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Psychological factors in retrograde amnesia: Self-deception and a broken heartAmee D. Baird a & Ryan T. McKay ba School of Behavioral Science, Department of Psychology , University ofMelbourne , Melbourne, Australiab Institute for Empirical Research in Economics, University of Zurich , Zurich,SwitzerlandPublished online: 31 Oct 2008.

To cite this article: Amee D. Baird & Ryan T. McKay (2008) Psychological factors in retrograde amnesia:Self-deception and a broken heart, Neurocase: The Neural Basis of Cognition, 14:5, 400-413, DOI:10.1080/13554790802422120

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NEUROCASE2008, 14 (5), 400–413

NNCS Psychological factors in retrograde amnesia:Self-deception and a broken heart

PSYCHOLOGICAL FACTORS IN RETROGRADE AMNESIAAmee D. Baird1 and Ryan T. McKay2

1School of Behavioral Science, Department of Psychology, University of Melbourne, Melbourne, Australia2Institute for Empirical Research in Economics, University of Zurich, Zurich, Switzerland

We explored potential contributing psychological factors in a patient (‘XF’) with focal retrograde amnesia, withinthe framework proposed by Kopelman (2000, Cognitive Neuropsychology, 17, 585). In particular, we investigated thepsychological trait of self-enhancement. We constructed a self-report questionnaire measure of self-enhancement andcompared XF’s score on this measure with the scores of 61 control participants. XF was found to have a signifi-cantly greater level of self-enhancement than the entire control group, and also than a smaller sample of age- andsex-matched controls. We propose that heightened self-enhancement may reflect a premorbid tendency thatpotentially predisposes individuals to develop retrograde amnesia.

Keywords: Self-enhancement; Positive illusions; Self-report measures.

INTRODUCTION

Focal retrograde amnesia is an intriguing conditionthat has received considerable attention in the recentliterature (see De Renzi, 2002, and reviews by Kapur,2000; Kopelman, 2000). It is characterised byimpaired retrograde memory, or inability to retrieveremote information, including autobiographical,semantic and in some cases procedural memories, incontrast with relatively well-preserved anterogradememory, or ability to learn and retrieve new informa-tion. The aetiology of this condition is a topic of greatcontroversy that raises questions about the long-heldorganic versus psychogenic distinction.

In many reported cases of focal retrogradeamnesia, the aetiology is unclear (see Kopelman,

2000 for a review of cases), and several authorshave proposed that the organic/psychogenicdichotomy fails to provide for the common coex-istence and potential aetiological contribution ofboth organic and psychological factors (Hodges,2002; Kopelman, 2000; Markowitsch, 2002). In anattempt to address this concern, Markowitschet al. (1999, p. 227) proposed the term ‘mnesticblock syndrome’ as a label that acts as ‘a bridgebetween the former division into ‘organic’ and‘psychogenic’ caused memory disorders’. Definedas a ‘blockage’ of autobiographical memoryprocessing, it is speculated that this syndrome isunderpinned by biochemical brain processes, spe-cifically the excessive and prolonged release ofstress hormones such as glucocorticoids that bind

This study was carried out at the Neuropsychiatry Service of James Fletcher Hospital, Hunter Mental Health, Newcastle, NSW,Australia.

We would like to thank Dr Peter Schofield, Director of the Neuropsychiatry Service, Newcastle, Australia for his support of theresearch and Mr Steve Lee for providing the famous face items. Thanks also to Patient XF and his mother for their assistance andcooperation. Presentation of this work at the International Neuropsychological Society 2008 Mid-year Meeting was funded by anOverseas Conference Grant from the British Academy and by a Brain Travel Grant, both awarded to the second author.

Address correspondence to Dr Ryan T. McKay, Institute for Empirical Research in Economics, University of Zurich,Bluemlisalpstrasse 10, Zurich CH-8006, Switzerland. (E-mail: ryantmckay@mac.com; rmckay@iew.uzh.ch).

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PSYCHOLOGICAL FACTORS IN RETROGRADE AMNESIA 401

to receptors found in memory- and affect-relatedmesial temporal regions. Markowitsch andcolleagues (e.g., Markowitsch, 2003; Markowitschet al., 2000) have found altered brain metabolismin memory processing regions, specificallyhypometabolism in the right frontotemporalregion in a number of patients with ‘psychogenic’or ‘functional’ amnesias. This has led to the notionthat organic and functional/psychogenic amnesiaare ‘two sides of the same coin’, both arising froma common brain mechanism. The precipitant ofthis syndrome is argued to be extreme stressagainst a background of traumatic conditions inearly childhood (Markowitsch, 2003).

A number of studies have documented psycho-logical factors associated with focal retrogradeamnesia (e.g., Fujiwara et al., 2008; Kritchevsky,Chang, & Squire, 2004). Some studies haveincluded an assessment of psychiatric and person-ality factors using scales such as the MinnesotaMulti-Phasic Personality Inventory (MMPI) (e.g.,Kritchevsky et al., 2004; Markowitsch, 1999), theSymptom Checklist-90-Revised (SCL-90-R) and theFreiburg Personality Inventory-Revised (FPI-R)(Fujiwara et al., 2008), or psychodynamic testssuch as the Rorschach and Blacky (Barbarotto,Laiacona, & Cocchini, 1996; Serra, Fadda, Buccione,Caltagirone, & Carlesimo, 2007) and/or clinical inter-views (e.g., Lucchelli & Spinnler, 2002; Papagno,1998). MMPI results have typically showed abnor-mal scores on the hypochondriasis, schizophreniaand depression scales (Kritchevsky et al., 2004;Markowitsch et al., 1999), and psychodynamictests have suggested histrionic personality traits(Barbarotto et al., 1996; Serra et al., 2007). Clinicalinterviews have revealed either no abnormalities(Cases 1 and 3 Lucchelli & Spinnler, 2002), psychoso-cial stressors such as relationship break-ups (e.g.,Kapur, Ellison, Smith, McLellan, & Burrows, 1992;Papagno, 1998) or financial problems (e.g., Case 2Kopelman, Green, Guinan, Lewis, & Stanhope, 1994;Lucchelli & Spinnler, 2002), and/or premorbid psy-chiatric conditions such as depression or post trau-matic stress disorder (e.g., Cases 1 and 5 Fujiwaraet al., 2008; all 10 patients Kritchevsky et al., 2004;Case 2 Lucchelli & Spinnler, 2002). Despite theobservation that the majority of patients with focalretrograde amnesia reported in the literature havepremorbid psychosocial stressors or psychiatric con-ditions, the nature of these potentially precipitat-ing factors is not well understood.

In the psychiatric literature, some studies haveinvestigated personality factors associated with

dissociative conditions. For example, Simeon,Guralnik, Knutelska, and Schmeidler (2002) usedquestionnaires to examine temperamental, psy-chodynamic and cognitive schemata factors associ-ated with dissociation in patients with DSM-IVdefined depersonalisation disorder. They foundthat harm avoidant temperament, immaturedefences, overconnection and disconnection cogni-tive schemata were significantly correlated withdissociation scores on the Dissociative ExperiencesScale, and concluded that these personality factorsmay predispose the manifestation of dissociativesymptoms. There have been some interesting obser-vations from the results of personality inventories inpatients with focal retrograde amnesia. For exam-ple, Fujiwara et al. (2008) found that four of theirfive patients had abnormal scores on the opennessdimension of the Freiburg Personality Inventory-Revised, a validity scale indicating socially desirablebehaviour. The authors commented that this mayreflect the patients’ reaction to their memoryimpairment. An alternative possibility is that thisreflects a premorbid personality trait that may pre-dispose individuals to focal retrograde amnesia.

Kopelman (2000) has emphasised the need formore detailed reporting of psychological factors inpatients with focal retrograde amnesia and has notedthat many published cases on this topic have failedto adequately explore psychosocial contexts. He hasproposed a model of ‘social factors and brain sys-tems influencing autobiographical memory retrievaland personal identity’, which postulates that severestress affects frontal/executive systems that inhibitthe retrieval of autobiographical and episodic mem-ories. This inhibition is predisposed and/or exacer-bated by a past learning experience of transientamnesia, extreme arousal or depression. Antero-grade learning and ‘new’ episodic memory retrievalremains intact due to the preservation of the medialtemporal/diencephalic system. Four areas of ‘severeprecipitating stress’ are identified, namely marital,employment, financial and offence (Kopelman,2000, p. 608). The specific nature of these stressorsrequired to elicit an amnesic reaction, however, hasnot been characterised. Kopelman’s model alsoincludes ‘personal semantic belief system’, compris-ing self and identity, in addition to the contributionof temporal and frontal executive brain systems.

Other authors have argued that such ‘psychogenictriggers’ are not relevant to the aetiology of focalretrograde amnesia (De Renzi, 2002; Lucchelli &Spinnler, 2002). In support of this notion there isthe observation that despite the frequency and

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heterogeneity of psychosocial stressors in everydaylife, focal retrograde amnesia is a rare but stereo-typed syndrome (Lucchelli & Spinnler, 2002). Fur-thermore, De Renzi (2002) notes that the supposedprecipitating event in many cases is a longstandingstressful condition to which the individual hasadapted, and he questions how this can precipitatea sudden and complete loss of past memories. Heargues that the mere finding of a cerebral lesion isnot sufficient for attributing aetiological significanceto that lesion unless the features of the symptom inquestion are congruous with the location of thelesion. Thus, ‘why should we accept that the merefinding of a state of psychic discomfort, no matterwhat its nature, intensity and length, should beresponsible for the sudden loss of past memories?’(De Renzi, 2002, p. 680).

If focal retrograde amnesia partly constitutes akind of defensive retreat from psychosocial stress,one must account for why it is that so few individualsseek this refuge. One possibility is that patientswith this condition are premorbidly extreme on acontinuum of self-deception – i.e., premorbidlypredisposed to engage in the kind of defensive psy-chological manoeuvring that strategic forgettinginvolves. For the onset of such psychogenic retro-grade amnesia to occur, therefore, an individualwould not only need to be experiencing significantpsychosocial stress, but would need to be predisposedtoward self-protective psychological manoeuvres.This is a possibility that we investigate in the presentstudy.

We describe a patient with focal retrogradeamnesia and explore the potential psychologicalfactors contributing to this condition. In particular,we investigate the psychological trait of ‘selfdeception’, which we operationalise as a tendencyto make unrealistically positive self-evaluations, orto self-enhance (Paulhus, Harms, Bruce, & Lysy,2003). We construct a self-report questionnairemeasure of self-enhancement for this purpose –specifically a measure of positive illusions (Taylor,1989; Taylor & Brown, 1988).

PATIENT ‘XF’

Patient ‘XF’ is a 25-year-old male who was seen forneuropsychological assessment over 2 days inSeptember 2006 at the Neuropsychiatry service ofJames Fletcher Hospital, Newcastle, Australia. XFprovided informed consent to participate in thestudy.

Background

The onset of XF’s retrograde amnesia was8 months prior to assessment. On a Friday night hehad returned to his parent’s house (where he wasliving at the time) after socialising at the pub wherehe worked. He was taken home by a friend whothought he was drunk. He told his mother he had‘lost time’, and complained of headache. Accord-ing to his mother he was otherwise fine and sleptfor most of the weekend. On Monday he phonedthe ambulance when his parents were at work. Hetold the phone operator ‘I’m in trouble, I needhelp. I don’t know who I am or where I am’. Hewas asked to read out the address on any mailhe could find, and he gave his parents’ address. Hedid not recognise their names or the address. Theambulance report noted that on their arrival XFwas conscious and sitting in an armchair. He com-plained of pain in the occipital region of head andposterior neck. He said he had woken on the bath-room floor and could not remember how he gotthere and had then phoned the ambulance. Hecould not recall his name, address, date of birth orfamily situation. Glasgow Coma Score was 14/15,with one point lost for orientation.

On admission to the emergency department atthe local hospital it was noted that XF had initialbilateral limb weakness. There were no focalneurological signs. He denied substance use, apartfrom some social drinking. He failed to recognisehis parents, brother and friends on their arrival. Hedid not know how to use his mobile phone. Nursingstaff noted that he was sleeping excessively and wasflat in his affect. He was evasive when questionedabout his mood. His response to most questionswas ‘I can’t remember’.

XF was transferred to the Brain Injury Unitafter 9 days on the ward. He frequently com-plained of headache that was not relieved by painmedications. The occupational therapist noted thathe required assistance in identifying kitchen itemssuch as a saucepan and chopping board duringmeal preparation. He did not know how to use amicrowave. He was, however, able to play a cardgame in the evening that a nurse had taught himduring the day, and was able to recall staff namesand verbal information. XF was oriented withinthe unit. On his first visit home he asked to go back‘home’ (to the hospital) after half an hour as he feltuncomfortable. He told staff that he was uncom-fortable kissing and hugging family members. Overthe duration of his stay his mood improved and he

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was seen laughing with friends and family. He wasdischarged home after 11 days.

Investigations

A CT brain scan at the time of presentation wasnormal, with an incidental finding of cysts on theanterior and medial walls of right maxillary atrium.An MRI brain scan and EEG investigation werealso normal. A SPECT scan performed 8 monthsafter onset of his retrograde amnesia showed milddiffuse hypoperfusion in the left cerebral hemi-sphere, most pronounced in the parietal lobe.

Past medical history

XF had recurrent otitis media as a young childwith removal of grommets at 2 years of age. Fiveyears prior to retrograde amnesia onset he wasmugged and hit on the head with a brief loss ofconsciousness but there were no cognitive sequelaesubsequent to this. Four years prior to the onset hefell down some stairs. He had a brief loss of con-sciousness, and on waking did not recognise hisfiancée at the time (see marital/relationship sectionunder ‘Potential stressors’ below). This occurredon the weekend that they had announced theirengagement. When his brother arrived XF recog-nised him but commented that he looked older. XFclaimed that he (XF) was 16 years old (he wasactually 20 at the time). His ‘fiancée specific’ amnesiawas transient and resolved after 1 h.

Eight months prior to the onset of his currentretrograde amnesia XF suddenly collapsed in a carpark. His mother was with him and reported thathe had flu-like symptoms at the time. He had abrief loss of consciousness. On waking he wastwitchy, drowsy and very pale. He had left sidedupper and lower limb weakness, which resolvedafter 40 min. Three months prior to onset he waspunched in the head by a group of boys afterretrieving a bottle that had been stolen by one ofthe boys from the bottle shop where he worked. Hedid not lose consciousness but vomited once andhad a headache.

Social, educational and occupational history

At the time of assessment XF was living with hisparents. His mother reported that they are a closefamily who are open and affectionate with one

another. His mother denied any significant or trau-matic childhood events with the exception of XFbeing very upset that he was unable to say goodbye tohis grandfather who died when XF was 18 years old.

XF completed 4 years of secondary school anddescribed himself as an average student. He deniedany learning difficulties and did not repeat anygrades. He began a locksmith apprenticeship withhis uncle, but did not enjoy this so left to undertakebar work. At the time of onset he was working as abar manager at a local pub and studying businesspart time. According to his mother his studies wereprogressing well. At the time of the assessment XFwas employed full time as a car detailer at a carsales yard. His duties include cleaning sales cars,and adding details such as roof racks.

Potential stressors according to the model outlined by Kopelman (2000)

Marital/relationship

XF’s mother reported that his fiancée broke offtheir engagement 2 years prior to the onset of hisretrograde amnesia and that he was ‘devastated’ atthe time. He subsequently had difficulty sleepingand was frequently tearful for 6 months. XF’smother was not aware of him having any signifi-cant relationships since then, with the exception ofa few brief ‘flings’. After his admission to hospital,however, XF’s mother searched through his bagsand found a diamond ring. She tracked it to a localjewellery shop and discovered that it was pur-chased just before Valentines Day (3 weeks prior toonset), and that he had told the jeweller it was aValentines Day gift. XF denied any knowledge ofthe ring and it remains unknown who the intendedrecipient was. None of his friends were aware ofthe ring or of any current girlfriend. The ring wassubsequently returned and XF was reimbursed.

Financial

XF moved in with his parents 3 months prior toonset due to his work hours being decreased toonly one night per week and consequent financialstress.

Employment

XF experienced some stress associated with thedecline in the number of shifts he was allocated athis work, and had intended to search for alterna-tive work at the time of onset.

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On the Friday night prior to the onset of retro-grade amnesia, XF was socialising at the pubwhere he worked and called his father to say thathe had won a cheque in a promotional competitionbut ‘there may be problems later’. He askedwhether his father could come by later if needed,which he agreed to do, but XF did not call again.His parents were unsure of the nature of the poten-tial ‘problems’.

Offence

XF and his mother denied any forensic history.

Presentation

XF presented as a slightly overweight young manwho was confident and witty. He appeared some-what indifferent to his memory loss, saying he had‘learnt to live with it and accept it’. Friends hadtold him about a documentary of a similar case,but he was not interested in seeing it, and com-mented, ‘it could be a completely different situa-tion to mine. Everyone is looking for answers but Ijust think if [my memory] is going to come back itwill. I just take it day to day’. He claimed that hewould like to get his memory back if he could, andsaid, ‘I know that there’s been some bad times butI still want to remember’.

XF said that the main disadvantage of his mem-ory loss was the difficulty in meeting apparentstrangers who claimed to know him. He said, ‘it’sstrange to think they know more about me than Ido. It’s hard to only be able to say stuff that I’velearnt about myself’. At initial assessment XFclaimed to dislike talking about his condition, as itis ‘such a big story’. He commented at this timethat friends had encouraged him to sell his story tothe media but he was not interested: ‘I don’t wantmy life under a microscope’. On review 2 monthslater, however, XF had recorded a story for a localcurrent affairs television program. He denied con-tacting the program and was vague about how theyhad heard of his story; he claimed that they musthave seen his comments in an ‘internet chatroom’.XF said that appearing on the program was ‘a wayfor people he had not spoken to for a while to seehis story’. He had not told his work mates as he didnot want to be treated differently, and felt that hisappearance on the program ‘got it out in the open’.XF claimed that he was not given any financialincentive for the interview. He was irritated thatthe reporter had asked his family and friends if

they thought he was lying, and was upset by theirquestion ‘what have you got to gain?’ He said hedid not want to be thought of as a liar.

When questioned about any changes in person-ality XF said he had been told he was now moreadventurous with food and that his music tasteshad changed. He had previously loved to singkaraoke and performed at his 21st birthday party,but now felt that he ‘would have to be very drunkto do it’. Interestingly, on review 2 months after hisinitial assessment he had returned to karaoke sing-ing and recently competed in the grand final for hislocal area. He had ‘relearned’ the songs he hadsung at his 21st birthday party for this event. He said,‘I’m still a smart ass and am happy to make peoplelaugh. Humour seems to work’. He described feelinglike a ‘different person’ and commented, ‘I’m 25 yearsold but experiencing everything for the first time’.

Self report of memory function

XF described impaired anterograde memory func-tion for the initial 3 months after the onset of hisretrograde amnesia (but note the nursing reports in‘Background’ section above). He said his ‘first[new] memory’ after the onset was shaving hisbeard off and listening to music CDs in preparationto go to a music concert with his brother, approxi-mately 3 months after onset. Since then he describednormal anterograde memory. XF watches televisionprograms such as ‘50 Years of Television’ to learnabout past events, and commented that this ‘isusually the reason that I know things’. In regard toprocedural memory, XF commented that he hadno difficulty driving or swimming, but that playingbaseball was a ‘whole new experience’ and he hadhad to relearn all the rules, despite having playedthe game for 10 years.

On review 2 months after the initial assessmentXF reported no change in memory function. Heremained somewhat indifferent, but commented ‘itwould be nice to know things myself rather thanfriends telling me’. He denied any depressive andanxiety symptoms. He was focused on saving foran overseas trip. His mother denied any significantmood symptoms, but noted that he became irritableif things were not going his way. She said he is a‘25 year old but has the mind of a child. He justwants to have fun all the time, and tires veryeasily’. She felt that he was more affectionate andloving towards her since immediately after theonset of amnesia. Interestingly, while interviewing

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his mother alone, XF became very irritable in thewaiting room and called her on her mobile phoneto say that he was tired of waiting and wanted toleave. His mother appeared very anxious and eagerto please him and the interview was discontinued.

Neuropsychological assessment results

The results of XF’s neuropsychological assessmentare displayed in Tables 1 and 2. With the exception

TABLE 1 Results of neuropsychological tests administered to XF

Test Patient XF

Intellectual functioning:Full Scale IQ (WAIS-III) 102Verbal IQ 92Performance IQ 114WAIS-III subtest Age-Scaled ScoresVocabulary 9Similarities 8Arithmetic 9Digit Span 11Information 8Comprehension 8Picture Completion 15Digit Symbol-Coding 11Block Design 11Matrix Reasoning 13Picture Arrangement 11

Verbal memory:Recognition Memory Test (words) >75%ile (49/50)RAVLT total learning 69%ile

Recall after distraction 58%ileDelayed recall 62%ileRecognition 66%ile

Logical memory (WMS-III) I ASS = 16II ASS = 14

Visual memory:Recognition Memory Test (faces) 50%ile (43/50)Visual reproduction (WMS-R)

I 99%ileII 99%ile

Rey Complex FigureImmediate recall 90%ileDelayed recall 90%ile

Language:Boston Naming Test 27%ile

Executive tests:Word Fluency:

Phonemic (CFL) 50%ileSemantic (animals) 25–50%ile

Trail Making Test B 75–90%ileStroop (DKEFS) Inhibition ASS = 11Inhibition/ Switch ASS = 13

(Continued)

TABLE 1 (Continued)

Test Patient XF

Speed of information processing:Trail Making Test A 50%ileDigit Symbol-Coding (WAIS-III) ASS = 11

Mood:Beck Depression Inventory-II 5 (minimal)Depression Anxiety Stress Scale-21 1 (normal)

Abbreviations and normative data used in order of appearance:WAIS-III = Wechsler Adult Intelligence Scale-III, Wechsler, D. A.(1981). Wechsler Adult Intelligence Test-Revised. London: ThePsychological Corporation.IQ = Intelligence Quotient.%ile = percentile.Warrington, E. K. (1984). Recognition Memory Test. Windsor,Berks: NFER-Nelson Publishing Co. Ltd.RAVLT = Rey Auditory Verbal Learning Test, Schmidt. M.(1996). Rey auditory and verbal learning test: A handbook. LosAngeles: Western Psychological Services.WMS-III/R = Wechsler Memory Scale Revised/3, Wechsler, D.(1987). Wechsler Memory Scale-Revised. London: PsychologicalCorporation.ASS = Age-Scaled Score.Rey Complex Figure: Rey, A. (1964). L’examen clinique en psy-chologie (2nd ed.). Paris: Presses universitaires de France.Kaplan, E. F., Goodglass, H., & Weintraub, S. (1983). TheBoston Naming Test (2nd ed.). Philadelphia: Lea & Febige.Word fluency: Spreen, O., & Strauss, E. (1998). A compendiumof neuropsychological tests (2nd ed., pp. 447–464). New York:Oxford University Press.Trail Making Test A & B: AJA Associates: Iowa City.Army Individual Test Battery. 1944 Manual & Directions forScoring, Washington, DC: War Department, AdjutantGeneral’s Office.DKEFS = Delis-Kaplan Executive Functions Scale, Delis,D. C., Kaplan, E., & Kramer, J. H. (2001a).Delis-Kaplan Executive Function System (D-KEFS). San Antonio,TX: The Psychological Corporation.Beck Depression Inventory-II: Beck, A. T. (1988). Sidcup, UK:The Psychological Corporation.Depression Anxiety Stress Scales-21: Lovibond, S. H., &Lovibond, P. F. (1995). Manual for the Depression AnxietyStress Scales. Sydney: Psychology Foundation.

TABLE 2 XF’s results on the Autobiographical Memory Interview

Autobiographical Memory Interview*

Personal semantic Autobiographical

Maximum 21 Maximum 9

Childhood 5 0Early adulthood 4.5 1Recent life 16 4Total 25.5/63 5/27

*Kopelman, M., Wilson, B. A., & Baddeley, A. (1990). BurySt Edmunds, UK: Thames Valley Test Company.

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of impaired autobiographical memory function asassessed by the Autobiographical Memory Inter-view (Kopelman, Wilson, & Baddely, 1990) (AMI,see Table 2), his performance in all cognitivedomains, including verbal, visual and semanticmemory was intact (see Table 1). Of note, XF wasable to recognise the faces of a range of famousindividuals including sporting stars, actors andcurrent political figures, but commented that hehad ‘re-learnt’ them after seeing them on TV afterthe onset of his amnesia. He denied any significantdepressive or anxiety symptoms as assessed by theBeck Depression Inventory-II (BDI-II, Beck, 1988)and Depression Anxiety Stress Scales-21 (DASS-21,Lovibond & Lovibond, 1995) (see Table 1).

METHODS

Experimental investigation

The following self-report questionnaire measure ofself-enhancement was administered to XF on thesecond day of the neuropsychological assessment.

Self-Enhancement/Positive illusions

Taylor and colleagues (Taylor, 1989; Taylor &Brown, 1988) document a series of biased self-perceptions that they refer to as positive illusions.These illusions include unrealistically positive self-evaluations and unrealistic optimism about thefuture (which Hoorens, 1995 subsumes under thelabel ‘self-serving biases’). To illustrate the first,evidence indicates that there is a widespread ten-dency for most people to see themselves as betterthan others on a range of dimensions – this is thebetter-than-average effect (Alicke, 1985). For exam-ple, most business managers consider their job per-formance to be superior to that of others (French,1968), while most college instructors believe thatthey are better-than-average teachers (Cross, 1977).In regard to the second bias, people tend to believethat they will have a longer-than-average lifespan(Myers, 2002), and that their chances of havinghealth problems (e.g., Weinstein, 1982) or of becom-ing the victim of crime (e.g., Perloff, 1987) are lowerthan average.

Given our intention to measure individual dif-ferences in self-enhancement (see Brown, 1986;Paulhus et al., 2003), we constructed an 18-iteminstrument for the measurement of these positiveillusions (see APPENDIX A). Each item ispresented with an associated rating scale (ranging

from 0 to 100%). Participants are asked to ratethemselves, relative to their ‘peers’, for eachitem. In every case a rating of 50% is average.The items incorporate a range of randomly inter-mixed positive characteristics (e.g., ethical,kind), negative characteristics (e.g., unhygienic,prejudiced) and negative future events (likeli-hood of developing a drinking problem, or ofgetting divorced). The average of these ratings(after appropriate reverse-scoring for half of the18 items) was used in this study to index an indi-vidual’s degree of self-enhancement.1

Control participants

XF’s score on this questionnaire measure of self-enhancement was compared with that of a sample ofcontrol participants, comprising 61 undergraduatepsychology students (10 males, 51 females) with amean age of 20.6 years (SD = 1.8). Participantsreceived course credit for taking part and providedinformed consent.

RESULTS

Based on the responses of our control participants,we first conducted a brief evaluation of the positiveillusions questionnaire measure we had constructed.In order to investigate whether the individualitems of the questionnaire elicited positive illusoryresponses, we conducted a series of 18 single-samplet-tests to compare the mean rating of each item(reverse-scored if negative) with 50 (in the absenceof bias, the mean rating of each item should not sig-nificantly differ from this value). Owing to the largenumber of comparisons, we adopted a stringentalpha level (.001) so as not to inflate Type I error.The mean ratings of all 18 items were significantlygreater than 50 at this level, indicating that eachitem elicited positively distorted responses in thecontrol participants. A Cronbach’s α of .78 for these18 items indicated that the internal consistencyreliability of our measure was satisfactory.

1Note that our measure might, strictly speaking, be considered ameasure of self-aggrandizement rather than self-enhancement, as itmeasures the degree to which individuals rate themselves morepositively than they rate others, rather than the tendency to overes-timate one’s positivity relative to a credible criterion (see Paulhus,1998). However, we have followed other authors (e.g., Brown,1986) in using the more common term of self-enhancement. Wereturn to the criterion issue in our Discussion.

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XF’s average rating on our positive illusionsquestionnaire (78.05) was compared to that of thecontrol group (63.05, SD = 8.4) using Crawfordand Howell’s (1998) modified t-test2 (one-tailed).XF was found to have a significantly greater levelof self-enhancement on this measure than the con-trol group, t(60) = 1.78, p = .04. In fact, XF’s scoreon this measure was higher than all but one of our61 control participants.

Given the high proportion of females in our con-trol sample, we conducted an additional analysiscomparing XF’s average rating on our positive illu-sions questionnaire to that of an age- and gender-matched subset of our control sample, namely theaverage rating of the ten male control participants(Mean age 20.9 years, SD = 2.4). There was no sig-nificant difference in age between XF and this con-trol subgroup, t(9) =1.62, p =.14.3 Our finding wasunchanged in that XF’s average rating was signifi-cantly greater than that of the matched controlgroup (60.94, SD = 8.5), t(9) = 1.93, p =.04.4 SeeFigure 1 for a comparison of XF’s scores on the 18individual questionnaire items with those of thematched control group.

DISCUSSION

In this case study we have described a patient withfocal retrograde amnesia and explored potentialpsychological factors contributing to this conditionusing the framework outlined by Kopelman(2000). In particular, we investigated the psycho-logical construct of ‘self deception’, which weoperationalised as a tendency to self-enhance. This isthe first study to document significantly heightenedlevels of positively biased self-appraisals in a patientwith retrograde amnesia, compared with controls.

According to the model proposed by Kopelman(2000), there are several psychosocial factors thatmay contribute to the manifestation of ‘psychogenic’amnesia. He outlines four areas of ‘severe precipitat-ing stress’, namely employment, financial, offenceand marital. XF had only mild employment andfinancial difficulties and denied any previousforensic offences. In contrast, we can speculate thathis marital/relationship situation may have been aprecipitating stressor. He suffered significant dis-tress 2 years prior to onset after the break-up of hisengagement, and the discovery of a diamond ringamong his possessions after the onset of his amne-sia raises the possibility that he may have beenrejected again. There have been previous reports ofretrograde amnesia manifesting after relationshipbreak-ups (see Kapur et al., 1992; Cases F and GKopelman, 2000; Papagno, 1998). Nevertheless,this is a very common psychosocial stressor andretrograde amnesia is a rare condition, thus otherfactors must also play a role.

Kopelman (2000) also identifies ‘current emotionalstate’, specifically ‘extreme arousal’ and ‘depression’,

2Computed using Crawford and Garthwaite’s (2002)singlims.exe program.

3(1998) modified t-test (two-tailed). The difference in agebetween XF and the larger, mixed-gender control group wassignificant using this test, t(60) = 2.47, p = .02.

4Crawford and Howell’s (1998) modified t-test (one-tailed).

Figure 1. Comparison of XF’s positive illusions questionnaire scores with those of the matched control group.

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as influential in psychogenic amnesia. XF’s familywere unaware of any emotional problems around thetime of onset and denied that he showed any signsof distress. However, we could again speculate thathe may have experienced ‘extreme arousal’ associ-ated with the rejection of his diamond ring and/orthe suspicious event in the pub a few nights prior tothe onset when he called his father asking for help.In terms of ‘learning experience’, Kopelman (2000)suggests that past transient experiences of organicamnesia are common in cases of psychogenicamnesia. XF had previously sustained four mildhead injuries and briefly lost consciousness onthree of these occasions. Of note, 4 years prior tohis current retrograde amnesia he had experienceda transient amnesia after falling down some stairs.At the time he was unable to recognise his fiancéeand believed that he was 4 years younger than hisactual age. This occurred on the weekend that heannounced his engagement and resolved after 1 h.In summary, many facets of XF’s psychosocial sta-tus are in keeping with Kopelman’s (2000) modeland may have contributed to the manifestation ofhis retrograde amnesia.

An additional component of Kopelman’s (2000)model is a ‘personal semantic belief system’, compris-ing self and identity (see also Kopelman, Stanhope, &Kingsley, 1999). We propose that psychological ten-dencies such as a tendency toward self-enhancementform part of this system. Our finding of significantlyexaggerated self-enhancement in XF is interesting inthe light of a recent study by Fujiwara et al. (2008).These authors found ‘a tendency for social desira-bility’ in four patients with retrograde amnesia.This was indicated by an unusually low score onthe openness dimension of the Freiberg PersonalityInventory-Revised in three patients, pointing toself repressive tendencies in social situations, and aheightened score in one patient, indicating a disre-gard of social norms (Fujiwara et al., 2008). As in ourcase, these individuals completed the personalityinventory after the onset of their amnesia, and thusit is impossible to determine whether this repre-sents a premorbid trait or a post amnesia state (seefurther discussion of this issue in the ‘Limitations’section below).

One feature of our case that is interesting to noteis the absence of frontal executive dysfunction.XF’s performance on five tests sensitive to execu-tive dysfunction was within the normal range.Other case studies of focal retrograde amnesiahave also reported preserved performance on vari-ous executive tests (Di Renzi, Lucchelli, Muggia, &

Spinnler, 1997; Repetto et al., 2007). In contrast,some cases have shown impaired performance onselective executive tests (Fujiwara et al., 2008;Markowitsch et al., 1999; Serra et al., 2007). Manyothers have failed to assess executive functions(Barbarotto et al., 1996; Kritchevsky et al., 2004;Luccheli, Muggia, & Spinnler, 1998; Nakamuraet al., 2002; Sellal, Manning, Seegmuller, Scheiber,& Schoenfelder, 2002). Neuroimaging findingsaddressing this issue are also inconsistent. Somestudies have documented frontal deactivation inpsychogenic amnesia (e.g., Markowitsch, 2003;Markowitsch et al., 2000), which would suggestimpaired performance on frontal/executive tests.In contrast, Anderson et al. (2004) documentedbilateral dorsolateral frontal activation during mem-ory suppression. This fits with Kopelman’s (2000)proposal that the inhibition of autobiographicalretrieval in some cases of focal retrograde amnesiais due to excessive inhibition by frontal controlmechanisms, implying supra-normal frontal orexecutive activation and integrity of frontal execu-tive test performance. The limited evidence to dateprevents any conclusion on this issue. Furtherresearch is needed to examine the relationshipbetween focal retrograde amnesia and executivefunctioning.

In regard to ‘organic’ factors that may havecontributed to XF’s retrograde amnesia, 8 monthsafter the onset of his retrograde amnesia he had anabnormal SPECT finding (see ‘Investigations’ sectionabove), specifically mild diffuse hypoperfusion in theleft cerebral hemisphere, most pronounced in theparietal lobe. Interestingly, this brain region containsthe precuneus, which has been implicated in anumber of functions that are highly relevant to thiscase (see Cavanna & Trimble, 2006 for a review). Forexample, recent neuroimaging studies have demon-strated that the precuneus plays a role in episodicmemory retrieval. In particular, the left precuneus isactivated during retrieval of source information(Lundstrom et al., 2003) and specific autobiographi-cal events (Addis, McIntosh, Moscovitch, Crawley, &McAndrews, 2004). Furthermore, it has been foundthat this brain region is involved in self processingtasks such as the processing of self relevant traits(Kircher et al., 2002) and assigning first personperspective (Vogeley et al., 2001). It has been sug-gested that in conjunction with the medial prefrontalregions, the precuneus represents a network that linkspersonal identity and past experiences. These are theexact functions that are impaired in retrogradeamnesia. While this link is intriguing, the aetiological

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significance of XF’s abnormal SPECT finding isunclear, and in any case the finding must be consid-ered with caution given the absence of any quantita-tive data and the margin of error associated withreported imaging abnormalities on SPECT scans.Future studies will need to explore the integrity of theprecuneus in patients with retrograde amnesia.

In regard to the previously used terms organic,psychogenic, and functional amnesia, XF’s condi-tion is not easily categorised under any of theselabels. His retrograde amnesia cannot be consid-ered purely organic, given the likely contribution ofpsychosocial factors discussed above. It is notpurely psychogenic, as he showed an abnormalSPECT finding, suggesting a functional brainabnormality, as discussed above (with appropriatecaveats). Furthermore, XF’s retrograde amnesiacannot be labelled functional, as there is evidenceof a brain abnormality and psychological factors,as opposed to no clear evidence of either. Thus,this case clearly challenges the organic/psychogenicdichotomy. In keeping with the view of otherauthors (e.g., Hodges, 2002; Markowitsch, 2002),we suggest that XF’s retrograde amnesia arisesfrom the coexistence and potential aetiologicalcontribution of both organic and psychologicalfactors, operating either independently or as differ-ent explanatory levels of a single causative process(in which case retrograde amnesia may represent‘simultaneously a low-level neurological impair-ment and a high-level psychological palliative’,McKay & Anderson, 2007, p. 1102; see alsoMcKay, Langdon, & Coltheart, 2005; McKay,Langdon, & Coltheart, 2007, for further discussionin the domain of delusions).

Limitations

It is important to point out some limitations of ourstudy. Firstly, given that XF completed our posi-tive illusions questionnaire after the onset of hisretrograde amnesia, it is impossible to determinewhether his heightened self-enhancement repre-sents a ‘state’ or ‘trait’. In particular, it is possiblethat rather than reflecting a cause of his memorydifficulties, the observed self-enhancement mayactually be an effect of those difficulties. After all,previous research has indicated that threats to self-esteem can occasion self-protective attempts toenhance self-esteem (see, for example, Brown &Gallagher, 1992; Wood, 1989). Insofar as XF’smemory difficulties (and/or the other psychosocial

stressors documented above) constituted a threatto his self-esteem, these difficulties may have beenthe impetus for defensive self-enhancement. Futurestudies might profitably administer our self-reportmeasure of self-enhancement (notwithstanding thelimitations of this measure; see below) to individu-als with other forms of memory impairment(including amnesias with unequivocally organic aeti-ologies), to determine whether self-enhancement is aunique feature of focal retrograde amnesia orwhether it is simply a feature of memory impairmentper se.5

In any case, although it is possible that XF’stendency to self-enhance may have developed inassociation with his retrograde amnesia, we feelthat our results are suggestive of a more interestingpossibility, namely that his results on our question-naire reflect a premorbid tendency that may havepredisposed him to develop retrograde amnesia.Longitudinal studies of patients with this conditionpose obvious logistical obstacles, but may benecessary to settle this issue decisively.

A second limitation concerns our methodologyfor gauging self-enhancement. We constructed aself-report measure requiring participants to com-pare themselves with their peers across a range ofcharacteristics and possible future events (cf.Brown, 1986). Our intention here was to measureindividual differences in self-enhancement. Thisapproach to measuring self-enhancement, how-ever, is open to an important criticism, namely thefact that no indicator of external reality is involved(Colvin, Block, & Funder, 1995). In other words,our approach makes no provision for distinguishingaccurate self-evaluations from positively biased self-evaluations. If XF actually is more intelligent,

5We note in this connection that other studies have found evi-dence of positive biases in organic memory syndromes.Fotopoulou, Conway, Griffiths, Birchall, and Tyrer (2007), forexample, found that the confabulations of a patient (‘LH’) whohad undergone surgical clipping of an anterior communicatingartery (ACoA) aneurysm were significantly more positivelyvalenced than both his true memories and the memories of fivehealthy control participants. Although these authors suggestedthat LH’s self-enhancing confabulations were best explained asthe product of motivational influences on memory constructionthat had become heightened as a result of his devastating braindamage (permitting him to ‘escape’ the unpleasantness of his real-ity), they noted that ‘Interestingly, LH’s pre-morbid behavioursuggested that he had always been someone who has tended toinflate his abilities and importance, particularly when undergoingstressful and self-threatening periods’ (p. 14; see also Fotopoulou,Solms, & Turnbull, 2004; Turnbull, Berry, & Evans, 2004).

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ethical, original and successful (etc.) than most ofhis peers, then he is not self-enhancing by indicatingas much on our questionnaire. Given the wide rangeof items on our questionnaire, we think it unlikelythat this factor accounts for XF’s significantly highscore. Nevertheless, we recommend that future inves-tigations of this topic employ alternative measures ofself-enhancement, for example criterion discrepancymeasures (which index self-enhancement by theextent to which a participant’s self-ratings are morepositive than warranted by a credible criterion; seeFunder & Colvin, 1997; Jansen, Smeets, Martijn, &Nederkoorn, 2006) or perhaps the over-claimingtechnique (the tendency to claim knowledge of non-existent items; see Paulhus et al., 2003).

In conclusion, we have provided a thoroughinvestigation of psychological and psychosocialfactors in a patient with focal retrograde amnesia.In particular, we have demonstrated for the firsttime that this condition is associated with signifi-cantly heightened positive self-appraisals, whichwe consider to be a form of ‘self deception’. Whilewe acknowledge that this case study does not pro-vide proof of any causal relationship, we suggestthat this heightened level of self-enhancement mayreflect a premorbid tendency that could potentiallypredispose individuals to develop focal retrogradeamnesia. Further research is required to determinethe aetiological significance of this and otherpsychological factors in retrograde amnesia.

Original manuscript received 25 April 2008Revised manuscript accepted 8 August 2008

First published online 30 September 2008

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APPENDIX A: Positive illusions questionnaire

Below are a series of items, each with an associated rating scale. You are asked to rate yourself, relative toyour peers, for each item. In every case a rating of 50% is average. For example, item 1 is ‘Please rate howintelligent you are relative to your peers’. If you feel that you are of average intelligence, you would make aclear mark at 50%. If, however, you feel that you are extremely intelligent, in the top 10% of people forexample, you might make a mark between 90 and 100%. If you feel that you are extremely unintelligent rel-ative to your peers, perhaps in the bottom 10% for intelligence, you would place your mark below 10%.

These items are not part of a test, and there are no right or wrong answers. Please attempt to answer all ofthem as honestly as you can, and try to answer with the first thing that comes to mind – don’t think toomuch.

Your answers will be kept strictly confidential. Thank you for your assistance.

1. Please rate how intelligent you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

2. Please rate how unreliable you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

3. Please rate how original you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

4. Please rate how friendly you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

5. Please rate how likely it is that you will become infected by the AIDS virus relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

6. Please rate how ethical you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

7. Please rate how prejudiced you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

8. Please rate how unhygienic you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

9. Please rate how much you care about social issues relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

10. Please rate your ability to get along with others relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

11. Please rate how good your sense of humour is relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

12. Please rate how kind you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

13. Please rate how bad-mannered you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

14. Please rate how likely it is that you will develop a drinking problem relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

15. Please rate how likely it is that you will have a heart attack before age 40 relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

16. Please rate how successful you are relative to your peers.0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

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17. What do you think your life expectancy is likely to be? (50%=average, below 50%=below average, above50%=above average).0.........10%.........20%.........30%.........40%.........50%.........60%.........70%.........80%.........90%.........100%

18. If you get married (or if you are already married), how likely are you, relative to your peers, to end upgetting divorced?0.........10%.........20%.........30%.........40%.........50% .........60%.........70%.........80%.........90%.........100%

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