Second edition

04.qxd 3/10/08 9:33 AM Page 136
136 Other signs and symptoms
patient’s reaction when corrected: the disoriented patient
may either accept the correction or simply make no comment;
the patient with ‘delusional disorientation’, however,
will stoutly maintain his or her belief, and may even
argue with the physician about it.
Treatment
Apart from treatment of the underlying cause, no confident
recommendations can be made. Should the syndrome
persist and be troubling, a case could be made for treatment
with an antipsychotic.
4.19 CONFABULATION
At times, patients with amnesia will report experiences,
which, though plausible-sounding, in fact did not occur.
These confabulations seem, as it were, to ‘fill in the blanks’
of those portions of the patient’s past that cannot be
recalled because of the amnesia.
Clinical features
Confabulations generally appear in response to questions
about the recent past. Patients, although not confused,
relate experiences which, upon examination, clearly did
not occur. For example, one patient, hospitalized for 3
days, when asked what he had done the evening before,
replied that he’d been out with friends at a restaurant,
where everyone had enjoyed a fine meal, etc. Most patients,
when pressed about their confabulated responses, do not
persist in them, but may offer other confabulated
responses. For example, the patient in question, when told
that, according to the nurse, he had been in the hospital on
the evening in question, hesitated a moment, then
responded that, yes, that was the case, and that he must
have been mistaken. Asked then what he had, in fact, done
the night before, he went on to relate how family members
had come to visit and had spent the night with him, an
event that did not, according to the nurse, in fact happen.
Further examination reveals that although patients are
neither confused nor incoherent, they do, however, have
short-term memory loss, as manifested by an inability to
recall all out of three test words after 5 minutes and by
some disorientation to date or place.
Etiology
Confabulations are most commonly seen in patients with
Korsakoff’s syndrome (Benson et al. 1996) and are discussed
further in Section 13.5. They may also occur in the
amnestic states following rupture of aneurysms of the anterior
communicating artery (DeLuca and Cicernone 1991;
Schnider et al. 2005), and may also be seen in patients with
dementia, for example frontotemporal dementia (Nedjam
et al. 2004).
Differential diagnosis
Simple lying is distinguished by the presence of a motivation
for the false statement and by the fact that liars tend to
persist in their lies, in contrast with confabulators who,
generally, when challenged, renounce their statements
without much ado.
Delusions about the past, as may be seen in psychosis
(e.g., schizophrenia), delirium or advanced dementia, are
generally implausible on their face. For example, a report
by a patient that the night before he had been tortured and
that the nurses had ripped his skin off should be considered
a delusion and not a confabulation. In these cases, the
patient’s speech is often rambling and more or less incoherent,
being composed of disconnected statements.
Treatment
Treatment is directed at the underlying condition.
4.20 AMUSIA
Amusia, also known as amelodia, is characterized by an
inability to either recognize or produce a melody, and may
occur on either an acquired or a developmental basis.
Clinical features
Amusia occurs in both receptive and expressive forms.
In receptive amusia, patients are, to a greater or lesser
degree, ‘tone deaf’. In such a case, if the patient were to listen
to a singer simply humming the tune to a song he
might be unable to recognize it, whereas if the singer actually
sang the song, the lyrics would immediately allow the
patient to recognize the song. As might be expected, if
patients with receptive amusia listen to instrumental music
they would have difficulty ‘naming the tune’ and might
complain that the music sounded flat.
Patients with expressive amusia have great difficulty in
‘carrying a tune’, and if such patients hum a tune, listeners
have great difficulty recognizing it; should these patients
sing the lyrics, however, listeners are able to recognize the
song but may comment that the singing is quite poor.
Patients with expressive amusia also have great difficulty
playing instruments.
In some cases, both receptive and expressive components
are present, producing a global amusia.
Etiology
Most cases of acquired amusia occur secondary to infarction
or hemorrhage. Receptive amusia has been noted with