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Brooks, Elinor (2022) Exploring the clinical management of confabulation
within neuropsychology services. D Clin Psy thesis.
https://theses.gla.ac.uk/83244/
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Enlighten: Theses
https://theses.gla.ac.uk/ [email protected]

Exploring the clinical management of confabulation within neuropsychology services.
Elinor Brooks, BSc (Hons) Psychology and Neuroscience, MSc Applied Neuropsychology.
Submitted in partial fulfilment of the requirements for the degree of Doctorate in Clinical Psychology
Institute of Health and Wellbeing College of Medical, Veterinary and Life Sciences University of Glasgow
October, 2022
© 2022, Elinor Brooks
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Contents
Chapter 1: A systematic review of interventions for confabulation in adults with acquired brain injury or dementia................................................... 7
Abstract ................................................................................................................................ 8 Introduction ......................................................................................................................... 9 Aims of the Present Review...........................................................................................10 Review Questions ...........................................................................................................10 Method ................................................................................................................................ 11 Eligibility criteria ...........................................................................................................11 Search Strategy ..............................................................................................................11 Screening ......................................................................................................................... 12 Data Extraction ..............................................................................................................12 Quality assessment.........................................................................................................13 Registration..................................................................................................................... 13 Results ................................................................................................................................. 13 Study Selection ...............................................................................................................13 Participant characteristics ............................................................................................14 Quality of evidence.........................................................................................................20 Primary review question ...............................................................................................21 Secondary review questions ..........................................................................................31 Discussion ........................................................................................................................... 37 Overall completeness and applicability of the evidence.................................................39 Potential biases in this review...........................................................................................39 Conclusions......................................................................................................................... 39 References........................................................................................................................... 41
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Chapter 2: Exploring the clinical management of confabulation within neuropsychology services.........................................................................46
Plain language summary...................................................................................................47 Abstract .............................................................................................................................. 49 Introduction ....................................................................................................................... 50
Aims.................................................................................................................................52
Research questions.........................................................................................................52 Method ................................................................................................................................ 52 Design .............................................................................................................................. 52 Participants ..................................................................................................................... 53 Sample Size.....................................................................................................................53 Materials .........................................................................................................................54 Procedure ........................................................................................................................ 55 Ethics, Governance and Data Protection.....................................................................55 Analysis ...........................................................................................................................56 Research team characteristics and reflexivity.............................................................57 Results ................................................................................................................................. 57 Demographics ................................................................................................................. 57 Quantitative analysis: Survey .......................................................................................58 Thematic Analysis: survey and interview....................................................................63 Discussion ........................................................................................................................... 72 Working with confabulation in clinical practice.........................................................72 Clinician confidence and experience ............................................................................75 Current limitations in the management of confabulation..........................................75 Study limitations ............................................................................................................76 Conclusions ..................................................................................................................... 76 References........................................................................................................................... 78
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Tables Chapter 1: Systematic Review
Table 1: the SPICE framework operationalising the scope of the search. ............................. 11 Table 2: participant characteristics. ........................................................................................ 16 Table 3: methodological quality scores using the QualSyst including the summary score (summary score: total sum/total possible sum). ...................................................................... 20 Table 4: intervention characteristics....................................................................................... 21 Table 5: others involved in interventions. .............................................................................. 31 Table 6: assessment and outcome measures...........................................................................35
Chapter 2: Major Research Proposal
Table 7: The number of participants indicating how often they undertake specific activities relevant to working with confabulation...................................................................................58 Table 8: The number of clinicians who have experience providing assessment, formulation and intervention of confabulation following ABI. .................................................................. 59 Table 9: Frequency (n) of clinician opinions relating to the reliability of current management approaches. .............................................................................................................................. 60 Table 10: Frequency (n) of clinician opinions relating to the variety of current management tools. ........................................................................................................................................ 61 Table 11: Number of clinicians who report that further research into the management of confabulation will be useful for their clinical practice............................................................61 Table 12: Number of clinicians who felt they had a good level of experience managing confabulation. .......................................................................................................................... 62 Table 13: Number of clinicians who felt confident managing confabulation. ....................... 62 Table 14: Frequency (n) of clinicians’ overall opinion. ......................................................... 63
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Figures
Chapter 1: Systematic Review
Figure 1: flowchart of the study selection process and results for inclusion in the systematic review. ..................................................................................................................................... 14
Chapter 2: Major Research Proposal
Figure 2: Frequency chart showing the number of participants by year of qualification.......58 Figure 3: Representation of overarching, superordinate and sub-themes from the thematic analysis of interview data........................................................................................................64
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Disclosure Statement
The authors report there are no competing interests to declare. This study was sponsored by the University of Glasgow.
Acknowledgements
I would firstly like to thank Dr Jessica Fish for the wisdom, kindness and support you have given, particularly in the final hours. I have thoroughly enjoyed learning from you throughout this process. Many thanks to Professor Jon Evans for your patience and generosity throughout this project. You both have helped me reach the finish line, and I will forever be grateful.
Secondly, I would like to thank all participants who gave their time to participate in this study and who shared their vast knowledge and experience in this area.
A special thanks to my colleagues in NHS Ayrshire and Arran, Dr Ken MacMahon, Dr Luke Williams, Dr Nikki Paterson and Dr Kim Robertson, for the continued support you have given throughout my training and in particular during my final year.
Particular thanks to my friend Ryan Slavin for your co-rating abilities and to the cohort of 2022.
Finally, complete gratitude and admiration to my family, in particular my mum Jane, and my friends (old and new) who really have pulled me through the last few years and have always given endless encouragement and support. I would not have been able to reach this point without you.
Elinor Brooks.
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Chapter 1: A systematic review of interventions for confabulation in adults with acquired brain injury or dementia.
Elinor Brooks1
Prepared in accordance with the author requirements for The Clinical Neuropsychologist https://www.tandfonline.com/action/authorSubmission?show=instructions&jou rnalCode=ntcn20
Word count (including references): 8945
Keywords:
Confabulation, Acquired Brain Injury, Dementia, Management, Interventions.
1 Mental Health and Wellbeing, Institute of Health and Wellbeing, University of Glasgow Email:
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Objective
Abstract
This systematic review aimed to identify and synthesise studies describing psychosocial interventions used in the management of confabulation following brain injury and dementia. More specifically, intervention type and efficacy were explored.
Method
Five databases were searched for studies using a range of psychosocial interventions with adult participants experiencing confabulation in the context of ABI and dementia. The Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (Kmet et al., 2004) was used to assess methodological quality.
Results
Of the thirteen included studies, most had case study designs though three group studies were also identified. In total, 132 participants were included, the majority male in the working-age category. Interventions incorporated a range of cognitive, emotion-focussed, and behavioural components and targeted processes including raising insight, ‘reality testing’ and self- monitoring. Most studies had poor-moderate methodological quality and there was inconsistency in the level of detail with which intervention and measurement procedures were reported.
Conclusions
Despite limitations of the evidence, general trends observed included similarities in treatment targets, despite variation in strategies used and involvement of family members in neurorehabilitation. Future research could build upon current literature by conducting robust investigations using single case experimental designs. In addition, due to reporting inconsistencies there is a need for future work to follow established reporting standards.
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Introduction
Confabulation can be described as the unintentional production of false or erroneous memories (Bajo et al., 2017). They are often autobiographical, and recollection may be entirely or partially erroneous (Burgess, 1996; Kopelman, 2010). For example, memory content may be inaccurate or misplaced in time and place context. Individuals may act upon confabulations, resulting in the production of statements and actions incongruent with current reality (Dalla Barba et al., 2020; Schnider, 2001). This neuropsychological phenomenon can occur in people with psychosis and acquired brain injury (ABI) and is often associated with difficulties in executive functions, insight and mood (Bajo et al., 2017). The few longitudinal studies that exist have shown confabulation can improve or even resolve over time (Bajo et al., 2017). However, it has been argued that its presence can interfere with neurorehabilitation and adjustment to disability; therefore confabulation is an important treatment target (Fotopoulou, 2008).
Confabulation has been classified as ‘provoked’ or ‘spontaneous’ (Kopelman, 2010). Provoked confabulations may occur in response to questioning, whereas spontaneous confabulations occur freely. Another approach to classifying confabulations identifies four subtypes: provoked, momentary, behaviourally-spontaneous and fantastic (Nahum et al., 2012). Although there are currently no agreed diagnostic criteria, these categories are based on empirical evidence and may serve as an appropriate classification method (Bajo et al., 2017). Other reported confabulation types include momentary and delusional (Dayus & Van Den Broek, 2000; Trivino et al., 2017). Theories propose various underlying mechanisms including errors in executive aspects of memory processing, distinguishing source and context of memories and discrimination between imagined versus experienced events (Gilboa & Verfaellie, 2010; Nahum et al, 2012; Schnider, 2008).
A small number of studies have examined the use of interventions to manage confabulation. Strategies include behaviour management, psychoeducation, collaborative formulation, provision of systematic feedback, and use of diaries and checklists (Fish & Forrester, 2018; Fotopoulou, 2008; Schnider, 2008; Trivino et al., 2017). These aimed to address a variety of cognitive, emotional, behavioural and systemic treatment target mechanisms and intended outcomes. One published systematic review provided a summary of existing pharmacological, surgical and non-pharmacological interventions for confabulation and their effectiveness, which also appears to include psychosocial interventions (Francis et al.,
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20212). However, the definition of ‘psychosocial’ is unclear and there is limited information pertaining to the inclusion criteria and keyword definitions for types of psychosocial interventions included, however the search strategy included the terms “intervention”, “treatment” and “therapy”. This provides a rationale for the current systematic review to systematically explore psychosocial interventions with a more rigorous methodology and with the sole focus on psychosocial interventions. The present study included review questions related to assessment and measurement of confabulation as well as treatment. Additionally, specific methodological refinements included the use of more sensitive search terms, searching the ‘grey’ literature (i.e., beyond peer-reviewed scientific journals), use of a transparent, pre-registered methodology, and incorporation of co-rating at both screening and quality appraisal stages.
Aims of the Present Review
This review aimed to identify and synthesise studies reporting the use of psychosocial interventions in the management of confabulation in the context of ABI or dementia. Specifically, this pertained to the direct management of confabulation as opposed to the management of wider difficulties in someone presenting with confabulation. Psychosocial interventions included psychological, educational, environmental and social approaches. See Appendix 1.1 (pp.82) for more details.
Review Questions
Primary question: interventions
What psychosocial interventions have been reported in the treatment and/or management of confabulation in people with ABI or dementia?
Secondary questions: study characteristics

• 
  

  In what settings did these interventions take place?

  
  


• 
  

  Who delivered the intervention?

  
  


• 
  

  How were confabulations assessed and characterised?

  
  


• 
  

  Were co-morbid disorders described?

  
  


• 
  

  What treatment targets were reported?

  
  


• 
  

  How were outcomes measured?
  2 Note the Francis et al., (2021) review was published after the original proposal for the current review was developed, but in time for our proposal to be refined in response to it.
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• 
  

  What were the effects of the interventions?

  
  


• 
  

  Were individuals followed up post-intervention?

  
  


• 
  

  Did intervention type relate to the type of confabulation identified?
  Method
  Eligibility criteria
  Due to the low number of studies identified in scoping searches, the frequent use of case studies and low n participant groups, a systematic review with a narrative synthesis was conducted. The SPICE (Setting, Perspective, Intervention, Comparison, Evaluation; Booth, 2006) framework was used to operationalise the scope of the review. Table 1 describes the SPICE framework and eligibility criteria used.
  Table 1: The SPICE framework operationalising the scope of the search.
  SPICE
  Setting
  Perspective
  Comparison Evaluation
  Search limits
  Any setting accepted
  Adults (18+ years)
  Experiencing confabulation
  Following brain injury or in context of dementia
  Studies with and without comparison groups and/or conditions were considered.
  Outcomes of interventions or studies which assess or comment on possible effects of intervention.
  Intervention
  Range of psychosocial interventions (any non- pharmacological, non-surgical and non-medical intervention was accepted; Appendix 1.1, pp.82, for definitions).
  Search Strategy
  Five databases were searched from inception to 08.05.2022: Cumulative Index to Nursing and Allied Health Literature (CINAHL; Ebscohost), Medline (Ovid), Embase (Ovid), Cochrane (Central) and psycINFO (Ebscohost) via the University of Glasgow library online services (https://www.gla.ac.uk/myglasgow/library/specificsearch/databasesbysubject/). A Boolean search technique combined terms for ‘confabulation’, with those for ‘brain injury, or ‘dementia’. Other potentially limiting terms related to settings, interventions, or outcomes were intentionally omitted to maximise sensitivity (Appendix 1.2, pp.83, for full details). For
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the search of Embase and Medline, key terms were mapped to medical subject headings (MESH headings). Additional search limits restricted the search to English language and human participants. Literature published outside of peer-reviewed scientific frameworks was included (i.e. ‘grey literature’), such as dissertations and book chapters. The search strategy was reviewed by a librarian and a PRISMA flow diagram details the full search strategies (Figure 1).
Screening
References were exported to the citation manager EndNote (http://endnote.com/), organised electronically and duplicates removed. Titles and abstracts of articles were screened against eligibility criteria, and any clearly ineligible papers excluded. The remaining papers underwent full text screening against inclusion and exclusion criteria (Appendix 1.3, pp.84), with reasons for exclusion documented (Figure 1). At each screening and data extraction stage, 25% of the papers (or a minimum of 10 papers, whichever was the greater) were independently screened by a second reviewer (RS) to ensure accurate application of criteria. Initial screening agreement was 89% (n=198/223) and full text-screening co-rating agreement was 85% (n=40/47). Screening stage discrepancies largely related to articles with limited data presented in the abstract, following discussion these were carried forward through to full text review. At the full-text screening stage discrepancies related to what constituted a psychological intervention and identification of confabulation, particularly when it was poorly defined. Disagreement was resolved through discussion and provision of information about confabulation, as the co-rater was less familiar with this phenomenon than the primary rater.
Data Extraction
A standardised data extraction form was developed using Microsoft Excel. This included instructions at each step to improve consistency, reliability and validity during the process. When determining confabulation type a standardised description of four main types was presented (Nahum et al., 2012). A pilot data extraction exercise was run on an initial sample of papers (n=3, approximately 25%), to confirm the reliability of the extraction template. The form was adjusted to include ‘recruitment procedure’ and ‘description of confabulation’ as confabulation type was not always explicitly reported.
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Quality assessment
The Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (QualSyst; Kmet et al., 2004; Appendix 1.4, pp.85) was used to assess the methodological quality of the studies. This tool has good reliability and is well suited to bodies of literature using a variety of methodologies. It consists of 14 items of quality assessment, with each assigned one of four scores (Yes = 2, Partial = 1, No = 0, Not applicable=N/A), using the provided criteria3. Rated scores are summed, with proration for items rated N/A. The second rater rated 50% of papers to establish inter-rater reliability. A two-way mixed intraclass correlation coefficient (ICC = .907, 95% CI [0.689, 0.972]) indicated good reliability. Differences in opinion were resolved through discussion. It was agreed that the ratings of the primary researcher were accurate and reliable and therefore the primary researcher conducted the quality assessment of the remaining papers.
Registration
The review protocol was registered on PROSPERO (https://www.crd.york.ac.uk/prospero/) under ‘A systematic review of interventions for confabulation in adults with acquired brain injury’ (registration number: CRD42022322630). An amendment was made to the protocol following registration, which included updating eligibility criteria to exclude medical interventions and published abstracts and posters.
Results
Study Selection
Figure 1 shows the flowchart displaying details of the search process and results. Thirteen articles were included in the review synthesis. No articles were found relating to interventions for confabulation in the context of dementia.
3 Note that ‘not applicable’ ratings are not permitted for items 1, 2 and 4.
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Identification of studies via databases and registers
Participant characteristics
Participant characteristics across all studies are summarised in Table 2, see Appendix 1.5 (pp.86-89) for summary of study characteristics. Most participants were male (M:F = 89:43) spanning working adult age range, but predominantly within 40-60 years. All studies were conducted in western cultural contexts. The aetiology of participants’ brain injuries varied, including traumatic brain injury (n=7; 6, 7, 8, 13), herpes simplex virus encephalitis (n=1; 3) and middle cerebral artery stroke (n=10; 13). The largest aetiological group was Wernicke’s and/or Korsakoff’s syndromes (n=52) reported in two cohort studies (10,11). However, most articles (1,2,4,5,11,12,13) reported on cases presenting with anterior communicating artery
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Records removed before screening:
Duplicate records removed (n = 393)
Records identified from:
MEDLINE (n = 234); Embase (n=633); PsycINFO (n=422); CINAHL (n=22); Cochrane (n=22).
TOTAL= 1286
Records screened
(n = 893)
Records excluded (n = 700)
Reports sought for retrieval
(n = 193)
Reports not retrieved (n = 4)
Reports excluded:
No intervention (n = 111)
No confabulation (n= 12) Pharmacological intervention (n = 31)
Surgical intervention (n=1) Inappropriate article type e.g. systematic review, poster presentation (n =12)
Not written in English (n=9)
Reports assessed for eligibility
(n = 189)
Included Screening Identification
Studies included in review
(n = 13)
Figure 1: Flowchart of the study selection process and results for inclusion in the systematic review.

aneurysms (ACoAA; n=24). Time since injury ranged from 15 days-3.5 years. Most studies reported the type of confabulation presented or a brief description. Where discussed, types of confabulation reported included behaviourally spontaneous (n=26), fantastic (n=23), momentary (n=20), provoked (n=2) and delusional (n=1). One study (11) reported group data only, therefore it was not possible to ascertain how many participants presented with each type. Limited data was provided on previous mental health and physical health histories and previous treatment. It is unclear if this is because studies did not assess for wider difficulties or assessed without reporting.