spring/summer 2006, no. 7



Neural Cartography and Confabulation


by Zachary P. Norwood




A review of Brain Fiction: Self-Deception and the Riddle of Confabulation by William Hirstein; MIT Press, 2005.



Imagine that your uncle suffers a stroke, resulting in severe brain damage. Alarmed, you visit the hospital to check on his status. "Are you all right?" you ask. "I've never been better, why?" he answers, unexpectedly. "Because you've suffered a terrible stroke, and I'm worried about you." "Nonsense! Why would you say such a thing? I had a mild blackout, that's all. Nothing's the matter with me."


You are more than a little puzzled by this response, since the doctor briefed you on the seriousness of his condition: not only has he lost all function of his left arm, the doctor said, but he has become mildly amnesic, forgetting previous visitations from family members and vaguely recollecting details from prior conversations.


You decide to press further: "Uncle, the doctor told me you can't move your left arm. Are you saying this isn't so?" "What?! He's a quack! Don't listen to him — my arm is fine!" he exclaims, with animated gesticulation of his right arm. The conspicuous immobility of his left arm does not go unnoticed, and for a moment you feel as if you've been caught up in a Monty Python skit. Regaining composure, you make a final, decisive inquiry: "show me you can move your left arm, uncle." "I would, but I'm a bit tired right now," he responds. Then, after a brief pause, something quite unexpected happens: with dilated pupils and radical alteration of countenance, your uncle shouts, somewhat startled, "Where did you come from?! Why'd you sneak up on me like that?"


You're dumbfounded. You don't know what to say. And who would, confronted with such an adventitious affirmation of our dependency on smooth neural functioning? You decide to hedge your bets and bow out with a terse goodbye, saving anymore pain and humiliation. You tell yourself you'll come back later; then perhaps his brain will have healed, and he will once again be the man you remember, your dear uncle.


As illustrated by this hypothetical scenario, neurological damage can produce disastrous side effects. Anyone who has witnessed a loved one transformed by a neural malady, such as a mood disorder or age-induced dementia, is rudely awakened to the unsettling reality that behind every perception is an immensely complex neural apparatus — the brain — and that this mass of neurons is ultimately responsible for constructing a stable world-image out of otherwise incomprehensible visual stimuli. Sound mental functioning, we learn, is the precursor to all experience, big and small, and with the slightest neural disturbance, the world becomes warped. If the brain operates without a hitch, we see the world as a coherent whole, and if not, consciousness is fractured.


One way to think of the brain in relation to reality detection is to think of our ideas and remembrances of things past as mental representations, or memory traces left behind by sense impressions. Distinguishing between mental representation and reality makes the whole process of weighing the differences and relationships between the two more intuitive. If you are startled by a bear in the woods, for example, certain variations of stimuli may alter the outcome of representation; if you are alone and the bear is a grisly, your brain will soak up every nuance of the encounter, calculating unconsciously all the possible reactive possibilities; but if you are with a large group of fellow travelers and spot a small black bear at a distance, you will likely look on with anxious, excited curiosity, not uncontrollable fear.


The bear in the woods is an example of external differences that may alter representation, but there are several internal influences as well: personality differences, such as introversion and extraversion; mood differences, like dysthymia and euthymia; and acquired or genetically predisposed neurological differences, such as brain damage, schizophrenia, and Alzheimer’s disease, all of which are examples of modulating factors that impinge on the verity or signification of remembrance.


With all this in mind, I looked forward to reading William Hirstein’s new book, Brain Fiction. Its primary subject, after all, deals with a rare clinical condition termed confabulation, which can be loosely defined as unintentional, severe misrepresentation of past or present beliefs, combined with both an apparent lack of awareness of the misrepresentation and an unwillingness to accept its potential falsity. There are a number of different instances of this condition, such as provoked versus spontaneous confabulation, which simply means confabulating in response to a question (provoked) or not (spontaneous), but on the whole, Hirstein focuses on the provoked variety, which is more common and less severe.

The bulk of Hirstein’s book is more or less a review of neuroscientific research directly or peripherally related to provoked confabulation, all of which leads to a speculative, tentative dénouement: an attempted operational definition of confabulation, grandly illustrated with the p’s and r’s of informal logic, which fleck the pages like an unfinished Jackson Pollack. While apparently necessary for Hirstein’s grand finale, the exhaustive review of neural anatomy conjures up images of a blind Sherlock Holmes trying to figure out how a Rube Goldberg machine works, though not by direct tactile sensation, but rather by reading descriptions of its inner workings in Braille. Chapters fly by, and you realize you’ve only learned that X brain area correlates with Y symptom, which may or may not elucidate the nature of confabulation. Hirstein’s seemingly never-ending review becomes all the more tiresome if you’ve already been introduced to the brain and its various functions, such as through the popular works of Damasio or Pinker — given the audience of Hirstein’s book, this will likely be the case.

Returning to the topic of confabulation, Hirstein outlines two primary components found in all cases of provoked confabulation. The first deals with the executive, “self-monitoring” function of the prefrontal cortex, and the second with disruption of neural anatomy subsuming memory functions, or as Hirstein likes to call them, equivocally, “knowledge domains.” When these two systems are conjointly damaged, confabulation occurs, yet when independently damaged, only various symptoms of confabulation are observed, and not the full blown, clinical syndrome.

In relation to the executive, prefrontal system, Hirstein raises several valuable insights, such as the innate interdependence of emotion and memory (or “epistemic” content, as he calls it). “In the view I propose,” writes Hirstein, rather confusedly, “confabulating is a behavior that results from disinhibition just as much as the behavior of disinhibited patients who make socially inappropriate remarks” (102). In other words, if one’s emotional centers are disengaged from mental representation of past or present beliefs, they will fail to receive any inhibitory feedback when misrepresenting those beliefs, and consequently they will fail to “self-monitor” their perceptions. Anyone who has come across the case of Phineas Gage — that is, most second-year college students, or everyone who gets past Chapter 4 — will immediately think “prefrontal cortex” when reading Hirstein’s discussion of disinhibition, and low and behold, he makes the predictable connection: executive processing appears dependent on a small region in the frontal lobe called the orbital frontal cortex (OFC). The OFC is also connected with areas in the midbrain, such as the amygdal and hippocampal areas, that seem to modulate memory formation and distribution, which is why, according to Hirstein, certain symptoms of confabulation may be observed when these areas are damaged independently. Given the bidirectional projections from the OFC, amygdala, and hippocampus, it makes sense to implicate all of these as potential candidates for producing confabulatory symptoms.


Beyond the elaborate, neuroanatomical details of the emotion‑memory interface, I believe Hirstein misses several opportunities to explore the nuances of everyday problems associated with representation, such as how the mind unconsciously evaluates stimuli held in short-term memory using what Damasio calls “primary emotions,” which are directly related to Hirstein’s discussions of disinhibition. Unfortunately, Hirstein only mentions Damasio and related scholars, such as Rolls, in passing, as if he were overeager to move on to his own choice of descriptive terminology.

In one section, however, Hirstein delivers on his promise to elaborate on the non-clinical components of confabulation. He suggests in the conclusion of Chapter 4, again all too briefly, that there is a psychological continuum ranging from sociopathy, on the one hand, to obsessive-compulsive disorder (OCD), on the other. Corresponding to the sociopathic end of the spectrum is confabulation, with its gross misconceptions of reality, while at the opposite end we have a type of hyperawareness of representation, similar to that of OCD. Envisioning such a continuum helps us understand the relationship between disposition and perception. As an example, we could think of the protagonist in Sartre’s novel, with his hyperconscious perceptions of the outer world, as situating somewhere on the OCD end of the spectrum; conversely, we could think of our enthusiastic neighbor, who has a penchant for telling sensationalized stories, as situated somewhere on the confabulatory end. Unfortunately, Hirstein does not venture past his original sketch of the sociopathy–OCD spectrum, and we are once again thrown back into labyrinthine descriptions of neurological Rube Goldberg machines.

Based on the full title of Hirstein’s book — Brain Fiction: Self-Deception and the Riddle of Confabulation — along with the synopsis on the dust jacket, which tells us that “normal people, too, sometimes have a tendency to confabulate,” I justifiably assumed Hirstein would go beyond clinical cases of confabulation and deal with everyday examples of misrepresentation, such as false memories and benign misrecollection. An example of this would be the tendency of some individuals to embellish certain features of an experience, such as a fisherman (or our next-door neighbor) who swears he caught a 10-pounder when, in reality, the fish only weighed 5 pounds. Sadly, Brain Fiction only mentions the non-clinical features of misrepresentation in passing, simply as a means of enticing the reader to hold out for learning something relevant to everyday experience, which never seems to materialize.

There are several problems with this book, some organizational and others conceptual. The latter are partially due to the inherent limitations of our knowledge regarding the subject matter. We simply do not know enough about confabulation to avoid speculative interpretations of observed phenomena, of which Hirstein has no short supply. In terms of organization, however, there were many occasions when it seemed as if I were reading a first draft of someone’s doctoral dissertation, or a collection of fragmentary asides hastily strung together without regard to transition or continuity. This was especially apparent during later chapters, but the problem of excessive and fragmentary subsectioning was present throughout. I believe Hirstein or his editors could have done his readership a service by cutting out or unifying all the dead wood.

One of the most apparent and frustrating conceptual problems was the overabundance of terms used to describe confabulatory symptoms: vis., “mind-reading” and “modeling” deficits, “epistemic failures,” “representation” degradation, “memory” distortion, etc. Such overabundance of terminology would not pose a problem if Hirstein did not treat each term as if it were its own, independent construct, but he does — “epistemic failures,” for instance, are mysteriously differentiated from memory deficits, and “mind-reading” is somehow only peripherally related to representation. How one can talk of “epistemic failures” without addressing the inherent relationship between knowledge and memory is beyond comprehension, but I suspect this is another instance of Hirstein’s attempt to (understandably), make a name for himself by interjecting his original analysis.

Despite my frustrations with the problems of Hirstein’s book, I admire his undertaking: confabulation, by virtue of its intricate neurological underpinnings, is an exceedingly difficult subject to cover, and in this regard, Hirstein covers considerable ground. When science finally catches up to our speculations, I think Hirstein will provide us with another installment on the nature of confabulation, an event I will certainly look forward to. Only next time, I hope he skips the preliminaries and cuts to the chase, offering up more utility and less verbosity.





Zachary P. Norwood graduated from the University of New Mexico with degrees in research Psychology and English literature. Come this fall, he is pursuing his PhD in literary studies, most likely at the University of Auckland, New Zealand. His dissertation will explore the relationship between affective neuroscience and literary semantics.




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