RESEARCH ARTICLE

Effectiveness of a neuropsychological
treatment for confabulations after brain
injury: A clinical trial with theoretical
implications
Mónica Triviño1,2*, Estrella Ródenas2, Juan Lupiáñez2,3, Marisa Arnedo2,4

1 Department of Neuropsychology. San Rafael University Hospital, Granada, Spain, 2 Mind, Brain, and
Behavior Research Center. University of Granada, Granada, Spain, 3 Department of Experimental
a1111111111 Psychology. University of Granada, Granada, Spain, 4 Department of Psychobiology. University of Granada,
a1111111111 Granada, Spain
a1111111111
a1111111111 * [email protected]
a1111111111

Abstract
Confabulators consistently generate false memories without intention to deceive and with
OPEN ACCESS
great feelings of rightness. However, to our knowledge, there is currently no known effective
Citation: Triviño M, Ródenas E, Lupiáñez J, Arnedo
treatment for them. In order to fill this gap, our aim was to design a neuropsychological treat-
M (2017) Effectiveness of a neuropsychological
treatment for confabulations after brain injury: A ment based on current theoretical models and test it experimentally in 20 confabulators
clinical trial with theoretical implications. PLoS ONE sequentially allocated to two groups: an experimental and a control group. The experimental
12(3): e0173166. doi:10.1371/journal. group received nine sessions of treatment for three weeks (three sessions per week). The
pone.0173166
sessions consisted of some brief material that participants had to learn and recall at both
Editor: Jerson Laks, Universidade Federal do Rio immediate and delayed time points. After this, patients were given feedback about their per-
de Janeiro, BRAZIL
formance (errors and correct responses). Pre- and post-treatment measurements were
Received: September 15, 2015 recorded. Confabulators in the control group were included in a waiting list for three weeks,
Accepted: February 15, 2017 performed the pre- and post- measurements without treatment, and only then received the
Published: March 3, 2017 treatment, after which a post-treatment measurement was recorded. This applied to only
half of the participants; the other half quit the study prematurely. Results showed a signifi-
Copyright: © 2017 Triviño et al. This is an open
access article distributed under the terms of the cant decrease in confabulations and a significant increase in correct responses in the exper-
Creative Commons Attribution License, which imental group; by contrast, patients in the control group did not improve during the waiting
permits unrestricted use, distribution, and list period. Only control group patients who subsequently received the treatment after serv-
reproduction in any medium, provided the original
ing as controls improved. The effects of the treatment were generalized to patients’ every-
author and source are credited.
day lives, as reported by relatives, and persisted over time. This treatment seems to be
Data Availability Statement: All relevant data are
effective and easy to implement and consequently of clinical interest. Moreover, it also has
within the paper.
theoretical implications regarding the processes related to the genesis and/or maintenance
Funding: This research was carried out in San
of confabulations. In particular, results point to a deficit in early stages of memory retrieval
Rafael University Hospital in Granada, Spain, and
was supported by the research grants from the with the preservation of later strategic monitoring processes. Specifically, some of the pro-
Spanish Ministry of Science and Education to Juan cesses involved may include selective attention or early conflict detection deficits. Future
Lupiáñez (PSI2011-22416 and PSI2014-52764-P) research should test these hypotheses.
and to Marı́a Jesús Funes (PSI2012-34158), the
research grant from the Regional Government of
Andalusia to Marı́a Jesús Funes (SEJ-6351), and
the research grant from the Progress and Health

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 1 / 25

 Effective neuropsychological treatment for confabulations

Foundation of the Regional Government of Introduction

Andalusia to Mónica Triviño (PI-0361-2014). The
funders had no role in study design, data collection A confabulation is the generation of false memories without intention to deceive. Confabula-
and analysis, decision to publish, or preparation of tors have a great feeling of rightness and show great resistance to being confronted with the
the manuscript. The study is part of a doctoral truth, which leads them to behave according to their own confabulations [1–2]. Four types of
dissertation by Estrella Ródenas, supervised by the confabulations have been proposed [3]: 1) intrusions in memory tests or simple provoked con-
other three authors. The funders had no role in
fabulations; 2) momentary confabulations or false verbal statements in a discussion or other
study design, data collection and analysis, decision
to publish, or preparation of the manuscript. situations; 3) fantastic confabulations, which have no basis in reality or logic; and 4) behaviorally
spontaneous confabulations, according to which patients act. These mnestic confabulations are
Competing interests: The authors have declared
always related to personal past memories or future plans. However, there are also non-mnestic
that no competing interests exist.
confabulations often known as paramnesic misidentification, such as reduplicative paramnesia
(the mental duplication of places or people), Capgras syndrome (misidentification of people),
Fregoli syndrome (hyperfamiliarity of unknown faces), and pseudohallucinations (misidentifi-
cation of objects). Mnestic and non-mnestic confabulations frequently co-occur. In fact, non-
mnestic confabulations have been described frequently in patients who also had behavioral or
bizarre confabulations. However, they have been dissociated, suggesting differences in their
neural basis and underlying cognitive mechanisms [3].
From a clinical viewpoint, confabulations have a major impact on daily functioning, as con-
fabulators require continuous supervision and are prevented from having normal social and
family lives. In addition, although confabulations are often described as a transient symptom,
multiple studies have shown that some patients chronically confabulate more than one year
after an injury [4–9]. As a result, it is very important to develop treatments to prevent confabu-
lations from becoming chronic and reduce their impact on patients’ functionality as well as
patients’ dependence on relatives.
However, we are only aware of two single case studies describing interventions with confab-
ulators [10–11]. Dayus and Van den Broek [10] trained a patient to reduce the number of swear
words that he said and control his many confabulations. They considered both behaviors to
reflect a deficit in self-monitoring. According to their predictions, an increase in self-control
over swear words (by reinforcing the patient every time he pressed a hand-held clicker when he
detected a swear word) would simultaneously lead to a decrease in the number of confabula-
tions. Their prediction was fulfilled after 51 sessions performed over three months. In another
study, Del Grosso et al. [11] focused on contrasting the confabulations recorded in a diary by a
patient with reality and confronting the patient with such reality. The authors considered the
central deficit to be anosognosia. An improvement was recorded after 76 sessions over three
months, in combination with conventional cognitive rehabilitation. The common point of both
interventions appears to be the systematic feedback provided about swear words or confabula-
tions, leaving no doubt about them; this seems to be critical, as providing non-systematic feed-
back seems to reinforce and favor the subsequent maintenance of confabulations.
However, although these interventions seem to be effective, they can hardly be accom-
plished in a standardized way for the following reasons: 1) the high frequency and long dura-
tion of the treatment, which might increase their efficiency but prevents their use in brief
hospitalizations during acute and subacute phases following brain injury; 2) the difficulty of
generalizing individualized procedures (e.g., the reduction of swear words) to most patients
because this type of behavior is infrequent; 3) the problems with using diaries due to the
comorbidity of severe memory deficits, writing disorders, illiteracy, visual problems, or ano-
sognosia, which lead patients to consider a diary useless; 4) the difficulty in determining the
effects of treatment when other therapies are administered simultaneously; and 5) the prob-
lems with generalizing the results due to the application of the treatment to single cases.

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 Effective neuropsychological treatment for confabulations

Hence, the main aim of the present study was to design a treatment inspired by the two pre-
vious interventions and focused on systematically contrasting momentary confabulations with
reality, while avoiding the shortcomings mentioned above. Our treatment was reasonably
short, was based on the confabulations themselves, focused on easy learning material without
diaries, and did not require another simultaneous therapy. Importantly, we based the treat-
ment on current theoretical models and tested it experimentally for the first time in a group of
confabulators.
One of the most influential models of confabulations, proposed by the Schnider group, is
the reality-filtering hypothesis [8,12–18]. This hypothesis suggests that patients fail to suppress
memory traces that were previously activated but are currently irrelevant. According to the
dual monitoring deficit proposed by the Toronto group [1–2,7,19], confabulators fail in one of
two ways: either at a very early, preconscious stage of memory retrieval, showing a deficit in
the mechanism that monitors the relevance of memory associations and the feeling of right-
ness that they generate, or in later monitoring processes, such as strategic retrieval or verifica-
tion. Other models propose variations in monitoring deficits, such as a deficit in source
monitoring, that is, the ability to locate the temporal and contextual sources of each recollec-
tion [20–21]. Recently, another approach has suggested that the core deficit is an excessive pro-
cessing of task-irrelevant information that inflates the ‘feeling of rightness’, leading to an
unsuccessful verification by later monitoring processes [6].
Based on these models, we designed a treatment and applied it to a group of patients (i.e.,
the experimental group). Results were compared to those of a control group of confabulators
who only received the treatment after serving as controls. This intervention was expected to
improve at least one or more of the following processes: 1) selective attention during the learn-
ing phase, training patients to focus on the relevant details of the stimuli that allowed them to
filter the irrelevant information; 2) monitoring processes during the retrieval phase, reinforc-
ing the strategic search processes and training patients to inhibit traces that were irrelevant for
the task; and 3) memory control processes after the retrieval phase, making patients aware of their
confabulations and teaching them to verify their memories before making decisions. If one or
more of these processes are involved in confabulations, as proposed by the above-mentioned
models, we should expect improvements among the patients. Specifically, we expected to find a
significant decrease in confabulations and an improvement in all the variables related to them.
Determining the mechanisms involved in confabulations was beyond the aim of the present
study. Yet, we expected to observe changes in behaviors and neuropsychological variables associ-
ated with either early, preconscious mechanisms (i.e., irrelevant information processing, reality fil-
tering impairment, or feeling of rightness deficit) or later, executive mechanisms (i.e., monitoring
processes), which could be useful for understanding the role of the different processes proposed.

Method
Design
After obtaining the results and verifying their clinical relevance, the study was registered as a
clinical trial on the ClinicalTrials.gov platform (ID: NCT02540772) in order to communicate
the results to the scientific community. The authors confirm that all the ongoing and related
trials required for this intervention are registered.
This trial was aimed at exploring the effectiveness of a neuropsychological treatment for con-
fabulations for three weeks. Due to the short duration of the intervention and in order to con-
trol for spontaneous recovery—given that the time since the injury was less than six months in
several patients (see below)—the treatment was compared against a control condition without
treatment (i.e., waiting list). Participants were assigned sequentially by a neuropsychologist (the

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 Effective neuropsychological treatment for confabulations

head of the San Rafael University Hospital Neuropsychology Department) to either the experi-
mental or the control group when they were referred to our unit. For ethical reasons, treatment
was also administered to participants in the control group after recording their measures for the
second time, following a three-week interval without treatment. Given that some of the first
patients allocated to the control group did not stay in the hospital enough time to complete the
treatment, patients who enrolled later were assigned to the groups according to geographical
provenance. Specifically, patients from the city of Granada were assigned to the control group
(and were later given the treatment), and patients from other towns and villages were assigned
to the experimental group. This allowed us to ensure that all participants received the treatment.
In any case, no differences were observed between firstly and lastly allocated patients in the
analyses performed subsequently.
Patients and their relatives were offered the opportunity to participate in a study in which
an experimental treatment for memory impairment was being tested. They were informed that
the treatment was harmless and consisted of learning and remembering different items, with-
out specifying that our main objective was to reduce the confabulations. Moreover, no infor-
mation about the possible outcomes was provided because they were currently being studied.
Depending on the assigned group, both participants and their relatives were informed about
one of the two procedures (i.e., treatment or waiting list before treatment) without mentioning
the existence of the other group. Only the therapist knew the group to which each patient was
assigned. The measurement and analysis of outcomes were also blinded to all the participants
and their relatives, although each participant received a clinical report with his/her neuropsy-
chological results before and after treatment (without knowing which group he/she belonged
to).
Repeated measures were included for both the experimental and control groups. Specifi-
cally, two measures were recorded in the experimental group (pre- and post-treatment), while
three were recorded in the control group (pre- and post-waiting, and post-treatment). Five of
the control patients were discharged prematurely, so the control group was divided into two
subgroups: a ’pure’ control group that never completed the treatment (we were not able to
record the post-treatment measure) and a ’mixed’ control group that completed it normally.
Moreover, five patients in the experimental group completed a long-term follow-up measure
(at three, nine, or 18 months after the treatment was finished). Fig 1 shows the CONSORT
flowchart with the selection, allocation, and follow-up of participants. More information about
the trial can be found in the CONSORT checklist included in the S1 File.

Participants
Sample size was difficult to establish, as previous studies with the same aim used single cases.
We determined that the necessary number of participants per group ranged form 6 to 10 on
the basis of our previous experience with frontal patients [22–24]. Our experience showed that
differences from a healthy or impaired control group could be significantly established (e.g., in
reaction times, accuracy or neuropsychological tests) with an N of about 10 participants. We
first collected data from six participants in each group and analyzed the data using GPower 3.1
[25] to compare the effect of treatment (pre- minus post-treatment) in the experimental group
with the effect of waiting list (pre- minus post-waiting) in the control group for a repeated
measures ANOVA. With an α value of .05 and estimated effect size of 12.10, the estimated
required sample size was four participants. Consequently, we completed the sample for up to
10 participants per group to ensure that the results were not spurious.
Thus, the sample was recruited during the period between April 2013 and April 2015 at
San Rafael Hospital. During this period, approximately 500 patients were treated at the

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 Effective neuropsychological treatment for confabulations

Fig 1. CONSORT flow diagram. The diagram shows the number of participants enrolled and those who
were excluded or assigned to each of the two groups (experimental vs. control).
doi:10.1371/journal.pone.0173166.g001

Neuropsychology Service of the hospital, where they were admitted for rehabilitation after an
acquired brain injury. Relatives or doctors reported the presence of spontaneous confabula-
tions for at least three months (from injury to the first clinical interview) and without clinical
improvement (interfering with the patient’s daily life with frequent arguments and exhaustive
supervision). Given that the treatment was intended to provoke confabulations in order to
provide feedback, the main inclusion criteria were showing momentary confabulations in the
Spanish adaptation of the Dalla Barba Provoked Confabulation Interview [26–27]. This struc-
tured interview contains 60 questions organized in the following categories: episodic knowl-
edge (e.g., what did you eat for dinner last night?), personal semantic knowledge (e.g., age,
current address), general semantic knowledge (e.g., what happened to the Twin Towers?),
semantic knowledge of words (e.g., what does ’bed’ mean?), ’I don’t know’ episodic (e.g., what
did you do on March 13, 1985?), ’I don’t know’ semantic (e.g., who won the World Cup in
1977?) and ’I don’t know’ non-words (e.g., what does ’adikapo’ mean?). Exclusion criteria
included the presence of impairment in alertness, dementia, acute confusional state, or a history
of alcohol or drug abuse, as well as a history of psychiatric illness. If the main criteria were met,
participants underwent a neuropsychological assessment (see below). From the original sample

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 5 / 25

 Effective neuropsychological treatment for confabulations

of 24 participants who showed spontaneous confabulations, two participants were excluded due
to the absence of momentary confabulations in the Dalla Barba interview. Another two partici-
pants were excluded because of a deficit in alertness in the neuropsychological assessment (see
Fig 1). Prior to their injury, all 20 patients included in the study were completely independent
in their daily living and the younger patients were occupationally active.
In addition to momentary confabulations, other types of confabulations were recorded. For
example, intrusions in memory were recorded in memory tests during the neuropsychological
assessment (see below). Additionally, both therapists and relatives recorded the presence of
behaviorally spontaneous or fantastic confabulations, as well as other non-mnestic confabula-
tions (i.e., Fregoli syndrome, Capgras syndrome, reduplicative paramnesia, and pseudohalluci-
nations). All the patients scored 10 or higher (18 on average) on the Dalla Barba interview
and had behaviorally spontaneous confabulations. Specifically, patients without motor dys-
function tried to go out or go to work and needed supervision to prevent their escape. Those
with motor deficits, such as hemiplegia, tried to walk and required mechanical restraints to
prevent their falling, but their intentions were beyond the anosognosia of hemiplegia since all
tried to do activities like going to work or doing housework. In fact, eight patients suffered
from neglect syndrome. Fantastic confabulations (i.e., false memories apparently unrelated to
past events, such as believing that the hospital is an art exhibition or that they have made
incredible journeys or met famous people) were present in 12 patients, although they were spo-
radic in six patients. Regarding non-mnestic confabulations, all patients experienced Fregoli
syndrome, 15 patients also showed reduplicative paramnesia (thus insisting on the existence of
two houses, cars, rooms, hospitals, bathrooms, gyms, roommates, etc.) and 17 had pseudohal-
lucinations. None suffered from Capgras syndrome. Information on behavioral and fantastic
confabulations, related symptoms and other relevant clinical data were obtained through the
clinical record and the questionnaire included in the Supplementary Data (S1 and S2 Tables).
The first two patients in the experimental group had received neuropsychological rehabili-
tation before the present study, without any improvement in their confabulations. The remain-
ing participants had not undergone any cognitive or behavioral interventions before the
present study, since they had been hospitalized to receive physiotherapy. As described in
Table 1 and shown in Fig 2, although with different etiologies, all the patients had lesions either
in their frontal areas or in their right hemisphere regions. The higher number of patients with
right hemisphere lesions is consistent with the increased frequency of confabulations, para-
mnesic misidentification, and anosognosia in these patients [3,28]; it is also consistent with the
presence of severe language disorders in patients with homologous lesions in the left hemi-
sphere. Table 1 shows patients’ demographic data and information on their lesions, as well as
the distribution of the patients between the experimental and control groups. The CT and
MRI images of most patients are shown in Fig 2.
The study was approved by the ethics committee of Virgen de las Nieves University Hospi-
tal (Granada, Spain) and the research met the ethical standards of the Declaration of Helsinki.
Written informed consent was obtained from all the participants. A surrogate consent proce-
dure was administered in the cases in which patients had a compromised capacity to consent.
In those cases, a next of kin or legally authorized representative consented on behalf of the par-
ticipants. This consent procedure was also approved by the same ethics committee (see S2 and
S3 Files for more detailed information).

Experimental treatment
Procedure. The experimental treatment was inspired by classical neuropsychological
memory treatments. Participants had to learn some brief material (12 stimuli per session),

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 Effective neuropsychological treatment for confabulations

Table 1. Patient demographic and lesion data.

Group Age Gender Education (in Etiology of Time from lesion (in Neuro- Localization
years) lesion months) image
Exp. 58 M 8 TBI 12 CT Bifrontal and right temporal
contusions
35 M 12 TBI 60 MRI Right fronto-temporal hematoma
68 F 8 TBI 4 CT Right fronto-parietal subdural
hematoma
68 F 12 Aneurysm in 8 MRI Frontobasal bilateral
ACoA
62 M 8 Stroke in rMCA 4 CT Right thalamus-capsular
hemorrhage
86 F 12 Stroke in rMCA 4 MRI Right parietal hematoma
59 M 8 Stroke in rMCA 5 - Basal ganglia and right frontal
lacunar infarcts
78 M 8 Stroke in rMCA 3 CT Right MCA territory ischemia
73 M 8 Stroke in rMCA 3 MRI Right thalamocapsular hematoma
52 M 6 CO2 intoxication 4 - Diffuse
Total Exp. mean = 63 3F/7M mean = 9 mean = 10.7
s.d. = 14.3 s.d. = 2.16 s.d. = 17.5
Pure 51 M 12 Stroke in rMCA 5 MRI Right occipito-parietal hematoma
Control 80 F 6 Stroke in rMCA 6 CT Right MCA territory ischemia
74 M 8 Stroke in rMCA 4 MRI Right basal ganglia ischemia
64 M 8 Stroke in rMCA 3 CT Right frontal hemorrhage
69 F 6 Hydrocephalus 42 CT Diffuse
Mixed 74 M 6 TBI 5 CT Bifrontal subdural hemorrhage
Control 66 F 15 Aneurysm in 10 MRI Frontobasal bilateral
ACoA
48 M 12 Aneurysm in 5 MRI Frontobasal bilateral
ACoA
81 F 8 Stroke in rMCA 3 CT Right MCA territory ischemia
74 F 6 Vascular MCI 12 MRI Diffuse & right frontal hyperostosis
Total mean = 68.1 5F/5M mean = 8.7 mean = 9.5
Control s.d. = 11.2 s.d. = 3.19 s.d. = 11.8

Exp. = experimental; s.d. = standard deviation; M = male; F = female; TBI = traumatic brain injury; ACoA = anterior communicating artery; rMCA = right
middle cerebral artery; MCI = mild cognitive impairment; CT = computed tomography; MRI = magnetic resonance imaging.

doi:10.1371/journal.pone.0173166.t001

after which they were asked for immediate and delayed recall. Each patient in the experimental
group underwent a total of nine treatment sessions that were different from each other during
three weeks, three sessions a week.
Regarding the learning phase, participants were told that they had to learn some stimuli
and that they would have to answer questions about such stimuli later. The treatment sessions
differed in the type of material that was presented, which was inspired by the classification of
the Dalla Barba interview. Specifically, the classification was: 1) semantic memory for words
and pictures; 2) general semantic memory; and 3) personal memory. There were 3 sessions of
each type—nine sessions in total—and the order of presentation was counterbalanced between
the sessions.
Concerning the modality of the stimuli, each session included both verbal and visual stimuli.
The ‘words and pictures’ and ‘general semantic’ sessions also included stimuli to be imagined
by the patient. The ‘personal’ sessions did not include imagined stimuli due to the difficulty of

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 Effective neuropsychological treatment for confabulations

Fig 2. Neuroimaging data. Magnetic resonance imaging (MRI) and computerized tomography (CT) of each
patient showing the main lesion: A) experimental group; B) ’pure’ control group; C) ’mixed’ control group. The
images of two patients in the experimental group (subjects 7 and 10) are missing because it was not possible
to access their medical records.
doi:10.1371/journal.pone.0173166.g002

contrasting this information with reality, which we believe is critical for the treatment to be
effective. The order of presentation of the stimuli was also counterbalanced across sessions. All
the visual stimuli, including the words and texts to be read by the patient, were presented on
the same 15-inch screen laptop computer. The therapist presented the rest of the stimuli (i.e.,
the words, texts, and stimuli to imagine).
Regarding the nature of the source, in each session the source was the patients themselves in
half of the stimuli (i.e., they imagined objects, read pieces of news, or saw pictures of events of
their lives) and the therapist in the other half (i.e., the therapist showed pictures of objects,
read a text, or showed pictures of herself to the patients). The order of presentation of the sti-
muli was also counterbalanced across sessions. After the recall of the material, patients were
asked to remember which modality corresponded to each recall (i.e., seen, heard, or imagined),
and who had presented the material or who the information was about during the learning ses-
sion (i.e., the therapist or themselves). Examples of the three variables—type of material,
modality of the stimuli, and source—are shown in more detail in Table 2. More detailed
descriptions of the stimuli are provided below, in the Stimuli section.
After the learning phase, the recall phase took place. In this phase, participants had to per-
form an immediate and a delayed recall test (after 10 minutes). A ‘free report’ paradigm—as
opposed to recognition paradigms—was chosen because only this condition allows subjects to
be responsible for the information that they have just produced [19]. At both moments (i.e.,
immediate and delayed), the patients were first asked for a free recall; if they could not

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 Effective neuropsychological treatment for confabulations

Table 2. Stimuli used in the treatment. Examples of stimuli organized depending on the type of material, the modality of stimuli, and the source (or subject
providing the information).
Type of Modality of Source Example of stimuli
material material
Words and Visual Therapist Pictures of objects presented by the therapist (e.g., a guitar)
pictures Imagined Patient Objects imagined by the patient based on semantic categories (e.g., Imagine an animal)
Verbal Therapist Words read by the therapist (e.g., child)
Patient Words read by the patient (e.g., coffee)
General Visual Therapist Faces of celebrities presented by the therapist (e.g., the king of Spain)
semantic Imagined Patient Celebrities imagined by the patient based on semantic categories (e.g., Imagine an actor)
Verbal Therapist Brief news read by the therapist (e.g., Enrique Morente died in Madrid)
Patient Brief news read by the patient (e.g., The first leg transplant in the world will take place in Valencia)
Personal Visual Therapist Photographs of the therapist (e.g., the therapist on the beach)
Patient Photographs of the patient (e.g., the patient at a wedding)
Verbal Therapist Sentences about the therapist’s or the patient’s life events, read by the therapist (e.g., Monica—the
therapist—will go to the theater at the weekend)
Patient Sentences about the therapist’s or the patient’s life events, read by the patient (e.g., Monica went
swimming yesterday)
doi:10.1371/journal.pone.0173166.t002

remember the material, they were subsequently asked for a cued recall. We used the categories
and the salient information of the stimuli (see the Stimuli section below for further details) as
cues. Next, the patients were asked to attribute a source to each recollection. The therapist
wrote the verbatim responses in a specially designed register where she could note all the
answers and cues provided. Non-responses were permitted.
After both the immediate and the delayed recall, the participants were confronted with
feedback about their correct responses, non-responses, and errors (i.e., confabulations and
errors of attribution). The main feature of this feedback was that errors were verified in 100%
of the cases, without giving patients the benefit of the doubt. This allowed us to ‘break’ the ano-
sognosia and made patients responsible for their errors. Importantly, the feedback was accom-
panied by the previously stimuli presented, which were shown again so that participants could
trust the feedback and have no doubts about it, but without a new learning phase. Specific
instructions were given that emphasized the need for patients to pay more attention to stimuli
and be more careful before answering (i.e., ’Think before answering. If you do not remember,
not answering is better than guessing’).
Before and after the treatment, three sessions (one with each type of material) were admin-
istered without feedback. These three sessions were identical before and after the treatment,
but used different material from that used in the nine treatment sessions to avoid practice
effects.
Stimuli. In the ‘semantic memory for words and pictures’ session, the patients read or lis-
tened to words, watched pictures of objects, or imagined objects. Words were extracted from a
Spanish database of four-letter words [29] in which the words were organized by frequency
(per 5 million words) and orthographic neighborhood. The selected words did not have any
neighbors with greater frequency than themselves and had F5 frequency, that is, they appeared
more than 100 times per 5 million words. We excluded all the words that were not nouns (i.e.,
verbs, prepositions, adverbs, and adjectives) and all those that could be both a noun and another
category (e.g., the word ‘swim’ can be a noun or a verb). Pictures were extracted from a Spanish
picture database [30] in which images are organized by semantic categories and classified by
familiarity on a scale of 0 to 5, with 5 being the highest familiarity. Images with a familiarity

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 Effective neuropsychological treatment for confabulations

score greater than 3.5 and belonging to different semantic categories were selected. The same
categories were used for imagined stimuli (e.g., the patient was asked to imagine a fruit).
In the ‘general semantic memory’ session, the patients read or listened to news pieces,
watched pictures of celebrities, or imagined celebrities. The news events were selected from a
local newspaper, due to the absence of a database of this type of material. News pieces were
selected based on six categories: politics, current news, tabloid press, health, sports, and bull-
fighting/culture. Half of the stimuli contained news about celebrities and the other half con-
tained news about current local or national events. None had a length greater than 100 ± 10
words and all included a headline with the most relevant information. The pictures of celebri-
ties were extracted from a Spanish database of famous faces (Espinosa & Arnedo, unpublished)
in which faces are organized by semantic categories and classified by familiarity (on a scale of
0 to 5, with 5 being the highest familiarity) and by the percentage of success in naming them.
Faces with a familiarity greater than 3.5 and success in naming >80% were selected. The same
categories were used for imagined stimuli.
Finally, in the ‘personal memory’ session, the patients were exposed to pictures of them-
selves or of the therapist as well as sentences about daily events involving them or the therapist.
The pictures of patients and biographical information were provided in advance by the rela-
tives. Half of the sentences referred to past events while the other half referred to immediate or
future activities. A maximum of four people appeared in each photograph. Half of the photos
depicted specific autobiographical events with a reference stimulus (e.g., a wedding or a trip)
and the other half depicted events without any specific reference (e.g., a beach day or time
spent in a bar with friends). A maximum of four people appeared in each photograph. Both
the semantic categories and the episodic references of each sentence and photograph were
used in the cued recall.

Neuropsychological assessment
Procedure. Both groups of patients underwent a neuropsychological assessment before the
treatment to identify the similarities them in neuropsychological variables other than the con-
fabulations. The same assessment was administered after the treatment to assess the possible
effect of the treatment on other cognitive processes and to record possible undesired effects.
The five patients of the ’mixed’ control group (who subsequently received the treatment) were
assessed before the waiting list time and after the treatment. They were not assessed after the
waiting list time to avoid the practice effect in some tests. As a result, the five patients of the
’pure’ control group only received the first assessment.
Stimuli. As mentioned above, we administered the Dalla Barba Provoked Confabulation
Interview to confirm the presence of momentary confabulations. We also performed the Audi-
tory A Test to exclude patients with alertness deficits. This test is a sustained attention task in
which patients have to identify when the therapist says the letter ’a’, among other different let-
ters. In addition, we administered two tasks (visual extinction and line cancellation) to detect
the presence of neglect syndrome, as 10 patients had experienced a stroke in the right middle
cerebral artery. We evaluated selective attention to study its relationship with early deficits lead-
ing to confabulations [31] using the Picture Completion subtest of the Wechsler Adult Intelli-
gent Scale, 3rd edition (WAIS-III). In this task, subjects have to identify the missing part of a
picture.
We also assessed variables that had been highlighted in previous studies. Specifically, we
included memory tests to assess learning, recall, and recognition abilities, since these patients
are usually amnesic and show multiple intrusions in recall as well as false positives in recogni-
tion [4,32]. Regarding auditory memory, we administered the Spanish version of the California

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 Effective neuropsychological treatment for confabulations

Verbal Learning Test (i.e., Test de Aprendizaje Verbal España Complutense, TAVEC). The test
has a learning phase (5 trials to learn a list of 16 words); an interference phase during which a
new list is presented once; a recall phase with both short- and long-term recall, as well as free
and cued recall; and finally a recognition phase, during which individuals have to recognize
the 16 words between different distractors. We assessed visual memory with the Rey Complex
Figure Test, in which subjects copy a figure. After a brief delay, they have to draw what they
remember.
Regarding executive functions, we included an animal fluency test, which has been associ-
ated with the controlled evocation deficit shown by confabulators [5–6,13]. We also included
measures of working memory, with the Digits subtest of the WAIS-III for the verbal compo-
nent and the Spatial Location subtest of the Wechsler Memory Scale, 3rd edition (WMS-III)
for the visuo-spatial component. Abstract reasoning was assessed with the Similarities subtest
of the WAIS-III, in which patients are asked about the similarity between two words. Planning
was assessed with the Key Search subtest of the Behavioral Assessment of Disexecutive Syn-
drome (BADS), in which patients have to plan a route to find a lost object (the house key) in a
large space (a field). We did not use tests that could be contaminated by the presence of neglect
in patients, such as the Wisconsin Card Sorting Test or Stroop tasks.

Measurements
The primary outcome measures were the sum of confabulations, correct responses, or non-
responses. These measures were recorded during the three sessions without feedback before
and after the treatment. The confabulations recorded were 1) guessed answers, 2) confusions
in time and space, 3) a mixture of two or more stimuli presented, and 4) devised or bizarre
responses. The scores ranged from 0 (no confabulations) to an unlimited number because of
devised or bizarre responses. Regarding the correct responses and non-responses, the scores
ranged from 0 (no correct answers) to 72 (12 stimuli remembered twice in each session: in the
immediate and delayed recall).
The secondary outcome measures were the sum of the errors and correct responses in source
attribution. The scores ranged from 0 (if all the answers were non-responses) to an unlimited
number (depending on the number of confabulations produced by patients).

Statistical analysis
The IBM SPSS 23 package was used to analyze the normality assumption for the experimental
and control groups as well as for the ’mixed’ control group by performing a Shapiro-Wilk test.
All the groups were normally distributed as regards their primary and secondary outcome
measures (all ps> 0.070). However, the assumption of normality was not met in several demo-
graphic and neuropsychological variables.
Next, in order to assess the effectiveness of the treatment, we tested for significant differ-
ences between the experimental and control groups by comparing the first two time-point
measures (pre- and post-treatment vs. pre- and post-waiting). Mean scores in confabulations,
correct responses, and non-responses, as well as correct source attribution and errors in source
attribution were submitted to a 2 (Group: experimental vs. control) x 2 (Time-point: pre- vs.
post-) mixed analysis of variance (ANOVA), with the first variable as a between-participants
factor and the other as a within-participants variable. Next, a dependent samples Student’s t
test was used to specifically analyze each group. First, we analyzed the improvement observed
in the experimental group and also obtained Cohen’s d to examine the effect sizes (small 0.2,
medium 0.5, and large 0.8) [33]. Second, we compared each variable at the three point-times
(pre-waiting, post-waiting, and post-treatment) of the ’mixed’ control group. The long-term

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 Effective neuropsychological treatment for confabulations

measurements were not analyzed due to the small number of patients in each condition (3, 6
or 18 months after the treatment finished).
Finally, we performed a nonparametric Mann-Whitney U test for independent samples to
compare the demographic data and the neuropsychological assessment in both the experimen-
tal and control groups before treatment to confirm that they did not differ in any of the vari-
ables. Meanwhile, we performed a Wilcoxon test for paired samples to compare the assessment
before and after treatment. This involved combining the experimental and the ’mixed’ control
groups (i.e., 15 patients) to explore the effect of the treatment on other cognitive processes.

Results
The groups did not differ in age, education, or time elapsed since the injury (all ps> 0.405).

Experimental treatment results

A mixed 2 (Group) x 2 (Time-point) ANOVA was performed on the mean scores of confabula-
tions, correct responses, and non-responses, as well as those of correct source attribution and
errors in source attribution (detailed data are presented in Table 3). Note that pre- and post-
waiting measures were analyzed in the control group, while pre- and post-treatment measures
were analyzed in the experimental group, through planned comparisons.
Regarding confabulations, the predicted Group x Time-point interaction was observed, F
(1,18) = 64.99; p<0.0001; μ2 = 0.783. The groups did not differ in the pre-measures, F<1, but
differed significantly in the post-measures, F(1,18) = 51.60; p<0.0001. Specifically, as can be
observed in Fig 3, the experimental group showed a significant decrease in the number of con-
fabulations after the treatment, F(1,18) = 82.43; p<0.0001, whereas the control group not only
did not improve but even showed more confabulations after three weeks without any interven-
tion, F(1,18) = 5.39; p = 0.032.
In the case of correct responses, the Group x Time-point interaction was also significant,
F(1,18) = 20.55; p = 0.0002; μ2 = 0.533. Again, the groups did not differ in the pre-measures,

Table 3. Scores before and after the treatment. Mean scores and standard deviations (sd) for confabulations, correct responses, and non-responses and
for both correct responses and errors in source attribution, organized by group and time-point measure. Note that the post-treatment measurement in the con-
trol group was performed by 5 patients. Note also that the direct scores of a single patient are shown in the post-treatment follow-up measure after both 9 and
18 months.
GROUP TIME-POINT (Sample) RESPONSES
Confabula- Correct Non- Correct source Errors in source
tions responses responses attributions attribution
Control Pre-waiting (N = 10) Mean 29.9 (13.8) 20.9 (10.6) 29.5 (11.8) 25.0 (13.2) 25.7 (12.5)
group (sd)
Post-waiting (N = 10) Mean 35.5 (11.3) 22.0 (8.9) 19.2 (8.8) 26.7 (12.1) 30.2 (11.6)
(sd)
Post-treatment (N = 5) Mean 11.0 (7.4) 39.2 (16.4) 22.6 (11.3) 37.6 (10.3) 12.4 (4.0)
(sd)
Exp. group Pre-treatment (N = 10) Mean 30.0 (9.9) 22.0 (13.6) 26.3 (15.8) 26.1 (13.7) 25.1 (6.1)
(sd)
Post-treatment (N = 10) Mean 8.1 (4.2) 42.6 (18.7) 22.3 (17.5) 38.0 (15.6) 12.2 (7.0)
(sd)
Post-treatment after 3 Mean 14.7 (13.5) 36.0 (18.4) 23.0 (7.9) 35.0 (20.1) 14.3 (14.9)
months (N = 3) (sd)
Post-treatment after 9 Direct 0 50 22 49 1
months (N = 1) score
Post-treatment after 18 Direct 6 59 12 50 13
months (N = 1) score
doi:10.1371/journal.pone.0173166.t003

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 Effective neuropsychological treatment for confabulations

Fig 3. Main results for both the experimental (left) and control (right) groups. When we compared the pre-treatment and post-treatment
measures, the experimental group showed a significant reduction in confabulations and an increase in correct responses, but non-responses
remained the same. However, when the pre-waiting and post-waiting measures were compared, confabulations not only did not decrease but
even significantly increased; non-responses decreased, while correct responses remained the same.
doi:10.1371/journal.pone.0173166.g003

F<1, but differed in the post-measures, F(1,18) = 9.91; p = 0.005. The experimental group
showed a significant increase in the number of correct responses after the treatment, F(1,18) =
45.87; p<0.0001, while the correct responses did not change in the control group, F<1.
Concerning non-responses, the main effect of Time-point was significant, F(1,18) = 22.55;
p = 0.0001; μ2 = 0.556, whereas the Group x Time-point interaction was marginally significant,
F(1,18) = 4.38; p = 0.051; μ2 = 0.195. In this case, the groups did not differ in either the pre- or
post-measures, both Fs<1. Specifically, the change in non-responses did not reach statistical signif-
icance in the experimental group after the treatment, F(1,18) = 3.53; p = 0.077, which suggests that
patients did not improve on the basis of a non-responding strategy. However, non-responses
decreased in the control group after the three weeks without treatment, F(1,18) = 23.40; p = 0.0001.
This result, together with the increase in confabulations, seems to suggest that the control group
became worse with the mere passage of time (Fig 3).
Finally, regarding correct source attribution, the main effect of Time-point was significant,
F(1,18) = 7.10; p = 0.016; μ2 = 0.283, and the Group x Time-point interaction was marginally
significant, F(1,18) = 4.00; p = 0.060; μ2 = 0.181. In fact, as shown by planned comparisons, the
performance of the control group did not differ between the time-point measurements, F<1,
while the experimental group showed a significant increase in correct source attribution, F
(1,18) = 10.88; p = 0.004. When we analyzed the errors in source attribution, the Group x
Time-point interaction was significant, F(1,18) = 21.46; p = 0.0002; μ2 = 0.544. Planned com-
parisons showed that the performance of the control group did not differ between measure-
ments, F(1,18) = 2.87; p = 0.107. However, the experimental group showed a significant
decrease in the number of errors in source attribution, F(1,18) = 23.60; p = 0.0001.
The calculations of Student’s t test and Cohen’s d for the experimental group confirmed the
previous results: confabulations decreased significantly, t(9) = 7.59; p<0.0001, with a huge
effect size, d = 2.85. Correct responses increased significantly, t(9) = -5.39; p = 0.0004, also
showing a large effect size, d = 1.25. However, non-responses did not change, t(9) = 1.51;
p = 0.164 and d = 0.24.

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 Effective neuropsychological treatment for confabulations

Fig 4. Main results of the treatment in the ‘mixed’ control group. Confabulations decreased and correct responses increased
only after the treatment was administered.
doi:10.1371/journal.pone.0173166.g004

More specifically, fewer confabulations were observed after treatment independently of the
type of material (words and pictures, general semantic, or personal), the modality of the stimuli
(visual, verbal, or imagined), the moment of the recall (immediate or delayed), and the type of recall
(free or cued), all ps<0.002. An increase in correct responses was also observed in all these condi-
tions (all ps<0.023), with the exception of the free recall condition, for which the difference was
marginal, t(9) = -2.15; p = 0.060. Non-responses decreased marginally for the imagined stimuli, t
(9) = 2.21; p = 0.054, but no significant changes were found in the number of non-responses for
any other variable (all ps>0.191). Regarding source attribution, the number of correct source
attribution responses increased significantly after treatment, t(9) = -2.71; p = 0.024, while the
number of errors in source attribution decreased significantly, t(9) = 6.83; p<0.0001.
Finally, a dependent samples Student’s t test was performed to compare each variable at the
three time points (i.e., pre-waiting, post-waiting, and post-treatment) of the ’mixed’ control
group. As in the experimental group, the number of confabulations decreased significantly only
after the treatment, t(4) = 4.73; p = 0.009, and an increase in correct responses was only
observed after the intervention, t(4) = -3.85; p = 0.018. As shown before, non-responses
decreased between the pre- and post-waiting measures, t(4) = 4.36; p = 0.012, but remained the
same after the treatment, as in the experimental group, t(4) = -1.16; p = 0.311 (see Fig 4). Regard-
ing source attribution, again the number of errors only decreased after the treatment, t(4) =
3.82; p = 0.019, whereas the increment of hits was marginally significant, t(4) = -2.33; p = 0.080.
It is important to note that the changes observed after treatment were generalized to patients’
everyday lives as reported by family members (e.g., fewer arguments and less supervision in activi-
ties of daily living). Likewise, after treatment, behaviorally spontaneous and fantastic confabula-
tions, reduplicative paramnesia, Fregoli syndrome, and pseudohallucinations had decreased

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 Effective neuropsychological treatment for confabulations

significantly or fully disappeared (see Table 4). Finally, the effect of treatment persisted beyond 18
months. Detailed data are included in Table 3.

Neuropsychological results
Before the treatment, the Mann-Whitney U test for independent samples did not show any dif-
ferences between the experimental and the control group in any of the neuropsychological var-
iables assessed (all ps>0.126). In addition, differences between the ’pure’ and ’mixed’ control
groups were not significant (all ps>0.095). See Table 5.
Patients were also assessed after treatment, which allowed us to observe the effects of treat-
ment on other neuropsychological variables as well as the presence of undesired consequences.
A Wilcoxon test for paired samples (see Table 6) showed a significant reduction of confabula-
tions in the Dalla Barba interview (T = 3.0; p = 0.001) and a significant improvement in some
of the variables related to confabulations in previous literature.
More specifically, selective attention improved but not significantly (picture completion:
T = 24.5; p = 0.079). Regarding the memory variables, we found significant reductions in per-
severations (T = 4.0; p = 0.028) and intrusions in free and cued recall (T = 1.0; p = 0.003 and
T = 5.0; p = 0.013, respectively), and a significant decrease in false positives in recognition
(T = 7.0; p = 0.012), with a consequent improvement in the ability to discriminate between
learned and novel material (T = 6.5; p = 0.010)—note that the discriminability index is computed
by comparing hits and false positives in recognition—. However, none of the other memory vari-
ables changed after treatment and the deficits in learning and recall persisted (all ps>0.176).
Moreover, although deficits in immediate recall and copy of the Rey Complex Figure improved,
they persisted (T = 1.0; p = 0.079 and T = 7.0; p = 0.066, respectively), but the presence of confab-
ulations (i.e., houses or rockets) decreased significantly (p = 0.015; a chi-square test was con-
ducted with a 95% confidence interval to compare the proportion of confabulations between
performance at pre-treatment and post-treatment). With regard to executive functions, none of
the variables changed after the treatment, although planning showed a marginal improvement
(key search: T = 18.0; p = 0.055). Therefore, since the neuropsychological variables improved or
remained the same, administering the treatment did not lead to any undesired effects.

Discussion
This study presents the effectiveness of a new treatment for confabulations after an acquired
brain injury. To our knowledge, this is the first time that a treatment of this nature has been
administered to a group of confabulators and tested against a waiting list control group.
Patients only improved after the treatment was administered, as observed in both the experi-
mental and the ’mixed’ control groups. After treatment, patients were not only able to remem-
ber the information more correctly but also to determine the modality of their recall (i.e.,
visual, verbal, or imagined) and the source of the information (i.e., the therapist or them-
selves). Moreover, this improvement was reflected in other neuropsychological variables and
in the daily lives of patients according to their relatives’ reports, and seemed to persist over
time. Importantly, all patients improved, regardless of the etiology of their confabulations.
The current results are promising, although some limitations should be acknowledged in
the study, due to the small sample and the potential bias caused by conducting an interim anal-
ysis before recruiting more patients to complete the sample. Future studies should replicate the
effectiveness of the present study in a larger sample of patients and compare the results of the
treatment group against those observed in an active control group; this will make it possible to
achieve a more appropriate blinding procedure. Also, it will be interesting for future studies to
verify whether a similar improvement occurs in other types of confabulations associated with

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 Table 4. Confabulations shown by patients and other comorbid symptoms. Mnestic and non-mnestic confabulations reported by relatives and therapists at pre-treatment or pre-
waiting (Pre), post-waiting (Post-W), and post-treatment (Post-T).
Behaviorally spontaneous Fantastic confabulations Fregoli syndrome Reduplicative paramnesia Pseudohallucinations
confabulations
Group Etiology Pre Post-W Post-T Pre Post-W Post-T Pre Post-W Post-T Pre Post-W Post-T Pre Post-W Post-T
Exp. group TBI Daily - Absent Absent - Absent Daily - Absent Daily - Absent Sporadic - Absent
TBI Daily - Absent Absent - Absent Sporadic - Absent Absent - Absent Absent - Absent
TBI Daily - Absent Sporadic - Absent Daily - Absent Absent - Absent Daily - Absent
ACoA Daily - Absent Daily - Absent Daily - Absent Daily - Absent Daily - Absent
rMCA* Daily - Absent Daily - Absent Daily - Absent Daily - Absent Daily - Absent
rMCA* Daily - Absent Absent - Absent Sporadic - Absent Absent - Absent Sporadic - Absent
rMCA Sporadic - Absent Sporadic - Sporadic Daily - Sporadic Daily - Absent Daily - Sporadic
rMCA Daily - Absent Sporadic - Absent Daily - Absent Absent - Absent Daily - Absent
rMCA* Daily - Sporadic Daily - Sporadic Daily - Absent Daily - Absent Daily - Absent
CO2 Intoxication Daily - Absent Absent - Absent Sporadic - Absent Absent - Absent Sporadic - Absent
Total experimental group 10/10 - 1/10 6/10 - 2/10 10/10 - 1/10 5/10 - 0/10 9/10 - 1/10

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017

Pure control group rMCA* Daily Daily - Daily Daily - Daily Daily - Daily Daily - Daily Daily -
rMCA* Daily Daily - Daily Daily - Daily Daily - Daily Daily - Absent Absent -
rMCA* Daily Daily - Sporadic Sporadic - Daily Daily - Daily Daily - Daily Daily -
rMCA* Daily Daily - Absent Absent - Daily Daily - Daily Daily - Daily Daily -
Hydroce-phalus Daily Daily - Absent Absent - Daily Daily - Daily Daily - Daily Daily -
Mixed control group TBI Daily Daily Absent Daily Daily Absent Daily Daily Sporadic Daily Daily Absent Daily Daily Absent
ACoA Daily Daily Sporadic Absent Absent Absent Daily Daily Daily Daily Daily Absent Daily Daily Sporadic
ACoA Daily Daily Absent Absent Absent Absent Daily Daily Sporadic Daily Daily Absent Daily Daily Absent
rMCA* Daily Daily Absent Sporadic Sporadic Absent Daily Daily Absent Daily Daily Absent Daily Daily Absent
Vascular Daily Daily Absent Sporadic Sporadic Absent Sporadic Sporadic Absent Sporadic Sporadic Absent Absent Absent Absent
MCI
Total control group 10/10 10/10 1/5 6/10 6/10 0/5 10/10 10/10 3/5 10/10 10/10 0/5 8/10 8/10 1/5
Total 20/20 10/10 2/15 12/20 6/10 2/15 20/20 10/10 4/15 15/20 10/10 0/15 17/20 8/10 2/15

Exp. = experimental; TBI = traumatic brain injury; AcoA = anterior communicating artery; rMCA = right middle cerebral artery; MCI = mild cognitive impairment; Daily = once or more
per day; Sporadic = once or less per week; Absent = not present.
* Patients with neglect syndrome.

doi:10.1371/journal.pone.0173166.t004

16 / 25
Effective neuropsychological treatment for confabulations
 Effective neuropsychological treatment for confabulations

Table 5. Neuropsychological results before the treatment. Mean scores and standard deviations (in parentheses) for each test in both control (pre-wait-
ing) and experimental (pre-treatment) groups, as well as the results of the comparison between them. The scores of the control group are divided into two sub-
groups (’pure’ and ’mixed’).
FUNCTION Pre-Waiting Pre-Treat. Comparison
Test, subtest, and score Pure Mixed Total Exp. Mann-Whitney U
N=5 N=5 N = 10 N = 10
Confabulations
Dalla Barba Provoked Confabulation Interview
Total number of confabulations 20.0 (6.7)* 15.4 (4.3)* 17.7 (5.8)* 18.4 (3.6)* U = 46.5;
p = 0.790
Attention
Sustained attention. Continuous Performance Test
Auditory A Test (Total errors) 0.4 (0.5) 0.4 (0.5) 0.4 (0.5) 2.0 (3.3) U = 39.0;
p = 0.355
Selective attention
Picture Completion Subtest of WAIS-III (SS) 3.2 (2.5)* 5.2 (1.8)* 4.2 (2.3)* 4.4 (4.4)* U = 41.5;
p = 0.512
Verbal memory
Test Aprendizaje Verbal España Complutense TAVEC** (DS)
Learning 19.6 (6.7)* 21.8 (8.1)* 20.7 (7.1)* 21.7 (10.9)* U = 39.5:
p = 0.964
Short-term free recall 1.4 (1.7)* 0.8 (1.3)* 1.1 (1.4)* 2.1 (2.0)* U = 27.5;
p = 0.249
Short-term cued recall 2.6 (2.5)* 2.4 (2.3)* 2.5 (2.3)* 3.0 (2.1)* U = 33.5;
p = 0.559
Long-term free recall 0.6 (0.9)* 1.0 (2.2)* 0.8 (1.6)* 2.4 (3.1)* U = 26.0;
p = 0.172
Long-term cued recall 2.8 (1.8)* 1.4 (1.1)* 2.1 (1.6)* 2.3 (1.9)* U = 36.0;
p = 0.709
Intrusions in free recall 4.6 (2.1) 7.6 (3.8)* 6.1 (3.3)* 14.4 (20.4)* U = 30.5:
p = 0.397
Intrusions in cued recall 8.8 (2.3)* 10.8 (7.3)* 9.8 (5.2)* 14.0 (12.9)* U = 32.5;
p = 0.503
Perseverations 2.4 (4.8) 3.2 (2.7) 2.8 (3.7) 7.1 (8.3) U = 24.5;
p = 0.163
Recognition 11.6 (3.8)* 13.0 (2.3)* 12.3 (3.1)* 12.4 (3.1)* U = 37.5;
p = 0.822
False positives in recognition 8.2 (4.5)* 14.6 (5.0)* 11.4 (5.6)* 11.1 (6.2)* U = 39.0;
p = 0.929
Discriminability index 71.6 (4.6)* 60.0 (14.9)* 65.8 (12.1)* 64.7 (10.3)* U = 32.0;
p = 0.476
Visual memory
Rey Complex Figure Test
Immediate recall (DS) 1.0 (0.0)* 1.0 (0.0)* 1.0 (0.0)* 2.0 (2.9)* U = 35.0;
p = 0.126
Presence of confabulations in immediate recall (no. of patients with 3/5 3/5 6/10 7/10 p = 0.645
confabulations/total patients) ***
Constructive praxis
Rey Complex Figure Test
Copy (DS) 1.0 (0.0)* 6.6 (5.9)* 3.8 (2.9)* 2.9 (3.2)* U = 42.0;
p = 0.752
Presence of confabulations in copy (no. of patients with confabulations/total 0/5 0/5 0/10 0/10 p = 1.000
patients) ***
Executive functions
(Continued)

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 Effective neuropsychological treatment for confabulations

Table 5. (Continued)

FUNCTION Pre-Waiting Pre-Treat. Comparison

Test, subtest, and score Pure Mixed Total Exp. Mann-Whitney U
N=5 N=5 N = 10 N = 10
Digit Span Subtest of WAIS-III (SS) 8.0 (2.1) 9.6 (3.0) 8.8 (2.6) 7.6 (3.5)* U = 40.0;
p = 0.447
Spatial Span Subtest of WMS-III (SS) 5.2 (2.9)* 6.8 (1.3)* 6.0 (2.3)* 6.1 (2.5)* U = 48.5;
p = 0.909
Similarities Subtest of WAIS-III (SS) 9.2 (2.4) 7.6 (4.5)* 8.4 (3.5) 9.2 (4.4) U = 49.0;
p = 0.939
Animal Fluency Test (DS) 6.8 (2.6) * 8.8 (3.7)* 7.8 (3.2)* 8.7 (4.5)* U = 48.5;
p = 0.909
Planning-Key Search Test of BADS (DS) 3.6 (2.7)* 5.8 (5.5)* 4.7 (4.2)* 5.5 (3.6)* U = 35.5;
p = 0.433

WAIS-III = Wechsler Adult Intelligence Scale, 3rd edition; WMS-III = Wechsler Memory Scale, 3rd edition; BADS = Behavioral Assessment of Disexecutive
Syndrome; DS = direct score; SS = scaled score.
* Pathological scores
** Spanish version of the California Verbal Auditory Test
*** The proportion of confabulations was analyzed using a two-tailed chi-square test with 95% confidence.

doi:10.1371/journal.pone.0173166.t005

progressive brain injury, such as Alzheimer’s disease, or in patients with disorders caused by
alcohol abuse, such as Korsakoff syndrome. It would also be interesting to know whether
patients showing spontaneous but not momentary confabulations also benefit from our
treatment.
Importantly, our results cannot be explained on the basis of spontaneous recovery, as
shown by the second assessment of the waiting list control group. Indeed, our patients had
been confabulating for several months without any improvement, as demonstrated by the
reports of their family members. In fact, the second measure taken after three weeks (equiva-
lent to the duration of the treatment) showed an increase in confabulations in the control
group as well as a decrease in non-responses. Therefore, letting patients confabulate seems to
induce more confabulations rather than spontaneous recovery. It is important to note that in
real life it is usually difficult, if not impossible, to show confabulators definitive evidence dem-
onstrating their confabulations. This is because patients usually make secondary supporting
claims that may be simple rationalizations or secondary confabulations [34] and sometimes
even their confabulations have some real evidence. Another important factor why family con-
frontation is usually not effective could be that patients might not trust relatives as much as
they trust the therapist, who has some medical authority over them that relatives do not have.
All these factors may explain why confrontation by the therapist in an experimentally con-
trolled and systematic setting clearly seems to work, whereas non-systematic confrontation by
relatives sometimes even increases confabulations.
Furthermore, our treatment has some innovative traits compared to those implemented
previously. First, it managed to decrease the number of confabulations in a very short time, so
it can be easily applied in hospitals allowing for early intervention. Second, it focuses only on
confabulations without applying other therapies that may interfere with the results, and uses
simple and versatile materials that can be adapted to the age, educational level, and sensorimo-
tor difficulties of each patient. Finally, it is based on a variety of tasks influencing multiple
processes that are traditionally impaired in confabulators and always implies the active partici-
pation of the patient, which is considered a very effective method in rehabilitation [10].

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 Effective neuropsychological treatment for confabulations

Table 6. Neuropsychological results after the treatment. Mean scores and standard deviations (in parentheses) for each test, both at pre-treatment and
post-treatment, and results of the comparison between them. Only data from 15 patients are reported (10 from the experimental group and 5 from the ’mixed’
control group).
FUNCTION Pre-T Post-T Wilcoxon Test
Test, subtest, and score N = 15 N = 15
Confabulations
Dalla Barba Provoked Confabulation interview
Total number of confabulations 17.4 (3.9)* 7.4 (4.3) T = 3.0; p = 0.001
Attention
Sustained attention. Continuous Performance Test
Auditory A Test (Total errors) 1.5 (2.7) 0.3 (0.7) T = 5.0; p = 0.249
Selective attention
Picture Completion Subtest of WAIS-III (SS) 4.7 (3.7)* 6.4 (2.1)* T = 24.5; p = 0.079
Verbal memory
Test Aprendizaje Verbal España Complutense, TAVEC** (DS)
Learning 21.8 (9.5)* 34.7 (30.2)* T = 34.0; p = 0.421
Short-term free recall 1.6 (1.8)* 1.9 (2.8)* T = 26.0; p = 0.878
Short-term cued recall 2.8 (2.1)* 3.3 (2.8)* T = 21.5; p = 0.540
Long-term free recall 1.9 (2.8)* 2.1 (2.4)* T = 13.0; p = 0.484
Long-term cued recall 2.0 (1.7)* 3.1 (2.9)* T = 6.0; p = 0.176
Intrusions in free recall 11.8(16.1)* 5.4 (10.2) T = 0.0; p = 0.003
Intrusions in cued recall 12.8 (10.8)* 3.9 (3.9) T = 5.0; p = 0.013
Perseverations 5.6 (6.8) 2.6 (3.1) T = 4.0; p = 0.028
Recognition 12.6 (2.8)* 13.2 (3.4)* T = 32.5; p = 0.964
False positives in recognition 12.5 (5.8)* 7.4 (5.6) T = 7.0; p = 0.012
Discriminability index 62.9 (11.9)* 76.7 (9.7) T = 6.5; p = 0.010
Visual memory
Rey Complex Figure Test
Immediate recall (DS) 1.7 (2.4)* 6.6 (10.8)* T = 1.0; p = 0.079
Presence of confabulations in immediate recall 11/15 4/15 p = 0.015
(no. of patients with confabulations/total patients) ***
Constructive praxia
Rey Complex Figure Test
Copy (DS) 7.1 (12.3)* 22.3 (29.9)* T = 7.0; p = 0.066
Presence of confabulations in copy (no. of patients with confabulations/total patients) *** 0/15 0/15 p = 1.000
Executive functions
Digit Span Subtest of WAIS-III (SS) 8.3 (3.4) 8.7 (2.3) T = 32.0; p = 0.583
Spatial Span Subtest of WMS-III (SS) 6.3 (2.2)* 7.2 (1.9)* T = 8.0; p = 0.085
Similarities Subtest of WAIS-III (SS) 8.7 (4.4) 10.1 (2.3) T = 21.0; p = 0.286
Animal Fluency Test (DS) 8.7 (4.1)* 9.8 (5.1)* T = 35.5; p = 0.485
Planning-Key Search Test of BADS (DS) 5.6 (4.1)* 7.8 (3.3) T = 18.0; p = 0.055

WAIS-III = Wechsler Adult Intelligence Scale, 3rd edition; WMS-III = Wechsler Memory Scale, 3rd edition; BADS = Behavioral Assessment of Disexecutive
Syndrome; DS = direct score; SS = scaled score.
* Pathological scores
** Spanish version of the California Verbal Auditory Test
*** The proportion of confabulations was analyzed using a two-tailed chi-square test with 95% confidence.

doi:10.1371/journal.pone.0173166.t006

Besides the relevance of these results from a clinical point of view, they may also have theo-
retical implications for explanatory models of confabulations. Why was the treatment so

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 19 / 25

 Effective neuropsychological treatment for confabulations

effective after only nine sessions? Which processes are involved in such an improvement? Con-
fabulations clearly cannot be explained by a memory deficit alone because some amnesic
patients do not confabulate. In addition, the patients whose confabulations decreased with our
treatment still showed general deficits in verbal and visual memory, although treatment
decreased perseverations, intrusions in free recall, and false positives in recognition.
In addition to memory problems, deficits in executive functions have also been proposed,
particularly in the monitoring and top-down control processes involved in memory retrieval
[19]. Nevertheless, some authors consider instead that bottom-up mechanisms are the basis of
confabulations. For example, Ciaramelli et al. [6] consider the main deficit of confabulators to
be early processing of irrelevant information, while Schnider [12] attributes confabulations to
an impairment in reality filtering. Perhaps both top-down and bottom-up mechanisms are
involved [19,35–36]. The tasks included in this treatment are evidently associated not only to
top-down mechanisms (e.g., awareness of memory problems and the falsehood of some mem-
ories, reorientation regarding the temporal context, monitoring, and logical inferences) but
also to bottom-up mechanisms (e.g., careful visual search, familiarity, and global and local per-
ception). Indeed, the joint action on both top-down and bottom-up mechanisms may be
responsible for the efficacy of our treatment in such short time.
In any case, if all these processes were impaired directly by the brain injury, their restora-
tion would be impossible or would take longer than three weeks. The fast recovery can only be
explained if some of these processes were affected but not completely impaired after brain
damage. As proposed by Ciaramelli et al. [6], top-down processes may be preserved but not
recruited. As proposed by Shallice [34,37], this strategic system is recruited 1) when competing
stimuli are likely to produce a mistake; 2) in conditions of uncertainty; or 3) when online mon-
itoring is required. Our results suggest that in confabulators this early competition between
representations and the consequent uncertainty never happens by default, leading to a selec-
tion of representations that the system does not verify and consequently does not call into
question. In fact, confabulators usually have no doubts about their memory (this is known as
the feeling of rightness). However, and importantly, the patients in our study reduced their out-
puts in the post-treatment measure, expressed low certainty in the few confabulations that
appeared sporadically after treatment, and were more aware of their memory deficits. There-
fore, the treatment seems to restore these memory control processes, a result recently reported
in patients who had a history of confabulations, compared to those who still confabulated [38].
Whether this improvement in control processes is what makes patients gain insight or vice
versa should be tested in future studies.
Recently, Gosh and Gilboa [39] reviewed the characteristics of memory schemas. Cross-
connectivity is an important feature to which schemas are sensitive, with the consequent com-
petition between them in the selection process (see [40–43] for other models suggesting cumu-
lative mechanisms in a successful retrieval). Therefore, a schema will be selected when its
activation is greater than that of its competitors. Confabulations could be related to schemas
that are sensitive to cross-connectivity, and failure in the competition processes may be the
key factor in producing them. Based on these models, we suggest that the selection of a specific
representation in memory (either a visual representation of a real object or a representation of
an autobiographical, past event) depends on early processing of the properties of the stimuli.
As the properties of a stimulus are being processed, certain representations are activated and
others are discarded. Activated representations start to accumulate matched properties. A
representation will be selected if it shows the highest correspondence with the properties of the
target stimulus (e.g., an object, a face, or an episodic event). Consequently, error detection and
verification processes will not be recruited because they are not necessary. By contrast, if sev-
eral (i.e., two or more) representations achieve an equivalent accumulation of matched

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 20 / 25

 Effective neuropsychological treatment for confabulations

properties, the monitoring processes will be recruited to detect the conflict and begin an effort-
ful and strategic search to resolve it, adding information that will be used to select one repre-
sentation over its competitors.
In fact, we have observed that confabulators showed serious difficulties in a visual search
task, especially when the target and the distractors were physically similar and therefore had
interconnected representations in memory [44]. In addition, they also seemed to have difficul-
ties detecting a stimulus-response conflict (i.e., Simon effect), especially when the target was
surrounded by distractors [45]. Future research should determine whether confabulations are
related to altered processing of stimuli properties or to conflict detection deficits.
Such a mechanism may explain the similarities between mnestic and non-mnestic confabu-
lations. These two types of confabulations are supported by different neural circuits: the ante-
rior limbic system in mnestic confabulations and right hemispheric lesions in non-mnestic
confabulations, which could explain the dissociation often described in the literature [3,46].
However, these neural bases seem to have a common target in the ventromedial prefrontal cor-
tex which may account for the frequency of comorbidities, the similarities between them, and
the improvement of both after our treatment. Future studies exploring the common and differ-
ent neural bases as well as cognitive mechanisms involved in mnestic and non-mnestic confab-
ulations could be of great interest to better understand this phenomenon.
Finally, changes in the neuropsychological tasks also provided some clues about what may
happen after treatment. Normal scores in working memory and similarities usually indicate
that the dorsolateral circuits involved in executive functions are preserved in most confabula-
tors [5, 47]. However, we observed a large number of intrusions and false positives in memory
tasks and an impairment of selective attention in picture completion and planning. In the Pic-
ture Completion subtest (WAIS-III), any detail could catch the patient’s attention and prevent
him/her from tracking the entire figure to find the missing part. For example, almost all of the
patients in our sample were unable to realize the absence of a leg on a table or the absence of a
nose on a face. Erroneously, they thought that a tablecloth or a vase was missing from the
table, and glasses or a hat were missing from a face. Moreover, when presented with the Rey
Complex Figure, confabulators focused their attention on specific details without attending
holistically to the figure and thereafter developed a response based on these details with abso-
lute certainty, as mentioned above. For example, they drew houses, tents, or mills attending to
the triangular shape on the right, drew stairs attending to the four lines on the left, or drew a
face attending to the circle with three dots inside.
After treatment, the greatest improvements were observed in several discriminability
scores, with results never described in the literature before. Specifically, perseverations, false
positives, and intrusions were reduced significantly, as were the number of confabulations in
the Rey Complex Figure Test. Although these results should be interpreted with caution, they
seem to support the idea that the top-down ability to monitor and selectively attend to stimuli
properties and control the output improved after treatment. Since several of our patients
showed both mnestic and non-mnestic confabulations, it will clearly be interesting to perform
future correlation and regression analyses with a larger sample size to study which neuropsy-
chological variables are related to each type of confabulation in similar or differential ways.
In summary, this study presents a useful and efficient tool in the clinical setting that could
improve the quality of life of confabulators, as it dramatically reduced their confabulations in
just three weeks, after nine sessions of treatment. Future studies should replicate the results of
the treatment in a larger sample. Although assessing the genesis of confabulations was not the
purpose of our study, we also obtained some clues about the mechanisms involved in generat-
ing confabulations, pointing to a deficit in the early selection of interconnected representations
in memory and a preservation of top-down retrieval-monitoring processes, which are

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 Effective neuropsychological treatment for confabulations

nevertheless not used during confabulations. The empirical basis for selective attention and
conflict-detection deficits in selecting representations from memory should also be tested in
future studies. Finally, it would be interesting to introduce event-related potentials (ERPs) or
functional neuroimaging studies before and after the treatment. This would allow testing
whether the treatment leads to a functional recruitment of monitoring processes that depend
on more lateral circuits, while early deficits—which presumably depend on more ventromedial
and anterior limbic circuits—remain impaired. Moreover, studies involving diffusion tensor
imaging could help to define the circuits involved in different types of confabulations in order
to better understand the common and differing mechanisms. The fact that changes in white
matter have been detected with these techniques after training [48] makes such future studies
quite promising.

Supporting information
S1 Table. Clinical record. The therapist completed it for each patient based on both the medi-
cal history and the neuropsychological assessment.
(DOCX)
S2 Table. Confabulations (and related symptoms) questionnaire administered to relatives
before and after the treatment. The questions were asked by the therapist who also wrote
down the answers.
(DOCX)
S1 File. CONSORT 2010 checklist. This checklist includes all the information to include
when reporting a randomised trial.
(PDF)
S2 File. Spanish version of the memory of the project. The memory was submitted to the
Ethics Committee of Virgen de las Nieves University Hospital (Granada, Spain) for its
approval.
(PDF)
S3 File. English translation of the memory of the project submitted to the Ethics Commit-
tee of Virgen de las Nieves University Hospital (Granada, Spain).
(PDF)

Author Contributions
Conceptualization: MT ER JL MA.
Data curation: MT ER.
Formal analysis: MT ER JL MA.
Funding acquisition: MT JL.
Investigation: MT ER.
Methodology: MT ER JL MA.
Project administration: MT.
Resources: MT.
Supervision: MT.

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 22 / 25

 Effective neuropsychological treatment for confabulations

Validation: MT ER MA.
Visualization: MT ER JL MA.
Writing – original draft: MT.
Writing – review & editing: MT ER JL MA.

References
1. Gilboa A, Alain C, Stuss DT, Melo B, Miller S, Moscovitch M. Mechanisms of spontaneous confabula-
tions: A strategic retrieval account. Brain, 2006; 129(6):1399–1414.
2. Moscovitch M, Melo B. Strategic retrieval and the frontal lobes: Evidence from confabulation and amne-
sia. Neuropsychologia, 1997; 35(7):1017–1034. PMID: 9226662
3. Schnider A. The confabulating mind. How the brain creates reality. Oxford: Oxford University Press;
2008.
4. Nahum L, Wahlen A, Guggisberg A, Ptak R, Schnider A. Forms of confabulations: dissociations and
associations. Neuropsychologia, 2012; 50:2524–2534. doi: 10.1016/j.neuropsychologia.2012.06.026
PMID: 22781813
5. Turner MS, Cipolotti L, Yousry TA, Shallice T. Confabulation: damage to a specific inferior medial pre-
frontal system. Cortex, 2008; 44:637–648. doi: 10.1016/j.cortex.2007.01.002 PMID: 18472034
6. Ciaramelli E, Ghetti S, Borsotti M. Divided attention during retrieval suppresses false recognition in
confabulation. Cortex, 2009; 45:141–153. doi: 10.1016/j.cortex.2007.10.006 PMID: 19150516
7. Gilboa A, Alain C, He Y, Stuss DT, Moscovitch M. Ventromedial prefrontal cortex lesions produce early
functional alterations during remote memory retrieval. J Neurosci, 2009; 29(15):4883–4893.
8. Schnider A, Ptak R, von Däniken C, Remonda L. Recovery from spontaneous confabulations parallels
recovery of temporal confusion in memory. Neurology, 2000; 55:74–83. PMID: 10891909
9. Turner MS, Cipolotti L, Shallice T. Spontaneous confabulation, temporal context confusion and reality
monitoring: a study of three patients with anterior communicating artery aneurysms. JINS, 2010;
16:984–994. doi: 10.1017/S1355617710001104 PMID: 20961471
10. Dayus B, Van den Broek MD. Treatment of stable delusional confabulations using self-monitoring train-
ing. Neuropsychol Rehabil, 2000; 10(4):415–427.
11. Del Grosso DN, Farina E, Calabrese E, Pinardi G, Imbornone E, Mariani C. (2002). Frontal impairment
and confabulation after herpes simplex encephalitis: A case report. Arch Phys Med Rehab, 2002; 83
(3):423–426.
12. Nahum L, Ptak R, Leemann B, Lalive P, Schnider A. Behaviorally spontaneous confabulation in limbic
encephalitis: the roles of reality filtering and strategic monitoring. JINS, 2010; 16:995–1005. doi: 10.
1017/S1355617710000780 PMID: 20719042
13. Nahum L, Ptak R, Leemann B, Schnider A. Disorientation, confabulation and extinction capacity: clues
on how the brain creates reality. Biol Psychiat, 2009; 65:966–972. doi: 10.1016/j.biopsych.2009.01.007
PMID: 19217613
14. Ptak R, Schnider A. Spontaneous confabulations after orbitofrontal damage: The role of temporal con-
text confusion and self-monitoring. Neurocase, 1999; 5:243–250.
15. Schnider A. Spontaneous confabulation and the adaptation of thought to ongoing reality. Nat Rev Neu-
rosci, 2003; 4:662–671. doi: 10.1038/nrn1179 PMID: 12894241
16. Schnider A. Orbitofrontal reality filtering. Front Behav Neurosci, 2013; 7:1–10.
17. Schnider A, Ptak R. Spontaneous confabulators fail to suppress currently irrelevant memory traces. Nat
Neurosci, 1999; 2:677–681. doi: 10.1038/10236 PMID: 10404203
18. Schnider A, von Däniken C, Gutbrod K. The mechanisms of spontaneous and provoked confabulations.
Brain, 1996; 119:1365–1375. PMID: 8813298
19. Gilboa A. Strategic retrieval, confabulations, and delusions: Theory and data. Cogn Neuropsychiatry,
2010; 15(1–3):145–180.
20. Johnson MK, Hashtroudi S, Lindsay DS. Source monitoring. Psychol Bull, 1993; 114(1):3–28. PMID:
8346328
21. Johnson MK, Raye CL. Falses memories and confabulations. Trends Cogn Sci, 1998; 2(4):137–145.
PMID: 21227110
22. Triviño M, Correa A, Arnedo M, Lupiáñez J. Temporal orienting deficit after prefrontal damage. Brain,
2010; 13(4):1173–1185.

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 23 / 25

 Effective neuropsychological treatment for confabulations

23. Triviño M, Arnedo M, Lupiáñez J, Chirivella J, Correa A. Rhythms can overcome temporal orienting defi-
cit after right frontal damage. Neuropsychologia, 2011; 49(14):3917–3930. doi: 10.1016/j.
neuropsychologia.2011.10.009 PMID: 22019698
24. Rodrı́guez-Bailón M, Triviño M, Lupiáñez J. Executive attention and personality variables in patients
with frontal lobe damage. Span J Psychol, 2012; 15(3):967–977. PMID: 23156906
25. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for
the social, behavioral, and biomedical sciences. Behav Res Methods, 2007; 39(2):175–191. PMID:
17695343
26. Dalla Barba G, Nedjam Z, Dubois B. Confabulation, executive functions and source memory in Alzhei-
mer’s disease. Cogn Neuropsychol, 1999; 16(3–5):385–398.
27. Llorente AI. La confabulación en la demencia de Alzheimer en fase leve. M. Sc. Thesis. Universidad
Autónoma de Barcelona, Barcelona, 2008.
28. Venneri A, Shanks MF. Belief and awareness: reflections on a case of persistent anosognosia. Neurop-
sychologia, 2004; 42:230–238. PMID: 14644108
29. Alameda JR, Cuetos F. Indices de frecuencia y vecindad ortografica para un corpus de palabras de
cuatro letras. Rev Electronic Metodol Apli, 1996; 1(1):11–29.
30. Pérez MA, Navalón C. Normas españolas de 290 nuevos dibujos: acuerdo en la denominación, concor-
dancia de la imagen, familiaridad, complejidad visual y variabilidad de la imagen. Psicológica, 2003;
24:215–241.
31. Lavie N. Distracted or confused?: Selective attention under load. Trends Cogn Sci, 2005; 9(2):75–82.
doi: 10.1016/j.tics.2004.12.004 PMID: 15668100
32. Turner MS, Cipolotti L, Yousry TA, Shallice T. Qualitatively different memory impairments across frontal
lobe subgroups. Neuropsychologia, 2007; 45:1540–1552. doi: 10.1016/j.neuropsychologia.2006.11.
013 PMID: 17196997
33. Cohen J. Statistical Power Analysis for the Behavioral Sciences, 2nd ed. Hillsdale, New Jersey: Erl-
baum; 1988.
34. Gilboa A, Moscovitch M. The cognitive neuroscience of confabulation: A review and a model. In: Badde-
ley AD, Kopelman MD, Wilson BA, editors. The handbook of memory disorders. 2nd ed. London:
Wiley; 2002. pp. 315–342.
35. Kan IP, Larocque KF, Lafleche G, Coslett HB, Verfaellie M. Memory monitoring failure in confabulation:
evidence from the semantic illusion paradigm. JINS, 2010; 16:1006–1017. doi: 10.1017/
S1355617710000536 PMID: 20630119
36. Turner MS, Coltheart M. Confabulation and delusion: a common monitoring framework. Cogn Neuro-
psychiatry, 2010; 15(1/2/3):346–376.
37. Shallice T. Deconstructing retrieval mode. In: Naveh-Benjamin M, Moscovitch M, Roediger H, editors.
Perspectives of human memory and cognitive aging: essays in honour of fergus craik. New York: Psy-
chology Press; 2001.
38. Hebscher M, Barkan-Abramski M, Goldsmith M, Aharon-Peretz J, Gilboa A. Memory, decision-making,
and the ventromedial prefrontal cortex (vmPFC): the roles of subcallosal and posterior orbitofrontal cor-
tices in monitoring and control processes. Cereb Cortex, 2015; October 1,
39. Ghosh VE, Gilboa A. What is a memory schema? A historical perspective on current neuroscience liter-
ature. Neuropsychologia, 2014; 53:104–114. doi: 10.1016/j.neuropsychologia.2013.11.010 PMID:
24280650
40. Donaldson DI, Wheeler ME, Petersen SE. Remember the source: dissociating frontal and parietal con-
tributions to episodic memory. J Cogn Neurosci, 2009; 22(2):377–391.
41. Ratcliff R, McKoon G. Speed and accuracy in the processing of false statements about semantic infor-
mation. J Exp Psychol Learn, 1982; 8:16–36.
42. Usher M, McClelland JL. The time course of perceptual choice: the leaky, competing accumulator
model. Psychol Rev, 2001; 108:550–592. PMID: 11488378
43. Roelfsema PR, Houtkamp R. Incremental grouping of image elements in vision. Atten Percept Psycho,
2011; 73:2542–2572.
44. Ródenas E, Lupiáñez J, Arnedo M, Triviño M. Are confabulations a memory or a selective attention defi-
cit? Oral communication presented at the International Workshop on Learning, Memory and Attention,
July 2015, Granada, Spain.
45. Ródenas E, Rodrı́guez-Bailón M, Funes MJ, Lupiáñez J, Triviño M. The role of conflict monitoring in
confabulations. Oral communication presented at the 10th Scientific Meeting on Attention, May 2015,
Madrid, Spain.

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 24 / 25

 Effective neuropsychological treatment for confabulations

46. Devinsky O. Delusional misidentifications and duplications: right brain lesions, left brain delusions. Neu-
rology, 2009; 72(1): 80–87. doi: 10.1212/01.wnl.0000338625.47892.74 PMID: 19122035
47. Turner MS, Simons JS, Gilbert SJ, Frith CD, Burgess PW. Distinct roles for lateral and medial rostral
prefrontal cortex in source monitoring of perceived and imagined events. Neuropsychologia, 2008;
46:1442–1453. doi: 10.1016/j.neuropsychologia.2007.12.029 PMID: 18294660
48. Yotsumoto Y, Chang LH, Ni R, Pierce R, Andersen GJ, Watanabe T, et al. White matter in the older
brain is more plastic than in the younger brain. Nature Comms, 2014; 5(5504):

PLOS ONE | DOI:10.1371/journal.pone.0173166 March 3, 2017 25 / 25