Altered Egos: How the Brain Creates the Self, 1st Edition

4

Mything Persons

In Capgras syndrome, patients lose some aspect of the personal; those ego-close aspects of himself or herself are alienated from the self. In the Frégoli patient, the opposite is true: the strange and unfamiliar takes on the warmth of the personal and the related. There is another transformation of the self that I refer to as personal confabulation.1 In personal confabulation, the patient misconstrues an actual event in his or her life or creates a wholly fictitious narrative about life, in which they play the starring role in another identity. The perturbation of the self here is a more subtle form than the flagrant forms of Capgras and Frégoli syndromes, but I believe that as these intricate, confabulatory narratives are appropriately analyzed, their fundamental nature can be seen as structurally similar to other varieties of misidentification.

What Is Confabulation?

The general term “confabulation” refers quite simply to an erroneous yet unintentional false statement. Confabulations occur in a wide variety of neurological and psychiatric disorders. Amnesia, when patients cannot recall some aspect of their past experience, is one of the conditions associated with profound and dramatic confabulations. Confabulation in amnesic patients traditionally has been divided into two types, although there is increasing recognition that these forms overlap. The first type is called momentary confabulation. According to Berlyne, momentary confabulations tend to be brief and are provoked in response to a question that probes the patient's defective memory.2He suggested that momentary confabulations are actual memories displaced in temporal context, and their content is autobiographical and refers to events in the patient's recent past. This type of confabulation is also referred to as “provoked confabulation.”3

Patients who exhibit momentary confabulations may make frequent use of elements in their immediate environment. For example, Stuss and his colleagues described a patient who was being interviewed in an office where there was an ornamental wall map entitled “Cuttyhunk

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Island, Dukes County, Massachusetts.”4 When the patient was asked the standard orientation question about where he was now located, he responded, “Massachusetts.” When probed further, he responded, “Cuttyhunk Island.”

I have examined many patients with this kind of “contamination” in an ongoing narrative. The following example can serve to illustrate this variety of confabulation.

Linda

Linda was a sixty-five-year-old woman who had recently undergone a surgical operation on an aneurysm in her brain. Previously, she had a successful career, but now Linda suffered from serious memory loss. Her primary problem was that she could not form any new memories, a condition called anterograde amnesia. Linda also had a form of memory loss known as retrograde amnesia, the loss of memories that had been formed in the past but that the patient can no longer recall.5 During my clinical rounds, I videotaped an interview with Linda at her bedside in the hospital.

FEINBERG: And why are you here?

LINDA: [Looking around.] We all came down here, they said it was a good idea to come down here. . . to be exposed to. . . the lights, the camera, the action. What it would be like. . . [at this point, a nurse caring for a patient in the next bed, can be overheard to say, “The cardiac monitor stays in place while you're in this room”]. . . what it would be like to ah. . . to get off the monitor, to get off the camera, right? So I said, Fine with me. So that's how it started. Then I went ahead with the thing with the monitor, and they were talking to me and telling me how. . .

FEINBERG: So what's your point of being here?

LINDA: To get off the camera. I'm going to get off this. . . blah. And you know what blah, blah, blah means [laughing]. The camera. . . and blah, blah, blah. . .

In this setting, confabulation seems to serve a “gap-filling” purpose, filling in the aspect of experience that the person cannot recall. The patient is simply trying to fill in lost memories in order to present a coherent sense of their world. In a face-saving effort, these patients seem to fill in their memory performance to appear as intact and socially appropriate individuals, rather than admitting that they simply cannot

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remember what they had for breakfast, where they are, or what they are doing there when questioned by the examiner.

Many authors have stressed the idea that confabulations are real memories displaced in time.6 The patients who confabulate in the presence of substantial memory loss may have difficulty placing their memories in the proper sequence. Past and present memories are blurred, confused, combined, condensed, and placed out of context. These confusions bring past memories to the present and may account for the falsification of memory. For example, Victor, Adams, and Collins described a patient who was examined on a daily basis for months, but who nonetheless claimed that he had seen the examiner only “two or three times before” and “about a week ago the last time.”

According to the patient, the examiner had appeared on the last occasion together with a fat man who wore eyeglasses and they had taken him to a gymnasium, where they talked about “old times.” Also on that occasion one of us allegedly upset a bottle of CocaCola, requiring the services of an attendant, who mopped up the mess. Actually the patient had last seen the examiner alone, on the day before. The fat man with eyeglasses was the physician in charge of the ward and the “gymnasium” was an empty, recently renovated ward. The patient had been taken there by a psychologist and an intelligence test had been performed (the patient was graded “bright-normal”). However, the patient remembered neither the prolonged testing nor the psychologist, who happened to be a thin man. The incident with the Coca-Cola bottle had indeed occurred, but several weeks before at his bedside on the ward during a visit from his wife.7

Momentary confabulations are often consistent with reality and plausible but false. They often involve the patient's occupation or location, which are wrong but not necessarily completely imaginary. Bonhoeffer suggested there was another variety of confabulation that appeared to go beyond the needs of memory impairment.8 These confabulations have the names “fantastic”or “spontaneous” confabulation. Here, the emphasis is on confabulations that are elaborate, long lasting, have a delusional quality, and may be spontaneously offered by patients without the examiners attempting to probe their memories. Indeed, some patients produce narratives for anyone who will listen. Bonhoeffer compared these confabulations to dreams, daydreams, or fantasies, since they often defy reality and tolerate great inconsistency. It is possible that the patient's underlying personality plays a greater role in the production of

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fantastic confabulation. It may also be the case that these confabulations reflect the patient's motivation, affect, and wishes to a greater degree than the momentary variety.

Patients with both varieties of confabulation—momentary and the more fantastic or spontaneous forms—often have impairment in autobiographical memory. Autobiographical memory, according to neuropsychologist Paul Eslinger, is that aspect of memory“composed of the personal facts, events and experiences of a person's life, contributing in significant ways to a sense of identity, personal history, temporal continuity, and relationships to people and places.”9 The majority of patients who confabulate have defects in the domain of autobiographical memory known as episodic memory. Episodic memories are tied to particular moments of one's life, and are memories of things personally experienced. The psychologist Endel Tulving referred to this type of memory as “mental time travel, a sort of reliving of something that happened in the past.”10 Some patients confabulate exclusively to questions that test their autgobiographical episodic knowledge. While we are just beginning to explore the anatomy of autobiographical memory, early indications suggest that the ability to recall specific memories from one's past requires an extensive network of neural connections involving many brain regions. Eslinger suggested that episodic autobiographical memories involve complex interactions between frontal and temporal areas bilaterally.11

Personal Confabulation

Memories of one's life experience are surely important for creating and maintaining the self, but the most interesting and personally meaningful confabulations are those kinds that the patient produces not just because they seem to have forgotten certain events, but because they seem to have a distorted sense of themselves. This is why I have suggested the term personal confabulation to describe these confabulations. The longlasting, elaborate, and fascinating forms of confabulation are those kinds that patients produce about themselves; they are ways of expressing feelings about the self.

Patients who display personal confabulations represent themselves, their personal experiences, and their problems and preoccupations in a story. The story is a narrative of events that ostensibly but not actually have occurred to the patient in the past, or it is an account of the patient's current experiences. The narrative may involve real or fictitious places or persons; it may be rather commonplace, but it is often quite

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fantastic in nature. It often involves the patient's neurological problems, but it may also be about any traumatic event or circumstance of a personal nature. These confabulations can be likened to a personal myth, a story about the self in disguised form.

Weinstein and Kahn recognized these personal aspects of confabulation. I think that Weinstein's position on confabulation can best be elucidated through his analysis of one of his cases.12

Sick Willie

In their classic work, Denial of Illness, E. A. Weinstein and R. L. Kahn described a fifty-three-year-old woman who was admitted to Mount Sinai Hospital. She had lung cancer that had spread to involve the right cerebellar hemisphere. She was confused, drowsy, and incontinent of urine. The patient denied her illness and denied that she had had an operation. She was the mother of twins who at the time were twentysix years old. One was a boy named William, whom she generally called “Bill.” The other was a daughter named Hilda. During the course of her hospitalization, she confabulated that, in addition to her daughter, she had twin sons: Bill, who was her real son, and a fictitious son, “Willie.” She described both Bill and Willie as sergeants in the army; but Bill had returned home on the Queen Mary, while Willie had returned home on the Queen Elizabeth. Both were commercial artists—which was Bill's real occupation—but they differed physically: Bill was taller, heavier, more athletic, and was more popular with the girls than Willie. Weinstein and Kahn emphasized that while the patient denied that she was herself ill and even seemed impervious to the thought of her own illness, she displayed great concern about the health of Willie. She reported that she had not seen him since Christmas, which was the time of the onset of her own illness; and she was concerned because she had heard that he was recuperating from an illness. She continued to express great concern about the missing Willie and insisted that he must really be very sick. She made accusations and complained that nobody would tell her the truth about him.

Weinstein and Kahn analyzed this case and suggested that the delusion of Willie was a vehicle for the expression of the patient's feelings and concerns about herself. This reduplication of her son symbolized some personal concern for the patient. Weinstein believed that the major motivating factor in the production of confabulation and reduplication was the patient's denial of their difficulties. According to Weinstein, these patients were in denial, but their personal problems and concerns would

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appear symbolically and metaphorically transformed in the guise of their confabulations.

In discussing the topic of delusions about children following brain injury, Weinstein, Kahn, and Morris reported that among patients with brain dysfunction the confabulation of an extra or nonexistent child was among the most common fantasies reported.13 They found that patients with no actual children might talk about having one or more children, while a patient who had children might add an extra son or daughter to their family.

Moreover, patients often reported that the phantom child had the same illness or disability as themselves, as demonstrated in the case of the fictitious Willie. That is, in their descriptions of their phantom children, the patients were expressing feelings about themselves. Those patients who talked about children were particularly involved with their families and structured their lives around parent-child roles. Indeed, this structure was most likely the reason that the child formed an apt symbol for the patients. Weinstein and his colleagues suggested that most of the altered behavior can be interpreted as an attempt to form a relatedness and establish a self-concept or social role in terms of the significant symbols of one's experience. In other words, the child was being used as a way of representing the self. This confabulation allowed the patient to restore the self-concept, identity, and social roles in the face of significant brain dysfunction.

The following case exemplifies some of these issues.

Sam

Sam, a man in his sixties, had an aneurysm repaired after suffering severe frontal brain injury that produced anterograde and retrograde amnesia. Sam demonstrated persisting confabulation, and had been in and out of hospitals for years. His illness had created terrible marital problems and unfortunately his wife had left him after his illness. He was the biological father of three children, but he had never adopted any children. Sam denied that he had any significant cognitive or memory impairments. My colleague Dr. Giacino obtained the following interview during a session when the patient's cognitive abilities were being evaluated. Sam spoke of a fictitious adoption that he was arranging with his wife.

SAM: I feel like I've got a little more ability than they give me credit for.

EXAMINER: So one last question: Has this aneurysm or the consequences of this aneurysm changed your life in any way at all?

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SAM: No.

EXAMINER: So basically your life is the way it was before?

SAM: Yeah, like the way it was before. We have another baby. . . we've just adopted, and I have three children of my own. I've got my own house.

EXAMINER: When did you adopt a baby?

SAM: We haven't gotten the final result, but about a month ago.

EXAMINER: They said you could have the baby?

SAM: But the baby has problems now. They're trying to sort out the problems before, you know, somebody really adopts it. . . the baby. They want to make sure it's the right direction.

EXAMINER: Who's actually adopting the baby?

SAM: Me and my wife.

EXAMINER: Have you seen the baby at all?

SAM: Well, we've seen pictures. And I've seen the baby in person, too.

EXAMINER: And where does the baby live now?

SAM: The baby lives with the mother, and I think it's the mother of the boy that was dumped. . . and the mother would like to have the baby. I guess she lost her sons she might as well have the baby. That's a little problem there.

After some discussion, the examiner asked about the child's problems.

EXAMINER: You said before the baby has some problems.

SAM: That's what the psychologists are telling the guy who is in charge of the hospital. You know it's like they say certain things I go along with and certain things I don't go along with. I think there's too much pressure on the kid to really give an honest answer. I don't think a kid who is six or seven years old is capable of giving you the right answer.

EXAMINER: What kind of problems does this child have?

SAM: I don't know. . . to tell you the honest truth, I don't know. I know this kid has been in the hospital off and on for a couple of years, and they kind of rate them as far as progress goes or things like that, [The patient was being rated during the interview.]

EXAMINER: How do they rate them?

SAM: I guess they must rate them when they don't hear the things they want to hear. . . like the kid is not accomplishing anything, which I think is very unfair to basically analyze a kid that way.

Sam's statements about the fictitious child and his planned adoption is a way of expressing concerns over his own illness, his own feeling of desertion, his current situation of being evaluated by the examiners, and

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other personal issues. The striking thing about personal confabulation is that the patient expresses their personal fears and desires yet they have no awareness that they are really talking about themselves.

Weinstein's patients confabulated not only about fictitious children but told stories in the course of their confabulation about other family members, either real or fictitious, as well. For instance, out of a group of mostly male veterans studied at Walter Reed General Hospital, all of whom had sustained head injuries in either car accidents, gunshot wounds, or ruptured aneurysms, many patients confabulated that someone in their family was ill. In most cases, it was a brother who was sick. These authors found that these stories were about an actual—not fictitious—brother, but they made up a story that one of the brothers had been ill or had a fate that corresponded closely to what in actuality had happened to the patient. The brother was said to have been in the same kind of accident and suffered similar injuries as the patient; in several instances, the brothers died.14

An excellent instance of this sort of self-referential confabulation was provided in a case described by Baddeley and Wilson.15 Their patient, referred to as RJ, was a civil engineer working as a publicity manager when, at the age of forty-two, he was involved in a serious car accident. He sustained a serious head injury with intracranial hemorrhages involving both of his frontal lobes and was admitted to Rivermeed Rehabilitation Center in Oxford. Since the patient was unconscious for many days after his car accident, they concluded that he had no genuine memory of the accident. When the patient told the story of what had happened to him, he trivialized the seriousness of the accident. Although he was nearly killed in this accident, was unconscious, and was taken immediately to the hospital, he confabulated that immediately after the accident, he told the person whose car he hit, “I'm sorry, Mate,” and, “Don't worry about it, it was as much my fault as yours.” Despite the seriousness of his condition, his current hospitalization, and all that had transpired after this accident, RJ claimed that the hospital staff told him “there's nothing wrong with you, you'd better bugger off home.” RJ had a real brother, Martin, an adult still in communication with the patient. However, RJ confabulated that he had two brothers, both named Martin, but one Martin had been killed in a car accident. He said his mother thought it was “a bit sort of morbid” that there were two Martins, but nonetheless “that's the way the situation was.”

These confabulations represent an astonishing repeating pattern found all over the world. Weinstein, Kahn, and Malitz reported a twenty-year-old

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hospital corpsman, in Walter Reed Hospital in June 1952, who was involved in an automobile accident and sustained a severe head injury.16

He reported that he had been killed in Korea and that his body had returned that morning, and later he stated that his brother had been killed and that his body was in a casket under his bed.

Linda, described above, also demonstrated the tendency to multiply or reduplicate other family members.

Linda

I have briefly described Linda at the beginning of this chapter. Linda is the sixty-five-year-old woman who confabulated about“the lights, the camera, the action.” Linda had a ruptured anterior cerebral artery aneurysm that caused bilateral frontal lobe hemorrhages (Figure 4-1).

Linda displayed poor insight into her surgery and illnesses. Initially, she denied any surgery or illness entirely. Later, she told us that she was visiting her niece who had an “aneurysm of the brain.” She also said she had an aunt who was in the hospital because “she couldn't think straight” due to an aneurysm. Although the patient did indeed have a niece and aunt, neither was in any way ill.

The following dialogue took place on a subsequent interview.

FEINBERG: OK, anyone else here you know?

LINDA: Yes, a couple of more cousins.

FEINBERG: A couple of more cousins? They're all in this hospital?

LINDA: Yeah.

 

Figure 41. Linda had an anterior cerebral artery aneurysm that burst. Her MRI revealed extensive damage to both frontal lobes of her brain. The dark areas on the figure represent blood from the hemorrhage, the cross-hatched areas show the regions of swelling or infarction that occurred around the hemorrhage. As a result of this extensive damage, Linda had memory impairment and personal confabulation.

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FEINBERG: Are they really?

LINDA: Yeah.

FEINBERG: Have you seen them since you've been here?

LINDA: Yeah.

FEINBERG: What are they here for?

LINDA: The same thing that I'm here for.

FEINBERG: Which is?

LINDA: Aneurysms, on top of their heads.

FEINBERG: So, you have multiple cousins here?

LINDA: For the same thing.

FEINBERG: All have. . .

LINDA: For the same reason. . . aneurysms on top of their heads.

FEINBERG: How many?

LINDA: Six.

FEINBERG: Six of them, and they all have aneurysms?

LINDA: Yeah.

I told this patient a story that is usually employed to test memory but can also be used to assess a patient's degree of confabulation, denial, awareness, and tendency to project oneself into narratives. The story is adapted from an old folk legend and appears in many different cultures in various forms. We call it “The King Story.”17

FEINBERG: I'm going to tell you a story, and I want you to tell it back to me as best you can. Once there was a king who was very ill and his doctors couldn't cure him. But his Wisemen told him, Oh King! You will be well, if you would wear the shirt of a happy man. So the King sent his messengers all over the kingdom, and they found a happy man, but he didn't own a shirt. Now you tell the story to me.

LINDA: There was a King who. . . had an aneurysm or something on his head [at this point the patient lifted her left hand on top of her head feeling her own surgical scar]. He could be cured forever if he found a man with a happy shirt. He went all over. The man with a happy shirt did not have a happy shirt. So, nothing was done. He never had an operation. There was no. . . nothing done for this unhappy man, and nothing was done for him! So, he was hanging around the hospital unhappy.

FEINBERG: So, how do you feel about what's going on?

LINDA: I feel that if I'm so unhappy, I should get an operation and be happy.

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Linda tended to minimize her own illness but spoke about multiple “others” with illnesses identical to her own. She did this in the context of a personal confabulation, where the boundaries of the patient are distorted and her own concerns are metaphorically represented in her narrative.

Some characters appearing in self-referential confabulations are quite fanciful and fantastic, as in the following patient.

Walter

I examined a fifty-five-year-old alcoholic man admitted to the psychiatric service for agitated behavior. He had fallen on hard times and was living in a one-flight, walk-up, single-occupancy hotel room. He apparently had been drinking quite heavily. His neighbors called 911 and had an ambulance take him to the hospital for confusion, agitation, and bizarre behavior. On admission, he was in alcohol withdrawal. Upon recovery, he recounted the reason for his admission as follows.

FEINBERG: So, sir, tell me what brought you to the hospital? What was the problem?

WALTER: I thought that some creatures had invaded my apartment. I was unable to get them out, and they would have just a strange look on their face, somewhat cynical. . . not laughing, smiling. They seemed to enjoy making a fool out of me.

FEINBERG: Tell me more.

WALTER: I tried to get rid of them by changing the locks. I changed the locks twice. . . and uh. . . I tried to kick them out but invariably they seemed to get back in. They were taking little things. . .uh. . . the remote control from the television.

FEINBERG: They would take them?

WALTER: Yeah, yeah. It would disappear. . . when it first started, I thought they sort of existed because I had things taken. How could they be taken by someone who didn't exist?

FEINBERG: Where did you think they came from when you first saw them?

WALTER: I never thought of where they came from. Once I got so angry, I lifted them up. . . this was a male one, and I threw him outside. . . and this was in January when it all first started, and I put him out on a very, very cold day on the front steps of the building.

FEINBERG: One of these creatures?

WALTER: And I put a little pair of shoes beside him, and I put clothes over

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him. And then someone must have called in that I was being cruel to animals and swiftly the ambulance came and picked him up. I don't know what they ever did with it. Yeah, but you know if it was a live being, it was a cruel thing to do, but I did it. . .and I felt ashamed. The temperature was extremely low; but I was just trying to get him out of my apartment, and I was desperate! I had his clothes and a little pair of shoes and I had set them on the steps in the front of the building. It was the only time I tried to kill one.

FEINBERG: How big were the shoes?

WALTER: Well, I think they were my shoes. They were very old. They were discarded shoes as I remember. They never put them on. . .I set out a pair of shoes and a pair of short pants.

Walter's story about the little creatures served many purposes. For one thing, it helped him explain his memory loss and lost items, producing an explanation for where his personal possessions were disappearing. It also served as a representation of his personal problems. When I consulted the residents caring for this man, they informed me that he had been found disheveled outside his apartment house from which he had been ejected on a cold night in the dead of the winter. He had to be taken by ambulance to the hospital. The story of his hospitalization closely parallels the story, which he doesn't consciously recall.

These confabulations, many of them in the form of reduplicated relatives, can be meaningfully interpreted as experiences of the self that are expressed in symbolic form. In other words, the experience of the patient is transformed into an experience of a real but duplicated spouse or family member or a fictitious entity on which the patient's own experiences or feelings are projected. Weinstein and his colleagues emphasized that one could view these narratives as metaphorical expressions of the patient's own feelings. They suggested that the fiction is a personification, reification, or metaphor for the patient's feeling particularly about himself, his difficulties, problems, concerns, fears, as well as motivations.18

Under the conditions of stress and disorganization, anomie, alienation, estrangement, and depersonalization caused by the catastrophic situation of brain dysfunction, the narrative produced by a confabulation as an explanation for the current situation takes on a greater reality than the actual circumstances in which the patients find themselves. Viewed in this way, the transformation of the self in these circumstances may be in some way an adaptation to severely disturbed brain function.

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Explaining Personal Confabulation

In chapter 3, I suggested that the Capgras-Frégoli dichotomy can serve as a unifying principle that can help us understand many of the neurological perturbations of the self. According to this principle, asomatognosia and the Capgras syndrome are interpreted as thewithdrawal of personal relatedness and environmental reduplication and Frégoli syndrome represent the insertion of personal relatedness. I believe this pattern of withdrawal and insertion of personal relatedness can aid our understanding of patients with personal confabulation. Consider the patient who confabulated about her missing son, Willie. This patient has lost the personal relatedness to her own experience. This may be due to many factors, including memory loss, confusion, and even the fact that some of the circumstances of the patient's illness may not have been revealed to her. This led the patient to disavow her own experience, to feel estranged from the events of her life. Through the vehicle of the fictitious Willie, as Weinstein suggested, the patient was able to reestablish relatedness to her own experience in a fashion that made sense to her. In this way, Willie represents those aspects of her experience that she had disavowed.

The same is true for the patient who confabulated that there were two Martins. This patient has lost his normal relationship to the traumatic events of his car accident, his subsequent hospitalization, his rehabilitation, and his injuries. He then confabulates a fictitious Martin to substitute for himself, in effect saying, “It doesn't feel like it happened to me, it feels like it happened to him.” My patient with all the relatives who had aneurysms told me, “I don't feel like I had an operation to save my life. . .I feel like I had an operation to save someone else's life!”

This pattern of deletion and insertion of personal relatedness for events of the self is repeated over and over in the cases with disorders of the self. The patient who confabulated about the “little creatures” being taken away in an ambulance has seemingly lost the memory for his own experience. Yet, at the same time, many of the elements of his own experience appear in the confabulation about the little man being taking to the hospital. Again, the experience attributed to the fictitious entity is representative of his own experience.

Perhaps the patient who confabulated about the adopted child is the most poignant of these. This patient—after repeated hospitalizations, loss of his livelihood, destruction of his life, and estrangement of his wife—confabulates an adopted child, whom he wishes to take care of, wishes to

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nurture, hopes will recover, complains he must defend, whom he feels that the examiners are too hard on, too judgmental, and too critical. The patient's feelings about himself are represented in the confabulation about this child. As Weinstein argued, these confabulations provide a greater sense of identity, a greater sense of stability, and feel more real than the actual events themselves.19 They are therapeutic, and help to restore a sense of identity and create a sense of belonging in the world that might otherwise be incomprehensible.

The elements that appear in these confabulatory narratives overwhelmingly involve things that people care about—brothers and sisters, spouses and children, jobs and homes. They reveal the structure of each individual's nexus of relationships and concerns—in short, their identities. They reveal how, in the fantasy of these patients’ confabulations, the self can be represented by an elf or a soon-to-be adopted child.

There is a dream-like quality to these productions. One often gets the feeling that the disturbance in consciousness that these patients demonstrate has permitted a “waking dream,” a personal myth, allowing the symbolic nature of the unconscious to speak to us directly, without the normal self-monitoring that most patients display when interviewed. It is perhaps this quality that makes these narratives in some respects so myth-like.

Personal Confabulation and the Anatomy of the Self

The area of the brain that is most often damaged in patients with fantastic and spontaneous confabulation is the frontal lobes. Stuss and coworkers described a series of cases with “extraordinary” confabulations of the fantastical variety.20 One patient claimed he injured his head during a rescue attempt to save his child, who was drowning. Another patient, when asked about his surgical scar, told how during World War II “he surprised a teenage girl who shot him three times in the head, killing him, but that surgery had brought him back to life.” The same patient “when asked about his family, he had at various times described how they had died in his arms, or been killed before his eyes, or would relate in lurid detail his sexual experiences with his daughters.” The first patient had damage to both frontal and temporal lobes; the second had a large right frontal infarct.

Kapur and Coughlan described a patient with frontal lobe damage as demonstrated by CAT scan.21 This patient initially displayed both fantastic and momentary confabulation, and on formal neuropsychological tests showed evidence for pronounced impairment of frontal lobe functioning

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and amnesia. Months later, the patient's confabulations decreased, and he produced only momentary confabulations comprised of memories of actual events placed in the wrong temporal order or inaccurate spatial context. Upon retesting, it was found that while the patient still had memory impairment, he no longer had the impairment in frontal lobe functioning that was present during the period of spontaneous confabulation.

Further evidence for the relationship between fantastic confabulation and frontal lobe damage came from Fischer and coworkers, who examined nine patients with ruptured anterior cerebral artery aneurysms and confabulation.22 All five cases that displayed“spontaneous” confabulation had severe amnesia and showed evidence of frontal impairment on neuropsychological testing and brain imaging. In contrast, four cases with momentary confabulation also had severe amnesia, but did not demonstrate the degree of frontal impairment shown by the spontaneous confabulators. Finally, DeLuca and Cicerone have provided evidence in that frontal lobe impairment plays a central role in the production of confabulation.23

Frontal lobe dysfunction has a complex and multifactorial influence on confabulation. It is well known that the frontal lobes play an important role in self-regulation and self-monitoring. Stuss and coworkers suggested that as a result of frontal lobe impairment, these patients may not be able to inhibit their responses, which could facilitate the impulsive verbal behaviors seen in confabulation.24Additionally, a disturbance in self-regulation and self-awareness caused by a frontal lobe lesion could lead to a failure to monitor behavior and a lack of concern regarding incorrect performance, both of which could contribute to confabulation.25

Many patients with personal confabulation have damage to their frontal lobes. Both Sam, who created the story about the adopted child, and Linda who had all the fictitious cousins, had significant frontal lobe damage, particularly on the right side. RJ, the patient of Baddeley and Wilson, also had bilateral frontal lesions. Many of the “extraordinary” confabulations described by Stuss and coworkers qualify as personal confabulations. The frequent occurrence of frontal lobe damage in patients with personal confabulation suggests that the manner in which the self is perturbed in these patients, and the manner in which the ego is altered in personal confabulation, is due in part to impaired functioning of the frontal lobes. The frontal lobes must also be important in the normal functioning of the ego boundaries and the self.

Although many patients with frontal lobe damage have significant perturbations of the self, this finding does not mean that the self is

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“contained” in the frontal lobes or that the frontal lobes “create” the self. We could not remove the self of a person if we removed their frontal lobes. We have already seen that damage to several other brain areas can perturb the self, and to this list we will add other regions important to the creation and maintenance of the self. For example, it should be apparent from the cases we have considered that the braindamaged person may employ language as one way to preserve the integrity of the self. Language facilitates a patient's ability to explain the catastrophic event to oneself and others. One example of this is the patient with asomatognosia. Although estranged from the limb, the patient may give the arm a name, or claim it belongs to a loved one. These verbal behaviors may help the patient sustain a relationship to the body part.

Patients with personal confabulation provide other examples of the manner in which language may sustain the self in the presence of brain damage. These patients with frontal damage create verbal narratives that provide coherence to the strange and disturbing circumstances of their present situation. In these particular conditions, we witness the role of language and dominant, usually left hemisphere functioning, in the maintenance of the self.

Michael Gazzaniga believes that language plays a key role in the creation of the self and consciousness. In his book The Social BrainGazzaniga presents the view that the verbal left hemisphere is the final arbiter of individual consciousness.26 According to Gazzaniga's account, different parts of the brain, called brain “modules,” are able to perform discreet functions. For instance, some modules might be important for memory functions, other modules are involved with emotional functioning, and still others are involved with performing computations. Sometimes these modules influence our behavior in ways that are outside of our conscious awareness. When this occurs, it is the job of what Gazzaniga calls the “interpreteter” module, located in the language dominant hemisphere, to provide a rationale for the behavior.

Gazzaniga gives the example of someone who suddenly develops the urge to eat frog's legs. The impulse to consume this unusual item seems to come out of nowhere, and the “interpreter” does not actually know why this craving has occurred. Nonetheless, the interpreter module constructs a theory for the behavior. In this case, the interpreter might hypothesize the urge to consume frog's legs developed “because I want to learn about French food.” According to Gazzaniga, it is the dynamics between the language-mediated interpreter module and the other modules of the brain that create our beliefs about ourselves.

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Many areas of the brain make a contribution to the self. It appears that the problem is not in deciding where in the brain the self is: Rather, the question is, if the self, the ego, is widely distributed across the brain, how is it possible for a single self to exist? This problem needs to be addressed if we are to understand how the brain creates a unified person, the “I.”



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