Bob Schwartz

Category: Medicine

Brain Fiction: Self-Deception and the Riddle of Confabulation

What if someone lies in the face of overwhelming contrary evidence? What if that person really believes what he is saying?

Confabulation is the construction of false answers to a question while genuinely believing that you are telling the truth.

This mysterious phenomenon usually accompanies neurological or cognitive disorders, and the puzzle of it has been the subject of some study among researchers. In his book Brain Fiction: Self-Deception and the Riddle of Confabulation, William Hirstein takes this study further than it has gone before:

“Both a neuroscientist and a philosopher, William Hirstein writes from his unique vantage point with great scholarship, precision, and clarity to tackle some of the deeper mysteries of the human mind. Brain Fiction is full of profound insights, and I recommend it to all who wish to better understand our human nature.”

—Fredric Schiffer, M.D., Harvard Medical School, author of Of Two Minds

Here is a description of the book:

Some neurological patients exhibit a striking tendency to confabulate—to construct false answers to a question while genuinely believing that they are telling the truth. A stroke victim, for example, will describe in detail a conference he attended over the weekend when in fact he has not left the hospital. Normal people, too, sometimes have a tendency to confabulate; rather than admitting “I don’t know,” some people will make up an answer or an explanation and express it with complete conviction. In Brain Fiction, William Hirstein examines confabulation and argues that its causes are not merely technical issues in neurology or cognitive science but deeply revealing about the structure of the human intellect.

Hirstein describes confabulation as the failure of a normal checking or censoring process in the brain—the failure to recognize that a false answer is fantasy, not reality. Thus, he argues, the creative ability to construct a plausible-sounding response and some ability to check that response are separate in the human brain. Hirstein sees the dialectic between the creative and checking processes—”the inner dialogue”—as an important part of our mental life. In constructing a theory of confabulation, Hirstein integrates perspectives from different fields, including philosophy, neuroscience, and psychology to achieve a natural mix of conceptual issues usually treated by philosophers with purely empirical issues; information about the distribution of certain blood vessels in the prefrontal lobes of the brain, for example, or the behavior of split-brain patients can shed light on the classic questions of philosophy of mind, including questions about the function of consciousness. This first book-length study of confabulation breaks ground in both philosophy and cognitive science.

A sample chapter can be read here. A couple of brief excerpts:

Why then does confabulation happen? Confabulation seems to involve two sorts of errors. First, a false response is created. Second, having thought of or spoken the false response, the patient fails to check, examine it and recognize its falsity. A normal person, we want to say, would notice the falsity or absurdity of such claims. The patient should have either not created the false response or, having created it, should have censored or corrected it. We do this sort of censoring in our normal lives. If I ask you whether you have ever been to Siberia, for instance, an image might appear in your mind of you wearing a thick fur coat and hat and braving a snowy storm, but you know that this is fantasy, not reality. In very general terms, the confabulating patient lacks the ability to assess his or her situation, and to either answer correctly, or respond that he or she does not know. Apparently, admitting ignorance in response to a question, rather than being an indication of glibness and a low level of function, is a high-level cognitive ability, one that confabulators have lost. ‘‘I don’t know,’’ can be an intelligent answer to a question, or at least an answer indicative of good cognitive health….

Young children sometimes confabulate when asked to recall events. Ackil and Zaragoza (1998) showed first-graders a segment of a film depicting a boy and his experiences at summer camp. Afterward the children were asked questions about it, including questions about events that did not happen in the film. One such question was, ‘‘What did the boy say Sullivan had stolen?’’ when in fact no thefts had taken place in the film. The children were pressed to give some sort of answer, and the experimenters often suggested an answer. When the children were interviewed a week later, the false events as well as the suggested answers had been incorporated into their recollections of the movie.

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DSM-5: Paranoia

DSM-5

I did not think that I would be returning to the DSM quite so soon after my recent post.

The caveat in my last post about the DSM bears repeating. Mental health is a serious issue. Using diagnostic tools and terminology merely for entertainment and “pop psychology” can be careless. On the other hand, these tools can help provide insights that may be useful, particularly when the subject and the subject matter are very important or even critical.

Non-professionals talk loosely and colloquially about paranoia. The DSM approaches this clinically and scientifically:

Paranoid Personality Disorder

Diagnostic Criteria

A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

  1. Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
  2. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
  3. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
  4. Reads hidden demeaning or threatening meanings into benign remarks or events.
  5. Persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights).
  6. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
  7. Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Diagnostic Features [selected]

They suspect on the basis of little or no evidence that others are plotting against them and may attack them suddenly, at any time and without reason.

They are preoccupied with unjustified doubts about the loyalty or trustworthiness of their friends and associates, whose actions are minutely scrutinized for evidence of hostile intentions.

They may refuse to answer personal questions, saying that the information is “nobody’s business.”

They read hidden meanings that are demeaning and threatening into benign remarks or events. For example, an individual with this disorder may misinterpret an honest mistake by a store clerk as a deliberate attempt to shortchange, or view a casual humorous remark by a co-worker as a serious character attack.

They may view an offer of help as a criticism that they are not doing well enough on their own.

Individuals with this disorder persistently bear grudges and are unwilling to forgive the insults, injuries, or slights that they think they have received.

Minor slights arouse major hostility, and the hostile feelings persist for a long time.

Because they are constantly vigilant to the harmful intentions of others, they very often feel that their character or reputation has been attacked or that they have been slighted in some other way.

They are quick to counterattack and react with anger to perceived insults.

DSM-5: Antagonism and Narcissistic Personality Disorder

 

DSM-5

Mental health is a serious matter and mental health practitioners are serious professionals. These are not to be treated lightly and off-handedly.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the “bible” of the mental health profession: “a classification of mental disorders with associated criteria designed to facilitate more reliable diagnoses of these disorders.” It is not a reference to be thrown around and used casually by non-professionals.

The DSM can nonetheless be fascinating, especially when certain strong behavioral traits observed in others seem to closely match the traits and possible related disorders referenced in the DSM.

With the above caution and caveat, here are selections from DSM-5 about the Personality Trait Domain of Antagonism. More from the DSM about the way this may or may not relate to Narcissistic Personality Disorder will follow in a subsequent post.

Personality trait: A tendency to behave, feel, perceive, and think in relatively consistent ways across time and across situations in which the trait may be manifest.

Personality trait facets: Specific personality components that make up the five broad personality trait domains in the dimensional taxonomy of Section III “Alternative DSM-5 Model for Personality Disorders.” For example, the broad domain Antagonism has the following component facets: Manipulativeness, Deceitfulness, Grandiosity, Attention Seeking, Callousness, and Hostility.

Antagonism: Behaviors that put an individual at odds with other people, such as an exaggerated sense of self-importance with a concomitant expectation of special treatment, as well as a callous antipathy toward others, encompassing both unawareness of others’ needs and feelings, and a readiness to use others in the service of self-enhancement. Antagonism is one of the five broad personality trait domains defined in Section III “Alternative DSM-5 Model for Personality Disorders.”

Manipulativeness: Use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s ends. Manipulativeness is a facet of the broad personality trait domain Antagonism.

Grandiosity: Believing that one is superior to others and deserves special treatment; self-centeredness; feelings of entitlement; condescension toward others. Grandiosity is a facet of the broad personality trait domain Antagonism.

Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events. Deceitfulness is a facet of the broad personality trait domain Antagonism.

Attention seeking: Engaging in behavior designed to attract notice and to make oneself the focus of others’ attention and admiration. Attention seeking is a facet of the broad personality trait domain Antagonism.

Callousness: Lack of concern for the feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one’s actions on others. Callousness is a facet of the broad personality trait domain Antagonism.

Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Hostility is a facet of the broad personality trait domain Antagonism.

Collateral Damage in Afghanistan

In the vocabulary of war, no term is darker or more chilling than “collateral damage.”

There was last week collateral damage in our war in Afghanistan, where a Doctors Without Borders hospital was the target of aggressive American airstrikes. A number were killed and injured, including children, and the hospital was destroyed.

The few facts, besides the destruction, are these.

Collateral damage is unavoidable, though it can and should be minimized.

The Taliban has overtaken the area, though not the hospital.

We are engaged in supporting the Afghan fight against the Taliban, by, for example, air strikes.

Hospital personnel contacted the U.S. military after the barrage began, but it continued anyway.

Now for the rest of the story, which the Pentagon tried to correct this morning.

Early reports were that the U.S. itself called for the air strikes.

Not so, says the Pentagon. It was the Afghans who identified the target as a Taliban position, and then we conducted the airstrikes.

Don’t you see the difference? The difference, of course, being some sort of operational and moral distinction, being entirely responsible for a tragic and avoidable error versus being only mostly responsible for a tragic and avoidable error. Now we see.

It isn’t really about the particulars anyway. It’s about the need for unceasing realization that if you choose war, you choose its worst impacts. The calculus can’t just include the big win and big benefits—assuming there are any—so that those cancel out the ill you do. It doesn’t work that way. So when and if we choose war, it is never illegitimate to keep the costs constantly in mind. In fact, it is always immoral and ill-advised not to.

Otherwise, you might end up with millions of underserved and nearly abandoned veterans. Or a badly damaged economy. Or a dispirited and skeptical nation. Or some of the world’s most selfless health workers in one of the world’s most needy countries watching as their patients and their hospital die and burn.

Coming Out: How Cosmetic Surgery Is Like Being Gay

South Park - Tom Cruise

In case you haven’t noticed, the noise surrounding Renee Zellweger’s about face sounds just like the conversations we have about celebrities being gay: did she or didn’t she, is he or isn’t he?

There are three kinds of cosmetic surgery: the public kind that can be explained as the result of exercise and nutrition (body shaping and toning), the public kind that is hard to explain that way (obviously enhanced breasts), and the private kind that is (sort of) meant to be private (vagina rejuvenation, penis enhancement).

Questions about the public kinds can be met with a variety of replies, all of them valid:

Yes.
No.
No comment.
It’s none of your business.

This remarkably parallels the situation of those who are “suspected” of being gay. Sometimes it is made public, sometimes it is kept private, sometimes it is treated matter-of-factly: it is what it is, it’s my life, take it or leave it, so what?

Admitting to plastic surgery is in many contexts (including and especially entertainment) as delicate as admitting to being gay—even if the fact is relatively obvious. One of the many reasons the late Joan Rivers was so beloved, why what was obnoxious in others was endearing in her, is that the fact of her many plastic surgeries was a prime subject of her own bits. As with other topics, she just gave you the finger, laughed, and had you laughing too.

In the scheme of all but the tiniest matters, Renee Zellweger’s face is inconsequential. But as with all the tongue wagging about the sexual preferences of some celebrity, it exposes unanswered and mostly unspoken questions about how people feel about certain things. Many people still don’t know exactly what they think about major or minor voluntary body mod, any more than they may have totally resolved their deepest puzzlement about homosexuality, no matter how genuinely progressive and tolerant they are.

For better or worse, we are actually seeing a bit of that in the Renee Zellweger situation: along with an avalanche of typically mindless chatter, there has been some useful discussion about the nature of celebrity, privacy, aging, feminism, and health. It is unfortunate that this has to fall on a single individual’s shoulders, with so much collateral and gratuitous hurt. But if we are careful, we might just learn something, mostly about ourselves. How rare and valuable an opportunity is that?

Illustration: The obvious illustration for this post would be yet another photo of Renee Zellweger, which neither the world nor she need. Instead, above is a frame from South Park, the 2005 episode called Trapped in the Closet. It is widely considered the show’s most controversial episode, which is saying something. In it, the fearless and brilliant and culturally incorrect Parker and Stone managed to skewer (eviscerate?) both Scientology and the rumored homosexuality of Hollywood stars. In this scene, Tom Cruise won’t come out of the closet (where he will ultimately be joined by John Travolta). Nicole Kidman, his then-wife, is trying to talk him out. As I said, culturally incorrect, and probably intolerant and spiteful in light of all that’s written above. But it is funny, and not surprisingly, it is the equally fearless and funny Joan Rivers who also took on the very same subject. Laughing and thinking. What a combo.

Thor Gives Birth to Twins

Thor
Nobody wants to hear from word nerds. They just stifle creativity and block linguistic evolution with their definitions and rules. Humpty Dumpty from Alice in Wonderland is the man (or eggman): words mean exactly what anybody says they mean.

Except they don’t, or they can’t or shouldn’t. If you tell a doctor you have a pain in your leg, and she examines and treats your arm, because leg now means arm, everybody has a problem.

Here’s the TMZ story that’s been widely picked up:

Chris Hemsworth and Elsa Pataky — Give Birth to Twins
Thor’s Got Twins Now!

3/20/2014 4:14 PM PDT BY TMZ STAFF
EXCLUSIVE

Chris Hemsworth and his wife are at Cedars Sinai Medical Center right now giving birth to twins … TMZ has learned.

It’s ultra-high security in their hospital suite … we’re told 2 security guards are standing at the door.  Chris is strolling the hallway and is being escorted with a guard.

Chris and his wife Elsa Pataky already have one baby — India Rose Hemsworth who is now 22 months old.  She’s about to have a couple new siblings.

Chris and Elsa were married in 2010.

This led to headlines like this one in the New York Daily News:

Chris Hemsworth, wife Elsa Pataky giving birth to twins

Nobody may care, except for mothers, doctors, and Mrs. Chris Hemsworth, but “giving birth” is not the same as parents having a baby. “Birth” is variously defined as “The emergence and separation of offspring from the body of the mother” or “The event of being born, the entry of a new person out of its mother into the world.”

Chris Hemsworth can be a proud and involved daddy. So can Thor. But neither of them can give birth, no matter what TMZ or the Daily News say.

League of Denial: The NFL’s Concussion Crisis

league-of-denial-raster-br10-8
You may not think that you want to watch the new PBS Frontline documentary League of Denial: The NFL’s Concussion Crisis.

You may not want to spend almost two hours on a documentary, even a superb one. You may not like football, may not know anybody who plays football at any level, may not care about the business of sports. Then again, some or all of those may apply to you.

It doesn’t matter. You can watch League of Denial online. Please watch it.

One of the many lessons you will learn, if you didn’t already know, is that we pay a price for everything. Or at least somebody does. The price is sometimes advertised and obvious, but sometimes hard to find or even hidden. The point is not that something is good or bad, right or wrong, but that we can only make informed and enlightened decisions when everything is known. No more or less.

The Most Significant Shutdown Front Pages

El Diario

Republicans should pay close attention to the front pages of America’s newspapers this morning, the first day of the government shutdown prompted by their obsessive opposition to Obamacare.

Most papers carry some version of “shutdown” or “gridlock,” with photos of John Boehner and Harry Reid, or John Boehner and Barack Obama (it’s all about John Boehner).

But the big story on two front pages is the opening of the Affordable Care Act insurance exchanges. These two papers just happen to be two of the largest Spanish-language dailies—El Diario in New York (above) and La Opinion in Los Angeles (below).

La Opinion

Why is this significant for Republicans? Because they claim (but in their heart of hearts still may not believe) that here in the second decade of the 21st century, they can’t become an American national party without broad Latino support. That is true, but the fact is that a large part of that constituency is uninsured and is deeply interested in the benefits of Obamacare. This is reflected in those front pages. But the Republicans are sworn enemies of Obamacare, so committed that they are willing to put people out of work to do it. How can the Republicans be a party attractive to Latinos under that circumstance?

The answer is that they can’t. It is a circle Republicans cannot square. And no matter how much lip service they pay to underserved populations, everything they do says something else. Actions, like front pages, speak louder than words.

The Government Shutdown and Masturbating Fetuses

Rep. Michael Burgess
In the contentious Saturday night House debate on the Continuing Resolution to fund the federal government—a resolution that guts Obamacare and will almost certainly lead to a partial government shutdown—Republican Rep. Michael Burgess of Texas revealed a little known fact about the Affordable Care Act: it was “never intended to be law,” even though it obviously is. How so?

And here’s the real crux, Mr. Speaker. Here’s what’s really wrong and why Washington is in such a lather right now: The Affordable Care Act was never intended to become law. It was a vehicle to get the Senators home on Christmas Eve before the snowstorm. It was never intended to be law. The law that was passed by the Senate was a rough draft. It’s equivalent to saying the dog ate my homework so I turned in the rough draft; and, unfortunately, the rough draft got signed into law the following March, and that’s why there’s so much difficulty with this.
Congressional Record, September 28, 2013

Who is Rep. Burgess and why is he saying these things? He is a medical doctor, an ob/gyn, and has become one of the Republican Congressional experts on health care. Research shows that he has some other interesting views. This from U.S. News on June 18 of this year:

Rep. Michael Burgess, R-Texas, said Monday he is opposed to abortion because fetuses masturbate in the womb, and so can feel both pleasure and pain.

“Watch a sonogram of a 15-week baby, and they have movements that are purposeful,” said Burgess, citing his experience as an OB/GYN, during a House Rules Committee hearing on a GOP bill that would ban abortions after 20 weeks. “They stroke their face. If they’re a male baby, they may have their hand between their legs. If they feel pleasure, why is it so hard to think that they could feel pain?”

His comments were first reported by women’s health site RH Reality Check.

But Burgess’s argument isn’t based in science, doctors say. “We certainly can see a movement of a fetus during that time, but in terms of any knowledge about pleasure or pain – there are no data to assess,” says Jeanne Conry, president of the American College of Obstetricians and Gynecologists, a professional association for OB/GYNs. “We don’t know enough about the biology and the science.”

One more medical opinion from Rep./Dr. Burgess on the country’s sickness: President Obama must be impeached. Burgess said to a Tea Party questioner in 2011: “It needs to happen, and I agree with you it would tie things up. No question about that.”

The Wait We Carry

The Wait We Carry
IAVA has been at the forefront of modern veterans advocacy—something desperately needed in the face of modern veterans benefit challenges (that is, much talk, little action).

The latest of these advocacy tools is dazzlingly innovative and personalizing. Here is the IAVA introduction:

This is the true face of the backlog. Introducing: The Wait We Carry.

By now, you’ve seen the big numbers behind the VA disability benefits backlog — over 565,000 vets waiting too long to get their claims resolved. But it’s not enough to talk about the numbers. We wondered: what are those vets going through? How is their wait for benefits affecting them and their families?

We asked vets to tell us about their experiences while waiting for their benefits. Their stories blew me away. I knew immediately that I wanted to do something that would give a voice to their struggle. Harnessing the power of technology, we have created a state-of-the-art data visualization tool to bring those stories to the world. It’s called The Wait We Carry.

The Wait We Carry is an interactive way for anybody to engage with the folks waiting for their benefits through their stories. There are several different search options so you can find a specific story, or you can simply take your time browsing through all of the stories. It drives our point home that there isn’t just one backlog experience. The weight of the wait is different for everybody.

The power of this tool is that it holds everybody accountable for the unacceptably long wait times. That’s why it’s crucial that this thing goes viral.

I’ve been working on this for months, and I am certain that The Wait We Carry is powerful enough to end the VA backlog for good. Make sure you check it out today — thewaitwecarry.org

Thanks,

Jacob Worrell
OIF Veteran, US Army 2004-2007
Product Strategy Associate
Iraq and Afghanistan Veterans of America (IAVA)