a component of
retrograde amnesia. These results back the sugges-
tion of Levine et al. (1998) that seemingly intact
anterograde memory in DRA is qualitatively
different from normal memory. Retrieval failure
is one possible explanation for CL’s DRA,
especially given the fact that the mechanisms for
retrieving material from post- and pre-onset
periods were both impaired (but see Reinvang,
1024 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
Nielsen, Gjerstad, & Bakke, 2000). In addition,
our results emphasised the fact that relatively
preserved performances on standardised word-list
episodic/anterograde memory tests could not be
generalised to autobiographical memory. In
effect, this evidence was obtained under conditions
that had little to do with the complex and self-
relevant autobiographical memory and the long
retention intervals of real life (Conway, 2001).
As in many previous publications, CL is a case
of disproportionate rather than focal RA
(Kopelman, 2000a). The pattern of CL’s retro-
grade amnesia matches the findings of previous
studies that have described patients with DRA
displaying both autobiographical deficits and
impaired knowledge of public events or famous
faces (De Renzi et al., 1995; Kapur, 1993;
Lucchelli, Muggia, & Spinnler, 1998; Yoneda
et al., 1992) for their entire lifespan (see
Mackenzie Ross, 2000). In particular, a single
case reported by De Renzi et al. (1997), suffering
from persistent ungraded DRA but without any
documented cerebral damage, showed very
similar behavioural patterns to CL. For 4 years,
this patient had lost his personal identity, episodic,
and general semantic memory, along with pro-
cedural skills, whereas his learning abilities had
remained intact. He displayed some implicit
knowledge of his past, showing rapid relearning
abilities for words. In our case (see
Neuropsychological Investigation), there were
also pronounced initial deficits of procedural
skills, but thereafter CL recovered his procedural
memory. At the time of the present study, as in
almost all previous cases, memory for procedural
skills and other aspects of implicit memory were
preserved (Barbarotto et al., 1996; Kihlström &
Schacter, 1995; Kopelman et al., 1994). Some
elements of CL’s case may argue also in favour
of the preservation of some implicit forms of
remote episodic and semantic memory, as demon-
strated by Reinvang et al. (2000) in a case of
organic FRA. Indeed, the promptness of relearn-
ing with re-exposure to old semantic knowledge
and the rapidity of adaptation to family life are
consistent with a relative sparing of implicit
knowledge that is more marked for semantic

than for episodic knowledge. Given the relative
sparing of his new learning abilities, it was there-
fore surprising that patient CL failed to relearn
and retain information about his personal past,
at least partially, as he did with general knowledge.
By contrast, in the majority of previous cases,
patients rapidly relearned almost all their past,
although they remained unable to re-experience
personal events as part of their own subjective
past (Dalla Barba et al., 1997; De Renzi &
Lucchelli, 1993; Mattiolli et al., 1996; Stracciari
et al., 1994). Together, these results may suggest
that CL’s retrograde amnesia resulted from an
overall disturbance of explicit memory retrieval,
namely conscious access to memory traces.
It is also interesting to note the contrast
between the patterns of recovery across the antero-
grade and retrograde components (Sellal et al.,
2002). As in previous cases (Kopelman, 2000a),
CL’s DRA arose following an initially more
severe episode of anterograde amnesia. As far as
his retrograde amnesia is concerned, all aspects
of memory were impaired at first, even the use
of familiar objects, like two cases reported by
Nakamura, Kunori, Mori, Nakaaki, Yoshida, and
Hamanaka (2002), but he then recovered his pro-
cedural memory. Since then, his general semantic
memory (i.e., knowledge of public names or
events, not just vocabulary) has improved,
although his episodic memory, which is the most
advanced memory system, remains deficient.
Three-and-a-half years after the investigation
described here, CL seems to have recovered pre-
onset general semantic and autobiographical
semantic memory but not episodic memory. Our
results are therefore compatible in DRA with a
common origin for anterograde and retrograde
deficits, with differential rates of recovery
(Kopelman, 2000a).
Cerebral dysfunction of DRA
CL’s PET scan revealed hypometabolism of the
right ventral frontal lobe (BA 11/47), although
an MRI of the brain was entirely normal. There
is an agreement that focal lesions to the frontal
lobe can contribute to autobiographical amnesia
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
(Baddeley & Wilson, 1986; Della Sala,
Laiacona, Spinnler, & Trivelli, 1993; Kopelman,
Stanhope, & Kingsley, 1999; Piolino et al.,
2003b). Moreover, neuroimaging studies in
normal subjects have shown that the frontal lobe
plays a crucial role in episodic memory and auton-
oetic consciousness (Tulving, 2001, 2002;
Wheeler & Stuss, 2003; Wheeler et al., 1997).
In particular, the ventrolateral prefrontal cortex,
which encompasses areas 11 and 47, is closely con-
nected with limbic structures involved in emotion-
al processing, behavioural self-regulation, and
complex personal decision-making (Wheeler &
Stuss, 2003). Moreover, this region is especially
involved in the retrieval of sad episodes
(Markowitsch, Yandekerckhore, Lanfermann, &
Russ, 2003). The finding of right-hemispheric
laterality concurs with the functional role of this
region in episodic memory retrieval (Cabeza &
Nyberg, 2000; Desgranges et al., 1998; Eustache
et al., 2004; Tulving, Kapur, Craik, Moscovitch,
& Houle, 1994). In particular, the site of hypome-
tabolism coincides with one of the three right
prefrontal cortical sites shown to be involved in
the establishment and maintenance of episodic
memory in “retrieval mode” (Lepage et al.,
2000). The right frontal lobe is also involved in
emotional processes (Cabeza & Nyberg, 2000)
and self-perspective when remembering past
episodes (Conway & Pleydell-Pearce, 2000;
Keenan, Wheeler, Markowitsch, & Ewers, 2003;
Piefke, Weiss, Zilles, & Fink, 2003), or in
affect-laden autobiographical memory (Costello,
Fletcher, Dolan, Frith, & Shallice, 1998; Fink,
Markowitsch, Reinkemeier, Bruckbauer, Kessler,
& Heiss, 1996; Markowitsch & Ewald, 1997;
Markowitsch et al., 2003). Nevertheless, most of
the neuroimaging studies in the field of auto-
biographical memory retrieval have pointed to a
widespread, but mainly left-sided, cerebral
network involving the prefrontal cortex with the
medial and lateral temporal cortex, the retrosple-
nial and the posterior cingulate cortex (Maguire,
2001; Piefke et al., 2003; Piolino et al., 2004).
The role of right frontal cortex is also in keeping
with findings from the neuropsychological litera-
ture on retrograde amnesia (Kopelman, 2000b,
1025
PIOLINO ET AL.
2002; Kopelman & Kapur, 2001; Kroll et al.,
1997). Interestingly, the site of hypometabolism
found in CL is extremely close to the sites
reported in the previous study of patient ML
(Levine et al., 1998), who suffered from organic
DRA after a head injury resulting in right-sided
ventral frontal damage (BA 47) that involved the
uncinate fasciculus (see also Reinvang et al.,
2000) and may have disconnected the frontal
and temporal structures. It is worth mentioning
that neuropsychological studies have emphasised
the major involvement of the right fronto-
temporal junction via the uncinate fasciculus
(Calabrese et al., 1996; Markowitsch, 1995) in
recollecting autobiographical memories. One
functional imaging investigation of a patient
with organic isolated retrograde amnesia has
noted right ventrolateral frontal hypometabolism
on PET scanning while the patient attempted to
recall personal events depicted by photograph
related to the amnesic period compared to the
nonamnesic period (Costello et al., 1998). This
patient, who suffered circumscribed damage to
the left dorsomedial frontal lobes, had developed
a retrograde amnesia that covered a period of 19
years, which contained many highly stressful situ-
ations. Costello et al. (1998) proposed that RA in
this case could be explained by a deficit in trigger-
ing off autobiographical memory retrieval. In sum,
CL’s right-sided ventral frontal hypometabolism
could explain the loss of remote episodic memories
and the abnormality of relatively recent ones in
terms of strategic deficits. In addition, the
absence of medial temporal lobe hypometabolism
could account for his relatively preserved “new”
episodic learning ability.
Attribution of causality
A major issue is now to identify the relative con-
tribution of psychogenic and organic factors to
CL’s retrograde amnesia. In this case, as in some
others, it is difficult to discriminate between
organic and psychogenic amnesia (Kapur,
1993; Mackenzie Ross, 2000; Stuss & Guzman,
1988) or even simulation (Barbarotto et al.,
1996; Kopelman et al., 1994). We examine
1026 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
alternatively the points in favour of these three
hypotheses, i.e., neurological/physiological dis-
turbance, unconscious psychological mechanisms,
or deliberate simulation, using objective guidelines
reviewed by Kopelman (2000a) and Mackenzie
Ross (2000).
Points in favour of an organic hypothesis
In CL’s case, several features seemingly suggested
an organic aetiology.
First, CL’s DRA was consistent with a series of
papers describing patients with extensive DRA
following only minor head injury, whose psycho-
genic aetiology is rejected (see, for review, De
Renzi & Lucchelli, 1993; Lucchelli et al., 1995;
Stracciari et al., 1994; Wheeler & McMillan,
2001).
Second, the resting PET scan clearly showed a
cerebral hypometabolism whose location matched
those mentioned in previous studies of organic
DRA (see above), which may be relevant to the
severe retrograde amnesia in this case.
Nevertheless, the attribution of causality in
DRA is a very complex issue (see Introduction),
especially in our case, which is characterised by
two dates of onset. It is effectively difficult to
state if the right frontal hypometabolism has had
its onset at the same time as either the loss of per-
sonal identity (second onset) or the original minor
head injury (first onset). Moreover, there is some
information about clinical background that
argues in favour of possible psychopathological
or emotional causes.
Points in favour of a psychological hypothesis
The patient CL met some criteria that support the
idea that unconscious psychological mechanisms
may have contributed to his DRA.
First, and most remarkably, the 8-month inter-
val between the minor head injury at the end of
September 1996 and the onset of severe retrograde
amnesia in June 1997 argues strongly against a
direct contribution of the head trauma.
Second, the loss of pre-onset autobiographical
memory, whatever its nature (identity and

memories), as well as the loss of fairly elementary
procedural skills and general semantic knowledge
seem rather out of proportion with the brain
dysfunction observed.
Third, the possibility of psychological causation
or contributing factors cannot be excluded in the
light of the clinical report and in the absence of a
more detailed background history. The loss of
identity immediately followed hospitalisation for
depression. Noteworthy, at the time of the
present study the patient CL did not still seem
to suffer from mood disorders or any other psy-
chiatric symptoms. Moreover, he has been
employed as a garden cleaner for the last 2 years.
We could make the assumption that the episode
of depression following the minor head trauma
caused by such an exceptionable bout of drinking,
the guilt related to the episode of drunkenness,
and circumstances surrounding hospitalisation
for antidepressant treatment might each have
been sufficiently stressful to contribute to CL’s
loss of identity, going against those authors who
consider that psychological trauma is not sufficient
to produce amnesia (De Renzi, 2002; Kihlström &
Schacter, 2000). In effect, depression causes auto-
biographical memory and self-schemata deficits.
In particular, depressed patients tend to recall
categoric overgeneral memories, rather than
specific memories (Barnhofer, de Jong-Meyer,
Kleinpass, & Nikesch, 2002; Watkins &
Teasdale, 2001; Williams, 1996). A mood-
congruent memory effect (Nandrino, Pezard,
Poste, Reveillere, & Beaune, 2002) and the com-
monality of intrusive memories of stressful events
(Brewin, Hunter, Carroll, & Tata, 1996) are two
other major features of autobiographical memory
functioning in depression. Neuroimaging studies
have shown reduced frontal activity in functional
activation paradigms in depression (Brody,
Barsom, Bota, & Saxena, 2001; Drevets, 1998)
compatible with CL’s cerebral dysfunction.
However, a loss of identity such as in the current
patient is not observed in depression.
Consequently, additional psychological mechan-
isms may explain the total loss of CL’s identity.
Fourth, several behavioural characteristics of
the patient are suggestive of psychological
COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
RIGHT FRONTAL HYPOMETABOLISM IN RA
mechanisms: for instance, his emotional detach-
ment to old acquaintances and surroundings, his
fear of meeting former friends and colleagues,
his refusal to undergo psychotherapy or hypnosis
and his definite preference of an organic expla-
nation for his disease, his resignation to live
without memories and past identity, his complete
change with his past habits. These behaviours
might be considered as attempts to inhibit past
personal memory (Conway & Pleydell-Pearce,
2000; see below).
In sum, psychological processes resulting from
unconscious mechanisms may therefore have
played a critical role either in initiating and main-
taining the loss of identity after the second onset
or exacerbating the loss of memory after the first
onset. The pattern of CL’s second onset amnesia
may be defined as combining particular predispos-
ing factors described by Kopelman (2000a, 2002):
a supposed exposure to emotional trauma, acute
psychological stress, depression, and a past
history of a transient organic amnesia (first
onset) resulting from a head injury. The first
onset may account for the focal frontal region of
hypometabolism on PET scan unless the second
onset corresponding to recovery from psychologi-
cal stress, may have involved functional disorgan-
isation within the frontal lobe, which severely
disrupts retrograde mnemonic processes compared
to anterograde ones.
Some investigators have pointed out the fre-
quent concomitance of neurological and psycho-
logical problems, especially in cases with mild
concussion accompanied by disproportionate
mnesic consequences (Kopelman, 2000a;
Kopelman & Kapur, 2001). Moreover, the pre-
sence of an abnormality revealed by functional
imaging is not inconsistent with the operation of
conscious or unconscious psychological factors
(Markowitsch, 1999; Parkin, 1996; Spence,
Crimlisk, Cope, Ron, & Grasby, 2000; Yasuno
et al., 2000). In psychogenic DRA, Markowitsch
and his colleagues (1996, 1997b, 1997c, 1999,
2000) have found cerebral dysfunction rather
similar to that seen in organic amnesia. They
have suggested that a stressful event may result
in the discharge of glucocorticoids (stress
1027
PIOLINO ET AL.
hormones), producing cerebral abnormalities that
cause a memory block.
Kopelman (2000a, 2002) has also proposed a
model that emphasises the complex interplay of
psychosocial factors and brain systems, especially
the frontal lobe, involved in triggering DRA.
This model postulates that severe stress can
sometimes affect frontal/executive systems,
thereby inhibiting the retrieval of autobiographi-
cal memories and additionally knowledge of self
and identity when a subject is extremely
depressed. It is noteworthy that several character-
istics within CL’s cognitive data (i.e., WMS
attention index of 87; digit backward span of 3;
low letter fluency) point out some attentional
and executive difficulties, which could explain
retrograde amnesia in terms of deteriorated
strategic search.
Conway’s self-memory system (2001) postulates
that autobiographical memory requires the binding
of episodic event-specific knowledge (sensory-
perceptual details) and semantic personal know-
ledge (facts about the self). Based on the discussion
of inhibitory processes on personal memories
proposed by Conway and Pleydell-Pearce (2000),
memory (in our case memory for an entire life)
that is discrepant with current goals of the self
may be actively prevented from entering conscious-
ness because it is tagged as to-be-forgotten.
According to this view, CL’s retrograde amnesia
should depend on his intention to forget his per-
sonal past (Anderson & Green, 2001).
Motivational influences on memory retrieval may
also have contributed to CL’s DRA. Related to
this, we noted that CL has learnt (and relearnt)
information that he believes is currently useful to
him (i.e., general semantic), but he manifested a
general loss of motivation for relearning his per-
sonal past. This point clearly illustrates the
cognitive-affective account of mechanisms of
CL’s DRA (Conway, 2003). Some new avenues
of research are particularly useful to explore
whether directed forgetting can reliably inhibit
the accessibility of an individual’s identity. In par-
ticular, some experiments proposed to investigate
the impact of inhibitory control processes on
memory by means of experimental methods of
1028 COGNITIVE NEUROPSYCHOLOGY, 2005, 22 (8)
inhibition as laboratory analogues of functional
amnesia, such as directed forgetting paradigm
(McLeod, 1998) and posthypnotic amnesia
paradigm (Cox & Barnier, 2003). Using a directed
forgetting paradigm, Conway and Fthenaki
(2003) have recently shown that frontal patients
with right-side lesions cannot intentionally
inhibit information. This result, applied to the
patient CL (who suffered from a right frontal
hypometabolism), may suggest that the inhibitory
process itself remained outside his direct conscious
control.
Points in favour of a deliberate simulation
hypothesis
Finally, another hypothesis would be that patient
CL feigned, at least partially, his retrograde
amnesia.
First, on the strength of some criteria proposed
in the literature that have been advocated to detect
simulated amnesia (Kopelman, 2000a; Barbarotto
et al., 1996; Kopelman et al., 1994), there was no
clear evidence to support simulation in this case.
CL’s recognition was not worse than free recall
(i.e., see new learning tests), priming effect was
normal (i.e., see the PRS investigation), and defi-
cits were consistent from one test to another
(i.e., see the two autobiographical memory
investigations).
Second, with regard to evidence of secondary
gain (such as escape from an unpleasant situation
or compensation), CL got no direct financial
benefit from his amnesia: He lost his job and
received no pension from his insurance policy,
the contract being denounced given that his
problems had begun after an episode of heavy
drunkenness, but he got some direct psychological
benefit from his amnesia. Indeed, as a result of his
amnesia, CL has escaped his guilt for the episode
of drunkenness and he received a considerable
amount of practical and emotional support from
his family. CL and his wife seemed drawn
together by their “common misfortune.”
To conclude, a combination of the three factors
(i.e., organic, unconscious psychological, and
deliberate simulation) was likely to contribute to

the profile of CL’s DRA, but we essentially
retained neurological/physiological disturbance
and unconscious psychological mechanisms
rather than deliberate simulation.
In summary, we report a detailed neuropsycho-
logical and functional neuroradiological single
case study of DRA in the absence of detectable
structural brain damage. Using strict matched
tasks, massive and extensive pre-onset episodic
and semantic memory loss as well as impairment
in post-onset episodic memory was detected.
Furthermore, both disturbances in the subjective
experience of consciously remembering pre-onset
as well as post-onset episodes and hypometabo-
lism in the right ventral prefrontal cortex were
observed and hypothesised to reflect disruptions
in the sense of past/present self in the absence of
clear aetiology.
Manuscript received 10 June 2003
Revised manuscript received 7 July 2004
Revised manuscript accepted 7 December 2004
PrEview proof published online 16 March 2005
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