5 a cognitive neuroscience perspective on confabulation: commentary by jorge canestri (rome)

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A Cognitive Neuroscience Perspective onConfabulation: Commentary by Jorge Canestri(Rome)Jorge Canestri

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To cite this article:Jorge Canestri (2000) A Cognitive Neuroscience Perspective on Confabulation: Commentary byJorge Canestri (Rome), Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences, 2:2,

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McCarley, R. W. (1977), The brain as a dream state

generator: An activation-synthesis hypothesis of the

dream process. Amer.

Psychiatry 134:1335 1348.

Kernberg, O. (1984), Severe Personality Disorders. New

Haven, CT: Yale University Press.

Meltzer, D. (1984),

Dream Life.

Perthshire, Scotland: Clu

nie Press.

Mesulam, M.-M. (1998), F rom sensation to cognition.

Brain 121:1013 1052.

Moscovitch, M., Melo, B. (1997), Strategic retrieval and

the frontal lobes: Evidence from confabulation and am

nesia. Neuropsychologia 35:1017 1034.

Nathaniel-James, D., Frith, C. (1996), Confabulation in

schizophrenia. Psycholog. Med. 26:391 399.

Perrett, D., Rolls, E., Caan, W. (1982), Visual neurones

responsive to faces in the monkey temporal cortex. Ex-

periment. Brain Res. 47:329 342.

Reiser, M. (1990), Memory in Mind and Brain: What Dream

Imagery Reveals. New York: Basic Books.

Jorge Canestri

Robinson, M., Freeman, W. (1954), Psychosurgery and

the Self. New York: Grone Stratton.

Schilder, P. (1930), Studies concerning the psychology and

symptomatology

of

general paresis. In: Organization

and

Pathology

of

Thought ed. D. Rapaport. New York: Co

lumbia University Press, 1951, pp.

519-580.

States, B. (1995), Dreaming

accidentally

of Harold

Pinter: The interplay

of

metaphor

and

metonymy in

dreams. Dreaming 5:229 245.

Szalita, A. (1958), Regression and perception in psychotic

states. Psychiatry 2 :53-63.

Weinstein, E., Lyerly, O. (1968), Confabulation follow

ing brain injury: Its analogues and sequelae. Arch. Gen.

Psychiatry 18:348 354.

Mark Blechner Ph.D.

145 Central Park West

New ork 10023

A Cognitive Neuroscience Perspective on Confabulation

Commentary by Jorge Canestri (Rome)

DeLuca's paper presents the psychoanalyst with sev

eral interesting points: an accurate examination of a

pathological phenomenon (confabulation) whose

definition, uniqueness, and causality are still under

discussion; an alternative model constructed on the

cognitive neuroscience perspective emphasizing the

differences between the various forms of confabula

tion; and the possibility of comparison with psychoan

alytic theories, specifically relative to this

phenomenon as well as in a wider sense concerning

the verisimilitude

of

certain statements of Freudian

metapsychology.

The neurosciences can offer to psychoanalysis

some tools that allow one to verify the biological plau

sibility of certain psychoanalytic hypotheses and to

find confirmation or refutation of them in the experi

mental field, while psychoanalysis can supply the neu

rosciences with a heuristic potential that cannot be

underestimated. In these brief notes I will try to illus

trate this viewpoint.

My task in presenting these notes is greatly facili

tated by Mark Solms's comment, which excuses me

from describing the fundamental principles of the

Freudian topographical model of the mind (Freud,

1900, 1911, 1915). With the addition of examples

taken from his clinical experience with bilateral ven

tromesial frontal lesioned patients, Solms highlights

what is essential to the Freudian task: the problem of

the psychoanalyst is not only to construct a causal

hypothesis, but above all to find meaning in the mani

festations of psychic life. This is evidenced by the

different consideration that the symptoms merit in De

Luca's work and in the discussion by Solms. The latter

emphasizes the fact that behind the positive (or

productive'

)

manifestations of the organic lesions,

there are underlying wishes, in consonance with

the Freudian model of the mind. It is therefore clear

that while DeLuca will put the accent

on

the deficit,

the psychoanalyst will also emphasize the produc

tive aspect of the symptom and its meaning.

It might perhaps be useful to dwell for a while

on this difference in the general line of thinking, which

could be significant for the neurosciences also. As we

know, Freud constructed a hypothetical model

of

a

mental apparatus. Setting aside for the time being

the verisimilitude of his construction, what is essential

is to note the implicit general concept: in a complex

system the global level of functioning

of

the system

cannot legitimately be explained by reference to the

atomic elements only. A deficit (in these cases due

to an organic lesion) must be interpreted also as a

function of the overall response of the system. This is

true at the physical level as well as at the level of

mental life. If, for example, we consider the (some-


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Commentary on Confabulation

times astonishing) cases

of

extensive malformations

of one hemisphere requiring early radical hemi

spherectomy (I recall a case with follow-up of left

hemispherectomy in a 2-year-old child), we can see

how the right hemisphere almost completely takes

over all the functions of the other hemisphere, privi

leging those higher functions that are essential from

the adaptive point

of

view.

Mental life operates no differently (and it could

not be otherwise). This justifies considering the gap

filling produced by the lesions in question as a function

of

the mind (as a system), and not necessarily or only

as a response to embarrassment or feelings

of

inade

quacy. Gazzaniga s observations (1998, quoted by De

Luca) can be viewed from the same angle: the point

is not so much in deciding whether this is confabula

tion from unawareness or not, but rather that in split

brain patients the left hemisphere contains a mecha

nism (the Interpreter) that in any case tries to interpret

information in a plausible manner, even

if

it is not

correct. What I would say,

if

Gazzaniga is right, is

that this is a function

of

the system as a whole. Mental

life at the level

of

dreams (secondary elaboration),

the narrative rewriting

of one s own history, regularly

works in the same way.

Solms insists on the fact that mature cognitive

functions (like the function that DeLuca described as

strategical retrieval

-which

we would classify as an

executive ego function) are built upon the founda

tions

of

more primitive mental functions. This leads

him to observe, rightly, that the symptomatology of

his patients is in consonance with the fundamental

principles of the Freudian topographical model of

the mind.

I would like to recall a Freudian concept that has

been somewhat forgotten (Canestri, 1989) and that

could prove useful in this context. The concept

emerges for the first time in Freud s analysis of the

Schreber case but reappears in other texts by Freud.

This is not the occasion for a detailed study of its uses

and applications, but I would only like to mention that

the concept in

question-reconciliation Versoh-

nung was subsequently transformed by Melanie

Klein into reparation thus modifying its original

meaning. What did Freud mean by reconciliation?

The Schreber case dealt with the fact that the patient

could reconcile himself with his homosexual fan

tasy because he was not able to eliminate it. Subse

quently the concept broadened to include the

reconciliation of the three mental agencies (ego,

id, and superego) in Freud s structural model. In con

clusion, through the deformations of the ego and the

5

use

of

different defense mechanisms, the entire system

seeks states

of

equilibrium (which

mayor

may not be

pathological) and this brings into consideration all the

elements

of

the system.

In my opinion, the general outline

of

Luria s

work (1973) in relation to confabulation is similar to

the one I have attempted to describe here. In fact,

whether he was analyzing attention disorders or mem

ory disorders (in patients with ventromesial frontal le

sions), Luria constantly emphasized that the classical

basic

concepts of neuropsychology needed to be

reexamined. Thus, from the concept of function we

pass to the notion

of

whole functional systems,

from single abilities to systemic organization, from

the cerebral zones to the articulation and hierarchical

organization of complex functional systems, from

the symptom to the collapse of the system in its en

tirety. In the same way, Luria s conceptualizing of the

structures within the ventromesial frontal region of the

brain as being an executive system with the task

of

organizing the available subroutines at lower hierar

chical levels, are congruent with some central aspects

of

Freudian metapsychology. This has already been

effectively pointed out by Solms when he quotes Lu

ria, but I would like to return to some particular as

pects, especially those concerning the function of

attention.

Freeman s (1992) paper Psychiatric Perspec

tives on Freud s Metapsychology, is pertinent to our

topic. Even though DeLuca expressly leaves aside

confabulatory psychopathology of psychiatric origin,

many of Freeman s examples, including those of

schizophrenia and chronic brain syndrome, demon

strate the value in studying confabulation in a broad

rather than a narrow sense, as Solms also recommends.

In these disorders Freeman identifies a failure

of

selec

tive attention (described by many authors, Luria in

particular) that, from a psychological point

of

view,

would result in the essential feature:

In the chronic brain syndrome reality has largely lost

its value

The loss

of

reality has not occurred be

cause it had become too frightening (Rosenfeld,

1952), too exciting (Katan, 1979), hated (Bion, 1959),

as is postulated in the case of schizophrenias. The

clinical phenomena suggest other causes for the break

with reality-namely the disorder

of

selective atten

t ion and the amnesic phenomena. Attention can no

longer be purposely directed to thoughts and percepts

although they have achieved mental registration [po

498].


4/6

6

I will later return to the problem of the (associated)

role that certain defense mechanisms-denial or dis

avowal Verleunung -----ean also play in these pathol

ogies.

What is specifically interesting in this case is that

Freeman (and also Solms) resorts to the Freudian the

ory of attention, another metapsychological concept

not always taken sufficiently into account. Freeman s

synopsis of the Freudian theory of attention highlights

the fact

that

selective attention is a function of the

ego system Pcpt-Cs which acts as a sense organ (p.

499). This implies that unconscious mental processes

(wishes) have to make contact with preconscious ver

bal representations to find conscious expression, and

this, in turn, requires that the Pcpt.-Cs. system should

have an adequate cathexis (activation). What hap

pens with pathology of the vetromesial frontal region

of

the brain? Luria and others emphasize that the

voluntary or selective attention-arousal systems of

the brain are defective, adding that the frontal lesion

disturbs only the higher cortical forms of such activa

tion, formed with the help of language, while the ele

mentary forms not only remain intact

ut

m y actually

be increased. Returning to the Freudian hypothesis;

on the one hand, we are brought back to what Solms

clearly explained when he writes that:

] defining property of the deficit in question must

be that it deprives the mental apparatus of something

that is fundamental to the whole mode

of

functioning

of

the system

Pcs.-Cs.-and

therefore to the second

ary process (and the reality principle) in general. This

implies that structures within the ventromesial frontal

region

of

the brain subserve functions that are prereq

uisite for the secondary process mode of functioning

that characterizes the system Pcs.-Cs.

On the other hand, there also appears to be a

deficit in the filtering of information and in its reg

ulation, as Luria describes (i.e., an increase in elemen

tary forms of arousal). In Freudian language, this is

attributed to absence

of

the

countercathectic barrier

that protects the operations linked to voluntary atten

tion from undesirable interference (or restated in terms

of primary and secondary processes: protects thought

from continuous invasion by the procedural forms of

the primary process).

In the same way as the functioning of the mental

apparatus presupposes the constant and simultaneous

presence of primitive functions, it also implies an

adequate control and filtering

of

these functions in the

development

of

higher cognitive capacities.

Jorge Canestri

In Freeman s words:

s

the Pes contents are hypercathected, a counterca

thectic barrier arises simultaneously to insulate di

rected thinking and perceiving from extraneous and

internal stimuli

In terms of Freud s theory (1900),

patients suffering from chronic brain syndrome can

not voluntarily recall preconscious ideas and percepts

because the system Pcpt-Cs is deprived of that

(bound) cathexis which would enable it to bring these

representations to consciousness. The accompanying

distractibility occurs because of the cathectic deple

tion of the barriers which protect consciousness from

excessive stimuli

the loss of functions served by

the system Pcpt-Cs leads to the appearance of an ele

mentary form of cognition (primary process)

po

499].

This is consistent with Luria s observations

(quoted by Solms) concerning a sharp decrease in

cortical tone and with the statements of Solms (and

psychoanalysis in general)

on

the importance of con

sidering not only the deficit but alsothe productive

aspects of pathology. If what I briefly mentioned

above, regarding the brain and the mental apparatus

as a complex system, is plausible, then these aspects

simultaneously reveal the

work

of the primary process

in terms of wishful states; but they also reveal the

striving toward a reconciliation with the new con

dition of the entire mental apparatus.

One

of

my patients with severe cyclical pathol

ogy, at a certain point in the analysis, had a partial

occlusion of the carotid. The excessive deficits that

ensued led to the suspicion of a second pathology.

Radiological investigations revealed diffuse atrophy

of the cortex, the extent of which amazed everybody

as it was difficult to imagine how the patient could

have led quite a normal life (at least from the neu

rological point of view) considering the extent of the

cortical atrophy. A surgical intervention to clear the

carotid (endartorectomy) brought the situation back to

the stato quo ante, but the following months of analy

sis provided a good opportunity to observe a complex

and articulated assemblage of productive symptoms,

deficits, and compensatory efforts by the patient

(pseudo-explanations, confabulations, rationaliza

tions, etc.) to reconcile himself to his state. The psy

chiatric pathology did not disappear, rather i t was

enriched by the intersection of organic symptoms and

psychiatric symptoms. The definition of denial by Pri

gatano and Klonoff (1998, quoted by DeLuca) could

be applied to some manifestations of this point: de

nial after brain injury reflects the individual s attempt


5/6

Commentary on Confabulation

to use previous coping strategies to deal with impair

ments that are only partially recognized. This defini

tion coincides with the above hypothesis on the

function

of

reconciliation. But how do we trace a

clear dividing line between denial

of

illness and un

awareness

of

illness?

Although itmay be reasonable to try to differenti

ate between anosognosia and functional denial

of

illness, as DeLuca does in the section

of

his paper

entitled Confabulation and Awareness, to me it

seems unsatisfactory to state (following the American

Psychiatric Association s definition) that the differ

ence must be sought in the fact that denial

of

illness

presupposes merely altered self-awareness rather than

actual unawareness. Here we must take account

of

the

fact that denial (in the Freudian sense

of

disavowal,

i.e., erleunung or erweifung is a very powerful

defense mechanism, the effects

of

which can produce

total unawareness (rather than mere altered aware

ness). Denial involves a cognitive alteration that can

be very serious, including substitution of one reality

with another. Theo Dorpat (1983), in hypothesizing

four phases

of

denial; (1) preconscious appraisal

of

danger or trauma, (2) painful affect, (3) cognitive ar

rest, and (4) screen behavior, describes how cogni

tive arrest concerning the painful object and the need

to adapt to the dangerous or traumatic situation stimu

lates the need to create a cover story or screen to hide,

as it were, the gap caused by the preceding phase. The

cognitive arrest is usually followed by some kind

of

screen behaviour the content

of

which is often the

opposite from what has just been negated (p. 54).

Moreover, this operation clearly shows how the

needs of the primary process (realization of a desire

through its opposite, screen behavior, etc.) are articu

lated alongside those of the entire system ( need to

adapt, neutralization

of

the trauma, consequent dis

tortion

of

the perception

of

reality, misidentification,

misrecognition); in other words, alongside distortions

of

the ego and alteration

of

its functions.

I think it will seem obvious to DeLuca that all

these observations invite a nuancing

of

the differ

ences, while his approach is to emphasize

them-to

consider only neurogenic confabulation and to set

aside psychiatric pathology, to differentiate un

awareness from denial

of

illness, to discriminate con

fabulation in a narrow sense from that in a broad sense.

This different orientation partly reflects a disparity be

tween the disciplines. It is difficult, and would be con

tradictory from the analyst s point

of

view, not to take

into account the premobid personality features, the

productive aspects

of

the illness, and the fact that they

7

express unconscious tendencies. From the DeLuca s

viewpoint, on the other hand, the search for clarity in

definitions and for precision in delimiting the field is

paramount. I do not think, however, that these two

orientations need necessarily be incompatible. From

the neurologist s viewpoint, the proposal DeLuca il

lustrates in Figure 1 could be useful, provided that

DeLuca also accepts that although it is useful in neuro

logical practice, it probably is not really accurate when

one deals with confabulatory phenomena as a whole.

Moreover, a radical separation between all these phe

nomena can risk impoverishing our understanding of

the overall functioning

of

the mental apparatus as well

as

of

the brain itself.

In his section reviewing the Neurobehavioral

Models

of

Confabulation, DeLuca adheres to the

third model, hypothesizing that the expression of con

fabulation requires

both

amnesia and executive dys

function. Solms on the other hand thinks that the

memory disorder is an executive disorder, that a

spe

cial type of executive disorder necessarily pro

duces a confabulatory amnesia, thus associating

himself with the second model. From this point of

view, Ptak and Schnider s (1999) observations

(quoted by DeLuca in support

of

the third model) seem

to lead in the direction proposed by Solms; in fact

Ptak and Schnider attribute a core role to the orbito

frontal cortex in the maintenance

of

temporal order in

memory, and it is mainly this (temporal order) that is

altered in memory confabulation, rather than memory

content

itself. We could therefore hypothesize that the

maintenance

of

temporal order is one

of

the executive

functions of the frontal cortex and that the amnesia,

as Solms says, is only the inevitable consequence.

However, some contradictory cases could be found;

for example, the case reported by Wheatly and

McGrath (1997, quoted by DeLuca)

of

confabulation

in

a

non-ACoA patient

with executive dysfunction and

impaired memory secondary to a diencephalic lesion,

and others. Such cases indicate that other nearby struc

tures, connected to the ventromesial portion of the

frontal lobes, are compromised (Damasio, Graff-Red

ford, Eslinger, Damasio, and Kassel, 1985). In my

opinion the argument remains open to further study

and is

of

considerable interest from the neuroscientific

and psychoanalytic point

of

view.

I have already mentioned how psychoanalysis

can have heuristic value for the neurosciences. Psy

choanalysis, of necessity, works with a wider vision

of

subjective phenomena, with a perspective that must

continuously take into consideration the phenomena

of meaning as well as the phenomena of deficit, and

with a viewpoint that must confront the mental appara

tus in its totality alongside each

of

its manifestations.


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148

Moreover, I do not believe it is useful, or episte

mologically correct, from the neuroscientific point of

view, to reject as nonscientific the descriptive data

resulting from subjective experience. First, they are

not in themselves less scientific by definition than ex

perimental data. Many disciplines-psychoanalysis

among

them are

based on

the accurate pro

grammed and intersubjectively controlled collection

o

empirical data

and this does not exclude them from

the field

of

empirical science. The neurosciences could

receive useful information from psychoanalysis rela

tive to the complexity

of

the phenomena to be studied,

for the reason that it possesses an overarching model

of

the mental apparatus still lacking in neuroscience.

Psychoanalysis in its turn could receive valuable help

from the neurosciences in order to test the empirical

and experimental probity

of

its hypothetical and some

times speculative concepts, derived from a particular

experience in the treatment

of

mental illness.

From this point

of

view, DeLuca's work provides

an excellent opportunity for reconsidering some basic

concepts

of

Freudian metapsychology, such as the dif

ference between bound and freely mobile energy, pri

mary process and secondary process, and the entire

Freudian concept

of

attention, and the like. But Solms

has already commented on these aspects.

References

Canestri,

J

(1989), Restauro, Riparazione, Riconciliazione.

In: Piccolo Hans Vol. 61. Milan: Media Press.

Neill Graff-Radford

Damasio, A. R., Graff-Radford, P. J., Eslinger, H., Damasio,

H., Kassel, N (1985), Amnesia following basal fore

brain lesions. Arch. Neurol. 42:263-271.

Dorpat, T. L. (1983), The cognit ive arrest hypothesis of

denial.

n

ternat. J Psycho-Anal. 64:47-57.

Freeman, T. (1992), Psychiatric perspectives

o n F re ud s

metapsychology. nternat Rev. Psycho-Anal.

19:497-502.

Freud, S (1900), The Interpretation of Dreams. Standard

Edition 4 5. London: Hogarth Press, 1953.

(1911), Formulations on the two principles of men

tal function.

Standard Edition

12:213-226. London: Ho

garth Press, 1958.

(1915), The unconscious. Standard Editon

14: 159-204. London: Hogarth Press, 1957.

Gazzaniga, M. S (1998), The Mind s Past. Berkeley: Uni

versity of California Press.

Luria, A R (1973), The Working Brain: n Introduction

to

Neuropsychology. Harmondsworth, U.K.: Penguin

Books.

Prigatano, G. P., Klonoff, P. S (1998), A clinician's

rating scale for evaluating impaired self-awareness and

denial of disability after brain damage. Clin. Neuropsy

chol. 12:56-67.

Ptak, R., Schnider, A (1999), Spontaneous confabulation

after orbitofrontal damage: The role of temporal context

confusion and self-monitoring.

Neurocase. 5:243-250.

Wheatly, J., McGrath, J (1997), Co-occurrence of execu

tive impairment and amnestic syndrome following suba

rachnoid haemorrhage: A case study. Cortex

33:711-721.

Jorge Canestri

Via

Sesto Rufo 23

00136 Rome Italy

e-mail: [email protected]@mclink.it

A Cognitive Neuroscience Perspective on Confabulation

Commentary by Neill Graff-Radford (Jacksonville, FL)

Dr. John DeLuca has written a scholary review

of

the

cognitive neuroscience perspective

of

confabulation,

while Dr.

Mark

Solms has made a compelling case

that many

of

the features characterizing confabulation

are found in Freud's model

of

the unconscious mind.

With these articles in mind, and from a pragmatic

point

of

view, it is important to ask the following ques

tions about confabulations: What are they? What are

Professor Graff-Radford is Chair, Department

of

Neurology, Mayo

Clinic, Jacksonville, Florida.

the known causes? Do we know the anatomy

of

the

lesion(s) causing them? Why do they occur? What are

the associated features?

What

Are They?

Dr. DeLuca has used the Moscovitch and Melo (1997)

definition

of

statements or actions that involve unin

tentional but obvious distortions. This is an all-inclu

sive definition and fits with the model in his Figure

1

5 a cognitive neuroscience perspective on confabulation: commentary by jorge canestri (rome)

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