I In the context of mental health treatment, client confabulation refers to inadvertent memory and formation of false memories, ranging from subtle adornments to grandiose elaborations. Confabulation can take the form of real memory inserted into an incorrect temporal, spatial, or event context. In other words, confabulated memories can be based on actual memory taken out of the temporal context, or they can result from the creation of a fully fabricated memory (one that is not based on a pre-recorded belief, lived event, or memory ). Confabulation can also involve the inclusion of confabulated details or events as part of a true memory.
It is important for mental health professionals to remember that people who confabulate do not know that they are engaging in this memory phenomenon and that they have no intention of deceiving. Clients who confabulate are not aware that their memory is wrong. In fact, they often firmly believe that their memory is true. Confabulation can also manifest itself in verbal or behavioral displays of unintentional dishonesty.
Confabulation differs from delusions, which are firm beliefs that follow a consistent theme and result from psychosis and often involve a lifestyle change to accommodate the false beliefs. It is also different from malpractice, deliberately deviating from the truth to achieve a desired outcome (e.g. reporting mental health symptoms that are not there in order to receive disability payments). Although confabulations and delusions can share a common pathophysiology (i.e., they can present themselves similarly), they are separate phenomena.
Confabulation is a complex and confusing topic with an uncertain etiology and is still little explored in the context of mental health care. It is loose with a range of neurobehavioral / neurodevelopmental disorders (e.g., fetal alcohol spectrum disorder [FASD] intellectual disability) and neuropsychiatric (e.g., schizophrenia), neurocognitive (e.g., dementia, traumatic brain injury), and medical health conditions (e.g., schizophrenia) , Korsakoff syndrome, various brain diseases). Adding to this confusion is that confabulation can also occur in people with no identified impairments, disorders, or illnesses if certain factors are present (e.g. confused memory, attempting to fill a memory gap, high-pressure and stressful interviews).
Although the underlying brain processes associated with confabulation are currently unknown, possible causes have been suggested in the research literature. These include:
Attempt to maintain self-coherence
Attempt at self-improvement
Competing memories of varying strength and emotional significance
Function deficits of the executive branch
Fast and stressful interview approaches
Dysfunction of the frontal lobe
Guided images
Hypnosis
Impaired attention control
Impulsiveness
Memory coding and retrieval deficits
Loss of memory
Confusing imaginary events with real ones
Superconsciousness
Attempt to maintain a sense of self-identity and self-worth
Deficits in monitoring reality
Repeated interview lines
Self-monitoring deficits
Zeal to please (i.e. wants to demonstrate the ability to answer all questions)
Confabulations, which are most commonly observed when retrieving autobiographical memories, may contain information inspired by peers, television, movies, and social media. Inspirations for confabulation can also come from listening to conversations with other people (e.g. inpatient treatment settings, group treatment programs, sober support sessions).
Psychiatrists are often not aware of this topic and are usually barely or not at all trained in the effects of confabulation on the client population. Because of its potential to interfere with screening, assessment, treatment efforts, discharge planning, and placement, confabulation is a critical clinical phenomenon that practitioners must understand and address.
Types of confabulation
There are two main forms of confabulation: provoked and spontaneous. Provoked confabulations are incorrect answers to questions or situations in which a person feels compelled to answer. Examples of such situations include admissions reviews, investigative interviews, and court statements.
Studies have shown that the more stressful a situation is perceived, the more likely it is that confabulation is. Because of this, mental health professionals working in the criminal justice or forensic mental health fields must be extra careful with the possibility of confabulation of a patient, which can lead to inaccurate diagnosis or symptom identification. In addition, unintentionally incorrectly stored information can interfere with the legal process if the person provides inaccurate eyewitness information, prematurely waives Miranda rights, makes false confessions to the police, or makes inaccurate testimony in court. In the worst case, it could even lead to false convictions.
Spontaneous confabulations are not tied to a specific reference. They range from mistakenly remembering insignificant information to creating fantastic and grandiose details. It is believed that they result from a reality monitoring deficit in the frontal lobe combined with organic amnesia. Spontaneous confabulations also differ from provoked confabulations in that most patients eventually stop engaging in the behavior.
Provoked and spontaneous confabulations can either be expressed verbally or through behavior. Verbal confabulation involves articulating a wrong memory, while behavior confabulation involves acting on a wrong memory (e.g., entering the wrong home because the person believes it is where they live). Regardless of the form in which they come in, false memories can evoke real emotions in customers who, despite evidence to the contrary, can have a high level of confidence in the accuracy of their recall.
An example that one of us experienced was during a forensic mental health interview with a woman who was later diagnosed with Korsakoff's syndrome. As the assessment progressed, it was clear that she had significant difficulty developing new memories, but was able to recall long-term historical memories (e.g., autobiographical childhood memories). She recently described babysitting a neighbor's three preschoolers, including repairing snacks and watching TV. Due to the woman's significant impairments and concerns about the safety of the young children she cares for, a report was sent to the child protection services. A subsequent investigation found that the woman did not have to babysit the neighbor's young children. This was an apparently confabulated memory.
Screening and treatment
There are various theoretical models to explain confabulation. It implies that tracks that were used in the past but are no longer relevant to what the person is currently remembering can no longer be suppressed. Another theory is that the person just couldn't get the relevant memory. Finally, another theory is that the person was unable to locate memory for that time and context, and essentially put another memory in its place.
Numerous conditions can increase the likelihood of confabulation, including:
Dementia
Encephalitis
FASD
Frontal lobe tumors
Frontotemporal dementia
Herpes simplex encephalitis
Learning difficulties
Nicotinic acid deficiency
Korsakoff syndrome
Multiple sclerosis
Schizophrenia
Subarachnoid hemorrhage
Traumatic brain injury
Given that confabulation has an unclear etiology, multiple definitions, and statistical and clinical associations with a range of neurobehavioral, neurodevelopmental, neurocognitive and neuropsychiatric conditions, the use of a valid and reliable screening method is essential. This will help mental health professionals avoid inaccurate diagnoses and developing ineffective treatment plans that could worsen the underlying conditions. Screening areas that must be considered in confabulation assessments include:
Abstract and sequential thinking
Attention deficit / hyperactivity disorder
Executive function
History of the trauma
sleep
Learning skills
Social skills
Memory
Receptive and expressive language
Sensory processing
Source monitoring
Suggestibility
Prenatal alcohol exposure
While confabulations can arise for a variety of reasons, early detection, support, and monitoring are vital. Possible screening tools that can be useful are the Nijmegen-Venray confabulation list and the confabulation screen. Using these tools may provide an initial analysis to further investigate this problem. If confabulation occurs but is believed to be due to an organic disease such as Alzheimer's, dementia, or FASD, a referral for neurological testing is appropriate and can help identify which areas of the brain are most affected. This can help in determining the best approach to treatment given the particular needs of the individual.
With regard to treatment, specific intervention strategies have proven useful in patients or patients who confabulate. These strategies include:
Avoid confrontation
Avoidance of central questions
Avoidance of sensory overload
Avoiding closed questions
Use a slow interview format
Use of sources of security to confirm the self-report
Use of a language appropriate for development
Assurance that it is acceptable not to know an answer
Check for understanding
Minimize stress
Providing education for families / support persons
Take additional processing time into account
Allow long pauses and silence
Treatment of the underlying mental illness
Treatment of the underlying physiological diseases
Teach use of memory diary
Teaching techniques to monitor reality
Teaching self-monitoring techniques
In order to develop a therapeutic relationship with such clients, it must be recognized that their false memory is not intentional and that there is a lack of malice. This can be challenging for doctors for a number of reasons: countertransference, frustration at not knowing whether a client's documented previous diagnoses or symptoms are correct, and an unconscious tendency to require memory of inaccurate memories is the outcome of the attempt the client's gaining something else (i.e., malingering) such as money or trying to get out of trouble.
Physicians should avoid minimizing the client's reporting or prematurely assuming that the client is intentionally non-compliant. Indeed, clinicians should recognize that the content of confabulations can even provide useful information about the client's perceptions and approaches to behavior. As mentioned earlier, the confabulated information can also lead to real emotions for the customer that need to be confirmed and processed.
Clinicians need to be aware of the fact that confabulators can inadvertently thwart treatment efforts because they fail to realize that their recalled memories are false. To address this lack of insight and ensure the collection of valid and reliable reviews, clinicians should seek collateral information to support or disprove a customer's allegations (especially when a false reminder could have significant consequences). If clear indications of confabulation are found, doctors should appropriately document this in the client's file and take this into account throughout the treatment process (e.g. admission, screening, treatment planning, discharge planning).
Adaptive functioning
Confabulation can impair a person's ability to care for themselves (e.g. personal hygiene, dressing, cooking), carry out activities of daily living (e.g. cleaning at home, tending to clothes, financial management) and effectively maintaining a social life (e.g. empathy, reading non-verbal behavior, building a social group, effective communication). These adaptive function deficits can also lead to problems with submitting forms for the use of government services (e.g. disability benefits, subsidized housing) and with access to medical records for high quality continuity of care and increased vulnerability to victimization ensure. Therefore, those who chronically confabulate are less likely to be able to live independently and more likely to need high levels of support.
Therefore, clinicians working with confabulated individuals should consider maintaining an adaptive behavior inventory based on the "gold standard" to guide and inform treatment planning. These inventories include the Skales of Independent Behavior-Revised, the Vineland Adaptive Behavior Scales Third Edition, and the Diagnostic Adaptive Behavior Scale. Similarly, clinicians working with clients who have significant deficits in adaptive function, particularly in higher-level skills such as money management, should look out for possible confabulations. 
Although using a standardized assessment to assess adaptive skills can be useful in assessing and planning treatment, clinicians should also be aware of certain disorders, such as FASD, for which confabulation is common and which standardized testing does not It is essential to identify deficits. For example, people with FASD may be able to complete daily living tasks like grocery shopping or personal hygiene management, but they may have poor judgment (and especially social judgment) that is not measured on typical adaptive functional scales. For example, they may be tricked out of the money by someone who is "kind" to them and then have difficulty understanding or explaining the missing money, so they resort to confabulation to explain it.
In such cases, in addition to using standardized tests, clinicians should carefully evaluate skills and interactions using a qualitative analysis. This can be particularly important for people with FASD with regard to social skills or other functional areas that are difficult to measure. Confabulation can be shown as a way to represent a more functional ability in relation to a wide range of adaptive skills and may need to be addressed through careful clinical interventions.
If adaptive behavior deficits are detected, it is the responsibility of the treating clinician to inform the client's support systems (family, friends, educational system) about the practical effects of these deficits. In cases of severe confabulation, these support systems may need to be used to keep the customer safe and oversee the customer's daily affairs, such as: B. Attending appointments and adhering to medication. Unfortunately, strong support systems may be less common with this customer population. Family, friends, and teachers may be suspicious of the confabulating person because they misperceive that they are deliberately trying to deceive them. Clinicians play an important role in intervening in such misperceptions by educating clients' support systems about the unintentional confabulations and explaining that they are the result of cognitive and neurological deficits.
Conclusion
Confabulation can be a serious obstacle for mental health professionals to provide effective care and services. This can negatively impact admission, screening, assessment, treatment planning, medication / treatment adherence, and discharge planning. For this reason, we urge clinicians to complete self-study and training via in-person and online courses to expand their knowledge of this complex and diverse phenomenon. If a case of potential confabulation is identified, professionals should seek advice from recognized subject matter experts who regularly review important research findings on confabulation at least quarterly.
Finally, additional research is needed to continue establishing evidence-based screening and intervention procedures to identify individuals who may be at increased susceptibility to confabulation. Such screening procedures could be used prior to the clinical interview and in the treatment planning process to ensure that the information obtained is of greater accuracy. Using such protocols would also familiarize users with the social and cognitive risk factors for confabulation that many mental health providers are currently unaware of. Adopting such guidelines and procedures can minimize the potential negative effects of confabulation, implement appropriate intervention approaches, and increase the likelihood of positive outcomes.
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Jerrod Brown is Assistant Professor, Program Director, and Senior Developer for the Masters in Human Services with an emphasis on Behavioral Forensic Health at Concordia University in St. Paul, Minnesota. For the past 16 years he was also employed at the Pathways Counseling Center in St. Paul. He is the founder and CEO of the American Institute for Advancement of Forensic Studies and Editor-in-Chief of Forensic Scholars Today. Contact him at [email protected].
Megan N. Carter is a board certified forensic psychologist practicing in Washington State. Her professional focus was on forensic psychological assessments in civil and criminal proceedings. She has also focused on providing education to mental health professionals about disorders of the fetal alcohol spectrum.
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