Screening for confabulations with the confabulation screen.

The objective of this work is to devise and validate a sensitive and specific test for confabulatory impairment. We conceived a screening test for confabulation, the Confabulation Screen (CS), a brief test using 10 questions of episodic memory (EM), where confabulators most frequently confabulate. It was postulated that the CS would predict confabulations not only in EM, but also in the other subordinate structures of personal temporality, namely the present and the future. Thirty confabulating amnesic patients of various aetiologies and 97 normal controls entered the study. Participants were administered the CS and the Confabulation Battery (Dalla Barba, G., & Decaix, C. (2009). "Do you remeber what you did on March 13 1985?" A case study of confabulatory hypermnesia. Cortex, 45(5), 566-574). Confabulations in the CS positively and significantly correlated with confabulations in personal temporality domains of the CB, namely EM, orientation in time and place and episodic plans. Conversely, as expected, they did not correlate with confabulations in impersonal temporality domains of the CB. Consistent with results of previous studies, the most frequently observed type of confabulation in the CS was Habits Confabulation. The CS had high construct validity and good discriminative validity in terms of sensitivity and specificity. Cut-off scores for clinical and research purposes are proposed. The CS provides efficient and valid screening for confabulatory impairment.

The confabulation battery: Instructions and international data from normal participants.

Confabulation is an unusual sign in neurological and in neuropsychological pathologies. In this article we present an objective neuropsychological instrument, the Confabulation Battery (CB), which allows the quantifying and qualifying of different types of confabulations. The CB was administered to French and Italian normal participants. Data from the present study will allow clinicians and researchers, using the CB, to know how much and in which memory domains their confabulating patients confabulate compared to normal participants. We present international data, instructions and guidelines for the CB, a tool used in different ways worldwide. Not quantifying confabulations, namely not reporting how much and in which domain patients confabulate, can hardly lead to conclusions on the neurocognitive bases of this phenomenon. Following the instructions in this article, versions of the CB can be adapted in different languages and cultures. Quantification and qualification of confabulation is necessary and demanded in order to compare sensibly data from different research and clinical groups.

Different patterns of confabulation in left visuo-spatial neglect.

Confabulating patients produce statements and actions that are unintentionally incongruous to their history, background, present and future situation. Here we present the very unusual case of a patient with right hemisphere damage and signs of left visual neglect, who, when presented with visual stimuli, confabulated both for consciously undetected and for consciously detected left-sided details. Advanced anatomical investigation suggested a disconnection between the parietal and the temporal lobes in the right hemisphere. A disconnection between the ventral cortical visual stream and the dorsal fronto-parietal networks in the right hemisphere may contribute to confabulatory behaviour by restricting processing of left-sided stimuli to pre-conscious stages in the ventral visual stream.

Different patterns of recollection impairment in confabulation reveal different disorders of consciousness: A multiple case study.

Recollection is used to refer to the active process of setting up retrieval cues, evaluating the outcome, and systematically working toward a representation of a past experience that we find acceptable. In this study we report on three patients showing different patterns of confabulation affecting recollection and consciousness differentially. All patients confabulated in the episodic past domain. However, whereas in one patient confabulation affected only recollection of events concerning his personal past, present and future, in another patient confabulation also affected recollection of impersonal knowledge. The third patient showed an intermediate pattern of confabulation, which affected selectively the retrieval of past information, both personal and impersonal. We suggest that our results are in favor of a fractionation of processes involved in recollection underling different disorders of consciousness.

The Memory Binding Test Detects Early Subtle Episodic Memory Decline in Preclinical Alzheimer's Disease: A Longitudinal Study.

Background: The asymptomatic at-risk phase might be the optimal time-window to establish clinically meaningful endpoints in Alzheimer's disease (AD). Objective: We investigated whether, compared with the Free and Cued Selective Reminding Test (FCSRT), the Memory Binding Test (MBT) can anticipate the diagnosis of emergent subtle episodic memory (EM) deficits to an at-risk phase. Methods: Five-year longitudinal FCSRT and MBT scores from 45 individuals matched for age, education, and gender, were divided into 3 groups of 15 subjects: Aß-/controls, Aß+/stable, and Aß+/progressors (preclinical-AD). The MBT adds an associative memory component (binding), particularly sensitive to subtle EM decline. Results: In the MBT, EM decline started in the Aß+/progressors (preclinical-AD) up to 4 years prior to diagnosis in delayed free recall (FR), followed by decline in binding-associated scores 1 year later. Conversely, in the FCSRT, EM-decline began later, up to 3 years prior to diagnosis, in the same group on both immediate and delayed versions of FR, while on total recall (TR) and intrusions decline started only 1 year prior to diagnosis. Conclusions: The MBT seems more sensitive than the FCSRT for early EM-decline detection, regarding the year of diagnosis and the number of scores showing AD-linked EM deficits (associated with the AD-characteristic amnesic hippocampal syndrome). Considering the MBT as a detection tool of early subtle EM-decline in an asymptomatic at-risk phase, and the FCSRT as a classification tool of stages of EM-decline from a preclinical phase, these tests ought to potentially become complementary diagnostic tools that can foster therapies to delay cognitive decline. Clinical trial registration title: Electrophysiological markers of the progression to clinical Alzheimer disease in asymptomatic at-risk individuals: a longitudinal event-related potential study of episodic memory in the INSIGHT pre-AD cohort (acronym: ePARAD).

Behavioural and magnetoencephalographic evidence for the interaction between semantic and episodic memory in healthy elderly subjects.

The relationship between episodic and semantic memory systems has long been debated. Some authors argue that episodic memory is contingent on semantic memory (Tulving 1984), while others postulate that both systems are independent since they can be selectively damaged (Squire 1987). The interaction between these memory systems is particularly important in the elderly, since the dissociation of episodic and semantic memory defects characterize different aging-related pathologies. Here, we investigated the interaction between semantic knowledge and episodic memory processes associated with faces in elderly subjects using an experimental paradigm where the semantic encoding of famous and unknown faces was compared to their episodic recognition. Results showed that the level of semantic awareness of items affected the recognition of those items in the episodic memory task. Event-related magnetic fields confirmed this interaction between episodic and semantic memory: ERFs related to the old/new effect during the episodic task were markedly different for famous and unknown faces. The old/new effect for famous faces involved sustained activities maximal over right temporal sensors, showing a spatio-temporal pattern partly similar to that found for famous versus unknown faces during the semantic task. By contrast, an old/new effect for unknown faces was observed on left parieto-occipital sensors. These findings suggest that the episodic memory for famous faces activated the retrieval of stored semantic information, whereas it was based on items' perceptual features for unknown faces. Overall, our results show that semantic information interfered markedly with episodic memory processes and suggested that the neural substrates of these two memory systems overlap.

Episodic memory false recognition for familiar information in Alzheimer's disease.

Patients with Alzheimer's disease (AD) suffer from various types of memory distortions. We showed that confabulations are plausible memories, mainly reflecting the recall of repeated personal events mistakenly considered by confabulating patients as specific and unique events. The aim of this study is to see whether the notion that over-learned information interferes in episodic memory recall, as it does in confabulation, can be extended to another type of memory distortion, namely false recognition (i.e., a claim to recognize something that was not encountered previously). If this is the case, it should be expected that in an episodic recognition memory task AD patients produce more false recognition for well known non-studied, non to-be-remembered material than for unknown non-studied, non to-be-remembered material. In order to verify this prediction, AD patients and normal controls (NC) were administered two experiments. In Experiment 1, we presented pictures, of which half were supposed to be well known and the other half unknown monuments. For each picture, participants were asked to say whether or not the monument was known or not to them. Immediately following this semantic encoding task, participants were administered an episodic recognition memory task in which, in the same way as in the previous phase, among the non-studied items, half were supposed to be well known and the other half unknown. In Experiment 2 the same procedure was used employing well known and unknown symbols. It was predicted that AD patients make more false recognitions for non-studied well-known items than for non-studied unknown items. The results show that this is actually the case, suggesting that confusion between "uniqueness," i.e., specific unique events, and "multiplicity," i.e., repeated events, is also involved in false recognition.

Confabulation in Alzheimer's disease and amnesia: a qualitative account and a new taxonomy.

Clinical and experimental observation have shown that patients who confabulate, especially but not exclusively when provoked by specific questions, retrieve personal habits, repeated events or over-learned information and mistake them for actually experienced, specific, unique events. Accordingly, the aim of this study is to characterize and quantify the relative contribution of this type of confabulation, which we refer to as Habits Confabulation (HC), to confabulations produced by 10 mild Alzheimer's disease (AD) patients and 8 confabulating amnesics (CA) of various etiologies. On the Confabulation Battery (Dalla Barba, 1993a, Dalla Barba & Decaix, 2009), a set of questions involving the retrieval of various kinds of semantic and episodic information, patients produced a total of 424 confabulation. HC accounted for 42% and 62% of confabulations in AD patients and CA, respectively. This result indicates that, regardless the clinical diagnosis, the brain pathology or their lesion's site, confabulation largely reflects the individuals' tendency to consider habits, routines, and over-learned information as unique episodes. These results are discussed in the framework of the Memory Consciousness and Temporality Theory (Dalla Barba, 2002).

Confabulation in Alzheimer's disease: poor encoding and retrieval of over-learned information.

Patients who confabulate retrieve personal habits, repeated events or over-learned information and mistake them for actually experienced, specific unique events. Although some hypotheses favour a disruption of frontal/executive functions operating at retrieval, the respective involvement of encoding and retrieval processes in confabulation is still controversial. The present study sought to investigate experimentally the involvement of encoding and retrieval processes and the interference of over-learned information in the confabulation of Alzheimer's disease patients. Twenty Alzheimer's disease patients and 20 normal controls encoded and retrieved unknown stories, well-known fairy tales (e.g. Snow White) and modified well-known fairy tales (e.g. Little Red Riding Hood is not eaten by the wolf) under three experimental conditions: (i) full attention at encoding and at retrieval; (ii) divided attention at encoding (i.e. performing an attention demanding secondary task) and full attention at retrieval; (iii) full attention at encoding and divided attention at retrieval. We found that confabulations in Alzheimer's disease patients were more frequent for the modified well-known fairy tales and when encoding was weakened by a concurrent secondary task (61%), compared with the other types of stories and experimental conditions. Confabulations in the modified fairy tales always consisted of elements of the original version of the fairy tale (e.g. Little Red Riding Hood is eaten by the wolf). This is the first experimental evidence showing that poor encoding and over-learned information are involved in confabulation in Alzheimer's disease.

Temporal consciousness and confabulation: is the medial temporal lobe "temporal"?

Since the early descriptions of this phenomenon, there is a large consensus on the distinction between two forms of confabulation. Provoked confabulations are plausible minor memory distortions in response to direct questioning, whereas spontaneous confabulations are unprovoked, often implausible, memories. However, as we show with the analysis of 284 provoked and 52 spontaneous confabulations produced by eight patients with confabulatory syndromes of different aetiologies, the provoked/spontaneous distinction fails to capture the quality of the great majority of confabulations that clearly do not fall in either of the two poles of the distinction. In this study, the majority of provoked (52%) and spontaneous (73%) confabulations consisted of what we refer to as "general memories, habits, and misplacements", i.e., either true episodes misplaced in time and place, or personal habits and routines which are considered by the patient as specific personal episodes. These observations are discussed within the framework of the Memory, Consciousness, and Temporality Theory. According to this theory, confabulation reflects an abnormal functioning of temporal consciousness (TC). The integrity of the medial temporal lobe (MTL) and related structures is crucial for the normal functioning of TC. Data from the literature show that what confabulators have in common is not a specific lesion site but rather the integrity of the MTL, which is consistent with the idea that the MTL is essential for the function of normal and confabulatory TC. In this sense the MTL is "temporal", because its integrity allows individuals to be consciously aware of a personal past, present and future. A better understanding of TC, including its neurobiological correlates, will help to better understand confabulation avoiding theoretically untenable and experimentally undemonstrated explanatory idols like memory traces and unconscious monitoring.

"Do you remember what you did on March 13, 1985?" A case study of confabulatory hypermnesia.

We report on a patient, LM, with a Korsakoff's syndrome who showed the unusual tendency to consistently provide a confabulatory answer to episodic memory questions for which the predicted and most frequently observed response in normal subjects and in confabulators is "I don't know". LM's pattern of confabulation, which we refer to as confabulatory hypermnesia, cannot be traced back to any more basic and specific cognitive deficit and is not associated with any particularly unusual pattern of brain damage. Making reference to the Memory, Consciousness and Temporality Theory - MCTT (Dalla Barba, 2002), we propose that LM shows an expanded Temporal Consciousness - TC, which overflows the limits of time ("Do you remember what you did on March 13, 1985?") and of details ("Do you remember what you were wearing on the first day of summer in 1979?") that are usually respected in normal subjects and in confabulating patients.

Which Episodic Memory Performance is Associated with Alzheimer's Disease Biomarkers in Elderly Cognitive Complainers? Evidence from a Longitudinal Observational Study with Four Episodic Memory Tests (Insight-PreAD).

BACKGROUND: Alzheimer's disease (AD) pathology is found in the brain years before symptoms are usually detected. An episodic memory (EM) decline is considered to be the specific cognitive sign indicating a transition from the preclinical to the prodromal stage of AD. However, there is still no consensus on the most sensitive tool to detect it. OBJECTIVE: The goal of our study was to determine which EM measures, among three clinically used EM tests and one research EM test, would be optimal to use for detection of early decline in elderly cognitive complainers. METHODS: 318 healthy elderly participants with subjective cognitive complaint were followed for two years. We applied generalized linear mixed models to investigate the effect of baseline brain amyloid and metabolism on the longitudinal evolution of four EM tests. RESULTS: Our findings show that participants performed significantly worse in two out of four EM tests (i.e., the Memory Binding Test and the Delayed Matched Sample test 48 items) as their level of brain amyloid load increased. However, we did not find an association between EM measures and brain metabolism. An interaction of the two biomarkers was associated with the number of intrusions in the Memory Binding Test over two years. CONCLUSION: As most clinical trials in AD are now including patients at its early clinical stage, the precise delineation of the transition phase between the preclinical and prodromal stages of the disease is of crucial importance. Our study indicates that challenging EM tests and intrusions are valuable tools to identify this critical transition.

Intrusions in story recall: when over-learned information interferes with episodic memory recall. Evidence from Alzheimer's disease.

Patients with Alzheimer's disease (AD) suffer from distortions of memory. Among such distortions, intrusions in memory tests are frequently observed. In this study we describe the performance of a group of mild AD patients and a group of normal controls on the recall of three different types of stories: a previously unknown story, a well-known fairy-tale (Cinderella), and a modified well-known fairy-tale (Little Red Riding Hood is not eaten by the wolf). The aim of our study was to test the hypothesis that in patients who tend to produce intrusions, over-learned information interferes with episodic recall, i.e., the retrieval of specific, unique past episodes. AD patients produced significantly more intrusions in the recall of the modified fairy-tale compared to the recall of the two other stories. Intrusions in the recall of the modified fairy-tale always consisted of elements of the original version of the story. We suggest that in AD patients intrusions may be traced back to the interference of strongly represented, over-learned information in episodic memory recall.

A longitudinal study of confabulation.

Confabulation, the production of statements and actions that are unintentionally incongruous to the subject's history, background, present and future situation, is a rather infrequent disorder, observed in several conditions affecting the nervous system. Little is known about the quantitative and qualitative evolution of confabulation in time. In this study we evaluated longitudinally the evolution of this disorder in a group of severe confabulators, using the Confabulation Battery (CB), a sensitive tool to detect confabulations in various memory domains. It was found that confabulations were stable over time and not temporally limited. It was also found that "Habits Confabulations" (HCs), i.e., habits and repeated personal events mistaken as specific, unique past and future personal episodes, or well-known public events when semantic knowledge is concerned, was the more frequently observed type of confabulation. Confabulations were also more prominent in the domain of Temporal Consciousness (TC), i.e., a specific form of consciousness that allows individuals to remember their personal past, to be oriented in their present world and to predict their personal future, than in Knowing Consciousness (KC), i.e., a specific form of consciousness allowing individuals to be aware of past, present and future impersonal knowledge and information. Confabulations showed also persistence, i.e., confabulations at the same questions over time, and consistency, i.e., same type of confabulation at the same question over time. These findings are discussed within the framework of the Memory, Consciousness and Temporality Theory.

Diffusion tensor imaging in early Alzheimer's disease.

Our aim was to investigate the extent of white matter tissue damage in patients with early Alzheimer disease (AD) using diffusion tensor magnetic resonance imaging (DTI). Although AD pathology mainly affects cortical grey matter, previous magnetic resonance imaging (MRI) studies showed that changes also exist in the white matter (WM). However, the nature of AD-associated WM damage is still unclear. Conventional and DTI examinations (b=1000 s/mm(2), 25 directions) were obtained from 12 patients with early AD (Mini Mental State Examination [MMSE] score=27, Grober and Buschke test score=33.2, digit span score=5.6) and 12 sex- and age-matched volunteers. The right and left mean diffusivity (MD) and fractional anisotropy (FA) of several WM regions were pooled in each patient and control, and compared between the two groups. Volumes of the whole brain and degree of atrophy of the temporal lobe were compared between the two groups. In AD, MD was increased in the splenium of the corpus callosum and in the WM in the frontal and parietal lobes. FA was bilaterally decreased in the WM of the temporal lobe, the frontal lobe and the splenium compared with corresponding regions in controls. Values in other areas (occipital area, superior temporal area, cingulum, internal capsule, and genu of the corpus callosum) were not different between patients and controls. No correlations were found between the MMSE score and the anisotropy indices. Findings of DTI reveal abnormalities in the frontal and temporal WM in early AD patients. These changes are compatible with early temporal-to-frontal disconnections.

Recovery from confabulation after normotensive hydrocephalus shunting.

Confabulation, the production of statements and actions that are unintentionally incongruous to the subject's history, background, present and future situation, is observed in several conditions affecting the nervous system, but it has never been described in normotensive hydrocephalus. In this article we report on a patient with normotensive hydrocephalus who suffered from an amnesic-confabulatory syndrome. After hydrocephalus shunting, both amnesia and confabulation cleared up abruptly. We discuss this finding in terms of a possible disconnection of the hippocampus, due to transitory white matter damage, which may have recovered after hydrocephalus shunting.

A neurophenomenological model for the role of the hippocampus in temporal consciousness. Evidence from confabulation.

Confabulation, the production of statements or actions that are unintentionally incongruous to the subject's history, background, present and future situation, is a rather infrequent disorder with different aetiologies and anatomical lesions. Although they may differ in many ways, confabulations show major similarities. Their content, with some minor exceptions, is plausible and therefore indistinguishable from true memories, unless one is familiar with the patient's history, background, present and future situation. They extend through the whole individuals' temporality, including their past, present and future. Accordingly, we have proposed that rather than a mere memory disorder; confabulation reflects a distortion of Temporal Consciousness (TC), i.e., a specific form of consciousness that allows individuals to locate objects and events according to their subjective temporality. Another feature that confabulators share is that, regardless of their lesion's location, they all have a relatively preserved hippocampus (Hip), at least unilaterally. In this article, we review data showing differences and similarities among forms of confabulation. We then describe a model showing that the hippocampus is crucial both for the normal functioning of TC and as the generator of confabulations, and that different types of confabulation can be traced back to a distortion of TC resulting from damage or disconnection of brain areas directly or indirectly connected to the hippocampus. We conclude by comparing our model with other models of memory and confabulation.

For a Cognitive Model of Subjective Memory Awareness.

The clinical challenge in subjective memory decline (SMD) is to identify which individuals will present memory deficits. Since its early description from Babinsky, who coined the term 'anosognosia' (i.e., the lack of awareness of deficit), the awareness of cognitive impairment is crucial in clinical neuropsychology. We propose a cognitive model in which SMD and anosognosia can be considered two opposite forms of distorted awareness of cognitive performance and can be accounted for within a model in which consciousness of memory performance can vary in a continuum from normal awareness of performance (preserved or impaired) to anosognosia through a disorder of consciousness related to SMD that we call "cognitive dysgnosia", i.e., awareness of normal performance as impaired. This model suggests that the neuropsychological assessment of memory performance should always be coupled with a deep evaluation of awareness of the subject's memory profile, which allow to better identify the disorder of consciousness with or without cognitive impairment. In this line, it seems necessary to develop more sensitive neuropsychological tools in order to discriminate, within the SMD, individuals who are likely to develop clinical Alzheimer's disease from those whose memory decline complaint is not associated with an underlying neurodegenerative pathology.

Confabulators mistake multiplicity for uniqueness.

Some patients with organic amnesia show confabulation, the production of statements and actions unintentionally incongruous to the subject's history, present and future situation. It has been shown that confabulators tend to report as unique and specific personal memories, events or actions that belong to their habits and routines (Habits Confabulations). We consider that habits and routines can be characterized by multiplicity, as opposed to uniqueness. This paper examines this phenomenon whereby confabulators mistake multiplicity, i.e., repeated events, for uniqueness, i.e., events that occurred in a unique and specific temporo-spatial context. In order to measure the ability to discriminate unique from repeated events we used four runs of a recognition memory task, in which some items were seen only once at study, whereas others were seen four times. Confabulators, but not non-confabulating amnesiacs (NCA), considered repeated items as unique, thus mistaking multiplicity for uniqueness. This phenomenon has been observed clinically but our study is the first to demonstrate it experimentally. We suggest that a crucial mechanism involved in the production of confabulations is thus the confusion between unique and repeated events.

Confabulation in healthy aging is related to poor encoding and retrieval of over-learned information.

Normal aging is characterized by deficits that cross multiple cognitive domains including episodic memory and attention. Compared to young adults (YA), older adults (OA) not only show reduction in true memories, but also an increase in false memories. In this study we aim to elucidate how the production of confabulation is influenced by encoding and retrieval processes. We hypothesized that in OA, compared to YA, over-learned information interferes with the recall of specific, unique past episodes and this interference should be more prominent when a concurrent task perturbs the encoding of the episodes to be recalled. We tested this hypothesis using an experimental paradigm in which a group of OA and a group of YA had to recall three different types of story: a previously unknown story, a well-known fairy tale (Snow White), and a modified well-known fairy tale (Little Red Riding Hood is not eaten by the wolf), in three different experimental conditions: (1) free encoding and free retrieval; (2) Divided attention (DA) at encoding and free retrieval; and (3) free encoding and DA at retrieval. Results showed that OA produced significantly more confabulations than YA, particularly, in the recall of the modified fairy tale. Moreover, DA at encoding markedly increased the number of confabulations, whereas DA at retrieval had no effect on confabulation. Our findings reveal the implications of two phenomena in the production of confabulation in normal aging: the effect of poor encoding and the interference of strongly represented, over-learned information in episodic memory recall.