Organic Amnesia Arthur P. Shimamura University of California, Berkeley

Organic Amnesia Arthur P. Shimamura University of California, Berkeley
Shimamura, A. P. (1992), Organic Amnesia, from
L. R. Squire (Ed.), Encyclopedia of Learning and
Memory, pp. 30-35, Macmillan: New York.

                                               Organic Amnesia
                                            Arthur P. Shimamura
                                       University of California, Berkeley

    Organic amnesia is a neurological disorder that
affects learning and memory but leaves other
mental abilities relatively preserved. One important
aim of research on this disorder is to understand
how learning and memory are disrupted by brain
dysfunction in order to obtain clues to brain orga-
nization and normal memory processes.
    Much of the current interest in memory and
brain function was initiated by Milner and col-
leagues who studied a now-famous patient with
organic amnesia, case H. M., who in 1953 under-
went surgery for relief of severe epileptic seizures.
The surgery involved bilateral excision of the me-
dial temporal region, which reportedly included
removal of the uncus (amygdala), anterior two
thirds of the hippocampus, and hippocampal gyrus
                                                             Figure 1. Schematic drawing of the medial surface of the
(see Figure 1). Following surgery, H. M.'s seizure           human brain showing structures in the medial temporal
activity was attenuated, but he exhibited a profound         lobe (e.g., hippocampus, amygdala) and in the diencephalic
anterograde amnesia—that is, he was unable to                midline (e.g., dorsomedial [DM] and anterior [AT] thalamic
remember events and information encountered                  nuclei, mammillary nucleus [M]). Figure reprinted from
since his operation. Despite this severe impairment          Squire (1984).
in new learning ability, there was no detectable
impairment in intellectual or language abilities.
There was some retrograde amnesia, which refers              minutes. Thus, the central feature of H. M.'s mem-
to impairment of memory for events that occurred             ory disorder is anterograde amnesia or new learn-
before the onset of amnesia. For example, H. M.              ing impairment. This impairment affects informa-
could not remember the layout of the hospital ward           tion received from all sensory modalities and in-
or recognize members of the medical staff.                   cludes impairment of both verbal and nonverbal
Moreover, he could not recall the death of a favor-          (e.g., spatial) memory. For example, H. M. has
ite uncle who had died three years previously. Yet,          failed to acquire new vocabulary words that have
following surgery H.M.'s retrograde amnesia was              been added to the dictionary since his surgery. He
not severe, as indicated by the fact that he per-            also exhibits severe impairment on laboratory tests
formed as well as control subjects on a test of              of word and picture recall, cued-word learning
memory for faces of celebrities who became fa-               (e.g., learning word pairs), and recognition mem-
mous prior to 1950. He was also capable of re-               ory.
calling well-formed autobiographical episodes                    Despite the severity of his amnesia, H. M. can
from his adolescence.                                        think and act normally, as indicated by his pre-
    H. M. is still alive, and clinical observations          served I.Q. Indeed, even some memory functions
indicate that memory for ongoing events is se-               are spared, such as short-term memory, which can
verely impaired. For example, 30 minutes after               be measured by intact performance on tests of
eating lunch, H. M. could not recall what he had             immediate digit span. Nevertheless, as soon as
eaten and could not even recall if he had lunch at           information is out of conscious experience, it is
all. H. M. is aware of his disorder and has re-              forgotten. The analysis of H. M.'s amnesia stands
flected upon his impairment as always "waking                as a milestone in our progress to understand
from a dream." In other words, he seems to lack              memory in the brain. He has provided the crucial
continuity in the memory of events across time,              evidence for the specific role of the medial tempo-
even when the events are separated by only a few             ral region in the process of memory formation and

                                                    Page 1
storage. Indeed, the analysis of H. M. by Milner        show bilateral damage along the diencephalic mid-
and colleagues has provided the impetus for many        line, typically involving the dorsomedial thalamic
important animal and human studies on the role of       nuclei and a subthalamic nuclei called the mam-
the medial temporal region in learning and mem-         millary bodies. In addition, cortical atrophy and
ory.                                                    cerebellar damage are often observed.
             The Anatomy of Memory                          Patients with Korsakoff's syndrome exhibit
    There are other neurological disorders that         severe anterograde amnesia and often extensive
damage the medial temporal region and thus pro-         retrograde amnesia. The severity of retrograde
duce an amnesic syndrome similar to that seen in        amnesia, however, is variable among these patients,
H. M. For example, tumors, head injuries, or vas-       with some showing extensive retrograde amnesia
cular disorders (e.g., strokes) in this region can      and others showing little. One factor that compli-
cause organic amnesia. Also, some neurological          cates the characterization of the memory impair-
disorders—such as viral infection, ischemia (i.e.,      ment in Korsakoff's syndrome is widespread cor-
loss of blood flow to the brain), or hypoxia (i.e.,     tical atrophy, which is presumed to be a conse-
loss of oxygen to the brain), particularly damage       quence of chronic alcohol abuse. Indeed, some
the medial temporal region. In these disorders,         mental functions, such as stimulus encoding, at-
anterograde amnesia is often the outstanding cog-       tention, and problem solving are impaired in pa-
nitive impairment, though retrograde amnesia can        tients with Korsakoff's syndrome but not in other
also occur. General intellectual abilities and short-   amnesic patients. Moreover, patients with Kor-
term memory are generally intact.                       sakoff's syndrome are often emotionally flat, apa-
                                                        thetic, and without insight about their deficit. These
    An amnesic patient studied by Zola-Morgan et        additional cognitive and personality disorders may
al. has provided additional clues concerning the        occur as a result of extensive cortical damage, in
prominent role of the hippocampus in memory.            particular damage to the prefrontal cortex.
Patient R. B. became amnesic in 1978, when he
experienced an ischemic episode that occurred               Not all amnesic syndromes are permanent. For
during open-heart surgery. R. B. was given exten-       example, head injury can cause a transient and
sive neuropsychological assessment and was              selective memory impairment. Following initial
found to exhibit anterograde amnesia but little if      stages of unconsciousness or confusion, an-
any retrograde amnesia. In 1983, R. B. suffered a       terograde and retrograde amnesia occurs, and the
fatal cardiac arrest, and, with the encouragement of    severity of anterograde amnesia is often correlated
his family, a comprehensive examination of his          with the temporal extent of retrograde amnesia.
brain was performed. This examination revealed a        Retrograde amnesia tends to follow Ribot's Law,
discrete bilateral lesion restricted to a portion of    which states that memory for the recent past is
the hippocampus called the CA1 subfield. R. B.          affected more severely than memory for the distant
represents the first extensively studied case of        past. Amnesia following head trauma can last for
amnesia that occurred as a result of damage re-         minutes, days, or even weeks. In mild trauma
stricted to the hippocampus.                            cases, new learning ability recovers to premorbid
                                                        levels. In more severe cases, both amnesia and
    Another area of the brain, the diencephalic mid-    other cognitive impairment can be long-lasting and
line, can also produce organic amnesia (see figure      sometimes permanent.
1). This area includes various midline thalamic
nuclei (nuclei are bundles of neurons) as well as           Amnesia can also occur after electroconvulsive
subthalamic nuclei. These nuclei receive and send       therapy (ECT), which is sometimes prescribed for
projections to various areas in the brain, including    severe depressive illness. Anterograde amnesia can
the medial temporal region. Patients with neuro-        be quite severe, particularly in patients who receive
logical damage due to cerebrovascular stroke or         bilateral ECT. Retrograde amnesia is often tempo-
head injury in this area often exhibit organic am-      rally-graded, following Ribot's Law. By several
nesia.                                                  months after ECT treatment, there is extensive
                                                        recovery of new learning capacity. Retrograde
    The best-studied cases of amnesia resulting         amnesia also resolves considerably when testing
from damage to the diencephalic midline are pa-         occurs 6-9 months after ECT. Although the bio-
tients with Korsakoff's syndrome. As reviewed by        logical factors that cause the transient amnesic
Butters and Cermak, Korsakoff's syndrome is an          disorder following ECT are not well understood, it
amnesic disorder that develops after many years of      is known that the hippocampus has one of the
chronic alcohol abuse and nutritional deficiency.       lowest seizure thresholds of all brain structures.
Studies by Victor et al. of postmortem brain tissue
Thus, hippocampal functioning may be particularly          trials and good retention when the same puzzle
compromised following ECT.                                 was given 1 week later.
   Advances in neuroimaging techniques, such as                Cohen and Squire observed preserved skill
computed tomography (CT), magnetic resonance               learning by amnesic patients on a mirror reading
(MR) imaging and positron emission tomography              task. In this task, subjects were asked to read mir-
(PET), have allowed more detailed analysis of the          ror-reversed words. Patients with Korsakoff's
brain areas that are damaged in neurological pa-           syndrome, patients prescribed ECT, and patient N.
tients. For example, analyses of computed tomo-            A. improved their reading speed of mirror-reversed
graphy (CT) brain scans of patients with Kor-              words across training sessions to the same extent
sakoff's syndrome corroborated postmortem                  as control subjects. Moreover, amnesic patients
findings by identifying signs of increased fluid           exhibited normal retention of the mirror-reading
and low neural density in the midline diencephalic         skill even when they were tested one month after
region. A new technique by Press et al. has been           learning. Despite this intact skill learning perform-
developed for MR imaging of the hippocampus.               ance, patients failed to recognize the the words
This technique produces a clear cross-sectional            used in the task. Moreover, the patients often did
image of the hippocampal formation and has al-             not even recognize the testing apparatus nor did
ready provided remarkable images of the extent of          they have conscious recollection of having en-
hippocampal damage in amnesic patients. For                gaged in the task before. Performance by amnesic
example, it was shown that, compared to control            patients in these tasks indicates that skill learning
subjects, amnesic patients exhibited an average            can be preserved even when the patient has little or
loss of 49% of tissue in the area of the hippocam-         no recollection of having acquired the skill. These
pal formation. Despite this tissue loss in the hip-        findings suggest that amnesic patients can exhibit
pocampal area, the average area of the temporal            a certain "unconscious" form of knowledge
lobe in these patients was nearly identical to that of     ("knowing how") in the absence of explicit or
control subjects. Although PET analyses of amne-           declarative knowledge ("knowing that").
sic patients have not been thoroughly studied, they            There are several other forms of preserved
offer another approach to the physiological dys-           memory function in amnesia. One form is illus-
function associated with organic amnesia.                  trated by an early anecdote of "unconscious"
                                                           memory that was reported by Claparede. During
   Preserved Memory Functions in Amnesia                   an interview with an amnesic patient, Claparede hid
   One of the most striking findings is that amne-         a pin between his fingers and surreptitiously
sic patients can perform in an entirely normal             pricked the patient on the hand. At a later time
fashion on certain "implicit" or "nondeclarative"          during the interview, he once again reached for the
memory tests. These tests involve habit or auto-           patient's hand, but the patient quickly withdrew her
matic learning, such as the kind of memory ex-             hand. The patient did not acknowledge the previ-
pressed on tests of skill learning, classical condi-       ous incident, and, when asked why she withdrew
tioning, and "priming." For example, H. M.                 her hand, she simply stated, "...sometimes pins are
showed considerable retention of perceptual-motor          hidden in people's hands." This anecdote is an
skill on a mirror drawing task in which he was             example of stimulus-response learning without
required to trace the outline of a star while viewing      awareness. Another form of such learning was
the star in a mirror. The task is difficult at first but   demonstrated by Weiskrantz & Warrington, who
then becomes easier and easier with practice. H.           assessed Pavlovian classical conditioning of the
M. also exhibited skill learning on a pursuit-rotor        eyeblink response in two amnesic patients. These
task in which a stylus must be kept on a rotating          patients retained the eyeblink response for as long
target. In these tests, H. M. performed as a skilled       as 24 hours, even though they did not recognize
individual but did not have conscious knowledge            the test apparatus.
of having performed the task before. Preserved                 A memory phenomenon known as priming is
skill learning has been observed in other cases of         also preserved in amnesia. Priming is an automatic
amnesia as well. For example, normal pursuit-rotor         facilitation or bias in performance as a result of
skill learning and one-week retention in three pa-         recently encountered information. The seminal
tients with Korsakoff's syndrome and two patients          evidence for preservation of priming in amnesia
with amnesia due to viral encephalitis. Also, in a         came from Warrington and Weiskrantz. Amnesic
jig-saw puzzle assembly task, these amnesic pa-            patients were asked to identify words or pictures
tients exhibited faster completion times across six        that were presented in a degraded form. If the
                                                           subject could not identify the stimulus, a succes-
sion of less degraded versions of the stimulus           scious" recollection from unconscious or auto-
were shown until identification was successful.          matic memory. Squire and colleagues suggested
When amnesic patients were asked to identify the         that amnesia impairs declarative memory and
same degraded words or pictures at a later time,         spares procedural or nondeclarative memory.
their performance was facilitated by the previous        Others have used related terms such as explicit and
experience; that is, they were able to identify the      implicit memory or memory and habit. Such de-
stimuli more quickly. This priming effect occurred       scriptions provide a framework for theoretical
despite failure to discriminate previously presented     views about the organization of memory in the
stimuli from new ones in a recognition memory            brain.
test.                                                              Memory Systems in the Brain
   Graf et al. used a word completion task to study         Findings from amnesic patients have led to the
priming effects. In this task, words are presented       conclusion that there are multiple memory systems
(e.g., MOTEL) to the subject and later cued by           in the brain, such that some forms exist entirely
three-letter word stems (e.g., MOT). Subjects are        outside the brain regions that are damaged in or-
asked to say the first word that comes to mind for       ganic amnesia. Amnesic patients apparently cannot
each word stem. In both amnesic patients and             explicitly or consciously recollect information
control subjects, the tendency to use previously         learned since the onset of amnesia. The impair-
presented words in the word completion test was          ment is often thought to affect the ability to store
increased by 100-200% over baseline levels. In           and also to retrieve newly learned information.
this test, words appear to "pop" into mind, and          Amnesic patients, however, can often perform in a
amnesic patients exhibited this effect to the same       normal fashion on certain "indirect" tests of mem-
level as control subjects. However, when subjects        ory—tests that do not require conscious recollec-
were asked to use the same word stems as aids to         tion of past learning sessions. Tests of skill learn-
recollect words from the study session, the control      ing, classical conditioning, and priming can be
subjects exhibited better performance than amnesic       characterized as indirect or implicit tests.
                                                            Various theories have been proposed to de-
   A variety of priming paradigms have since been        scribe the amnesic disorder. Squire and colleagues
used to demonstrate preserved priming in amnesia.        have specified a neurological basis for declarative
For example, in one task subjects were presented         memory—the form of memory that is impaired in
words (e.g., BABY) and later asked to "free asso-        amnesia. It is hypothesized that declarative mem-
ciate" to related words (e.g., CHILD). Amnesic           ory involves a storage or consolidation process
patients exhibited a normal bias to use recently         that depends critically on the interaction of the
presented words in this word association task.           hippocampus with areas in neocortex. The hippo-
This finding suggests that semantic associations         campal "system" receives projections from many
can also be used to prime information in memory.         neocortical areas. Thus this region may be in-
This priming effect, as well as others, are short-       volved in relating or connecting information be-
lasting, and decline to baseline levels after a 2-hour   tween various neocortical areas so that memory
delay. Although patients with circumscribed dien-        storage and retrieval can be accomplished quickly
cephalic or medial temporal lesions exhibit normal       and efficiently. Warrington and Weiskrantz have
priming effects, patients with the clinical diagnosis    suggested that amnesia is due to a disruption of
of Alzheimer's disease do not. For example, im-          diencephalic midline projections that connect the
paired word completion and word association              medial temporal region to the prefrontal cortex.
priming has been observed in patients with senile        Similarly, Mishkin has suggested that amnesia is
dementia of the Alzheimer type. These findings           caused by disruption of the interaction of the hip-
suggest that priming effects may depend critically       pocampus and amygdala with structures in neo-
on neocortical areas that are damaged in Alz-            cortex and in the diencephalic midline (mediodor-
heimer's disease.                                        sal and anterior nuclei of the thalamus).
   Demonstrations of preserved memory functions             In summary, neuropsychological studies of
in amnesic patients suggest that some memory             memory functions in amnesic patients have pro-
processes can be dissociated from the brain re-          vided useful information about the organization of
gions that are damaged in organic amnesia. As            memory systems in the brain. Damage to the me-
reviewed by Squire, various taxonomies have been         dial temporal region or diencephalic midline
used to distinguish the memory forms that are            causes an amnesic syndrome in which conscious
impaired in amnesia from those that are preserved.       or declarative memory is severely impaired. Inter-
For example, many distinguish between "con-              estingly, other implicit or procedural functions
(e.g., skills, habits) are entirely preserved. These   Shimamura AP: Priming in amnesia: Evidence for
findings suggest that there are multiple memory            a dissociable memory function. Q J Exper
systems in the brain and that one system can be            Psychol 38, A: 619-644, 1986
dissociated from other memory and cognitive sys-       Squire LR: The neuropsychology of memory. In
tems. These findings may offer important avenues           Marler P, Terrace H (Editors), The Biology of
for both rehabilitative and pharmocological inter-         Learning, Dahlem Konferenzen, Berlin:
ventions. That is, it may be possible to develop           Springer-Verlag, 1984.
more efficient and more specific diagnoses and         Squire LR: Memory and Brain. New York: Ox-
therapies for neurological patients as well as for         ford University Press, 1987
individuals with more subtle forms of memory           Victor M, Adams R.D, Collins GH: The Wer-
dysfunction, such as that observed in aging.              nicke-Korsakoff Syndrome. Philadelphia:
                                                          Davis Company, 1971
                                                       Warrington EK, Weiskrantz L: Amnesia: A dis-
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