Affective–autobiographical uncoupling in Korsakoff syndrome: A theoretical refinement illustrated by a post-bariatric case

Abstract

Objective: This study aimed to propose a theoretical refinement of the hypothesis that Korsakoff syndrome is a disorder of experience integration, reconciling it with recent evidence that emotional reactivity is largely preserved in the syndrome. Methodology: theoretical-conceptual study based on a narrative review of the literature, mainly from the last five years, on emotional and autobiographical memory, confabulation, intrusions, future thinking, awareness and the anatomy of the diencephalic memory system, with a clinical vignette used only for illustration. Results: the evidence indicates that patients with Korsakoff syndrome generate emotion but fail to incorporate emotionally relevant events into autobiographical memory and prospection, with a particular weakness for negative information. We propose a three-level model: affective reactivity (relatively preserved), relational binding and selection in the hippocampal–mammillary–thalamic system (damaged), and autobiographical integration and prospection in cortical networks (intact in principle but deprived of bound input). The uncoupling between the first and third levels generates five mechanisms: encoding without consolidation, the past occupying the present, gist without context, emotion without consequence, and future without content. A patient who developed the syndrome after bariatric surgery and persistent drinking illustrates each mechanism, and the model is compared with frontal, limbic and contextual accounts. Conclusion: affective–autobiographical uncoupling explains the lack of concern, the persistence of reward-seeking and the clinical misdiagnoses of the syndrome, and generates testable predictions.