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Brain Wonders
By Susan Fitzgerald

Learn About Confabulation, Also Known as “Honest Lying"

Damage to the brain can sometimes cause confabulation, an unusual neurologic phenomenon in which people talk, often with great flourishes, about events or experiences in their lives—unaware that their stories are false.

Illustration by Bratislav Milenkovic

In detailed and vivid language, a middle-aged woman talked about her plans for the day and how she had arranged the rooms in the house where she was staying. She explained that in the morning she had awakened, packed her suitcase, and said goodbye. She was off to look after her little boy, who needed to be fed.

The woman's account, while seemingly ordinary, was extraordinary to the researchers who wrote about it in the journal Brain in 1996. Nothing the 58-year-old woman said was true. The house was a hospital, and her hungry little boy was a grown man. As the scientists noted, this story was a case of confabulation, an unusual neurologic phenomenon in which people talk, often with great flourishes, about events or experiences in their lives—unaware that their stories are false.

“Confabulation is an intriguing disorder of memory and thought. Patients tell stories about their recent doings and plans for the future that are blatantly incompatible with reality,” says Armin Schnider, MD, professor of neurorehabilitation at the University of Geneva in Switzerland, who wrote about the woman in various medical journals and is considered a leading authority on the disorder.

“In contrast to lying, confabulation is not intentional and, in many cases, not even consciously perceived by the confabulator,” says Dr. Schnider. Because there is no intent to deceive and nothing to be gained, confabulation is sometimes referred to as “honest lying” by researchers.

Confabulation usually happens after a brain injury, whether from trauma, a stroke, or a tumor. The woman described by Dr. Schnider had bleeding in her brain from a ruptured aneurysm. In another case referenced in the same article, a 45-year-old man sustained a head injury in a motorcycle accident. After regaining consciousness and being transferred to a rehabilitation ward, the charming and chatty man told stories, some true, others imaginary, according to his relatives.

The man occasionally acted on his confabulations. One time he went to a physician's office in the ward and asked if he could use the telephone to arrange a deer hunt for that afternoon with his friends. Another time he told a physician he was worried that he might not get leave from his military duties the next day.

Scrambling Reality

Frequently confabulations contain shreds of truth, with some details perhaps drawn from a snippet of conversation, a photograph, or a television show. The woman wanting to feed her little boy, for instance, did have children, but they were all adults. In other cases, a confabulation may touch on a pastime or habit from a person's life preceding the brain injury or relate in some way to a sad or even happy event from the past.

“Most confabulations become obvious in a discussion about recent doings or plans for the day,” says Dr. Schnider, author of The Confabulating Mind: How the Brain Creates Reality (Oxford University Press, 2018). “They reflect a confusion of current reality,” he says. “Subjects perceive themselves in another time, place, and situation—often related to their near or distant past—and act according to this feeling.”

The term was likely introduced into medical literature in the early 1900s by Carl Wernicke, a German physician who characterized it as “the emergence of memories of events and experiences that never happened.” The exact mechanisms of confabulation may vary from one case to another, but usually it's due to damage or dysfunction of the front part of the brain, says Dr. Schnider. There's a preconscious mechanism in this part of the brain that Dr. Schnider calls the orbitofrontal reality filter, which flags thoughts and memories that don't correlate with reality. “Severe confabulations also may occur in conjunction with delirium, advanced dementia, or uncontrolled psychosis where brain damage is less local.”

Even healthy people experience some degree of faulty memory at one time or another. It may involve a favorite story from childhood or college days that as it is told and retold over time has some details mixed up. Such instances “reflect normal alterations of memory traces over time, which are particularly likely to occur when the memory of an event is weak and the false information is plausible,” says Dr. Schnider.

Some people also embellish. They recount a real event or experience but exaggerate a bit, adding details that didn't quite happen as told.

Confabulation differs from delusional thinking, which typically is part of a psychiatric disorder, such as schizophrenia, and involves an unshakable belief in something that has no basis in reality.

“Normally we think of our memory as a repository of things that have happened,” says Sara Manning Peskin, MD, assistant professor of clinical neurology at the University of Pennsylvania in Philadelphia. When memory loss stems from a brain injury or disease, she says, a person may unknowingly “fill in gaps in their memory with new memories that never really happened.

“You create a prior reality,” says Dr. Manning Peskin, who writes about confabulation in her new book, A Molecule Away from Madness: Tales of the Hijacked Brain (W.W. Norton & Company, 2022).

Though confabulation is not intentional, it may have the effect of boosting a person's sense of worth or helping a person make sense of a confusing situation.

Vitamin Deficiency

In her book, Dr. Manning Peskin chronicles a case of confabulation brought on by severe alcoholism, a condition known as Korsakoff's syndrome. Excessive drinking and poor nutrition can cause a deficiency in thiamine, a B vitamin, which can lead to brain damage. Dr. Manning Peskin describes Lisa Park, a woman with alcohol use disorder who spun fantastical stories. A picture of a celebrity, for instance, triggered a detailed but untrue tale of Park's brush with fame. Her confabulation eased after she received high doses of thiamine intravenously.

Confabulation is not easy to spot. The tales are often told with such sincerity that “you might assume the person's word was fact,” Dr. Manning Peskin says.

Another group prone to confabulation is children with fetal alcohol syndrome disorder, says Jerrod Brown, PhD, assistant professor at Concordia University in St Paul, MN. A variety of factors, including social, emotional, and intellectual immaturity and poor impulse control, contributes to the problem, he says. It may be difficult for parents to sort out truth from falsehood, leading to arguments and mistrust of their children. “It can get in the way of family relationships,” says Dr. Brown, who has done podcasts on the subject. He says superficial chattiness or excessive storytelling may be signs of a problem.

Possible Treatments

Confabulation generally falls into two subtypes, provoked and spontaneous, says Dr. Brown, who co-authored a review article on the condition in 2017 in the International Journal of Neurology and Neurotherapy. Provoked instances are usually in response to a question the person feels compelled to answer (“What did you do last night?”). Spontaneous ones are when the person volunteers false information unprompted (“Last night I went to…”).

Confabulation may seem relatively harmless, but it can be stressful and hurtful for family members and caregivers, who may equate it with lying or find it tedious and embarrassing. People who engage in confabulation also may be vulnerable to manipulation, Dr. Brown says, which could have legal repercussions if they make false statements or confessions to police or in court.

Because there are many causes of confabulation, there is no one general treatment. The phenomenon may fade as the underlying condition is resolved, Dr. Schnider says. Keeping “memory” diaries to record real events may be useful for recalling what actually happened yesterday or a while ago. Occasionally medications such as antipsychotics may be helpful, he says.

Questionnaires can be used to evaluate patients with memory problems, says Dr. Schnider. “They do not, however, replace observing the behavior of patients to see if how they behave agrees with what they are saying,” he adds. Because doctors may not always be able to sort out what's true from what isn't when evaluating a new patient, family members can play an important role in helping verify information.

Otherwise, it isn't necessary to correct a confabulation as long as the person is in a safe environment and the false memories can't lead to dangerous behavior, Dr. Schnider says.

“The study of confabulation has led to ways to explore how the brain distinguishes between thoughts that refer to current reality and thoughts that do not, such as fantasies and daydreams,” says Dr. Schnider. Understanding more about the disorder, he says, will help reveal “how we sense reality.”