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Confabulation in Dreaming, Psychosis, and BrainInjury: Commentary by Mark J. Blechner (New York)Mark J. Biechner Ph.D.a

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To cite this article: Mark J. Biechner Ph.D. (2000) Confabulation in Dreaming, Psychosis, and Brain Injury: Commentary byMark J. Blechner (New York), Neuropsychoanalysis: An Interdisciplinary Journal for Psychoanalysis and the Neurosciences,2:2, 139-144, DOI: 10.1080/15294145.2000.10773296

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Commentary on Confabulation

Confabulation in Dreaming, Psychosis, and Brain InjuryCommentary by Mark J. Blechner (New York)

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In science, there is always the choice of how wide anarea to investigate. If our gaze is too wide, we mayget lost and miss important details. If our gaze is toonarrow, we may see some details well but miss thebig picture. The definition of confabulation adoptedinitially by DeLuca from Moscovitch and Melo (1997)is very broad: "statements or actions that involve un­intentional but obvious distortions . ..." But havingsubscribed to such a sweeping definition, DeLuca thennarrows his gaze by some selections that seem arbi­trary. He eschews confabulation in dreams and schizo­phrenia rather summarily, even though they arguablyfit into his definition of broad sense confabulationwhile also sharing certain significant characteristics ofnarrow sense confabulation.

Like Solms, I would prefer to keep dreams andschizophrenia in our consideration, at least to start,and examine the phenomenology of all confabulationsas thoroughly as possible. When we have specified thedifferences between all kinds of confabulation and thesignificant dimensions involved, we will be in a betterposition to categorize confabulations and refine ourmodel of the way or ways that confabulation canoccur.

In our dreams, we are all confabulators-wework out stories that never happened, although, aswith waking confabulation in those who are brain in­jured, many elements of the story can be based onactual experiences drawn from different time periodsin our lives.

Even in nonpsychoanalytic approaches to dream­ing, there is much to be learned from a comparisonof dreams and waking confabulation. For example,Hobson and McCarley's (1977) activation-synthesishypothesis of dreaming is very much about confabula­tion. In their model, the pons produces an image or aset of images, and the cortex invents a story based onthem (i.e., confabulates). As I have noted (Blechner,1998), it is like a brain administering a TAT to itself,which is, in effect, a model of intrapsychic confabu­lation.

In recent years, I have been identifying the kindsof cognitive peculiarities that can occur in dreams,and, equally significant in my view, the kinds of cogni­tive peculiarities that cannot occur in dreams(Blechner, 1998, in press, a). It has been my hope to

specify the processes involved in dreaming and tomake comparisons with some of the cognitive distor­tions that occur in various psychopathologies and inbrain-injured populations.

I would like to outline my findings briefly, withthe hope that they may suggest some ways of structur­ing further study of confabulation. They may also sug­gest ways of revising and updating Freud's descriptionof the operation of the system unconscious (Ucs.).Solms points out the similarity between aspects ofconfabulation and those properties of the unconsciousidentified by Freud, including the toleration of oppo­sites and contradictions, and the aspects of time­lessness. I would like to consider how those twofactors are characteristic of dreams, too, althoughthere are certain important constraints on them.

Disjunctive Cognitions in Dreams

One of the most common contradictions that is toler­ated in dreams is the difference between a person'sapparent identity and his or her actual identity. Almosteveryone has dreamt, or heard a dream, with some­thing like: "I knew she was my mother, although shedidn't look like her."

It surprises me that this is not usually surprisingto people. Many people, when reporting a bizarre ex­perience in a dream, will prepare the listener by say­ing, "It was the strangest thing ..." or "I don't reallyunderstand how this could happen, and yet. ..." Butwhen people see someone in a dream whose identitydoes not match their appearance, they usually do notneed a qualifying preface to describe the experi­ence-at least my patients do not. They take it forgranted that I will know what they mean.

It is a commonplace bizarreness of dreamlife. Thedreamer recognizes a character's identity, even thoughthe person's appearance does not match the identity.There is a disjunction between appearance and iden­tity. This is one example of what I call "disjunctivecognitions." Two aspects of cognition do not matcheach other; the dreamer is aware of the disjunction,yet that does not prevent it from remaining. In wakinglife, most sane people would assume that they mis­saw or misidentified the person, and correct for it; butnot necessarily in dreams.

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Such dream reports qualify as confabulations byDeLuca's adopted definition. And yet, when awake,the dreamer is not shocked. We may ask, isn't it oddto feel so certain about the identity of the person, inthe face of contradictory physical evidence? Whatdoes this division tell us? It suggests that the processesof seeing the physical attributes of a person are notidentical, perhaps not even isomorphic, with the recog­nition of the identity of that person. But is there anyother evidence that those processes are separate inour minds?

Indeed, there is. From neuropsychology, weknow that a prosopagnosic man may look at his wifeof 50 years, see all of her features clearly, and yet notknow who the person is. In such people, the processof seeing is intact, but the process of facial recognitionis not (Bodamer, 1947).

We also have the phenomenon of Capgras syn­drome, in which a person may feel that a close relativeis actually an impostor. The features are recognizable,but the person's identity is not. And in Fregoli's syn­drome, a person may feel convinced that a stranger issomeone he knows, even though he can see that thestranger looks nothing like the person he believes himto be.

We also can find relevant data from research onvisual perception in animals and humans, that seeksto identify the parts of the brain that are responsiblefor different aspects of face recognition (see Mesulam,1998). Gorno Tempini et al. (1998) found that in hu­mans, identifying unfamiliar faces activates unimodalvisual association areas in the fusiform region whilethe recognition of familiar faces also activatestransnodal regions, including those in the lateral mid­temporal cortex. This division of function can befound in subhuman primates, too. Perrett, Rolls, andCohn (1982) have found that in the macaque monkey,there is a specific region of the cortex responsive tofaces. From these findings, we have come to recognizethat the process of facial recognition is indeed verycomplex and may be achieved by a part of the brainthat is different from the brain areas involved in gen­eral visual analysis.

We have thus a case of several kinds of data con­verging on a single phenomenon; we have data fromhuman neuropathology, from experimental brain re­search with humans and animals, and from dreams,all showing how the processes of visual feature per­ception and facial identity recognition are separated.

However, there is an important asymmetry to thisphenomenon. It is less common, at least in my clinicalexperience, for people to report a dream, saying: "It

Mark J. Blechner

looked like my mother, although I knew it was not mymother." In fact, I have not been able to find a singleexample of this in my records of patients' dreams ormy own. I have asked several audiences of cliniciansand dream researchers if they can provide a verbatimaccount of such a dream, and none has. Of course thatis not the most systematic research; we would like amuch larger sample, collected not only from cliniciansbut also from experimental dream researchers, to statedefinitively that such a dream does not occur or occursonly very rarely. If this tendency is true for the generalpopulation of dreamers, it is a significant fact. It maymean that not all contradictions are tolerated uncon­sciously; something more constrained and systematicthan Freud described may be involved. A more precisemodel may result from a collaborative synthesis ofdata of clinicians immersed in the phenomenology ofdreams, experimental dream researchers and neurobi­ologists, and neurologists and neuropsychologistsstudying related phenomena in brain-injured popula­tions.

Time Distortion

DeLuca notes that one of the most common areas ofdistortion in confabulation has to do with time. Timedistortion is also quite common in dreams. Dreamersfrequently report something like: "I was at my par­ents' house. It looked like it did 20 years ago, but Iwas there as an adult."

The transposition of time is another aspect ofdream bizarreness that usually does not surprise peo­ple. It suggests an important relationship between thecognition of the person who dreams and the personwith brain damage. In both, the past can be experi­enced as if it is the present. DeLuca's patient VR talksabout a friend visiting, going to New York City, andthen stopping by to say hello to a manager at the Jims­burg store. VR's wife confirms that this had actuallyhappened, but years earlier, not on that day, as VRclaimed.

But it is worth noting that not all disjunctions intime are equally tolerated in dreams. According to myrecords, it is not unusual to dream that "I was backin the house I grew up in, but I was my current age."It is much less common to dream that "I was in mycurrent house, but I was a child." In fact, I have norecord of the latter sort of dream, nor have requeststo several audiences produced any examples. If sucha dream does not occur, it would be significant for ourtheory. It might indicate a division in the brain, of our

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Commentary on Confabulation

sense of the time or our self representation separatefrom our sense of time about other aspects of our expe­rience, and an asymmetry in how these can be com­bined.

We would then want to know if there is a similarasymmetry with respect to time transpositions inbrain-injured patients. In DeLuca's and Solms's exam­ples, there are reports of patients who presume thatan experience of the distant past happened relativelyrecently. There are no examples of the opposite phe­nomenon, in which a recent experience is thought tohave occurred in the distant past. If this asymmetry oftransposition holds up for certain or all brain-injuredpopulations, how would we understand it? One possi­bility is that older events are stored in a different loca­tion than recent events, and only one kind of storagewas damaged. An alternative explanation might bethat in these patients, all events lose their' 'time mark­ers" and everything becomes transposed into the re­cent present.

Confabulation in Schizophrenia

DeLuca eliminates confabulations of schizophrenicsfrom his consideration because "such a presentationappears to be related to a thought disorder." He citesthe study of Nathaniel-James and Frith (1996), but, inmy reading of their work, they concluded from theirdata that "thought disorder may be a contributor tothe severity of the confabulation rather than to its pres­ence" (p. 397). And is not confabulation itself a kindof thought disorder? There are differences, to be sure,but these need to be spelled out. Like Solms, I wouldprefer to consider further the structural and experien­tial nuances of confabulation seen in schizophrenicand brain-injured populations.

Some distortions of schizophrenics fit DeLuca'sadopted definition of confabulation. Nevertheless,there may be certain identifiable characteristics thatdifferentiate schizophrenic confabulation. Consider,for example, ideas of reference. A schizophrenic maydraw causal connections between forces of nature orother people and himself that are distorted. He mayassume that voices are telling him to do things, or thatradio signals are being transmitted to his brain withmessages that guide his behavior. While all of thesephenomena may have compelling personal reasons,and may be based on actual experiences of feelingcontrolled by others (Blechner, 1995), they are a sortof confabulation that does not seem to be typical ofthe brain-injured patients described by DeLuca and

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Solms. Solms's patient sees the clock as always beinga 5 o'clock, but, as reported, he does not see it asbeing locked there by a made-up force. This is true ofthe examples of confabulation in brain-injured pa­tients provided by Weinstein and Lyerly (1968) aswell. Their examples of reduplication of place andperson could be considered thought disordered, butwith a very specific kind of distortion that is differentfrom the thought disorder of many schizophrenics.

If we go back to the Nathaniel-James and Frith(1996) study, they found that much of schizophrenicconfabulation, although not all, is derived from clangassociations and from morphemic interchanges thatoften sound like plays on words. Thus, when asked torepeat a story which contained the words passengers,one schizophrenic's confabulated version added "apassing boat." Such morphemic interchange is charac­teristic of dreams as well. For example, Reiser (1990)reports a patient whose friend was involved with mari­juana (pot) and committed suicide. The patient dreamtof throwing a pot at the doctor and saying, "Get outof here, you are supposed to be dead!"

Many of the changes in schizophrenic confabula­tions reported by Nathaniel-James and Frith alsoseemed to reflect persecutory fantasies of the patient.Thus, the story of "A farmer whose sons were alwaysquarreling tried to make them see how pointless theirarguing was" was changed by the schizophrenic to"A farmer whose sons were quarreling tried to beatthem." The addition of persecutory material and ofmorphemic interchanges seem more characteristic ofschizophrenics than of the confabulators described byDeLuca and Solms, although there may be comparableexamples from other brain-injured confabulators.

Category Boundaries

There is another characteristic of dreams and schizo­phrenic speech that also differentiates them from theconfabulations of the brain-injured patients describedby DeLuca and Solms. This is the violation of categoryboundaries. In dreams, we can combine objects in newways. Sometimes, instead of the dream thoughts con­verging on a single familiar object in the manifestdream, they converge and create a new object thatcould not occur in waking life. It may have a vaguestructure that is described as "something between anX and a Y." The dreamer may say, "It was somethingbetween a phonograph and a balance" (Meltzer, 1984)or "something between a swimming pool and an aque­duct" (States, 1995). Hobson (1988) dreamt of "a

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piece of hardware, something like the lock of a dooror perhaps a pair of paint-frozen hinges."

In dreams we accept these sorts of intermediatestructures, which I call interobjects (Blechner, inpress, a). The combination is not fully formed into anew object with a complete "Gestalt" but rather re­mains incompletely fused. This sort of thing is nottolerated in waking life. In fact, there is a natural ten­dency, when discussing such dreams, to "regularize"such cognitions, to make "something between an aq­ueduct and a swimming pool" into just an aqueductor just a swimming pool (Blechner, 1998).

Interestingly, children are more adamant thanadults about retaining the disjunctive cognition. Achild dreamt that a seal swam up to him and hisfriends. They thought it was just a seal, but then theylooked and under the water it was a whole boat, it washuge, so they climbed onto the seal/boat, and itbrought them to the shore of the mainland. When theboy told his father the dream in the morning, the fa­ther, speaking like an adult who cannot tolerate contra­dictions, said to him: "So really, it was a boat, a big,safe boat." The child, holding fast to the integrity ofhis dream, said, "It was a boat, but it was still a big,friendly seal" (Blechner, in press, a).

Schizophrenics are also apt to violate categoryboundaries. They tend, for example, to create neolo­gisms that fuse two words, such as one of my patientswho said I was consaring (i.e., concerned and caring).I hear no such blending of categories in the examplesof DeLuca or Solms, although I would be interestedto know if they have evidence of their occurrence inbrain-injured populations.

I would also like to mention here that some pa­tients with borderline personality and ambulatoryschizophrenics report dreams that are notably lackingin confabulation, dreams that do not sound like dreamsbut rather like reports of actual experiences. I wroteon this subject (Blechner, 1983), thinking it to be anew finding, but have since discovered that it had beenobserved several times before, going back to Dostoy­evky's Crime and Punishment in 1866. The confabula­tory and other bizarre aspects of dreaming are oftenabsent in these patients, while their waking thoughtscan be quite distorted. This phenomenon may haveimplications for Freud's view of the unconscious sowell outlined by Solms. As I wrote (Blechner, 1983):

It is possible that psychotic pathology involves a shiftof "bizarre" thoughts from dreaming to waking, andof more rational thoughts from waking to dreaming.This would also imply changing our view of dreams

Mark J. Blechner

from the expression of content that is latent to theexpression of a whole kind of mental processing thatmay be latent. And that which may be latent in psy­chotic patients may be rational thinking. If we assumethat dreams reflect unconscious processes, then thepattern of borderline dream structure may lead us toconclude that it is erroneous to conceptualize uncon­scious thinking in terms of specific types of contentor process as in classical psychoanalytic theory. If weavoid the reified notion of "the unconscious" as anentity, which is limited to any kinds of structural fea­tures or types of contents, and adhere to the usageof "unconscious" only as an adjective, describing aquality of experience, without awareness, which mayapply to any forms of thinking and emotional states,we may begin to consider in some patients that thatwhich is unconscious may well be the kind of rationalthinking and variegated affect that form the bulk ofconscious experience in less troubled individuals [po497].

Level of Awareness

DeLuca contrasts aware versus unaware distortion.From a psychoanalytic perspective, we should have toquestion such a binary distinction. As we often see inour clinical work, awareness is not an all-or-nothingquality of experience, but exists on a continuum thatincludes dynamic repression, dissociation, simple un­awareness, selective inattention, unformulated experi­ence, and fully syntaxic awareness. In fact, Schilder(1930, p. 575-576) suggested that in all confabula­tions, we consider the levels of the patients' convictionabout reality value, which "form a whole spectrum,ranging from those the truth of which is asserted,through those which are bracketed, to those accompa­nied by correction tendencies."

Several of the cases described by DeLuca andSolms reflect the need for a taxonomy of awareness.Of what is the patient aware? Some confabulationsare logically consistent but false, nevertheless. Otherconfabulations are logically inconsistent. In confabu­lations that are logically inconsistent, we have severalfactors to consider: Does the patient see the logicalproblem in the confabulation? If so, how does the pa­tient assess and integrate the logical problem?

Some of the patients are aware that their confabu­lation causes logical difficulties, yet they have givenup the need to therefore consider modifying theirviews or beliefs. Solms describes a patient whoclaimed to have just met his friend, who had died years

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Commentary on Confabulation

ago in Africa. When the analyst questioned how thepatient could have just met a man who had died yearsago, the patient replied that "it must create interestinglegal complications, being alive in one location anddead in another." While the initial experience mayqualify as a confabulation, the patient's responseshows a certain level of insight and lack of confabula­tion. In fact, I think that the quotation strikes one ashumorous, precisely because the man uses a logicalprocess to analyze his premise that is so patently il­logical.}

I would analyze this, along the lines that I havebeen pursuing with dreams. Which aspect of experi­ence is confabulated and which is not? It is as if thereis a split of experience-one aspect of self confabu­lates illogically; the other views the confabulation, ac­cepts it, yet perceives the complication involved.

Interestingly, one of the psychotherapeutic strate­gies for addressing delusional beliefs in schizophrenicpatients is to approach the question, without prejudg­ment, in the spirit of collaborative empirical investiga­tion (Ferenczi, 1922; Fromm-Reichmann, 1948;Szalita, 1958; Kernberg, 1984; Blechner, in press, b).This approach, which can evoke insight in someschizophrenics, fails with Solms's patient and similarconfabulators (see Robinson and Freeman [1954] fora verbatim description of an attempt to work this waywith a reduplicating patient, who claimed to have anew second family since his entry into the hospital).But in the patient described by Solms, there is clearlya different level of awareness from those cases of ano­sognosia, in which there is downright denial of illness,and even denial of what is happening in the moment.A stroke patient who has just been unable to lift herleft hand may nevertheless deny that this is the case.

Pseudologia Fantastica

My last point is, I acknowledge, quite speculative. Ishould like to mention one other psychopathology thatseems to me to suggest a potentially important com­parison to the kinds of confabulation that occur inbrain-injured patients, namely, that of pseudologiafantastica. In this syndrome, patients fabricate stories,usually of a self-aggrandizing nature, that sound plau­sible. Indeed, other people often believe these stories.There is the famous case of Jeff Beck, who workedin a major New York financial institution and regaled

IComic Gracie Allen's zany humor often was based on this sort ofhighly logical approach to totally illogical premises.

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clients with stories of his experiences in Vietnam. Hewas ultimately made a consultant for Platoon, OliverStone's film about the Vietnam War. He also spokefreely about his family's great wealth. When the fi­nancial backing for one of his deals fell through, hesaid he would use his family money to replace it. Onlythen did it emerge that he had no family money, andthat he had never served in Vietnam.

You may object that such a fellow does not fitDeLuca's definition of confabulation, since the firstimpression, when people with pseudologia fantasticaare found out, is to presume that they are willfullyand knowingly making up facts about themselves. Butit is not always clear to what degree that is so, and atleast some such patients seem not to know or to losetrack of how much they are making up about theirlives (Bleuler, 1912). I believe that it might be worthconsidering whether patients with pseudologia fantas­tica have a brain disorder that may be linked to otherkinds of brain disorders that lead to confabulation.

References

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--- (1998), The analysis and creation of dream mean­ing: Interpersonal, intrapsychic, and neurobiological per­spectives. Contemp. Psychoanal., 34: 181-194.

--- (in press, a), The Dream Frontier. Hillsdale, NJ:Analytic Press.

--- (in press, b), Delusions. In: The Freud Encyclope­dia, ed. E. Erwin. New York: Garland.

Bleuler, E. (1912), Autistic thinking. In: Organization andPathology of Thought, ed. D. Rapaport. New York: Co-lumbia University Press, 1951, pp. 399-435. ,

Bodamer, J. (1947), Die Prosopagnosie. Archiv. Psychia­trische Nervenkrankheiten, 179:6-54.

Ferenczi, S. (1922), Paranoia. In: Final Contributions to theProblems and Methods of Psycho-Analysis. New York:Brunner/Mazel, 1980, pp. 212-215.

Fromm-Reichmann, F. (1948), Notes on the developltIentof treatment of schizophrenics by psychoanalytic psy­chotherapy. Psychiatry, 11 :263-274.

Gorno-Tempini, M., Price, C., Vandenberghe, R., Joseph,0., Cappa, C. F., & Fracowiak, R. (1998), The neuralsystems sustaining face and proper name processing.Brain, 121 :2103-2118.

Hobson, J. A. (1988), The Dreaming Brain. New York:Basic Books.

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---McCarley, R. W. (1977), The brain as a dream stategenerator: An activation-synthesis hypothesis of thedream process. Amer. J. Psychiatry, 134:1335-1348.

Kernberg, O. (1984), Severe Personality Disorders. NewHaven, CT: Yale University Press.

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Mesulam, M.-M. (1998), From sensation to cognition.Brain, 121:1013-1052.

Moscovitch, M., & Melo, B. (1997), Strategic retrieval andthe frontal lobes: Evidence from confabulation and am­nesia. Neuropsychologia, 35:1017-1034.

Nathaniel-James, D., & Frith, C. (1996), Confabulation inschizophrenia. Psycholog. Med., 26:391-399.

Perrett, D., Rolls, E., & Caan, W. (1982), Visual neuronesresponsive to faces in the monkey temporal cortex. Ex­periment. Brain Res., 47:329-342.

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Jorge Canestri

Robinson, M., & Freeman, W. (1954), Psychosurgery andthe Self. New York: Grone & Stratton.

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States, B. (1995), Dreaming "accidentally" of HaroldPinter: The interplay of metaphor and metonymy indreams. Dreaming, 5:229-245.

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Mark Blechner, Ph.D.145 Central Park WestNew York, NY 10023

A Cognitive Neuroscience Perspective on ConfabulationCommentary by Jorge Canestri (Rome)

DeLuca's paper presents the psychoanalyst with sev­eral interesting points: an accurate examination of apathological phenomenon (confabulation) whosedefinition, uniqueness, and causality are still underdiscussion; an alternative model constructed on thecognitive neuroscience perspective emphasizing thedifferences between the various forms of confabula­tion; and the possibility of comparison with psychoan­alytic theories, specifically relative to thisphenomenon as well as in a wider sense concerningthe verisimilitude of certain statements of Freudianmetapsychology.

The neurosciences can offer to psychoanalysissome tools that allow one to verify the biological plau­sibility of certain psychoanalytic hypotheses and tofind confirmation or refutation of them in the experi­mental field, while psychoanalysis can supply the neu­rosciences with a heuristic potential that cannot beunderestimated. In these brief notes I will try to illus­trate this viewpoint.

My task in presenting these notes is greatly facili­tated by Mark Solms's comment, which excuses mefrom describing the fundamental principles of theFreudian topographical model of the mind (Freud,1900, 1911, 1915). With the addition of examplestaken from his clinical experience with bilateral ven­tromesial frontal lesioned patients, Solms highlights

what is essential to the Freudian task: the problem ofthe psychoanalyst is not only to construct a causalhypothesis, but above all to find meaning in the mani­festations of psychic life. This is evidenced by thedifferent consideration that the symptoms merit in De­Luca's work and in the discussion by Solms. The latteremphasizes the fact that behind the "positive" (or"productive' ') manifestations of the organic lesions,there are "underlying wishes," in consonance withthe Freudian model of the mind. It is therefore clearthat while DeLuca will put the accent on the deficit,the psychoanalyst will also emphasize the "produc­tive" aspect of the symptom and its meaning.

It might perhaps be useful to dwell for a whileon this difference in the general line of thinking, whichcould be significant for the neurosciences also. As weknow, Freud constructed a hypothetical model of a"mental apparatus." Setting aside for the time beingthe verisimilitude of his construction, what is essentialis to note the implicit general concept: in a complexsystem the global level of functioning of the systemcannot legitimately be explained by reference to the"atomic" elements only. A deficit (in these cases dueto an organic lesion) must be interpreted also as afunction of the overall response of the system. This istrue at the physical level as well as at the level of"mental life." If, for example, we consider the (some-

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