Honolulu, HI — Even as some patients with frontotemporal dementia slowly lose their language function, they may develop extraordinary new artistic abilities, Bruce L. Miller, MD, told a plenary session at the AAN Annual Meeting here.
“What these cases have taught me is that we need to focus on both the strengths and weakness of our patients,” said Dr. Miller, the A.W. and Mary Margaret Clausen Distinguished Professor of Neurology at the University of California-San Francisco School of Medicine.
As Dr. Miller described his patients, similarities emerged. They all created artwork that was realistic in style, never abstract. The images typically depicted scenes from the past, suggesting that even as the patients were losing their memory for words, their visual memories were up to par.
Remarkably, most of the patients who began to draw or paint after the onset of dementia had no prior interest in art, Dr. Miller said.
ANOMIA A COMMON SYMPTOM
Another common denominator was that nearly all suffered from a subtype of frontotemporal dementia known as semantic dementia. “This subtype is strongly associated with marked anomia,” Dr. Miller said. “The degeneration not only knocks out language, but also deletes the very concept of what the words are.”
Importantly, the anatomy of this type of dementia is bitemporal, with the left temporal portion harder hit, he said. “You see a lot of loss of symbolic language function, and the concept of what items are is lost due to the involvement of the left anterior temporal lobe.” The ability to recognize faces is also obliterated (prosopagnosia).
And because the parietal lobe is spared, almost all the patients can copy with incredible precision, he said.
Often, the compulsive behaviors associated with frontotemporal dementia serve as a stimulus for the artistic expression, he said, with paintings drawn over and over until the artist is satisfied with the result.
The amygdala is also involved, so these patients undergo emotional changes, he said. And since the frontal lobe is somewhat spared in semantic dementia, so, too, is the ability to visually represent the world.
In other words, even if patients can't name what they are looking at, they can probably plan, organize, and paint it beautifully.
LEFT SIDE OF THE BRAIN
One of the lessons that has emerged from lesion studies and cognitive psychology is that certain areas of the brain are particularly important for the cognitive aspects of artistry, Dr. Miller said.
The right hemisphere is dominant for the three key features of visual artistry: visual constructive ability, spatial attention, and internal representation, he said.
That is not to say the left hemisphere is not involved in artistry at all. Indeed, it appears that the dominant hemisphere is involved with conceptualization and linguistic symbolic components of art, which is why symbolism and abstraction may be absent in the drawing of patients with damage due to frontotemporal dementia, Dr. Miller said.
He described one famous artist known for his symbolic, non-representative pieces. “After he had a left hemisphere stroke, his ability to make symbolic pieces was completely lost, but his ability to make visual representations was completely spared,” Dr Miller said. “It emphasizes that an important aspect of art is in the dominant hemisphere.”
Dr. Miller described one patient with semantic dementia whose artwork clearly demonstrates the loss of symbolic concepts of items due to involvement of the left anterior temporal lobe. The woman was asked to draw a dog. As the disease progressed, her drawing depicted an animal that looked like it came out of evolution with features of dogs and other animals, Dr. Miller said.
In another aspect of the phenomenon, a man with semantic dementia showed extraordinary creativity in the setting of progressive aphasia, he said. The patient, who had no artistic talent prior to his disease, said he could see and feel colors better than ever before. He became very eccentric, and wore purple shirts and yellow pants to each office visit; the same colors dominated all his paintings.
As the disease progressed, language dysfunction worsened, but the pictures became more and more interesting, Dr. Miller said.
The patient was compulsive, obsessed, he added. He would draw the same painting over and over again, 20 to 30 times. As the patient worsened to the point at which he was almost completely aphasic and unable to name a bird, he drew, from his imagination, an extraordinary picture of a bird he remembered from Hawaii. Eventually, the patient lost the ability to draw altogether, though he is still alive. In retrospect, this artistic phase heralded the onset of his dementia, Dr. Miller said.
The visual creativity that emerges in the patient with semantic dementia was also observed in an autistic artistic savant who demonstrated damage to the left anterior temporal lobe on imaging studies.
The child had a compulsive need to draw from the time he was an infant, Dr. Miller said. “By 18 months, the toddler began to withdraw linguistically and socially, but was compelled to draw. He drew horses on a phone book, any book he could get his hands on, sometimes making the same picture over and over, working 18 to 24 hours a day. So strong was his need to draw that he forewent sleep.
“As he grew older, the child portrayed an extraordinary internal representation of the world. He would see a movie, come home, and thanks to his extraordinary visual memory, draw out the movie in sequence.”
THE BIG QUESTION
Why are patients with semantic dementia able to produce such extraordinary art? That is still an open question, Dr. Miller said. “But there are lots of possibilities.”
The prevailing theory is that as the left side of the brain degenerates, creative impulses that were always present, but turned off, on the right side of the brain are released and flourish, he said.
The dominant, bullying hemisphere, in other words, has to be suppressed to let the nondominant visual hemisphere do its thing. Other factors may play a role as well. The loss of inhibition may free people to do things they might never have done before. There is some evidence pointing to slow rewiring of the cortex over the course of the illness.
Finally, some have proposed that paradoxical functional facilitation may be the explanation: Injury to one part of the brain releases another part, increasing its output and function, Dr. Miller said. “These are questions that functional magnetic resonance imaging and modern neurology can begin to address.”
Figure. Dr. Bruce L....Image Tools
IMPLICATIONS FAR REACHING
Jeffrey L. Cummings, MD, Director of the University of California-Los Angeles Alzheimer's Center, said that the research is a prime example of “clinical observations providing insight into a very human capacity.
“By observing what patients can and cannot do, we gain new insights into the creative process itself,” he said. The cases provide a hint of what goes on in the right hemisphere of the brain, of how the brain works, of the origin of our artistic abilities and how they are generated.
This in turn, Dr. Cummings said, may lead to a better understanding of and treatments for frontotemporal dementia and other forms of dementia.
There is also a more immediate implication of the research. The findings could help neurologists to diagnose frontotemporal dementia earlier, Dr. Cummings said.
“It would be unusual for someone to suddenly become entranced with artistic activity in mid-life,” he said. “Without impugning the late blooming artist, it is fair to say one might suspect such a patient is exhibiting early signs of dementia if there is any degree of language problems.”
ARTICLE IN BRIEF:
✓ Dr. Bruce L. Miller, of the University of California-San Francisco, described some patients with frontotemporal dementia who developed new artistic abilities at the same time as they lost their language function.
✓ The anatomy of this type of dementia is bitemporal, with the left temporal portion harder hit.