Graphic Transmutations: When Meaningless Pictures are Remembered as Familiar Objects

Graphic Transmutations: When Meaningless Pictures are Remembered as Familiar Objects | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Graphic Transmutations: When Meaningless Pictures are Remembered as Familiar Objects Miriana Migliaccio, Ciro Rosario Ilardi, Elena Salvatore, Chiara Criscuolo, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6502291/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Feb, 2026 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract When asked to reproduce abstract figures from memory, people with brain damage may draw meaningful figures or add extra features unrelated to the original stimulus. Such a phenomenon has been classified as an uncommon type of confabulation. However, this interpretation is unsatisfactory. The aim of this study was to revisit this phenomenon to provide a more robust interpretation. The records of 493 people presenting with cognitive complaints have been reviewed. Their copy and their reproduction by memory of the Rey-Osterrieth Complex Figure were analysed. Sixteen people presented with clear instances of the phenomenon. Their demographics, and cognitive profiles, including memory and executive functions, did not differ from those of a matched control group of people from the same sample who did not present with the phenomenon. Considering this phenomenon as a confabulation is misleading. We suggest that the compulsion to semantically process the meaningless figure as a meaningful object leads to the production of Graphic Transmutation . The meaningful object overrides the original due to a failure of monitoring functions associated to a defective visuo-spatial memory. Identifying Graphic Transmutation in neuropsychological evaluations may provide valuable insight into the cognitive profile of people with brain damage. Biological sciences/Psychology Health sciences/Neurology Graphic transmutation Rey-Osterrieth’s complex figure confabulation semantic Figures Figure 1 Figure 2 Figure 3 1. Introduction Productive symptoms, such as intrusions and perseverations, have been reported in people with brain diseases in drawing tasks, both when drawing from dictation [ 1 ] and when copying [ 2 , 3 ]. A particular phenomenon involves the production of meaningful drawings or the addition of extra features unrelated to the original stimulus in delayed copying tasks when reproducing a meaningless figure from memory. It has been documented in cases of Alzheimer’s Disease [ 4 ], fronto-temporal dementia [ 5 ], Wernicke-Korsakoff syndrome [ 6 ] and bilateral medio-basal frontal lesion caused by a ruptured aneurysm (case 7b, [ 7 ]). This phenomenon has been branded as an uncommon type of confabulation [ 8 ]; Pelati et al.[ 9 ] introduced the term “graphic confabulation” to describe such additional or distorted elements unrelated to the target in delayed drawing tasks. In their retrospective study, 267 individuals with heterogeneous neurodegenerative diseases were asked to copy the Rey-Osterrieth Complex Figure (ROCF – [ 10 , 11 ] and then reproduce it from memory after a 20-minute delay. Fourteen individuals (4.9%) added unrelated elements or altered its configuration by drawing recognizable figures, like a house, a face, a human silhouette, a fish, or a flower plot. Similar instances of simplifying the ROCF into familiar items such as houses, boats or fish have been reported in 4–5 years old children [ 11 ]. This behaviour becomes rarer by age 6 and diminishes with age [ 11 ]. Notably, it has never been reported in the healthy adults [ 12 , 13 , 14 , 15 , 16 ]. This type of graphic production bears some resemblance to confabulations seen in dysexecutive syndromes. Accordingly, it has been labelled also “graphabulation” [ 6 ], “graphic confabulatory tendency” [ 4 ], “visuo-spatial confabulation” [ 5 ], as well as “constructional confabulating behaviour” [ 9 ]. However, unlike confabulations, which can occur spontaneously, regardless of the task, stimulus, or testing condition, this phenomenon emerges only during delayed copying of meaningless figures, appearing in highly specific tasks and under precise testing conditions. The phenomenon has been accounted for also as a manifestation of orientation agnosia [ 7 ], tough it is never observed during the copy phase, but only at delay. While it has been linked to amnesia, it has never been reported in cases of pure amnesia, even when performance on the ROCF was impaired [ 17 ]. As none of these explanations are fully satisfactory, we suggest that this phenomenon should not be classified as confabulation. Instead, we propose the descriptive term "Graphic Transmutation" (GT) to designate the delayed reproduction of the ROCF as a meaningful object. The aim of this study is to characterize this phenomenon. Pelati et al. [ 9 ] noted that when their patients produced a meaningful drawing in the delayed recall phase instead of the abstract ROCF they were exposed to, they appeared to be guided by “automatic semantic processing” (p. 379) during the encoding phase. Similarly, Migliaccio et al. [ 18 ] reported three cases whose delayed drawing of the ROCF was clearly influenced by the spontaneous description they provided during the copy phase. We propose that GT could be understood as a specific instance of the generation effect [ 19 ], wherein self-generated meaningful labels replace the meaningless configurations presented during encoding (see [ 20 ]). To test this hypothesis, we conducted two experiments. The first assessed the performance on the ROCF of a selected sample of people with a variety of cognitive impairments. The second was an ad hoc experiment devised to provide further evidence supporting our hypothesis and offer an account for the patterns of errors presented by the individuals with brain damage. 2. Experiment 1: Delayed drawing in a brain damaged sample 2.1 Results 2.1.1 Quantitative analyses As shown in Table 3, people presenting with GT and those who did not (NT) were statistically matched in terms of demographic and clinical profiles ( α adj = 0.006). Specifically, no differences were observed in sociodemographic data ( i.e. ,biological sex, age, and education), disease duration, global cognition ( i.e. , MMSE score), neuropsychiatric symptoms ( i.e. , NPI), and scales of daily functions ( i.e. , BADL and IADL). As concerns the formal neuropsychological assessment, after correction for multiple comparisons, no significant between-group differences emerged in any of the explored cognitive domains (see Table 1). ----- Please insert Table 1 about here ----- In the copy of the ROCF, no significant differences were observed between people with or without GT in the overall score (ROCF-Copy, t = -1.517, df = 30, p = 0.14). No significant between-group differences were observed in terms of correctly reproduced elements, inaccurate but well-placed elements, inaccurate and badly placed but recognizable elements and omitted elements. Specifically, neither people with GT nor those without GT rotated the figure, by reorienting the sagittal axis with the triangular part of the figure pointed upwards, during the copy. The only between-group difference was observed in the number of people committing at least one perseveration (see Table 2; χ 2 = 8.127, df = 1, standardized residuals = |2.9|, p = 0.004, Φ = 0.50). However, the number of perseverations among those showing the phenomenon did not differ between the two groups (Mann-Whitney U = 0.141, df = 1, p = 0.71). 2.1.2 Qualitative analyses The productive phenomena of the 16 people with GT are presented in Figure 1. The drawings of the control group are depicted in Figure 2 for comparison. ----- Please insert Figure 1 and Figure 2 about here ----- Most of the GTs refer to buildings. GT1, GT3, GT5, GT6, GT8, GT11, GT12 and GT14 drew a house. All these participants had memory deficits. GT1, GT3 and GT5 clearly explained what they drew. Some of them presented with neuropsychiatric symptoms: GT3 had coprolalia, GT8 had episodes of verbal disinhibition, and GT14 presented with phobia of loneliness. GT2 drew a cemetery; spontaneously, she described to the examiner details of her drawing, explaining what it was. She presented with psychiatric symptoms, including visual hallucinations (she reported seeing white cotton threads between the fingers of her hands), and had memory deficits. GT9 reproduced a factory. The participant’s caregiver referred to episodes of coprolalia and episodes of craving for sweet foods. GT7 drew a church with a human figure floating above the roof and a face on the left side. He presented with memory impairment, religious hallucinations (he claimed to see Padre–Father–Pio, a venerated Italian mystic) and repetitive motor mouth stereotypies. A second category of GT was represented by figures or elements that remind human features. GT15 drew a face with hair and nose. She had memory impairments but no psychiatric symptoms. GT16 drew a human silhouette with head, arms, and chest. GT10 and GT13 drew a smiley face inside a partial reproduction of the original figure. They should be considered as mild transmutations [25]. Finally, GT4 drew a pattern unrelated to the original figure; she had memory deficits but no psychiatric symptoms. 2.1.3 Follow-up We could retest nine participants (5 GT and 4 NT) after 2 years with the same neuropsychological battery. As expected, given the nature of their deficits, in all instances, their cognitive profile had worsened in several domains. Two of them, GT10 and GT16 did not show GT at follow-up. Three of the GT presented again with productive phenomena when drawing the ROCF from memory at the retrieval phase. One, GT6 reproduced the same transmutation as before. In the other two cases, the production was confabulatory but different from the previous one; GT14 drew a house with a smiley face, GT7drew a figure completely unrelated to the original (see in detail in [18]). None of the NT presented productive phenomena in the delayed drawing. 2.2 Discussion In this retrospective study, we report on the phenomenon of GT, which occurs during the retrieval phase of the ROCF, when participants are asked to reproduce the complex figure from memory. Among our sample of 493 individuals with brain damage and cognitive impairments, the prevalence of this phenomenon was relatively low (3.24%). This finding aligns with the only other large-sample study available; Pelati et al. [9] observed the phenomenon in 4.9% of people with neurodegenerative disorders in a sample of 267 individuals. In our study, people committing GT had profiles not dissimilar from those of the people not showing the phenomenon (NT) in terms of sociodemographic variables, global cognitive functioning, neuropsychiatric symptoms, and functional autonomy. These observations are consistent with those of Venneri et al. [4] and Pelati et al. [9]. At follow up, about two years later, we found that all participants who could be retested showed a decline in their cognitive profile. However, some did not replicate the phenomenon of GT, while others presented it again but produced a different meaningful graphic reproduction. One participant, though, drew a figure similar to their initial GT. The most common GT were drawings resembling a house or an upright building (11 of 16), which requires rotating the figure counter clockwise by 90 degrees. When rotated, elements 2 and 13 [13] of the ROCF outline a house (see Fig.1b in [9]). This phenomenon is akin to that observed in people with Orientation Agnosia [26]. Solms et al. [7]described 16 people with different type of brain damage, who rotated the whole drawing at the copy phase of the ROCF, by reorienting the sagittal axis of the figure, with the triangular part of the figure pointed upwards, as if it were a roof. This rotated configuration was maintained in the delayed reproduction of the ROCF [7]. Given the impoverishment of graphic details usually observed in the retrieval phase of the ROCF, such drawings may look like recognizable houses, just like in GT. However, typically agnosia for object orientation is observed also in copying and concerns nameable objects that are misoriented even if correctly recognized. In our study, no participant rotated the ROCF upwards at copy phase, and there was no indication of spontaneous instances of Orientation Agnosia [27,28] (see review by [29]). In our sample, as in previous reports [4, 9], GT occurred after a certain time delay, with individuals showing GT following a 10-minute delay. Roh [6]described a single-case study of a person with Wernicke-Korsakoff’s syndrome who increasingly added extra meaningful details to her delayed reproduction of the ROCF as more time elapsed between presentation and retrieval. This suggests that memory deficits may play a role in eliciting GT. Although several patients showing GT in our sample had long-standing memory deficits, no significant differences in memory test scores were observed between the GT and NT groups. This productive symptom is rarely observed in cases of dense amnesia (see example in Fig. 1 by [7], case 7b). Kixmiller et al. [17] reported that people with Korsakoff’s syndrome exhibited poor performance on the ROCF, with errors including omissions, misplacements, and disproportionate figural details during the immediate copy of the ROCF. These errors persisted leading to impaired performance at delayed retrieval, yet none of the participants showed any instance of GT. People with amnesia due to other causes, including anterior communicating artery aneurysm [30], hippocampal or perirhinal cortex lesions [31] also presented with the same pattern of overall poor performance on the ROCF delayed, but without any evidence of GT. Similarly, detailed reports of single cases with dense amnesia described the poor performance at the ROCF but GT is never mentioned (e.g., [32,33]). Hence, memory deficits appear to be not sufficient per se to elicit GT. There is also little indication that GTs in our sample are caused by an isolated dysexecutive disorder. None of the people with GT presented clear executive behavioural deficits in daily life and their average performance on executive tasks did not differ significantly from that of the NT. This contrasts with the extensive neuropsychological literature indicating that verbal confabulation is often associated with poor performance on executive tasks (e.g., [34, 35, 36,37, 38, 39]). The only partial exception in our study was that the number of participants showing perseverations in the copy phase of the ROCF was higher in people with GT than in those without. This result apparently aligns with the observation by Sedda et al. [5]. They reported grapho-motor productive phenomena ( e.g ., perseverations) associated with a dysexecutive syndrome in a person (called BM) with fronto-temporal dementia without overt memory deficits presenting with GT at the ROCF as well as in other tests (Trail Making Test) requiring following a pattern. In both instances, the patient drew a fish. It is noteworthy that BM did not confabulate verbally, indicating a possible dissociation between verbal confabulation and GT. Patients affected by different forms of neurodegeneration often manifest verbal confabulations (e.g., [40]), but GTs are rarely reported. Only a few studies on Alzheimer’s Disease and other neurodegenerative conditions have documented the co-occurrence of confabulations and GTs [9, 4]. In our study, 3 out of 16 participants showing GT also made intrusions or verbal confabulations in Prose Memory while none of those without GT did. However, given the small number of people with both GT and verbal confabulations, we cannot support the view positing that GT is a supra-modal phenomenon akin to verbal confabulations. Considered together, the results from the current study challenge the hypothesis that memory or dysexecutive deficits alone are sufficient to elicit GT, as seen in verbal confabulations [41,42, 43, 44, 45]. Individuals in this study reproduced at delayed retrieval the original meaningless figure or its elements as recognizable meaningful objects, such as buildings or human parts. Semantic processing might have played a role in these GT. Pelati et al. [9] suggested that a semantic mechanism was underlying GT because of an automatic activation of semantic representations during copying. Such semantic activations would interfere with the memory for meaningless graphic elements in amnesic patients during the retrieval phase. To test this hypothesis, we set up an experimental study administered to healthy older participants. 3. Experiment 2: Selective interference in healthy controls 3.1 Results Seven out of the 12 participants drew at delay figures embedding elements derived from the meaningful labels they gave at encoding to describe the meaningless patters of the ROCF (see Supplementary Material). This did not result in a facilitatory effect, as there was no difference in overall performance at delay between participants who did embed the associated meaningful label and those who did not (ROCF raw score: t = -1.572, df = 11, p = 0.14; ROCF demographically adjusted score: t = -1.504, df = 11, p = 0.16). An incidental finding which was not predicted is a difference in education ( t = 2.866, df = 12, p = 0.014, Cohen’s d = 1.53) between those who did show GT (mean years = 13.14) and those who did not (mean years = 8.71). However, given the small sample size, this should be replicated in future appraisals. 3.2 Discussion GT is not observed in normal testing conditions, as healthy participants never show the phenomenon [ 12 , 13 , 14 , 15 , 16 ]. The outcome from our ad hoc experiment indicates that when visuo-spatial memory is malfunctioning, due to experimental interference, people are more likely to rely on self-generated labels as short-cuts to retrieve encoded information and reproduce a drawing after a delay. It remains to be determined whether specific deficits in visuo-spatial memory (see e.g., [ 46 ]), rather than generic memory impairments, are associated with GT. Drawing a complex meaningless figure from memory is a highly demanding task, requiring visual imagery [ 47 ] (see discussion in [ 48 ]) and semantic processing [ 49 ]. This was demonstrated experimentally by Bower et al. [ 50 ], who showed that meaningless droodles (a neologism combining doodle and riddle) were better remembered at delay when a label at encoding activated semantic schemas. This link between the ability to label a picture and subsequent successful retrieval is further demonstrated by studies with children showing that younger participants were more likely to remember a picture during the retrieval phase if they named it aloud [ 51 , 52 ]. It is much easier to remember complex geometrical figures when giving them a generic label [ 53 ]. Carmichael et al. [ 54 ] demonstrated that the retrieval of ambiguous figures, which could be interpreted in two ways, for example like a pair of sketched glasses or a handlebar, was influenced by the label given at encoding. When the figure was labelled “glasses”, the participants drew a figure interpretable as glasses at retrieval, on the contrary when the figure was labelled “handlebar”, they depicted a drawing resembling a handlebar. This result is reminiscent of the Encoding Specificity theory of Tulving and Thomson [ 55 ] since the identification of the ambiguous figure with a familiar one at encoding could assume the role of contextual cue at retrieval. According to this theory the operations performed at encoding on what is perceived determine what is stored, which in turn would determine retrieval. These encoding operations would be even more effective if based on self-generations of the participants [ 19 ] which has been shown to affect also non-verbal material [ 56 ], like the ROCF. Notably, the self-generation effect is even more pronounced in people with memory deficits [ 57 , 58 , 59 ]. We propose that a similar phenomenon could account for GT. When presented with the complex meaningless stimulus of the ROCF to be copied, people may associate it to meaningful objects. If their visual memory capacity is defective and their monitoring system is malfunctioning, then at delay, the self-generated label would overcome the abstract pattern and superimpose to it, generating GT. We recently reported on three cases of people with brain damage whose performance illustrates this hypothesis [ 18 ]. During the copy phase of the ROCF, these examinees repeatedly commented on the resemblance of the ROCF to some meaningful objects. 4. General Discussion The production of drawings at delay representing meaningful and nameable objects instead of the abstract, meaningless probes, is a rare but observable phenomenon. In discussing his Theory of Abstraction [ 60 ], Kurt Goldstein showed that some people following brain damage were unable to reproduce reasonable copies of abstract figures from memory unless they managed to name them at encoding (see Fig. 6, p. 162, in [ 61 ]). Migliaccio et al. [ 18 ] posited that such impairment may underlie GT when cognitive impairments would not allow the inhibition of this interfering semantic processing, or when a compromised visuo-spatial memory system fails to retrieve the original abstract figure. De Anna et al. [ 62 ] and Attali et al. [ 63 ] suggested that verbal confabulations may arise from the tendency to replace poorly encoded material with overlearned information at recall. In their experimental memory tasks, they administered to people with AD and healthy participants, three different types of brief stories: one unfamiliar story, one well-known fairy tale (e.g., Snow White or Cinderella) and one modified well-known fairy tale (e.g., Little Red Riding Hood with a different ending). The results showed that AD individuals exhibited significantly more verbal confabulations when recalling the modified fairy tale compared to the other two conditions. This suggests that the activation of the original version of the fairy tale interfered with the encoding of the modified elements, leading to the misidentification of the story and the substitution of the most familiar version, ultimately generating false memories. The mechanisms underlying the production of GT are different. In the immediate copying task of our study, the meaningless figure was correctly encoded and reproduced. Interference occurs during the retrieval phase, whereby subsequent labelling influences delayed reproduction. In sum, in De Anna et al.’s [ 62 ] and Attali et al.’s [ 63 ] studies the conflict lies in the encoding phase between the presented story and the representation of the overlearned story in semantic memory; in our study, and in GT in general, the conflict lies in the retrieval phase between the encoded, meaningless stimulus figure and the episodic memory of the assigned meaningful label. We propose that GT arises from the effect of semantic processing of the original meaningless figure. GT can be understood as a particular aspect of the generation effect coupled with a specific cognitive profile that includes deficits of visuo-spatial memory and monitoring functions. GT may be driven by the meaning that people spontaneously assign when scrutinizing or reproducing a complex abstract figure containing elements interpretable as common objects. When people are unable to reconstruct the original meaningless configuration or are unable to inhibit the memory of the assigned verbal label, GT would emerge. Specific executive functions, including monitoring and inhibition [ 64 ], have never been studied within the frame of GT. These, rather than generic executive tests, may offer an insight into the phenomenon. Considering the presence of GT may be valuable to better elucidate the neuropsychological profile of people following brain damage or with a neurodegenerative disease, especially those seeking evaluation at memory clinics. This study has some limitations. While the participants are well-characterised clinically, the absence of homogeneous neuroimaging data prevents the identification of the neuroanatomical correlates of GT. The study’s retrospective design means that the available tests are not always optimal; for example, verbal confabulations were measured using prose memory rather than with ad hoc confabulation questionnaires. The selective interference experiment offers interesting hints for the interpretation of the productive phenomenon of GT, but it calls for replication with a larger sample and more controlled experimental conditions. Future research should explore the role of visuo-spatial memory deficits and of impairment to specific executive functions, like inhibition and monitoring in eliciting GT. Additionally, observational studies should revamp Goldstein’s proposal [ 61 ] of a cognitive syndrome that hinders abstraction, leaving people unable to remember meaningless configurations unless processed as meaningful and familiar objects. 2.3 Material and Methods 2.3.1 Participants Data from 493 people who attended the Center of Cognitive Disorders and Dementia of the University of Naples “Federico II” due to cognitive complaints for one year (January 2022-January 2023) were scrutinized. A total of 16 patients (11 women and 5 men) presented with GT. A group of 16 people (9 women and 7 men) without any sign of GT was also randomly selected from the whole sample using an algorithm with the constraints of demographic matching within the target group ( n = 204). All patients gave informed consent to participate. The clinical diagnoses were based on medical history, disease duration, neuropsychological and, when available, neuroimaging data. The diagnoses for the participants from the two groups are reported in Table 2 . All participants underwent a comprehensive neuropsychological test battery examining long and short-term verbal and visuo-spatial memory, executive function, fluid intelligence and constructional ability. Demographic and neuropsychological characteristics of the two samples are reported in Table 3 . All experimental procedures followed the ethical standards in the Declaration of Helsinki. Accordingly, the study received approval by the Federico II Ethics Committee [332/21]. ----- Please insert Table 2 and Table 3 about here ---- 2.3.2 Procedure This is a retrospective study. We assessed the presence of GT in the delayed reproduction of the ROCF in the whole sample of 493 individuals We considered recognizable figures ( e.g. , house, church, or human face) or unrecognizable drawings that were unrelated to the model at the retrieval phase of the ROCF as instances of GT. Over and above the presence of GT, we considered the count of verbal confabulations, false memories, perseverations, and intrusions in the execution of the ROCF as well as in the following tests: Rey-Auditory Verbal Learning Test, Prose Memory, Attentional Matrices, and Phonological Verbal Fluency. 2.3.3 Tests Rey-Osterrieth Complex Figure (ROCF) The ROCF [ 10 , 11 , 14 ] is a bidimensional figure that consists of 18 elements including lines, crosses, triangles, rectangles, and circles. The administration procedure, following Rey’s original criteria [ 10 ], involves two phases: copy and delayed retrieval. ROCF is presented on an A4 sheet of paper in landscape orientation aligned with the midline of the participant’s body. The examinee is instructed to copy the figure on a blank sheet as accurately as possible, without any limit of time. The figure is then removed, and, after a 10-minute delay, the participant is asked to reproduce ROCF from memory (i.e., delayed retrieval phase). In the context of a general neuropsychological assessment, the 10-minute interval is filled by non-visuo-spatial tasks. Drawings at the copy and retrieval phases were scored according to Rey's [ 10 ] original criteria: 2 points were given when element is correct and well-placed; 1 point when the element is correct and poorly placed or when it is deformed or incomplete but recognizable and well-placed; ½ point when detail is deformed or incomplete but recognizable and poorly placed and 0 point when element is missing or unrecognizable. The total score for each phase ranges from 0 to a max of 36. In the copy of the ROCF, perseverations were repetitions or overscoring elements in the figure while intrusions were incongruent and unrecognizable elements added to the figure. A neuropsychologist (M.M) and a neurologist (E.S.) examined the delayed reproductions of the ROCF and vetted the drawings for the presence of GT after a consensus. Recognisable drawings or meaningless figures unrelated to original figure, as well as elements with meaning included in a partial reproduction of the original stimulus ( e.g. , an embedded smiley face), according to The Boston Qualitative Scoring System for the Rey-Osterrieth Complex Figure (BQSS; [ 25 ]), were classified as GT. Rey-Auditory Verbal Learning Test (RAVLT) The Rey-Auditory Verbal Learning Test (RAVLT; [ 21 ]) includes the immediate, retrieval, and recognition phases. The immediate phase evaluates learning abilities by requiring the examinee to verbally provide 5 consecutive repetitions of the same 15-word list. Each repetition is scored from 0 to 15 and the max total score is 75. The retrieval phase occurs after a 15-minute delay, during which no verbal tasks are administered. This phase assesses the long-term memory of the previously presented 15-word list. Finally, after an additional 15-minute delay, the recognition phase starts. This is a classical old-new recognition task, where the participant is required to discriminate, within a 30-word list, which word was or was not presented in the original list. In the RAVLT-Immediate and Recall, a word produced which was not included in the original list, and uttered only once, constituted an intrusion. Perseverations were systematic (≥ 2) repetitions of words present in the list and already produced by the participant, or ≥ 2 repetitions of words not included in the list. In the RAVLT-Recognition, false memories were words erroneously identified as previously presented in the original list. Prose Memory Test Prose Memory [ 22 ] requires the participant to repeat immediately and after a 10-minute delay a short story read aloud by the examiner. The max total score is 16, which is derived by the sum of the scores achieved in both the immediate and the delayed phases (from 0 to 8 points each). Verbal confabulations were distorted memories of the information presented in the short story, regardless of whether they occurred in the immediate or retrieval phases. Attentional Matrices Test The Attentional Matrices Test [ 23 ] is employed to assess visual search and selective attention. The test material consists of three numerical matrices, where the examinee is prompted to mark one (“5”), two (“2” and “6”) and three (“1”, “4” and “9”) target numbers, avoiding distracting numbers. Each trial lasts 45 seconds. The total score is the sum of the target numbers correctly crossed out across all trials, ranging from 0 to a max of 60. Perseverations consisted either of target stimuli repetitively marked within a single matrix or keep marking the target stimuli given in the preceding matrix, being the result of proactive interference. Phonological Verbal Fluency The Phonological Verbal Fluency Test [ 24 ] evaluates the generation of language and set shifting. The participant is requested to produce as many different words as possible, beginning with letters “F”, “A” and “S” (except first and family names and geographical names) within 60 seconds for each target letter. The score is the sum of all words correctly produced across the three trials. Intrusions were violations of the given prompt. Perseverations were repetitions of words previously generated. 2.3.4 Statistical analyses Descriptive statistics were expressed as mean ± standard deviation for quantitative variables and frequency for categorical variables. Between-group comparisons were performed via parametric (Student’s t -test) or non-parametric analyses ( e.g. , 2-way χ 2 test, Mann-Whitney U test, One-sample Wilcoxon signed rank test), as needed. Regarding quantitative data, univariate normality of each demographic, clinical, and neuropsychological variable was assessed by checking the skewness and kurtosis indices. Values of skewness and kurtosis that fell within the range of -2 and + 2 indicated no appreciable deviations from parametric probability distributions [ 76 ]. To reduce the type I error inflation, Bonferroni’s adjustment for multiple comparisons was applied to the nominal alpha level ( α = 0.05). No missing data were detected. Statistical analyses were conducted by means of IBM SPSS Statistics v. 27. 3.3 Methods and procedures We used the procedure of dual tasking [ 77 , 78 , 79 ]. The rationale of the experiment was to “disrupt” the visuo-spatial memory of the participants by means of a secondary task interposed between the presentation of the stimulus materials and the attempt to retrieve them. A total of 14 (7 women) healthy individuals all aged over 65 (M = 68.50 ± 3.46; age range: 65–77 years; level of formal education: M = 10.93 ± 3.60; education range: 8–17 years) participated in this experiment as volunteers. They were asked to observe the ROCF for 3 minutes, during which time the examiner invited them to give a nameable label to the figure according to what it reminded them of (“What does it look like? What does it remind you of?”). Contrary to traditional instructions, participants were not asked to copy the figure. Following this phase, participants were asked to watch a series of 15 (21 cm wide x 12.2 cm high) abstract, two-dimensional, colourful paintings (taken from the work of J. Pollock and other avant-garde artists) presented on a 31 cm x 17.2 cm computer screen by means of software PsychoPy® 2024.1.4 for Windows. Participants were simply asked to judge the pleasantness of the paintings by pressing an “I like it” key or an “I do not like it” key. Each stimulus was randomly repeated twice, for a total of 30 stimuli. There was no time constraint for answering. Following the experimental tasks, participants were engaged in conversation. After an interval of 10 minutes, they were asked to reproduce the ROCF by drawing as per traditional testing instructions (Fig. 3 ). Two neuropsychologists aware of the definitions of GT for the scope of the present study (see Methods) established consensually whether the participant produced a GT in their drawing. ----- Please insert Fig. 3 about here ----- Declarations Author contributions MM contributed to investigation, data curation, and writing – original draft. CRI contributed to formal analysis and writing – review & editing. ES contributed to project administration, conceptualization, and investigation. CC contributed to investigation and provided resources. RC contributed to methodology and writing – review & editing. SDS contributed to conceptualization, methodology, and writing – review & editing. All authors reviewed and approved the final manuscript. Data availability statement Data analysed in the present study are available from the corresponding author upon request Disclosure statement No potential conflict of interest was reported by the author(s). Funding No funding was received for conducting this study. References Lamar, M. et al. Perseverative behavior in Alzheimer’s disease and subcortical ischemic vascular dementia. Neuropsychology 11 , 523–534 (1997). Fuld, P. A., Katzman, R., Davies, P. & Terry, R. D. Intrusions as a sign of Alzheimer dementia chemical and pathological verification. Ann. Neurol. 11 , 155–159 (1982). 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Descriptive statistics of productive signs within neuropsychological assessment in the participants showing graphic transmutation (GT) and participants who did not (NT). The number of productive phenomena is expressed as frequency of individuals exhibiting at least 1 productive sign (mean ± standard deviation). Domain Productive phenomena GT ( n = 16) NT ( n = 16) χ 2 Mean-comparison tests ROCF Intrusions in ROCF-Copy 6 (1.17 ± 0.40) 3 (1.66 ± 0.58) ns ns c Perseverations in ROCF-Copy 11 (2.72 ± 1.85) 3 (2.67 ± 1.15) * ns c Long-term memory Intrusions in RAVLT 12 (3.25 ± 2.18) 12 (2.67 ± 2.10) ns ns a Perseverations in RAVLT 11 (3.45 ± 1.69) 8 (3.75 ± 1.83) ns ns a False memories in RAVLT-Recognition 13 (6.31 ± 3.52) 13 (4.61 ± 3.95) ns ns a Verbal confabulations in Prose Memory 3 (1.00 ± 0.00) 0 ns ns b Executive functions Perseverations in Attentional Matrices 3 (3.00 ± 2.64) 0 ns ns b Intrusions in Phonological Verbal Fluency 2 (2.00 ± 1.41) 2 (2.50 ± 2.12) ns ns c Perseverations in Phonological Verbal Fluency 8 (2.87 ± 1.64) 7 (2.43 ± 1.62) ns ns a Note : ROCF = Rey-Osterrieth Complex Figure Rey [10, 11, 14]; RAVLT = Rey’s Auditory VerbaL Learning Test, immediate and delayed recall [21]; Prose Memory [22]; Attentional Matrices [23]; Phonological Verbal Fluency [24]. a Indipendent Samples t- test b One-sample Wilcoxon signed rank test (expcted median = 0) c Mann-Whitney U test * p < α adj = 0.02 Table 2 . Clinical diagnoses of the participants showing (GT) or not showing (NT) graphic transmutation. GT NT Mild Cognitive Impairment 1 4 7 Alzheimer Disease 2 3 3 Parkinson’s Disease Dementia 1 - Vascular dementia (VD) 2 3 VD and Normal Pressure Hydrocephalus 3 - 1 VD and Epilepsy 1 - Anterior Communicating Artery Aneurism 4 1 - Traumatic Brain Injury 4 1 2 Korsakoff’s Syndrome 1 - Pseudodementia 2 5 - TOTAL 16 16 1 According to Peterson’s criteria [65] 2According to the NINCDS–ADRDA criteria [66] 3Confirmed by Computed Tomography 4 Confirmed by Magnetic Resonance Imaging 5 The psychiatric diagnosis was bipolar disorder in one case and anxiety/depressive disorder in the other Table 3. The sociodemographic and neuropsychological characteristics of the participants with (GT) and without (NT) graphic transmutations included in the study. Values are expressed as mean ± standard deviation. GT NT General demographic and clinical profile Sex (w/m) 11/5 9/7 ns a Age (years) 66.69 ± 10.47 67.00 ± 10.86 ns b Education (years) 7.44 ± 3.24 7.31 ± 2.65 ns b Disease duration (years) 5.81 ± 8.61 7.94 ± 11.90 ns c MMSE 21.94 ± 4.11 22.00 ± 6.68 ns b NPI 28.25 ± 18.11 22.19 ± 11.20 ns b BADL 5.38 ± 0.62 5.56 ± 0.51 ns b IADL 5.31 ± 1.81 4.69 ± 2.41 ns b Neuropsychological assessment Short-term memory Disyllabic Word Span 4.25 ± 5.05 3.31 ± 0.79 ns c Visuo-spatial (Corsi) Span 3.25 ± 1.24 3.38 ± 1.09 ns b Long-term memory RAVLT-Immediate 19.88 ± 8.26 22.50 ± 11.15 ns b RAVLT-Delayed 3.00 ± 2.71 4.00 ± 3.31 ns b RAVLT-Recognition 10.63 ± 5.57 10.00 ± 4.83 ns b Prose Memory 4.35 ± 3.88 5.04 ± 4.71 ns b ROCF-Delayed 3.37 ± 3.83 7.12 ± 5.39 ns b Executive functions FAB 11.36 ± 3.25 11.12 ± 3.67 ns b Attentional Matrices 32.56 ± 12.34 39.81 ± 11.14 ns b Phonological Verbal Fluency (FAS) 16.94 ± 9.78 18.25 ± 12.92 ns b Stroop Test (errors) 4.41 ± 4.65 5.71 ± 7.22 ns b Stroop Test (time in sec) 47.69 ± 25.67 32.07 ± 16.97 ns c Fluid intelligence CPM 47 17.44 ± 6.08 17.38 ± 4.94 ns b Constructional Ability Clock Drawing Test 5.59 ± 2.75 4.97 ± 3.30 ns b ROCF-Copy 18.69 ± 7.82 22.84 ± 7.67 ns b Constructional Apraxia Test 9.56 ± 2.10 9.69 ± 2.47 ns b Note : MMSE = Mini-Mental State Examination [67]; NPI = Neuropsychiatric Inventory [68]; BADL = Basic Activities of Daily Living [69]; IADL = Instrumental Activities of Daily Living [70]; Dysillabic Word Span [22]; Corsi Span [22]; RAVLT = Rey’s Auditory VerbaL Learning Test [21]; Prose Memory [22]; ROCF = Rey-Osterrieth Complex Figure [10, 11, 14]; FAB = Frontal Assessment Battery [71]; Attentional Matrices [23]; Phonological Verbal Fluency [24]; Stroop Test [72]; CPM47 = Raven's Coloured Progressive Matrices [73], CDT = Clock Drawing Test [74]; Constructional Apraxia Test [75]. ns : non-significant. a χ 2 b Indipendent Samples t-test c Mann-Whitney U test Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":485113,"visible":true,"origin":"","legend":"\u003cp\u003eRecall of ROCF by the participants showing graphic transmutation (GT).\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6502291/v1/e57e51165759b79198f81139.jpg"},{"id":82606365,"identity":"1918281e-9997-45d3-a29d-dafba51109fd","added_by":"auto","created_at":"2025-05-13 10:06:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":249994,"visible":true,"origin":"","legend":"\u003cp\u003eRecall of ROCF by participants not showing graphic transmutation (NT).\u003c/p\u003e","description":"","filename":"Figure2.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6502291/v1/8d7b95a3d43c898390ff5c9b.jpg"},{"id":82606366,"identity":"ea6c0569-b276-4747-a7ee-18aea0bb0c8d","added_by":"auto","created_at":"2025-05-13 10:06:32","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":164431,"visible":true,"origin":"","legend":"\u003cp\u003eOutline of the procedure of Experiment 2.\u003c/p\u003e","description":"","filename":"Figure3.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6502291/v1/c612bb8df4e13b069cb9708d.jpg"},{"id":102234209,"identity":"9eb86e6d-3c37-4727-bb8d-50449e73009e","added_by":"auto","created_at":"2026-02-09 16:07:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1954091,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6502291/v1/4093963e-0b88-4330-9a65-a8d748371566.pdf"},{"id":82602566,"identity":"baeac453-4499-432b-bd92-9086b2d7a765","added_by":"auto","created_at":"2025-05-13 09:50:32","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":458169,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialSR.docx","url":"https://assets-eu.researchsquare.com/files/rs-6502291/v1/d43edc640a80abea4d5da830.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eGraphic Transmutations: When Meaningless Pictures are Remembered as Familiar Objects\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eProductive symptoms, such as intrusions and perseverations, have been reported in people with brain diseases in drawing tasks, both when drawing from dictation [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] and when copying [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A particular phenomenon involves the production of meaningful drawings or the addition of extra features unrelated to the original stimulus in delayed copying tasks when reproducing a meaningless figure from memory. It has been documented in cases of Alzheimer\u0026rsquo;s Disease [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], fronto-temporal dementia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], Wernicke-Korsakoff syndrome [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and bilateral medio-basal frontal lesion caused by a ruptured aneurysm (case 7b, [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]).\u003c/p\u003e \u003cp\u003eThis phenomenon has been branded as an uncommon type of confabulation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]; Pelati et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] introduced the term \u0026ldquo;graphic confabulation\u0026rdquo; to describe such additional or distorted elements unrelated to the target in delayed drawing tasks. In their retrospective study, 267 individuals with heterogeneous neurodegenerative diseases were asked to copy the Rey-Osterrieth Complex Figure (ROCF \u0026ndash; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and then reproduce it from memory after a 20-minute delay. Fourteen individuals (4.9%) added unrelated elements or altered its configuration by drawing recognizable figures, like a house, a face, a human silhouette, a fish, or a flower plot. Similar instances of simplifying the ROCF into familiar items such as houses, boats or fish have been reported in 4\u0026ndash;5 years old children [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This behaviour becomes rarer by age 6 and diminishes with age [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Notably, it has never been reported in the healthy adults [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis type of graphic production bears some resemblance to confabulations seen in dysexecutive syndromes. Accordingly, it has been labelled also \u0026ldquo;graphabulation\u0026rdquo; [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], \u0026ldquo;graphic confabulatory tendency\u0026rdquo; [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], \u0026ldquo;visuo-spatial confabulation\u0026rdquo; [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], as well as \u0026ldquo;constructional confabulating behaviour\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, unlike confabulations, which can occur spontaneously, regardless of the task, stimulus, or testing condition, this phenomenon emerges only during delayed copying of meaningless figures, appearing in highly specific tasks and under precise testing conditions.\u003c/p\u003e \u003cp\u003eThe phenomenon has been accounted for also as a manifestation of orientation agnosia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], tough it is never observed during the copy phase, but only at delay. While it has been linked to amnesia, it has never been reported in cases of pure amnesia, even when performance on the ROCF was impaired [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As none of these explanations are fully satisfactory, we suggest that this phenomenon should not be classified as confabulation. Instead, we propose the descriptive term \u003cem\u003e\"Graphic Transmutation\"\u003c/em\u003e (GT) to designate the delayed reproduction of the ROCF as a meaningful object.\u003c/p\u003e \u003cp\u003eThe aim of this study is to characterize this phenomenon. Pelati et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] noted that when their patients produced a meaningful drawing in the delayed recall phase instead of the abstract ROCF they were exposed to, they appeared to be guided by \u0026ldquo;automatic semantic processing\u0026rdquo; (p. 379) during the encoding phase. Similarly, Migliaccio et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported three cases whose delayed drawing of the ROCF was clearly influenced by the spontaneous description they provided during the copy phase. We propose that GT could be understood as a specific instance of the generation effect [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], wherein self-generated meaningful labels replace the meaningless configurations presented during encoding (see [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]). To test this hypothesis, we conducted two experiments. The first assessed the performance on the ROCF of a selected sample of people with a variety of cognitive impairments. The second was an ad hoc experiment devised to provide further evidence supporting our hypothesis and offer an account for the patterns of errors presented by the individuals with brain damage.\u003c/p\u003e"},{"header":"2. Experiment 1: Delayed drawing in a brain damaged sample","content":"\u003cp\u003e\u003cstrong\u003e2.1\u003c/strong\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1.1 Quantitative analyses\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, people presenting with GT and those who did not (NT) were statistically matched in terms of demographic and clinical profiles (\u003cem\u003eα\u003c/em\u003e\u003csub\u003eadj\u003c/sub\u003e = 0.006). Specifically, no differences were observed in sociodemographic data (\u003cem\u003ei.e.\u003c/em\u003e,biological sex, age, and education), disease duration, global cognition (\u003cem\u003ei.e.\u003c/em\u003e, MMSE score), neuropsychiatric symptoms (\u003cem\u003ei.e.\u003c/em\u003e, NPI), and scales of daily functions (\u003cem\u003ei.e.\u003c/em\u003e, BADL and IADL).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs concerns the formal neuropsychological assessment, after correction for multiple comparisons, no significant between-group differences emerged in any of the explored cognitive domains (see Table 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e----- Please insert Table 1 about here -----\u003c/p\u003e\n\u003cp\u003eIn the copy of the ROCF, no significant differences were observed between people with or without GT in the overall score (ROCF-Copy, \u003cem\u003et\u003c/em\u003e = -1.517, \u003cem\u003edf\u003c/em\u003e = 30, \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.14). \u0026nbsp;No significant between-group differences were observed in terms of correctly reproduced elements, inaccurate but well-placed elements, inaccurate and badly placed but recognizable elements and omitted elements.\u0026nbsp;Specifically, neither people with GT nor those without GT rotated the figure, by reorienting the sagittal axis with the triangular part of the figure pointed upwards, during the copy. The only between-group difference was observed in the number of people committing at least one perseveration (see Table 2; χ\u003csup\u003e2\u003c/sup\u003e = 8.127, \u003cem\u003edf\u003c/em\u003e = 1, standardized residuals = |2.9|, \u003cem\u003ep\u003c/em\u003e = 0.004, Φ = 0.50). However, the number of perseverations among those showing the phenomenon did not differ between the two groups (Mann-Whitney \u003cem\u003eU\u003c/em\u003e = 0.141, \u003cem\u003edf\u0026nbsp;\u003c/em\u003e= 1, \u003cem\u003ep\u003c/em\u003e = 0.71).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1.2 Qualitative analyses\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe productive phenomena of the 16 people with GT are presented in Figure 1. The drawings of the control group are depicted in Figure 2 for comparison.\u003c/p\u003e\n\u003cp\u003e----- Please insert Figure 1 and Figure 2 about here -----\u003c/p\u003e\n\u003cp\u003eMost of the GTs refer to buildings. GT1, GT3, GT5, GT6, GT8, GT11, GT12 and GT14 drew a house. All these participants had memory deficits. GT1, GT3 and GT5 clearly explained what they drew. Some of them presented with neuropsychiatric symptoms: GT3 had coprolalia, GT8 had episodes of verbal disinhibition, and GT14 presented with phobia of loneliness. GT2 drew a cemetery; spontaneously, she described to the examiner details of her drawing, explaining what it was. She presented with psychiatric symptoms, including visual hallucinations (she reported seeing white cotton threads between the fingers of her hands), and had memory deficits.\u0026nbsp;GT9 reproduced a factory. The participant’s caregiver referred to episodes of coprolalia and episodes of craving for sweet foods. GT7 drew a church with a human figure floating above the roof and a face on the left side. He presented with memory impairment, religious hallucinations (he claimed to see Padre–Father–Pio, a venerated Italian mystic) and repetitive motor mouth stereotypies.\u003c/p\u003e\n\u003cp\u003eA second category of GT was represented by figures or elements that remind human features. GT15 drew a face with hair and nose. She had memory impairments but no psychiatric symptoms. GT16 drew a human silhouette with head, arms, and chest. GT10 and GT13 drew a smiley face inside a partial reproduction of the original figure. They should be considered as mild transmutations [25].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, GT4 drew a pattern unrelated to the original figure; she had memory deficits but no psychiatric symptoms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e2.1.3 Follow-up\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe could retest nine participants (5 GT and 4 NT) after 2 years with the same neuropsychological battery. As expected, given the nature of their deficits, in all instances, their cognitive profile had worsened in several domains. Two of them, GT10 and GT16 did not show GT at follow-up. Three of the GT presented again with productive phenomena when drawing the ROCF from memory at the retrieval phase. One, GT6 reproduced the same transmutation as before. In the other two cases, the production was confabulatory but different from the previous one; GT14 drew a house with a smiley face, GT7drew a figure completely unrelated to the original (see in detail in [18]). None of the NT presented productive phenomena in the delayed drawing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Discussion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this retrospective study, we report on the phenomenon of GT, which occurs during the retrieval phase of the ROCF, when participants are asked to reproduce the complex figure from memory. Among our sample of 493 individuals with brain damage and cognitive impairments, the prevalence of this phenomenon was relatively low (3.24%). This finding aligns with the only other large-sample study available; Pelati et al. [9] observed the phenomenon in 4.9% of people with neurodegenerative disorders in a sample of 267 individuals. In our study, people committing GT had profiles not dissimilar from those of the people not showing the phenomenon (NT) in terms of sociodemographic variables, global cognitive functioning, neuropsychiatric symptoms, and functional autonomy. These observations are consistent with those of Venneri et al. [4] and Pelati et al. [9].\u003c/p\u003e\n\u003cp\u003eAt follow up, about two years later, we found that all participants who could be retested showed a decline in their cognitive profile. However, some did not replicate the phenomenon of GT, while others presented it again but produced a different meaningful graphic reproduction. One participant, though, drew a figure similar to their initial GT.\u003c/p\u003e\n\u003cp\u003eThe most common GT were drawings resembling a house or an upright building (11 of 16), which requires rotating the figure counter clockwise by 90 degrees. When rotated, elements 2 and 13 [13] of the ROCF outline a house (see Fig.1b in [9]). This phenomenon is akin to that observed in people with Orientation Agnosia [26]. Solms et al. [7]described 16 people with different type of brain damage, who rotated the whole drawing at the copy phase of the ROCF, by reorienting the sagittal axis of the figure, with the triangular part of the figure pointed upwards, as if it were a roof. This rotated configuration was maintained in the delayed reproduction of the ROCF [7]. Given the impoverishment of graphic details usually observed in the retrieval phase of the ROCF, such drawings may look like recognizable houses, just like in GT. However, typically agnosia for object orientation is observed also in copying and concerns nameable objects that are misoriented even if correctly recognized. In our study, no participant rotated the ROCF upwards at copy phase, and there was no indication of spontaneous instances of Orientation Agnosia [27,28] (see review by [29]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our sample, as in previous reports [4, 9], GT occurred after a certain time delay, with individuals showing GT following a 10-minute delay. Roh [6]described a single-case study of a person with Wernicke-Korsakoff’s syndrome who increasingly added extra meaningful details to her delayed reproduction of the ROCF as more time elapsed between presentation and retrieval. This suggests that memory deficits may play a role in eliciting GT. Although several patients showing GT in our sample had long-standing memory deficits, no significant differences in memory test scores were observed between the GT and NT groups. This productive symptom is rarely observed in cases of dense amnesia (see example in Fig. 1 by [7], case 7b). Kixmiller et al. [17] reported that people with Korsakoff’s syndrome exhibited poor performance on the ROCF, with errors including omissions, misplacements, and disproportionate figural details during the immediate copy of the ROCF. These errors persisted leading to impaired performance at delayed retrieval, yet none of the participants showed any instance of GT. People with amnesia due to other causes, including anterior communicating artery aneurysm [30], hippocampal or perirhinal cortex lesions [31] also\u0026nbsp;presented with the same pattern of overall poor performance on the ROCF delayed, but without any evidence of GT. Similarly, detailed reports of single cases with dense amnesia described the poor performance at the ROCF but GT is never mentioned (e.g., [32,33]). Hence, memory deficits appear to be not sufficient per se to elicit GT.\u003c/p\u003e\n\u003cp\u003eThere is also little indication that GTs in our sample are caused by an isolated dysexecutive disorder. None of the people with GT presented clear executive behavioural deficits in daily life and their average performance on executive tasks did not differ significantly from that of the NT. This contrasts with the extensive neuropsychological literature indicating that verbal confabulation is often associated with poor performance on executive tasks (e.g., [34, 35, 36,37, 38, 39]). The only partial exception in our study was that the number of participants showing perseverations in the copy phase of the ROCF was higher in people with GT than in those without. This result apparently aligns with the observation by Sedda et al. [5]. They reported grapho-motor productive phenomena (\u003cem\u003ee.g\u003c/em\u003e., perseverations) associated with a dysexecutive syndrome in a person (called BM) with fronto-temporal dementia without overt memory deficits presenting with GT at the ROCF as well as in other tests (Trail Making Test) requiring following a pattern. In both instances, the patient drew a fish. It is noteworthy that BM did not confabulate verbally, indicating a possible dissociation between verbal confabulation and GT.\u003c/p\u003e\n\u003cp\u003ePatients affected by different forms of neurodegeneration often manifest verbal confabulations (e.g., [40]), but GTs are rarely reported. Only a few studies on Alzheimer’s Disease and other neurodegenerative conditions have documented the co-occurrence of confabulations and GTs [9, 4]. In our study, 3 out of 16 participants showing GT also made intrusions or verbal confabulations in Prose Memory while none of those without GT did. However, given the small number of people with both GT and verbal confabulations, we cannot support the view positing that GT is a supra-modal phenomenon akin to verbal confabulations.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsidered together, the results from the current study challenge the hypothesis that memory or dysexecutive deficits alone are sufficient to elicit GT, as seen in verbal confabulations [41,42, 43, 44,\u0026nbsp;45]. Individuals in this study reproduced at delayed retrieval the original meaningless figure or its elements as recognizable meaningful objects, such as buildings or human parts. Semantic processing might have played a role in these GT. Pelati et al. [9] suggested that a semantic mechanism was underlying GT because of an automatic activation of semantic representations during copying. Such semantic activations would interfere with the memory for meaningless graphic elements in amnesic patients during the retrieval phase.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo test this hypothesis, we set up an experimental study administered to healthy older participants.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Experiment 2: Selective interference in healthy controls","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Results\u003c/h2\u003e \u003cp\u003eSeven out of the 12 participants drew at delay figures embedding elements derived from the meaningful labels they gave at encoding to describe the meaningless patters of the ROCF (see Supplementary Material). This did not result in a facilitatory effect, as there was no difference in overall performance at delay between participants who did embed the associated meaningful label and those who did not (ROCF raw score: \u003cem\u003et\u003c/em\u003e = -1.572, \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.14; ROCF demographically adjusted score: \u003cem\u003et\u003c/em\u003e = -1.504, \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.16). An incidental finding which was not predicted is a difference in education (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.866, \u003cem\u003edf\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.014, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.53) between those who did show GT (mean years\u0026thinsp;=\u0026thinsp;13.14) and those who did not (mean years\u0026thinsp;=\u0026thinsp;8.71). However, given the small sample size, this should be replicated in future appraisals.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Discussion\u003c/h2\u003e \u003cp\u003eGT is not observed in normal testing conditions, as healthy participants never show the phenomenon [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The outcome from our ad hoc experiment indicates that when visuo-spatial memory is malfunctioning, due to experimental interference, people are more likely to rely on self-generated labels as short-cuts to retrieve encoded information and reproduce a drawing after a delay. It remains to be determined whether specific deficits in visuo-spatial memory (see e.g., [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]), rather than generic memory impairments, are associated with GT.\u003c/p\u003e \u003cp\u003eDrawing a complex meaningless figure from memory is a highly demanding task, requiring visual imagery [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] (see discussion in [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]) and semantic processing [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e]. This was demonstrated experimentally by Bower et al. [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], who showed that meaningless \u003cem\u003edroodles\u003c/em\u003e (a neologism combining doodle and riddle) were better remembered at delay when a label at encoding activated semantic schemas. This link between the ability to label a picture and subsequent successful retrieval is further demonstrated by studies with children showing that younger participants were more likely to remember a picture during the retrieval phase if they named it aloud [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. It is much easier to remember complex geometrical figures when giving them a generic label [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCarmichael et al. [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] demonstrated that the retrieval of ambiguous figures, which could be interpreted in two ways, for example like a pair of sketched glasses or a handlebar, was influenced by the label given at encoding. When the figure was labelled \u0026ldquo;glasses\u0026rdquo;, the participants drew a figure interpretable as glasses at retrieval, on the contrary when the figure was labelled \u0026ldquo;handlebar\u0026rdquo;, they depicted a drawing resembling a handlebar. This result is reminiscent of the Encoding Specificity theory of Tulving and Thomson [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] since the identification of the ambiguous figure with a familiar one at encoding could assume the role of contextual cue at retrieval. According to this theory the operations performed at encoding on what is perceived determine what is stored, which in turn would determine retrieval. These encoding operations would be even more effective if based on self-generations of the participants [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] which has been shown to affect also non-verbal material [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], like the ROCF. Notably, the self-generation effect is even more pronounced in people with memory deficits [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe propose that a similar phenomenon could account for GT. When presented with the complex meaningless stimulus of the ROCF to be copied, people may associate it to meaningful objects. If their visual memory capacity is defective and their monitoring system is malfunctioning, then at delay, the self-generated label would overcome the abstract pattern and superimpose to it, generating GT. We recently reported on three cases of people with brain damage whose performance illustrates this hypothesis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. During the copy phase of the ROCF, these examinees repeatedly commented on the resemblance of the ROCF to some meaningful objects.\u003c/p\u003e \u003c/div\u003e"},{"header":"4. General Discussion","content":"\u003cp\u003eThe production of drawings at delay representing meaningful and nameable objects instead of the abstract, meaningless probes, is a rare but observable phenomenon. In discussing his Theory of Abstraction [\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e], Kurt Goldstein showed that some people following brain damage were unable to reproduce reasonable copies of abstract figures from memory unless they managed to name them at encoding (see Fig.\u0026nbsp;6, p. 162, in [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]). Migliaccio et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] posited that such impairment may underlie GT when cognitive impairments would not allow the inhibition of this interfering semantic processing, or when a compromised visuo-spatial memory system fails to retrieve the original abstract figure.\u003c/p\u003e \u003cp\u003eDe Anna et al. [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] and Attali et al. [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] suggested that verbal confabulations may arise from the tendency to replace poorly encoded material with overlearned information at recall. In their experimental memory tasks, they administered to people with AD and healthy participants, three different types of brief stories: one unfamiliar story, one well-known fairy tale (e.g., Snow White or Cinderella) and one modified well-known fairy tale (e.g., Little Red Riding Hood with a different ending). The results showed that AD individuals exhibited significantly more verbal confabulations when recalling the modified fairy tale compared to the other two conditions. This suggests that the activation of the original version of the fairy tale interfered with the encoding of the modified elements, leading to the misidentification of the story and the substitution of the most familiar version, ultimately generating false memories.\u003c/p\u003e \u003cp\u003eThe mechanisms underlying the production of GT are different. In the immediate copying task of our study, the meaningless figure was correctly encoded and reproduced. Interference occurs during the retrieval phase, whereby subsequent labelling influences delayed reproduction. In sum, in De Anna et al.\u0026rsquo;s [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e] and Attali et al.\u0026rsquo;s [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] studies the conflict lies in the encoding phase between the presented story and the representation of the overlearned story in semantic memory; in our study, and in GT in general, the conflict lies in the retrieval phase between the encoded, meaningless stimulus figure and the episodic memory of the assigned meaningful label.\u003c/p\u003e \u003cp\u003eWe propose that GT arises from the effect of semantic processing of the original meaningless figure. GT can be understood as a particular aspect of the generation effect coupled with a specific cognitive profile that includes deficits of visuo-spatial memory and monitoring functions. GT may be driven by the meaning that people spontaneously assign when scrutinizing or reproducing a complex abstract figure containing elements interpretable as common objects. When people are unable to reconstruct the original meaningless configuration or are unable to inhibit the memory of the assigned verbal label, GT would emerge. Specific executive functions, including monitoring and inhibition [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], have never been studied within the frame of GT. These, rather than generic executive tests, may offer an insight into the phenomenon. Considering the presence of GT may be valuable to better elucidate the neuropsychological profile of people following brain damage or with a neurodegenerative disease, especially those seeking evaluation at memory clinics.\u003c/p\u003e \u003cp\u003eThis study has some limitations. While the participants are well-characterised clinically, the absence of homogeneous neuroimaging data prevents the identification of the neuroanatomical correlates of GT. The study\u0026rsquo;s retrospective design means that the available tests are not always optimal; for example, verbal confabulations were measured using prose memory rather than with ad hoc confabulation questionnaires. The selective interference experiment offers interesting hints for the interpretation of the productive phenomenon of GT, but it calls for replication with a larger sample and more controlled experimental conditions.\u003c/p\u003e \u003cp\u003eFuture research should explore the role of visuo-spatial memory deficits and of impairment to specific executive functions, like inhibition and monitoring in eliciting GT. Additionally, observational studies should revamp Goldstein\u0026rsquo;s proposal [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e] of a cognitive syndrome that hinders abstraction, leaving people unable to remember meaningless configurations unless processed as meaningful and familiar objects.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Material and Methods\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Participants\u003c/h2\u003e \u003cp\u003eData from 493 people who attended the Center of Cognitive Disorders and Dementia of the University of Naples \u0026ldquo;Federico II\u0026rdquo; due to cognitive complaints for one year (January 2022-January 2023) were scrutinized. A total of 16 patients (11 women and 5 men) presented with GT. A group of 16 people (9 women and 7 men) without any sign of GT was also randomly selected from the whole sample using an algorithm with the constraints of demographic matching within the target group (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;204). All patients gave informed consent to participate.\u003c/p\u003e \u003cp\u003eThe clinical diagnoses were based on medical history, disease duration, neuropsychological and, when available, neuroimaging data. The diagnoses for the participants from the two groups are reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e. All participants underwent a comprehensive neuropsychological test battery examining long and short-term verbal and visuo-spatial memory, executive function, fluid intelligence and constructional ability. Demographic and neuropsychological characteristics of the two samples are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAll experimental procedures followed the ethical standards in the Declaration of Helsinki. Accordingly, the study received approval by the Federico II Ethics Committee [332/21].\u003c/p\u003e \u003cp\u003e----- Please insert Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e about here ----\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Procedure\u003c/h2\u003e \u003cp\u003eThis is a retrospective study. We assessed the presence of GT in the delayed reproduction of the ROCF in the whole sample of 493 individuals We considered recognizable figures (\u003cem\u003ee.g.\u003c/em\u003e, house, church, or human face) or unrecognizable drawings that were unrelated to the model at the retrieval phase of the ROCF as instances of GT. Over and above the presence of GT, we considered the count of verbal confabulations, false memories, perseverations, and intrusions in the execution of the ROCF as well as in the following tests: Rey-Auditory Verbal Learning Test, Prose Memory, Attentional Matrices, and Phonological Verbal Fluency.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3 Tests\u003c/h2\u003e \u003cp\u003e \u003cem\u003eRey-Osterrieth Complex Figure\u003c/em\u003e (ROCF)\u003c/p\u003e \u003cp\u003eThe ROCF [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] is a bidimensional figure that consists of 18 elements including lines, crosses, triangles, rectangles, and circles. The administration procedure, following Rey\u0026rsquo;s original criteria [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], involves two phases: copy and delayed retrieval. ROCF is presented on an A4 sheet of paper in landscape orientation aligned with the midline of the participant\u0026rsquo;s body. The examinee is instructed to copy the figure on a blank sheet as accurately as possible, without any limit of time. The figure is then removed, and, after a 10-minute delay, the participant is asked to reproduce ROCF from memory (i.e., delayed retrieval phase). In the context of a general neuropsychological assessment, the 10-minute interval is filled by non-visuo-spatial tasks. Drawings at the copy and retrieval phases were scored according to Rey's [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] original criteria: 2 points were given when element is correct and well-placed; 1 point when the element is correct and poorly placed or when it is deformed or incomplete but recognizable and well-placed; \u0026frac12; point when detail is deformed or incomplete but recognizable and poorly placed and 0 point when element is missing or unrecognizable. The total score for each phase ranges from 0 to a max of 36. In the copy of the ROCF, perseverations were repetitions or overscoring elements in the figure while intrusions were incongruent and unrecognizable elements added to the figure.\u003c/p\u003e \u003cp\u003eA neuropsychologist (M.M) and a neurologist (E.S.) examined the delayed reproductions of the ROCF and vetted the drawings for the presence of GT after a consensus. Recognisable drawings or meaningless figures unrelated to original figure, as well as elements with meaning included in a partial reproduction of the original stimulus (\u003cem\u003ee.g.\u003c/em\u003e, an embedded smiley face), according to The Boston Qualitative Scoring System for the Rey-Osterrieth Complex Figure (BQSS; [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]), were classified as GT.\u003c/p\u003e \u003cp\u003e\u003cem\u003eRey-Auditory Verbal Learning Test\u003c/em\u003e (RAVLT)\u003c/p\u003e \u003cp\u003eThe Rey-Auditory Verbal Learning Test (RAVLT; [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]) includes the immediate, retrieval, and recognition phases. The immediate phase evaluates learning abilities by requiring the examinee to verbally provide 5 consecutive repetitions of the same 15-word list. Each repetition is scored from 0 to 15 and the max total score is 75. The retrieval phase occurs after a 15-minute delay, during which no verbal tasks are administered. This phase assesses the long-term memory of the previously presented 15-word list. Finally, after an additional 15-minute delay, the recognition phase starts. This is a classical old-new recognition task, where the participant is required to discriminate, within a 30-word list, which word was or was not presented in the original list. In the RAVLT-Immediate and Recall, a word produced which was not included in the original list, and uttered only once, constituted an intrusion. Perseverations were systematic (\u0026ge;\u0026thinsp;2) repetitions of words present in the list and already produced by the participant, or \u0026ge;\u0026thinsp;2 repetitions of words not included in the list. In the RAVLT-Recognition, false memories were words erroneously identified as previously presented in the original list.\u003c/p\u003e \u003cp\u003e \u003cem\u003eProse Memory Test\u003c/em\u003e \u003c/p\u003e \u003cp\u003eProse Memory [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] requires the participant to repeat immediately and after a 10-minute delay a short story read aloud by the examiner. The max total score is 16, which is derived by the sum of the scores achieved in both the immediate and the delayed phases (from 0 to 8 points each). Verbal confabulations were distorted memories of the information presented in the short story, regardless of whether they occurred in the immediate or retrieval phases.\u003c/p\u003e \u003cp\u003e \u003cem\u003eAttentional Matrices Test\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe Attentional Matrices Test [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] is employed to assess visual search and selective attention. The test material consists of three numerical matrices, where the examinee is prompted to mark one (\u0026ldquo;5\u0026rdquo;), two (\u0026ldquo;2\u0026rdquo; and \u0026ldquo;6\u0026rdquo;) and three (\u0026ldquo;1\u0026rdquo;, \u0026ldquo;4\u0026rdquo; and \u0026ldquo;9\u0026rdquo;) target numbers, avoiding distracting numbers. Each trial lasts 45 seconds. The total score is the sum of the target numbers correctly crossed out across all trials, ranging from 0 to a max of 60. Perseverations consisted either of target stimuli repetitively marked within a single matrix or keep marking the target stimuli given in the preceding matrix, being the result of proactive interference.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePhonological Verbal Fluency\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe Phonological Verbal Fluency Test [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] evaluates the generation of language and set shifting. The participant is requested to produce as many different words as possible, beginning with letters \u0026ldquo;F\u0026rdquo;, \u0026ldquo;A\u0026rdquo; and \u0026ldquo;S\u0026rdquo; (except first and family names and geographical names) within 60 seconds for each target letter. The score is the sum of all words correctly produced across the three trials. Intrusions were violations of the given prompt. Perseverations were repetitions of words previously generated.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4 Statistical analyses\u003c/h2\u003e \u003cp\u003eDescriptive statistics were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation for quantitative variables and frequency for categorical variables. Between-group comparisons were performed via parametric (Student\u0026rsquo;s \u003cem\u003et\u003c/em\u003e-test) or non-parametric analyses (\u003cem\u003ee.g.\u003c/em\u003e, 2-way χ\u003csup\u003e2\u003c/sup\u003e test, Mann-Whitney U test, One-sample Wilcoxon signed rank test), as needed. Regarding quantitative data, univariate normality of each demographic, clinical, and neuropsychological variable was assessed by checking the skewness and kurtosis indices. Values of skewness and kurtosis that fell within the range of -2 and +\u0026thinsp;2 indicated no appreciable deviations from parametric probability distributions [\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e]. To reduce the type I error inflation, Bonferroni\u0026rsquo;s adjustment for multiple comparisons was applied to the nominal alpha level (\u003cem\u003eα\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.05). No missing data were detected. Statistical analyses were conducted by means of IBM SPSS Statistics v. 27.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Methods and procedures\u003c/h2\u003e \u003cp\u003eWe used the procedure of dual tasking [\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e, \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e78\u003c/span\u003e, \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e79\u003c/span\u003e]. The rationale of the experiment was to \u0026ldquo;disrupt\u0026rdquo; the visuo-spatial memory of the participants by means of a secondary task interposed between the presentation of the stimulus materials and the attempt to retrieve them. A total of 14 (7 women) healthy individuals all aged over 65 (M\u0026thinsp;=\u0026thinsp;68.50\u0026thinsp;\u0026plusmn;\u0026thinsp;3.46; age range: 65\u0026ndash;77 years; level of formal education: M\u0026thinsp;=\u0026thinsp;10.93\u0026thinsp;\u0026plusmn;\u0026thinsp;3.60; education range: 8\u0026ndash;17 years) participated in this experiment as volunteers. They were asked to observe the ROCF for 3 minutes, during which time the examiner invited them to give a nameable label to the figure according to what it reminded them of (\u0026ldquo;What does it look like? What does it remind you of?\u0026rdquo;). Contrary to traditional instructions, participants were not asked to copy the figure. Following this phase, participants were asked to watch a series of 15 (21 cm wide x 12.2 cm high) abstract, two-dimensional, colourful paintings (taken from the work of J. Pollock and other avant-garde artists) presented on a 31 cm x 17.2 cm computer screen by means of software PsychoPy\u0026reg; 2024.1.4 for Windows. Participants were simply asked to judge the pleasantness of the paintings by pressing an \u0026ldquo;I like it\u0026rdquo; key or an \u0026ldquo;I do not like it\u0026rdquo; key. Each stimulus was randomly repeated twice, for a total of 30 stimuli. There was no time constraint for answering. Following the experimental tasks, participants were engaged in conversation. After an interval of 10 minutes, they were asked to reproduce the ROCF by drawing as per traditional testing instructions (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Two neuropsychologists aware of the definitions of GT for the scope of the present study (see Methods) established consensually whether the participant produced a GT in their drawing.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e----- Please insert Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e about here -----\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMM contributed to investigation, data curation, and writing – original draft.\u003c/p\u003e\n\u003cp\u003eCRI contributed to formal analysis and writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eES contributed to project administration, conceptualization, and investigation.\u003c/p\u003e\n\u003cp\u003eCC contributed to investigation and provided resources.\u003c/p\u003e\n\u003cp\u003eRC contributed to methodology and writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eSDS contributed to conceptualization, methodology, and writing – review \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData analysed in the present study are available from the corresponding author upon request\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLamar, M. \u003cem\u003eet al.\u003c/em\u003e Perseverative behavior in Alzheimer\u0026rsquo;s disease and subcortical ischemic vascular dementia. \u003cem\u003eNeuropsychology\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 523\u0026ndash;534 (1997).\u003c/li\u003e\n\u003cli\u003eFuld, P. 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Constructional apraxia and hemispheric locus of lesion. \u003cem\u003eCortex.\u003c/em\u003e \u003cstrong\u003e1\u003c/strong\u003e, 170\u0026ndash;197 (1964).\u003c/li\u003e\n\u003cli\u003eGeorge, D. \u0026amp; Mallery, P. \u003cem\u003eSPSS for Windows Step by Step: A Simple Guide and Reference, 17.0 Update\u003c/em\u003e. (Allyn \u0026amp; Bacon, 2010).\u003c/li\u003e\n\u003cli\u003eDella Sala, S., Gray, C., Baddeley, A., Allamano, N. \u0026amp; Wilson, L. Pattern span: a tool for unwelding visuo\u0026ndash;spatial memory. \u003cem\u003eNeuropsychologia.\u003c/em\u003e \u003cstrong\u003e37\u003c/strong\u003e, 1189\u0026ndash;1199 (1999).\u003c/li\u003e\n\u003cli\u003eLogie, R. H. Visuo-spatial processing in working memory. \u003cem\u003eQ. J. Exp. Psychol. \u003c/em\u003e\u003cstrong\u003e38\u003c/strong\u003e,\u003cem\u003e \u003c/em\u003e9\u0026ndash;247 (1986).\u003c/li\u003e\n\u003cli\u003eQuinn, J. G. Irrelevant Pictures in Visual Working Memory. \u003cem\u003eQ. J. Exp. Psychol. \u003c/em\u003e\u003cstrong\u003e49\u003c/strong\u003e, 200\u0026ndash;215 (1996).\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e Descriptive statistics of productive signs within neuropsychological assessment in the participants showing graphic transmutation (GT) and participants who did not (NT). The number of productive phenomena is expressed as frequency of individuals exhibiting at least 1 productive sign (mean \u0026plusmn; standard deviation).\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"671\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eDomain\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eProductive phenomena\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u003c/em\u003e = 16)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNT\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(\u003cem\u003en\u003c/em\u003e = 16)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean-comparison tests\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003eROCF\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eIntrusions in ROCF-Copy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e6 (1.17 \u0026plusmn; 0.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (1.66 \u0026plusmn; 0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePerseverations in ROCF-Copy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e11 (2.72 \u0026plusmn; 1.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e3 (2.67 \u0026plusmn; 1.15)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term memory\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eIntrusions in RAVLT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e12 (3.25 \u0026plusmn; 2.18)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e12 (2.67 \u0026plusmn; 2.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePerseverations in RAVLT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e11 (3.45 \u0026plusmn; 1.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e\u0026nbsp;8 (3.75 \u0026plusmn; 1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eFalse memories in RAVLT-Recognition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e13 (6.31 \u0026plusmn; 3.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e13 (4.61 \u0026plusmn; 3.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eVerbal confabulations in Prose Memory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3 (1.00 \u0026plusmn; 0.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003eExecutive functions\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePerseverations in Attentional Matrices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3 (3.00 \u0026plusmn; 2.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003eIntrusions in Phonological Verbal Fluency\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e2 (2.00 \u0026plusmn; 1.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e2 (2.50 \u0026plusmn; 2.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 178px;\"\u003e\n \u003cp\u003ePerseverations in Phonological Verbal Fluency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e8 (2.87 \u0026plusmn; 1.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 142px;\"\u003e\n \u003cp\u003e7 (2.43 \u0026plusmn; 1.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 89px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: ROCF = Rey-Osterrieth Complex Figure Rey [10,\u0026nbsp;11,\u0026nbsp;14]; RAVLT = Rey\u0026rsquo;s Auditory VerbaL Learning Test, immediate and delayed recall [21]; Prose Memory [22]; Attentional Matrices [23]; Phonological Verbal Fluency [24].\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eIndipendent Samples \u003cem\u003et-\u003c/em\u003etest\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e One-sample Wilcoxon signed rank test (expcted median = 0)\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u0026nbsp;\u003c/sup\u003eMann-Whitney U test\u003c/p\u003e\n\u003cp\u003e* \u003cem\u003ep\u003c/em\u003e \u0026lt; \u0026alpha;\u003csub\u003eadj\u0026nbsp;\u003c/sub\u003e= 0.02\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e. Clinical diagnoses of the participants showing (GT) or not showing (NT) graphic transmutation.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eMild Cognitive Impairment\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eAlzheimer Disease\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eParkinson\u0026rsquo;s Disease Dementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eVascular dementia (VD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eVD and Normal Pressure Hydrocephalus\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eVD and Epilepsy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eAnterior Communicating Artery Aneurism\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eTraumatic Brain Injury\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003eKorsakoff\u0026rsquo;s Syndrome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003ePseudodementia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e2\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 299px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTOTAL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e16\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003eAccording to Peterson\u0026rsquo;s criteria [65]\u003c/p\u003e\n\u003cp\u003e2According to the NINCDS\u0026ndash;ADRDA criteria [66]\u003c/p\u003e\n\u003cp\u003e3Confirmed by Computed Tomography\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e4\u003c/sup\u003eConfirmed by Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e5\u003c/sup\u003eThe psychiatric diagnosis was bipolar disorder in one case and anxiety/depressive disorder in the other\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3.\u0026nbsp;\u003c/strong\u003eThe sociodemographic and neuropsychological characteristics of the participants with (GT) and without (NT) graphic transmutations included in the study. Values are expressed as mean \u0026plusmn; standard deviation.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNT\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eGeneral demographic and clinical profile\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eSex (w/m)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11/5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e9/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e66.69 \u0026plusmn; 10.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e67.00 \u0026plusmn; 10.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eEducation (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e7.44 \u0026plusmn; 3.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7.31 \u0026plusmn; 2.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eDisease duration (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.81 \u0026plusmn; 8.61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7.94 \u0026plusmn; 11.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eMMSE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e21.94 \u0026plusmn; 4.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e22.00 \u0026plusmn; 6.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eNPI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e28.25 \u0026plusmn; 18.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e22.19 \u0026plusmn; 11.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eBADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.38 \u0026plusmn; 0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e5.56 \u0026plusmn; 0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eIADL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.31 \u0026plusmn; 1.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4.69 \u0026plusmn; 2.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eNeuropsychological assessment\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003eShort-term memory\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eDisyllabic Word Span\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.25 \u0026plusmn; 5.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e3.31 \u0026plusmn; 0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eVisuo-spatial (Corsi) Span\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.25 \u0026plusmn; 1.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e3.38 \u0026plusmn; 1.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003eLong-term memory\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eRAVLT-Immediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e19.88 \u0026plusmn; 8.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e22.50 \u0026plusmn; 11.15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eRAVLT-Delayed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.00 \u0026plusmn; 2.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4.00 \u0026plusmn; 3.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eRAVLT-Recognition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e10.63 \u0026plusmn; 5.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e10.00 \u0026plusmn; 4.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eProse Memory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.35 \u0026plusmn; 3.88\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e5.04 \u0026plusmn; 4.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eROCF-Delayed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3.37 \u0026plusmn; 3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e7.12 \u0026plusmn; 5.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003eExecutive functions\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eFAB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11.36 \u0026plusmn; 3.25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e11.12 \u0026plusmn; 3.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eAttentional Matrices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e32.56 \u0026plusmn; 12.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e39.81 \u0026plusmn; 11.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003ePhonological Verbal Fluency (FAS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e16.94 \u0026plusmn; 9.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e18.25 \u0026plusmn; 12.92\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eStroop Test (errors)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4.41 \u0026plusmn; 4.65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e5.71 \u0026plusmn; 7.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eStroop Test (time in sec)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e47.69 \u0026plusmn; 25.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e32.07 \u0026plusmn; 16.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003eFluid intelligence\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eCPM 47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e17.44 \u0026plusmn; 6.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e17.38 \u0026plusmn; 4.94\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003eConstructional Ability\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eClock Drawing Test\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5.59 \u0026plusmn; 2.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e4.97 \u0026plusmn; 3.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eROCF-Copy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18.69 \u0026plusmn; 7.82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e22.84 \u0026plusmn; 7.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 222px;\"\u003e\n \u003cp\u003eConstructional Apraxia Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9.56 \u0026plusmn; 2.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 109px;\"\u003e\n \u003cp\u003e9.69 \u0026plusmn; 2.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 51px;\"\u003e\n \u003cp\u003e\u003cem\u003ens\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: MMSE = Mini-Mental State Examination [67]; NPI = Neuropsychiatric Inventory [68]; BADL = Basic Activities of Daily Living [69]; IADL = Instrumental Activities of Daily Living [70]; Dysillabic\u0026nbsp;Word Span [22]; Corsi\u0026nbsp;Span [22]; RAVLT = Rey\u0026rsquo;s Auditory VerbaL Learning Test [21]; Prose\u0026nbsp;Memory [22]; ROCF = Rey-Osterrieth Complex Figure [10,\u0026nbsp;11,\u0026nbsp;14]; FAB = Frontal Assessment Battery [71]; Attentional\u0026nbsp;Matrices [23]; Phonological Verbal Fluency [24]; \u0026nbsp;Stroop\u0026nbsp;Test [72]; CPM47 = Raven\u0026apos;s\u0026nbsp;Coloured Progressive Matrices [73], CDT = Clock Drawing Test [74]; Constructional Apraxia Test [75].\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ens\u003c/em\u003e: non-significant.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003eb\u0026nbsp;\u003c/sup\u003eIndipendent Samples \u003cem\u003et-test\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003ec\u0026nbsp;\u003c/sup\u003eMann-Whitney U test\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Graphic transmutation, Rey-Osterrieth’s complex figure, confabulation, semantic","lastPublishedDoi":"10.21203/rs.3.rs-6502291/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6502291/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWhen asked to reproduce abstract figures from memory, people with brain damage may draw meaningful figures or add extra features unrelated to the original stimulus. Such a phenomenon has been classified as an uncommon type of confabulation. However, this interpretation is unsatisfactory. The aim of this study was to revisit this phenomenon to provide a more robust interpretation.\u003c/p\u003e \u003cp\u003eThe records of 493 people presenting with cognitive complaints have been reviewed. Their copy and their reproduction by memory of the Rey-Osterrieth Complex Figure were analysed.\u003c/p\u003e \u003cp\u003eSixteen people presented with clear instances of the phenomenon. Their demographics, and cognitive profiles, including memory and executive functions, did not differ from those of a matched control group of people from the same sample who did not present with the phenomenon.\u003c/p\u003e \u003cp\u003eConsidering this phenomenon as a confabulation is misleading. We suggest that the compulsion to semantically process the meaningless figure as a meaningful object leads to the production of \u003cem\u003eGraphic Transmutation\u003c/em\u003e. The meaningful object overrides the original due to a failure of monitoring functions associated to a defective visuo-spatial memory. Identifying \u003cem\u003eGraphic Transmutation\u003c/em\u003e in neuropsychological evaluations may provide valuable insight into the cognitive profile of people with brain damage.\u003c/p\u003e","manuscriptTitle":"Graphic Transmutations: When Meaningless Pictures are Remembered as Familiar Objects","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 09:50:27","doi":"10.21203/rs.3.rs-6502291/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-01T09:10:54+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-26T15:32:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"135267245671523020562950383066889646306","date":"2025-05-22T10:34:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-14T10:28:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167657649222770830498116135705104747607","date":"2025-05-09T12:10:02+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-08T12:37:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-08T12:26:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-05T05:17:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-02T04:54:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-04-22T08:51:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f4c0759-c77b-48f0-b186-7e1c2c014122","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":48456555,"name":"Biological sciences/Psychology"},{"id":48456556,"name":"Health sciences/Neurology"}],"tags":[],"updatedAt":"2026-02-09T16:04:46+00:00","versionOfRecord":{"articleIdentity":"rs-6502291","link":"https://doi.org/10.1038/s41598-025-33833-7","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-02-04 15:57:54","publishedOnDateReadable":"February 4th, 2026"},"versionCreatedAt":"2025-05-13 09:50:27","video":"","vorDoi":"10.1038/s41598-025-33833-7","vorDoiUrl":"https://doi.org/10.1038/s41598-025-33833-7","workflowStages":[]},"version":"v1","identity":"rs-6502291","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6502291","identity":"rs-6502291","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}