Medial temporal lobe amnesia: Gradual acquisition of factual information by nondeclarative memory

Most amnesic patients with damage to the medial temporal lobe retain some capacity to learn new information about facts and events. In many cases, the learning appears to depend on a residual ability to acquire conscious (declarative) knowledge. We have studied the capacity for semantic (fact) learning in the profoundly amnesic patient E.P., who has extensive damage limited primarily to the medial temporal lobe. E.P. was presented with factual information (novel three-word sentences) during 24 study sessions across 12 weeks. E.P. performed much more poorly than controls but demonstrated unmistakable improvement across the sessions, achieving after 12 weeks a score of 18.8% correct on a cued-recall test and 64.6% correct on a two-alternative, forced-choice test. Unlike controls, E.P.'s learning was not accompanied by conscious knowledge about which answers were correct. He assigned the same confidence ratings to his correct answers as his incorrect answers. Moreover, on the forced-choice test his response times were identical for correct and incorrect responses. Furthermore, unlike controls, he could not respond correctly when the second word in each sentence was replaced by a synonym. Thus, what E.P. learned was rigidly organized, unavailable as conscious knowledge, and in all respects exhibited the characteristics of nondeclarative memory. Thus, factual information, which is ordinarily learned as declarative (conscious) knowledge and with the participation of the medial temporal lobe, can be acquired as nondeclarative memory, albeit very gradually and in a form that is outside of awareness and that is not represented as factual knowledge. We suggest that E.P.'s learning depended on a process akin to perceptual learning and occurred directly within neocortex.