Neuropsychology of Art

Art production following left hemisphere damage

Honor art student

In 1936, a neurological report describing patients with left hemisphere damage, some with aphasic disturbance, was published (Kennedy & Wolf, 1936). One of the cases was of an artist, a 19-year-old honor art student (in an art school) who suffered a sudden injury to the left fronto-parietal area, which resulted in a mild weakness of the right hand for a period of three days (the cause of the injury was not described). There were no obvious aphasic symptoms, and no verbal expressive or receptive language disturbances. However, there was a disturbance in expressive drawing. Two weeks after the injury, she was asked to draw a face. All she could produce was a circle containing two dots for the eyes, a vertical line representing the nose, and a single horizontal line for the mouth (see Figure 2.1a). Then, she was asked to draw a picture of the American statesman Alexander Hamilton. She drew a bare outline in profile. She worked daily on this profile until she succeeded in producing a more detailed figure. Interestingly, the most glaring “error” was the disproportionately large head. At one point, she improved decidedly and was able to produce a very good three-quarter view of a normal-looking Alexander Hamilton. At the end of six months, her drawings of other figures returned to their normal artistic levels as well. Examples of the evolution of her work during the period after the damage occurred are shown in Figure 2.1 a–g. Together, they reveal that the unilateral injury interfered with execution of her artistic abilities, but only temporarily. Importantly, this case illustrates the dissociation between language and art production even with left hemisphere damage.

Subsequently, in 1948, Alajouanine published the first neurological report in English devoted exclusively to the effects of brain damage in several established artists (Alajouanine, 1948). The article described three artists from divergent art fields (visual art, music, and literature) who sustained brain damage in the left hemisphere that severely compromised their language abilities. The alteration in their artistic expressions varied widely.

Alajouanine’s visual artist

The visual artist in Alajouanine’s publication was a 52-year-old successful painter (his identity was not revealed at that time) when a stroke occurred in the left hemisphere of his brain. Now we know that he was Paul-Elie Gernez (Boller, Sinforiani, & Mazzucchi, 2005). After the stroke, he suffered from Wernicke-type aphasia (also known as fluent aphasia). There was no right-sided hemiplegia and this implies no involvement of the motor cortex in the left frontal lobe. Often with this aphasia, speech is fluent but can be nonsensical, made up mostly of jargon, and language comprehension is very poor or non-existent. Writing and reading are grossly affected in such patients in ways analogous to speech and comprehension. But in this case,

Figure 2.1 A 19-year-old art student and professional artist with left hemisphere damage in the fronto-parietal region showed progressive improvement in her artistic expression in the six weeks that followed an accident (resulting in a depressed skull fracture) and surgery. The initial symptoms were expressed not in aphasia or linguistic deficits but only in right-hand weakness that lasted for three days. Two weeks afterwards, she was asked to draw a face. (a) shows her response to this request. Notice that she can write numbers better than she can draw (although number nine was reversed). (b) Three days later she was asked to look at a picture of Alexander Hamilton and render her version on paper. Both the drawing and number-writing have improved, although the drawing remains rather sketchy. There is an irrelevant circle in the area in the back of the head. The lines of the figure are angular while the numbers have gained a flowing technique. (c), (d), (e), and (f) all show the student’s steady improvement in depicting Alexander Hamilton. (It is not known from the original publication whether she went on to use different pictures of Hamilton in her renderings.) All this time there was no aphasia, alexia, or agraphia. Kennedy and Wolf (1936) point out that this is a case of an artist in whom there was an expressive disorder but not of a linguistic nature. (g) Finally, the student produced this drawing of a man’s head. (Kennedy & Wolf, 1936). Reprinted with permission from Lippincott Williams & Wilkins, Medical Research.)

comprehension was not severely affected. This artist had two separate strokes (time interval was not mentioned), which resulted in language impairments. He had severe anomia (word-finding difficulties) and exhibited paraphasic errors (words substituted for the ones that could not be retrieved from the mental lexicon), but with relatively better comprehension than would be expected. Both his writing and reading were quite impaired; the reading deficits suggest involvement of posterior temporal and occipital lobes. However, given the symptoms, it is possible that the damage was not extensive, and, although including Wernicke’s area, may have spared regions surrounding it. Alternatively, the damage may have occurred much earlier than the time when Alajouanine saw him and the acute symptoms of Wernicke’s aphasia could have disappeared in the interim. However, Alajouanine observed that artistic skills remained unchanged:

Artistic realization in our painter since his aphasia remains as perfect as before. According to connoisseurs, he has perhaps gained a more intense and acute expression. If one tries to analyze his production before and after his aphasia, one cannot find since his language deterioration any mistake in form, expression or colour interpretation … I am of the opinion that he lays emphasis on thematic characteristics with a poetical strength, in a completely unaltered manner, and that since his illness he has even accentuated the intensity and the sharpness of his artistic realization. Moreover, his activity and production have not slowed down, and he seems to work with the same speed. Perhaps, because of new affective conditions, his works are less regular … Perhaps he is more prone, however, to use a previous model, or a discarded sketch.

(Alajouanine, 1948, p. 235)

The last remarks are revealing; they seem to refer to the fact that the artist continued to produce art at the same rate as prior to the damage. This case also illustrates the dissociation between language abilities and art production, that one mode of communication can be damaged while the other remains relatively intact.

Fashion designer

Macdonald Critchley, the British neurologist, examined a multilingual fashion designer and artist who was highly regarded and successful in his career (Critchley, 1953). He suffered a stroke in the left temporal–parietal lobes that resulted in a mixed aphasia in English, German, and French, and a short-lived right-sided weakness. As would be expected, he had difficulties in comprehension as well as in speaking. Critchley did not describe in full the details of the language impairments. Before the brain injury the artist’s work was characterized by fine, closely spaced, detailed illustrations consisting of minute strokes and cross-hatchings, and resulting in accurate representations. After the stroke, his artistic technique changed (see definition of artistic style in the introduction to this chapter) in the sense that there were fewer detailed strokes and figure identity was characterized by strong contour lines. This could be interpreted to mean that intact regions in the right hemisphere contributed to the global and wholistic configuration now that critical regions in the left hemisphere were damaged and could not contribute to the details and fine lines within the contour frame. The work of McFie and Zangwill (1960) would certainly support this conclusion. Still, as with the honor student and Alajouanine’s artist, the ability to paint and illustrate was not obliterated by the damage. What changed drastically was the manner of depiction.

Zlatio Boyadjiev (ZB)

The Bulgarian painter Zlatio Boyadjiev (also referred to sometimes in the neuropsychological literature as ZB) suffered a left hemisphere stroke in 1951, when he was about 48 years old, which resulted in severe right-hand paralysis and mixed aphasia (Zaimov, Kitov, & Kolev, 1969). For many years afterwards the aphasia consisted of both the Broca type and the Wernicke type, and was accompanied by alexia and agraphia. In the few years after the stroke he drew a bit, but not much is known about his artistic productions from those years. Starting around 1956 new works emerged and were exhibited in museums; he learned to use his left hand in order to paint (the right was paralyzed). Boyadjiev was very prolific between 1956 and 1972 (he died in 1973). He continued to paint, and his ability to depict realistic figures was largely unchanged. The new work was well executed, very aesthetic, and highly regarded. However, compared to the pre-injury artistic techniques, several interesting changes occurred. The colors became less exuberant and somewhat less varied, the number of figures in a given composition declined, there was now a blending of imaginary and real themes in a single composition, and there was less convergent perspective than prior to the stroke. Indeed, a number of paintings seemed to lack depth altogether, with figures appearing piled in a vertical plane, not unlike traditional Chinese paintings. This in itself is surprising given that only left hemisphere damage is suspected (no CT (computerized tomography) scan or MRI (magnetic resonance imaging) scan is known to have been taken). One would have expected absence of convergent linear perspective to be associated with a right hemisphere lesion. Also, a sort of balanced left–right mirror symmetry emerged in his compositions that was not present previously. The new symmetry could reflect the fact that he now was using his left hand as the right hand, his dominant hand, was paralyzed. The mirror symmetry contributed to an abstract appearance of the whole picture, although the individual figures were often highly representational. The balanced mirror symmetry lends an impression of regularity and stability. The new paintings, highly skilled and aesthetic, appear somewhat flat compared to the convergent perspective and depth representation in Boyadjiev’s pre-stroke paintings. Nevertheless, his post-stroke works are exhibited in Bulgarian museums.

Parietal lobe cancer

A 72-year-old professional artist who suffered from a fast growing cancerous tumor, glioblastoma, in the left parietal lobe presents an interesting case (Marsh & Philwin, 1987). In the five months before surgical removal of the tumor, he suffered from mixed aphasia, inability to write his name on command, and, similarly, inability to draw or copy on command. There were abnormal right arm reflexes, and abnormal electroencephalogram activity over the left hemisphere but particularly over the temporal lobe. After the tumor was removed, he appeared less aphasic than previously. Unfortunately, he died less than two months after surgery, and whether or not he painted in that interval is not discussed in the published report. The authors compare two paintings, one made four years before the tumor onset and one made around the time of the supposed appearance of the tumor. They observe that the second painting was composed with a shift toward the left so that there was greater emphasis on details in the left half than in the right half of space. It is not that there is a complete or even a partial neglect (ignoring or neglecting to pay attention to the half of space) of the right half of the canvas, a type of incompleteness of figures observed in patients with right parietal damage for the left half of space (see Chapter 8). It is an absence of details in the right half of the canvas as well as in the upper left corner that is interesting here. The authors emphasize that the whole canvas was filled with lines and paint. Defined human figures were painted only in the lower three-quarters of the canvas. Thus, this case illustrates a shift of attention to the portions of the visual field controlled by the non-damaged hemisphere. The damage in the left parietal lobe altered the composition as a whole while the artist’s drawing skills remained largely intact.

Polish art professor

The Polish artist RL was a professional artist and also a professor in the art department in the University of Lublin (Kaczmarek, 1991). He had a stroke at age 51 in the left frontal lobe; he became aphasic and developed right-arm paralysis. A second stroke a short while afterwards resulted in paralysis of his right leg. Neuropsychological testing revealed an inability to describe the theme of pictures (suggesting presence of simultanagnosia), digressions, poor memory for stories, confabulations, inability to derive the essence of read or spoken stories, limited vocabulary, difficulties in planning, and emotional lability. His artistic skills were preserved but the subject matter of his art changed. Specifically, whereas prior to the stroke he focused on figurative symbolic topics, afterwards he was unable to produce such themes. Subsequently, increased artistic productivity was accompanied by increase in language abilities (Kaczmarek, 2003). Unlike Zlatio Boyadjiev, however, he produced landscape paintings that showed good perspective and depth, and no distinct organizational strategy of left–right symmetry emerged in his paintings. His post-stroke art was highly aesthetic, he was able to sell it, his craft and talent clearly remained intact, and eventually, thanks to consistent art and cognitive therapy, he regained his ability to depict symbolic ideas.

Jason Brown’s artist

Are there selective effects of aphasia on art production? Jason Brown (1977) provides the following brief description of yet another professional artist:

This 73-year-old woman was a professional artist, strongly right-handed without a family history of left-handedness. She suffered a stroke with right hemispheric lesion and left hemiparesis (i.e., crossed aphasia) and presented characteristic features of phonemic (conduction) aphasia. Preliminary studies of her sketching, both spontaneously and as illustrations to short stories, demonstrated no apparent alteration in artistic ability.

(Brown, 1977, p. 168)

Art production following right hemisphere damage

Film director Federico Fellini

Federico Fellini was not only a highly acclaimed film director and screenplay writer but also a professional cartoonist and painter. He made his last film in 1990, The Voice of the Moon. His highly regarded films, including La Strada in 1954, The Nights of Cabiria in 1957, La Dolce Vita in 1960, 8½ in 1963, Juliet of the Spirits in 1965, and Satyricon in 1969, received numerous awards, among them the illustrious Oscar award. At the age of 73 (August 3, 1993), he suffered a stroke in the right posterior temporo-parietal junction, which resulted in neglect of the left half of space, and motor and sensory deficits in the left half of the body (Blanke & Pasqualini, 2012; Cantagallo & Della Salla, 1998; Dieguez, Assal, & Bogousslavsky, 2007). The neglect extended to difficulties in reading, clinically known as neglect dyslexia (ignoring the left half of words by not reading them out loud due to presence of hemi-neglect; see Chapter 8). Yet, there was no neglect agraphia; that is, he could write complete words. He was aware of the motor condition in his left hand and the neglect deficits. Despite this awareness, however, he was unable to compensate for the neglect deficits. There were no language impairments and no general cognitive decline. His sense of humor remained unchanged. He did not have prosopagnosia, a deficit in recognizing previously familiar faces that can occur following damage to the right parietal lobe (De Renzi, 1999; Landis, Cummings, Christen, Bogen, & Imhof, 1986), and he did not have memory deficits. Despite the fact that he showed neglect of the left half of space, his drawing abilities, particularly the humor in his spontaneous cartoons, remained unchanged. The lines were firm and confident, their character was the same, the figures were just as recognizable as previously, and the humor depicted was appropriate. Amazingly, while he ignored the left half of a straight line in the line-bisection test, the cartoons he drew on the right half of the page were complete and whole (if anything was missing on the left half, this could be attributed to the schematic nature of cartoons). One would have expected the drawings to have many omissions on their left half, but this was not the case with Fellini. When, however, he drew figures from memory, upon request, some left-sided lines were omitted but then spontaneously corrected after further inspection. Spontaneously executed cartoons did not show left-sided neglect. The deficits that were observed were present in the first two months after the stroke. Afterwards, no evidence of neglect in drawings was noted. The major lessons from Fellini’s case are that his drawing skills were clearly not obliterated by the brain damage, that the conceptualization required for cartoon humor remained, that the lines and strokes were firm, and that no major changes in overall artistic style or techniques occurred. The sad part for society is that he never made another film. He died on October 31, 1993, not long after the stroke.

Film director Luchino Visconti

Lucino Visconti, also a highly successful and highly acclaimed movie director, suffered a right hemisphere stroke at the age of 66 (Blanke & Pasqualini, 2012; Dieguez et al., 2007). It resulted in left-sided paralysis of the arm and leg; this suggests posterior frontal lobe damage (because the paralysis indicates damage in the pre-central motor cortex). Little is known about the neuropsychological consequences of his stroke compared to what is known about Fellini, but it is assumed that for a while after the stroke hemi-neglect was present, and this implies damage in the parietal lobe as well. It may even have been present for quite a while post-stroke, as an analysis of his two last films (Conversation Piece, 1974, and The Innocent, 1976) suggests:

the scenes in both post-stroke films are often filmed with the characters facing the camera in a close-up, and not in a natural position in space, such as in “Senso,” “The Leopard,” “The Damned,” or “Ludwig,” where complex spatial positions of the cameras in the interior generate a spatial mosaic of first- and third-person perspectives within the rooms.

(Blanke & Pasqualini, 2012, p. 7)

The idea proposed by the authors is that prior to the stroke Visconti applied the use of panoramic views, which he mastered with his intact visuospatial cognition, views that were his signature cinematographic style, whereas after the stroke this type of cognition was impaired (possibly because of lingering hemi-neglect) and he resorted to the use of close-ups. The important thing to note is that despite the acquired brain damage he continued to practice his craft of film-making, and produced highly valued films.

Sculptor Tom Greenshields

An established well-known British artist, the painter and sculptor Tom Greenshields, suffered a stroke in his right hemisphere at age 75, in August 1989 (Halligan & Marshall, 1997). Subsequent to the stroke he had left visual hemi-neglect of space, mild weakness in the left arm and leg, and visual field blindness in the left lower quadrant. All of this implies damage in the right parietal lobe, as well as in the posterior region of the right frontal lobe, and possibly damage in the right occipital lobe; no localization information from brain imaging or neurological examination is provided in the published report (Halligan & Marshall, 1997). Although he was a right-handed person, he was forced to switch his manual activities to the left hand eight years prior to the stroke because an accident damaged his right hand. Working with his left hand did not prevent him from producing art for sale throughout the world. After 1989 we see an artist suffering from sensory-motor weakness in the left hand, the only hand he apparently can use for his art. In the few months following the stroke he concentrated mostly on the right half of both drawings and sculptures. Some spatial distortions and deformities were reportedly observed as well in some of the figures, but those were most apparent in the left half. The obvious deficits diminished slowly within a year; some were still seen afterwards particularly in drawings and paintings (presumably none of those early impairments were seen for sculptures). Throughout the period between the time of the stroke and the artist’s death five years later (in 1994), artistic skills, as judged from the character of the lines and their coherent relationships, remained intact and were applied appropriately, including the production of non-canonical perspective views. Greenshields’ case, too, illustrates preservation of artistic skill despite right hemisphere damage and highlights the pervasive influence of talent and lifelong practice.

Color neglect artist

Left hemi-neglect (see Chapter 8 for discussion on hemi-neglect) can extend to colors and be more prominent for colors than for visual space itself. Such a rare case of an artist was described by Blanke, Ortigue, and Landis (2003). A 71-year-old professional painter had a stroke in the right posterior parietal lobe that resulted in visual blindness in the left lower quadrant of the visual field and a mild left hemi-neglect. There was no sensory–motor loss on the left half of the body. Attention to detail was applied mostly to the right half of drawings while the left half was somewhat incomplete. The most interesting feature in the post-injury art, however, was an exaggerated neglect of color application in the left half of the painting. Thus, even while contour lines were produced in the left half, colors were more obviously absent in that half. All of this lasted for only six weeks after the stroke first occurred. Afterwards, the color neglect disappeared. No lasting changes in artistic techniques were noted. The important clue from this case to art production is that spatial layout and color are subserved by separate attentional mechanisms. (In this context, it is interesting to observe that several autistic artists, discussed in Chapter 4, did not use much color in their highly skilled graphic drawings, and, when it was used, it was not imaginative and was applied within strict drawn contours.)

Swiss artist

A locally established Swiss artist, 54 years old, suffered from two right hemisphere strokes separated by approximately six days, resulting in an extensive lesion in the right parieto-temporo-occipital junction (Schnider, Regard, Benson, & Landis, 1993). The consequences of the damage were left-sided paralysis, left hemi-neglect, visual hallucinations, delusions, and mood changes. There were no impairments in recognizing familiar faces, environmental sounds, facial emotions, or colors; no impairment in verbal or non-verbal memory was observed. In order to understand some of his symptoms, it is important to note that about 15 years before the stroke incidents the patient had suffered from visual hallucinations when under the influence of the hallucinogenic drug LSD. In the ensuing year or so after the stroke, his art consisted mainly of charcoal and pencil drawings. A few days after the second stroke he centered his drawing mostly in the right half of the paper, but, at least judging from the published drawings, all the individual figures that were depicted were completed on the left side. They appeared whole. The striking feature of this new work was the blending of text material and figural drawings. Such combinations in his art lasted for a brief period (four weeks) but during that period he also engaged in lengthy verbal dialogues that were not characteristic of his pre-stroke state. The amount of detail in his drawings following the stroke did not differ from the pre-stroke days.

However, interestingly, the neglect of space did not necessarily manifest in the left half of the paper but rather in the left half of a figure depicted in the right half of the paper. Thus, there was a “hole” of incompleteness due to the right hemisphere damage but this appeared in the right half of the composition as a whole. Such a form of expression suggests that not all components of a painted composition are controlled by a unitary cognitive process and embodied in a single idea applied to the canvas. The idea could consist of an image of the whole composition but the execution of the idea requires shifting attention to specific components (consisting of figures, whole forms, whole shapes).

In this artist’s case, no obvious loss of talent, skill, or creativity was observed. Nor was there a major change in artistic style or topics of interest. He did not abandon his work in oil paintings. The principal change consisted of left-sided neglect, and that was not particularly gross. He did suffer from mood changes and irritability, both of which prevented him from further elaborations of individual drawings. “The character of lines and shades, the basic compositions, and his ability and desire to express himself through art, however, were preserved” (Schnider et al., 1993, p. 254).

French painter

Another case is that of an accomplished professional French painter who had a right hemisphere stroke at the age of 66 years (on April 15, 1973), which resulted in left-sided paralysis and left hemi-neglect (Vigouroux, Bonnefoi, & Khalil, 1990). He was well known both for his paintings and his drawings. After a period of depression (that occurred after the stroke) had dissipated he began to draw and paint again, and prolifically. There was, as would be expected, visual hemi-neglect in his work, particularly in the initial phases after the damage, but this was not long lived. The spatial organization of his compositions was described as being excellent, and the overall artistic style did not change, nor did the topics that interested him. Forms, character, firmness of lines, and proportionality were also largely unaffected.

Anton Räderscheidt and Otto Dix

In 1974 the German neurologist Richard Jung published neurological descriptions of several artists who suffered from damage in the right hemisphere, and in whom left hemi-neglect was also present. The neglect ranged from mild to moderate. After reviewing, pondering, and discussing their cases, Jung (1974) observed that the damage had not brought a halt to artistic productivity, or caused alterations in subject matter. Skills remained unchanged in all of these artists. One painter was the renowned German expressionist Anton Räderscheidt, who suffered a right parietal lobe stroke on October 1967 but went on painting until his death a few years later. The changes that took place in his work are hard to define but it is clear upon viewing that they were produced skillfully (Gardner, 1974). Another artist was Otto Dix, another famous German expressionist (Bäzner & Hennerici, 2007; McKiernan, 2014). Both Räderscheidt and Dix continued to produce their art following their strokes, and in both cases the pre-stroke art genre was not altered.

Lovis Corinth

Lovis Corinth, a renowned German artist considered innovative and skillful, was another artist described by Jung (1974). In December 1911 he suffered a stroke in his right hemisphere, which resulted in left hemi-neglect that was not long lived, and a left-sided weakness. Following the stroke, his drawing abilities remained excellent, and the character of lines and the proportionality of entire figures, details, and receding planes all indicated preserved skills. As early as February 1912, no distortions or abnormal exaggerations were seen in his self-portraits, even as he accurately attempted to depict his own facial expression; there was, however, evidence of a mild neglect of the left half of the canvas. There was also a system of very careful diagonal hatchings in the background that appeared to go from right to left (Butts, 1996). This system seems to have been new. In a landscape drawing that he prepared a few months later, in the summer of 1912, he used his careful, deliberate hatching system to impart an impression of light entering the scene from the right side, those straight lines of the hatchings representing light rays. His power of observation had not been altered by the right parietal stroke. For example, he depicted the asymmetry in his eyes that developed subsequent to the stroke, namely, a larger left than right eye. The spatial features of compositions went unaltered, in the sense that there was a logical proportionality and receding planes, although there appeared to be less deep convergent perspective than previously (Bäzner & Hennerici, 2007; Blanke & Pasqualini, 2012). What had changed seemed to be apparent in the oil and watercolor paintings; specifically, brush strokes appeared broader, color patches appeared larger than before, and there was abundant and widespread use of white color touches. Together, his compositions appeared coherent and one wonders if a naïve observer could identify anything amiss.

Ambidextrous Polish artist

The case of an ambidextrous contemporary Polish artist has been reported by Pachalska (2003). In art production, the ambidexterity expressed itself in outlining the figures with the left hand and drawing in the details with the right hand. In daily life, the artist wrote predominantly with the right hand (but could write with the left hand as well) and mainly used the left for eating. The artist, Krystyna Habura, suffered a massive right hemisphere stroke at age 61. A CT scan showed involvement of the frontal, temporal, and parietal lobes. Afterwards she had mild motor aphasia and left hemiparesis. The aphasia consisted of slight anomia, slowing of speech output, and difficulties in initiating speech. At first, she complained of absence of imagery. In addition, neuropsychological tests revealed some impairment in spatial orientation, writing, and drawing. In the period right after the stroke the artist was unable to draw or paint. Later, after a period of multiple art therapy sessions for eight weeks she began to draw and paint again. As a result of these sessions the artist developed a new subject matter that consisted of combining drawing and writing on the same surface. These were called “painted letters.” No evidence for scaling or spatial errors in compositions was reported, despite damage in the right hemisphere. However, whereas before the stroke she drew a close likeness of Einstein’s face, after the stroke a similar attempt at drawing him did not produce a close likeness. However, she eventually returned to being an active and prolific artist. In all, her drawing and painting skills remained unchanged and led to successful exhibition and sale of her post-stroke works. Pachalska summarizes the artist’s case thus:

The fact that she was ultimately able to return to an active artistic career is eloquent evidence against any argument that something essential to artistic creation was destroyed in her brain. This is not to say that the effects of the stroke on Habura’s art were transient or reversible. The poststroke, post-rehabilitation works are different. Technically she recovered most of what she lost, but not all: the line in the later works is somewhat less strong, sure, crisp, and the details are not always worked out with the same precision as before. Although she returned to some of the themes that had interested her before the stroke, her thematic range after rehabilitation included much greater interest in suffering and despair, while most of the social and political commentary characteristic of some earlier work disappeared.

(Pachalska, 2003, p. 54)

Slow brain diseases: progressive neurodegeneration

Parkinson’s disease

Horst Aschermann

Horst Aschermann, a known and established artist specializing in sculpture, decorative art, ceramics, and vases, was born in Thüringen, Germany, in 1932 (Lakke, 1999). Onset of Parkinson tremor was in 1965, particularly in the right hand. In 1970 he began taking L-Dopa. In 1975 his condition began to deteriorate because of increased hyperkinesia and dystonia (muscle contractions that result in abnormal painful postures), but no signs of dementia were observed. As of 1999, the right-hand tremors continued to be severe, speech became unintelligible, and the dystonia had worsened. The disease hampered his ability to use a hammer and chisel. So he resorted to using clay-plaster, and this in innovative ways. Despite many years with the disease, he continued to create artwork, sculptures, and drawings that consistently received high praise. His productivity did not diminish even despite debilitating motor control. In the 20 years after the onset of symptoms, he produced 27 works, which include two large bronze reliefs.

Parkinson’s artists

The works of 26 professional artists with Parkinson’s disease (eight women, 18 men) were evaluated by Lakke (1999). Their works before and after the onset of symptoms were analyzed and the results described in the publication. None suffered from dementia, which often accompanies the disease. The artists either made a living from their art or had been artists their whole lives. Some never received any formal art training while others did. They created paintings in oils, in watercolors, and on silk, drawings, sculptures, cartoons, graphic designs, stained glass sculpting, textile designs, and architectural plans. The artist who drew cartoons worked for Playboy magazine; he did not lose his wit after disease onset and no alteration in artistic style was observed. In the other artists, technical alterations were noted consisting of direction of hatchings, implementation of the tremor itself (putting it to use to create special effects), slightly tilted composition because of difficulty in maintaining vertical centrality, including slight tilting of the objects being depicted, and asymmetrical emphasis on one side of the canvas relative to the other side (but not as is seen in hemi-neglect cases). Some artists were not aware that they slightly tilted objects in their depictions. Importantly, Lakke observed that their art continued to mature and evolve, and they developed as artists even while the disease progressed (see Inzelberg, 2013).

Dementia

Commercial artist MH

An extensively studied case is that of MH, a commercial artist (Franklin, Sommers, & Howard, 1992). At age 77 years she was seen by a neurologist and found to have general cortical atrophy that was more pronounced in the area of the left lateral sulcus (see Figure 1.1); this was presumed to have arisen from vascular causes (not progressive) including possibly a small stroke. Neuropsychologists administered a series of tests that revealed presence of anomia (word-finding difficulties) and serious deficits in language and pictorial comprehension. Otherwise, her speech was fluent. She had no impairments in copying drawings of simple figures or in real-life drawings of modeled objects (e.g., fork, comb, orange). To be sure, the latter drawings had touches of shadings that talented, experienced artists apply to their work. Her artistic talent was further demonstrated in copying Botticelli’s Portrait of an Unknown Man with a Medal. The work on an excellent pencil reproduction of the head took several weeks. It was a very close likeness to the original. But when MH was asked to draw objects from memory, after being given only the object’s name (e.g., comb, glasses, chair, pencil), her drawings were poor; they were sketchy, representing outlines and lacking any of the nice artistic shadings that she applied when she drew the same or similar objects from models. Some were missing convergent perspective and representation of depth. This was particularly apparent in drawing a bus, book, suitcase, matchbox, pipe, and eyeglasses. Rendition of space was not missing in a spoon, apple, bucket, table, or chair. This is interesting if only because right parietal regions control productions of two-dimensional renditions of spatial depth; MH’s cortical atrophy was bilateral (even if the most salient symptoms were linguistic, consistent with extensive atrophy in the localized language-related region in the left hemisphere). However, despite the brain damage she was still able to engage in commercial artwork.

The significant clue from this case study is that artistic output is not related to artificial psychological tests administered in the laboratory. The case can serve as an illustration of the notion that artistic expertise and talent have multiple representations in the brain due to lifelong over-practice, which possibly are subserved by extensive neuronal networks, including subcortical regions. There may not be any neuropsychological tests that can ever tease out the components of art. All the interesting dissociations in performance by this artist do not explain the preservation of her artistic competence.

Leo Schnug: dementia due to alcoholism

Leo Schnug was a well-known painter and illustrator in Germany (Sellal, 2011; Sellal & Musacchio, 2008). His artistic talents were recognized early on when he was admitted to art academies, and at a young age he earned a living from book illustrations. Unfortunately, he became a heavy drinker and this led to troubles with the law as well as to steadily deteriorating health. The latter ended with a worsening mental state when he began to suffer from visual and auditory hallucinations, delusions (of grandeur, paranoia), panic attacks, cerebellar tremor, and weakness of hand muscles. Eventually he was confined to a psychiatric institution, where he remained for many years until his death. “The mental deterioration had been detected as of 1914, but had progressively worsened. Nevertheless, he never stopped painting and drawing, sometimes on a simple piece of paper, the back of a timetable or, on the request of the medical staff, on the asylum’s dining room walls” (Sellal, 2011, p. 191). Prior to the ravages of the alcohol and the dementia, his personal artistic genre was realistic, representational, and had much attention to details. The themes were inspired by heroic national history and the military uniforms of the time. His artistic talent and creativity did not appear to diminish throughout the progression of his illness. However, the cerebellar tremor as well as the muscle weakness in his limbs prevented him from making the same long brush strokes and from depicting the fine details that characterized his pre-disease works. He did not begin to paint in abstract genre after his disease onset. But the themes of his art changed to depict the contents of his hallucinations (still representational) as well as the thoughts that formed in his mind now that alcoholism had wreaked havoc in his brain, and the dementia prevented him from forming crisp concepts and abstraction. The dementia interfered with the production of coherent, aesthetically pleasing works.

Corticobasal degeneration

Book illustrator and painter

A professional illustrator and portrait painter, aged 68 years, developed several sudden neurological symptoms. He behaved inappropriately (associated with frontal lobe damage), was unable to find his way in familiar surroundings (associated with right parietal damage), could not relocate personal items (memory deterioration), developed difficulty in dressing himself (dressing apraxia, associated with right parietal damage), and had emotional outbursts. Personality changes were noted as well; he became apathetic and irritable, and was unaware of his condition (Kleiner-Fisman, Black, & Lang, 2003). In another three years, additional symptoms appeared: he began to show intellectual decline, left hemi-neglect of space, some visuospatial deficits, sensory loss in the left limbs, and abnormal reflexes on the left side. There were no obvious language deficits. An MRI of his brain revealed generalized atrophy throughout the brain that was more pronounced in the right hemisphere, including the right brainstem. Another imaging technique, single-photon emission computed tomography (SPECT), revealed marked atrophy in the right hemisphere and the left frontal region. The medical diagnosis was corticobasal degeneration. His ability to paint had not changed essentially throughout this period but there were alterations. Specifically, faces were distorted, facial features were misrepresented, brush strokes became wide, paint was applied in greater quantity to certain parts than was necessary, color use changed, and there was a striking loss of detail. The colors now appeared brighter than prior to the illness. Also, the paintings lacked the fine details needed for real-life representations, and the appropriate size-ratio of body parts appeared distorted. The artist was aware of the changes in his paintings at this point but his attempts to correct what he perceived as imperfect were not successful. Reportedly, his dissatisfaction and frustration eventually led to giving up painting altogether.

Ms. B.

Ms. B. had been a successful professional painter and sculptor for 35 years when she first sought clinical consultation for her neurological symptoms (Safar & Press, 2011). She was 57 years old at the time, although her symptoms began around age 55. She was diagnosed with corticobasal degeneration based on neurological, neuropsychological, and MRI evidence. The MRI scan revealed diffuse atrophy throughout the brain but with marked atrophy in the right parietal lobe. Her visuospatial abilities were indeed impaired on neuropsychological evaluation, but her verbal speaking and comprehension abilities appeared intact. About six months after the initial clinical evaluation, she developed apraxia in her left hand, dressing apraxia, signs of simultanagnosia, ocular apraxia, optic ataxia, and some left-sided neglect. Together, the symptoms and the MRI scan suggested bilateral occipito-parietal damage. Although she continued to paint as her disease progressed, she was nevertheless aware and insightful regarding her symptoms, as well as of the limitations the disease imposed on her art and the changes that were taking place in its expression. Most notable was the loss of the ability to depict three-dimensional space. Unlike the previous patient described above, she received art therapy instructions in her studio in order to compensate for the perceptual loss. Illustrations of her works following the onset of the disease (appearing in the publication of her case) indicate that her artistic talent, skill, and creativity were not lost or impaired, nor was her desire to continue producing art, nor her ability to invoke positive aesthetic reactions in viewers.

Alzheimer’s disease

Willem de Kooning

Willem de Kooning belonged to the Abstract Expressionism art movement and is regarded as one of the important artists of the twentieth century. He is believed to have suffered from dementia for the last 25 years or so of his life (Espinel, 1996, 2007). The issue and implications of slow changes (alterations) in the brain seen in dementia as opposed to sudden changes are discussed in Chapter 4. The dementia and concomitant brain damage could have been due to several neurological causes including Alzheimer’s disease, severe alcoholism, arteriosclerosis, hypothyroidism, poor nutrition, and effects of prescription drugs. In the mid-1970s, when the dementia was noticed, friends and associates reported that de Kooning suffered from progressively increased memory lapses, and there was a noticeable physical deterioration as well. At that time he was in his early seventies, not an unreasonable age to see onset of dementia, including Alzheimer’s. Some Alzheimer’s disease cases show asymmetrical involvement of the cerebral hemispheres. In de Kooning’s case, there is no information regarding this possibility. His productivity was beginning to drop in the mid-1970s, presumably because motor control and cognitive capacities became compromised. But, then, after reportedly receiving help from his former wife and several of his friends, productivity increased so that between 1981 and 1986 he reportedly created 254 paintings, which were abstract (in keeping with his lifelong artistic style), displayed curvy lines, and had smoother boundaries than previously. (It should be stressed, however, that there is controversy among art historians regarding the nature of the help.) Of those 254, only 40 have been exhibited and they received mostly positive reviews.

During those five productive years, when he received help with producing his art, de Kooning was presumed to already be suffering from Alzheimer’s disease (unfortunately, a brain tissue biopsy, to the best of my knowledge, was never undertaken). Any changes in artistic techniques (consisting of creating curvy, repetitious lines as opposed to straight lines and angles) observed between 1981 and 1986 in his paintings may already have begun in the early 1970s. There is ongoing debate concerning when exactly and why those curvy, sinuous, wide lines made their appearance. There was also a major change in the choice of colors in the 1980s compared to earlier years. Toward the end, fewer elements appeared and fewer colors were applied. Large areas of canvas were unpainted whereas previously his technique had been to fill every empty space. The paints were applied thinly now whereas previously they were thick. The changes in color may not be surprising given observations that several aspects of color perception, particularly in discriminating blues and greens, are affected in Alzheimer’s disease (Wijk, Berg, Sivik, & Steen, 1999a). Moreover, it should be pointed out that age alone would have affected his vision (see Chapter 3): with increased age there is reduced sensitivity to contrast (Jackson & Owsley, 2003). The curvy, widely spaced, and smoothly applied brush strokes could be seen by his aging visual system better than the tightly packed strokes of his younger and visually healthier days. Regardless, de Kooning was an established, creative, innovative, and highly regarded artist whose work from before the 1970s was widely exhibited throughout the world. In the last seven years of his life, a time when the disease was taking a very heavy toll, he did not produce very much art, whereas at the beginning of the disease he was able to produce.

How can the end-period technique changes, within his established abstract representation, be characterized in the context of his lifelong art endeavors? De Kooning was an abstract expressionist who painted discordant, disharmonious lines that together added up to a particular dynamic expressive message, one that is diametrically opposite to classic, figurative style. When his brain disease was taking its toll, de Kooning did not start producing figurative art. In fact, he continued producing abstract art. This shows that his lifelong interest in non-figurative art survived the ravages of the disease.

Portrait painter William Utermohlen

William Utermohlen, an established portrait painter born in 1933 and living in Britain, was interested in drawing from an early age. He began to experience memory problems and deterioration in writing around the age of 57. Formal neuropsychological tests at age 61 revealed global cognitive impairment (e.g., in verbal memory, arithmetical calculations, and visuospatial and visuoperceptual tasks) and an MRI showed generalized cortical atrophy, with no asymmetry (Crutch, Isaacs, & Rosso, 2001; Harrison, 2013). The pattern of impairments and damage together indicated the presence of Alzheimer’s disease. Facial memory did not appear to be compromised. As the disease progressed from age 61 on, several stylistic changes appeared. Paintings went from being realistic and balanced to being more and more abstract. Facial distortions were introduced. Perspective and depth were by and large lost while form and color were still used. However, judging from the few published examples, color was applied with broad brush strokes and different shades of color appeared unblended, giving an impression of patchiness. Whatever was produced was consistent with Utermohlen’s artistic essence. Around age 65 he resorted to drawing with pencil. Confirmation of Alzheimer’s disease diagnosis was obtained at that age when another MRI and neuropsychological evaluations were administered.

Both of these cases illustrate the fact that artistic production is possible during the early and middle stages of the disease. The fact that alterations in technique emerge is an indication of sensory, perceptual, and cognitive alteration stemming from progress of the disease, including the onset of motor impairments and visual deterioration (Rizzo, Anderson, Dawson, & Nawrot, 2000; Wijk et al., 1999a). The cognitive alterations consist of increasingly poor memory, visuospatial deficits, and verbal impairments (Koss, 1994). The visuospatial deficits are well documented (Henderson, Mack, & Williams, 1989). The end stages of the disease signal artistic decline and seem to preclude further production because, possibly, there is loss of motor control and motivation, severe cognitive decline, and, importantly, disinhibition, presumably indexing frontal lobe deterioration.

Commercial artist Carolus Horn

A third case is that of German artist Carolus Horn (Maurer & Prvulovic, 2004), who earned a living from illustrations and drawings for commercial advertising. During World War II he was imprisoned in a Russian prisoners of war camp; he drew scenes from that period and claimed that doing so helped him live through the whole experience. Around age 61 years he began to display signs of Alzheimer’s disease. The early symptoms appeared in conjunction with a heart attack and a bypass surgery, and were interpreted at that time to be associated with the heart condition. Poor memory as well as language impairments and visuospatial difficulties emerged as the disease progressed. Nevertheless, he continued to paint throughout this period although with visible technique alterations and manner of expressing his art.

The most obvious markers of the disease in his art were mild visuospatial distortions of scenic spatial layouts and distortions in facial features. As the disease progressed the colors changed, too: they became stronger and brighter, and were applied throughout the canvas. This implies alterations in the sensitivity of Horn’s retinal cones (in his eyes). In the pre-disease paintings there are few colors and they appear subdued. During the disease there seemed to have been a preference for colors in the middle and long wavelength range, yellow–red. In addition, small realistic graphic details present in the pre-disease days seemed now to be absent by and large. Instead, a painting technique, within the bounds of his figurative style, seemed to have emerged with further disease progression. The brush strokes and careful composition symmetry of his pre-disease days were retained. But strong, regular black lines now delineated contours and forms. This further suggests alterations in his visual system, in addition to the retina, in which there was further reduction in contrast sensitivity. The strong black lines helped him see what he was doing. On the whole, the new compositions depicted stylized human figures and objects; faces lacked individuality even as they were highly colorful. Ornaments were now added, left–right mirror symmetry emerged, and paintings became less and less realistic, although they did not become abstract. As with de Kooning, Horn did not go on to develop a diametrically opposite manner of artistic genre style. And his works went on to be just as aesthetically pleasing as those produced during his healthy period.

Maurer and Prvulovic (2004) summarize the end stages in Horn thus:

A second important change in CH’s artwork within the severe stage of his disease could be attributed to a disturbed visual contrast sensitivity. This is the minimum amount of visual contrast a person needs to resolve light-dark boundaries in a stimulus. It is known that AD-patients [Alzheimer’s disease] are more impaired in the lower than the higher spatial frequency range (Cronin-Golomb et al., 2000; Cronin-Golomb, Rizzo, Corkin, & Growdon, 1991). Since low frequency information is more important for face discrimination this may explain CH’s impairment in object and face recognition, which led to the inability to visually recognize his wife for instance and as such had serious interpersonal consequences for himself, his wife and the caregivers. The implications of this inability can be seen in his painting. It is very likely, that CH downsized objects and persons in his later drawings in order to compensate increasing deficits of low-frequency contrast sensitivity.

(Maurer & Prvulovic, 2004, pp. 243–244)

Near the end of his life, there was a further change in his technique but at this point his ability to paint saw a sharp turn for the worse; he drew only individual objects (as opposed to whole scenes), simple lines, geometrical forms, and a few scribbles. However, even those creations retained an “artistic flair.”

Danae Chambers

This professional artist developed dementia symptoms when she was about 49 years old, and was diagnosed with Alzheimer’s disease (Fornazzari, 2005). In brain imaging, the left hemisphere showed greater atrophy than the right, particularly in posterior regions of the temporal and parietal lobes. She continued painting and producing art for at least 10 years after diagnosis, despite steady progression in symptoms in daily life, and all the while she did not lose artistic expressions of creativity or talent. Remarkably, in those 10 years use of colors was not impaired, nor were pattern organization or general visual organizational dimensions. Eventually, however, in the last year of her life visible alterations were noted for spatial relationships, colors (they became darker), and proportions. Similarly, her artistic skills suffered due to general motoric control deficits. Published illustrations of her works do not display positive artistic creativity. The late works do not inspire strong aesthetic reactions.

Musician with Alzheimer’s disease

Preservation of skills despite extensive brain damage due to Alzheimer’s disease was also reported for a musician with 12 years of formal training and 40 years as a music editor (Crystal, Grober, & Masur, 1989). He was a pianist who practiced playing the piano on a daily basis and regularly involved his family in listening to various compositions. After the disease set in, he was no longer able to recall composers’ names or titles of their compositions, something that he had been very skilled in doing in the pre-morbid stage; he was nevertheless able to play the same composers’ compositions on the piano. This case illustrates the dissolution of specialized, highly localized functions such as language (naming, in this case) and diffuse representation of certain non-verbal skills.

Progressive primary aphasia in FTD

Art teacher

The effects of dementia on art production by an established local artist and high school art teacher have been investigated by Mell, Howard, and Miller (2003). At age 57 she was diagnosed with progressive aphasia syndrome, a type of language-related dementia. The authors refer to the artist’s condition as FTD. The aphasic symptoms evolved for 10 years before she decided to retire from teaching. She also exhibited social disinhibition, consistent with frontal lobe atrophy. Her speech was non-fluent and effortful. Language comprehension was normal only for simple commands. She had no problems in copying figures. She failed on tasks that measured frontal lobe functions. An MRI revealed moderate atrophy in the frontal lobes bilaterally, with more pronounced atrophy in the left frontal lobe. There was also a mild atrophy in the left temporal lobe. Artistically, she was exceptionally prolific even though the disease was several years in the making. Along with the decline in language and social disinhibition symptoms, there were changes in her artistic expression. As her condition worsened, colors were applied to the canvas in large, bright patches; drawings became less realistic and more sketchy (but not abstract); and, judging from the published examples, faces and objects blended into each other in an incoherent manner. However, we do not see compositions made of blocks of colors, but rather we see a desire to depict figurative representations. Dark contour lines framing forms were now introduced, and this suggests alterations in her vision, whereby sharp contrast was needed for seeing properly (see discussion of previous case, Carolus Horn, regarding contrast sensitivity). If we consider art to be a form of expression, then as her language expression worsened, so did her artistic expression. Her art expression became vague but did not become abstract. The important observation, however, is that the art continued to be produced even as other aspects of her mind were obviously deteriorating.

Not all aphasic conditions lead to the same artistic results. Other cortical conditions need to be taken into account. The Alajouanine case described above continued painting reportedly with no changes in technique. The art of this FTD patient did reflect extensive technique alterations because the brain deterioration was extensive and included sensory impairments in vision (Rankin et al., 2007).

Anne Adams

A scientist by formal education and occupation (chemistry professor) and at the same time a professional artist, who started to practice her art around age 46, was diagnosed with fronto-insular variant FTD at age 60 years (Gretton & ffytche, 2014; Seeley et al., 2008). At that time, her speech and syntactical difficulties emerged, and a serious worsening of her symptoms finally at age 64 resulted in her becoming mute. However, she continued to express her art despite all of this. She painted until her death at age 67. Published examples of her works reveal some change in technique with the progression of her disease: she painted delineated, detailed, realistic objects and geometrical figures both before and after the disease progressed. The published samples indicate that her pre-disease personal genre remained unaltered throughout, and, importantly, aspects of her artistic skills and talent appear unimpaired; at the same time there does not seem to be enhancement of their expression. On the whole, positive aesthetic quality is not apparent in these published samples.

Florida artist LH

This FTD patient was diagnosed with the disease at age 73, although her language communication problems emerged around age 67 (Finney & Heilman, 2007). An MRI scan revealed a brain with generalized atrophy but with greater atrophy in the left anterior temporal lobe and insula. Another diagnostic label for her type of FTD is frontotemporal lobar degeneration (FTLD). “Her major hobby for many years was painting, especially still lifes. This activity remained unchanged in quality during her disease, but she recently stopped because she felt her painting had changed” (Finney & Heilman, 2007, p. 7). Published examples of her paintings show adherence to the same personal genre, namely still lifes. As the disease progressed, her talent and artistic skills did not deteriorate, although, as with other patients with FTD, no evidence for increased creativity was noted. The authors conclude, “Observations of this patient suggest that FTLD may not lead to improved artistic skills in those already possessing them, and does not enhance innovation, a critical component of creativity” (Finney & Heilman, 2007, p. 9). Indeed, her art from the period with advanced stages of the disease does not invoke positive aesthetic reactions.

Dementia with Lewy bodies

Mervyn Peake

The British artist Mervyn Peake is well known for his poetry, illustrations, novels, and plays (Sahlas, 2003; Winnington, 2008). He was highly prolific and extremely well regarded. He studied in art school and had his first exhibition in 1931. He is famous for his illustrations of survivors of the Belsen-Bergen concentration camp, an infamous German killing camp where hundreds of thousands of innocent people were murdered during World War II. He is also very well known for his Gormenghast novels, which he began to write in the early 1940s. In the mid-1950s, around 1956, he began to display symptoms of Parkinsonism and progressive cognitive deficits. When he was about 45 years old, tremor was detected in both hands and then spread to his legs. He developed a stooped posture and facial expression characteristic of Parkinson’s patients. Around the time when the Parkinsonism symptoms developed, he began to experience visual hallucinations. Yet, he was able to concentrate on drawing many illustrations in the course of just one hour, only to stop abruptly and return to sitting silently. He displayed difficulties in writing, attention, and cognition. Memory deficits were not apparent among those initial symptoms. Rather, fluctuations in cognitive and attentional activities and visuo-constructive problems were more salient. Such a constellation of symptoms, although representing a dementing process, is not seen in patients with Alzheimer’s disease. The nature of his neurodegenerative disease was a matter of much debate at the time, debate that persisted until an insightful publication by Sahlas (2003). Sahlas proposes that the symptoms that afflicted Peake add up to a diagnosis of dementia with Lewy bodies, a neurodegenerative disorder now considered a variant of Alzheimer’s disease. The symptoms include Parkinsonism, visual hallucinations, and visuo-perceptive impairments (perceptual, spatial, and constructional). Several brain sites are atrophied, including cortical and subcortical regions. The hallmark of the neuropathology is the presence inside some brain neurons of Lewy bodies, intracytoplasmic inclusions that mark the disease process, although how they originate is not known.

Peake’s illustrations and poems reflected his distillation of experiences during the hallucinations and psychotic states, a time when he also had paranoid delusions. However, on the whole, his writing style began to disintegrate as the dementia progressed. He ended up being treated with neuroleptics, to which he did not respond well at all, and anticonvulsant shock therapy, which was also not helpful. There was no doubt that there was deterioration in all of his art forms (although publications showing his art from that period are not available for direct comparison with the pre-illness days). He died at the age of 57.

Visual artist

This case of a professional artist who developed dementia with Lewy bodies was a 78-year-old man (Drago et al., 2006). He exhibited progressive dementia with agitation, depression, hallucinations, and diminished verbal conversations, and was dependent on others for all daily activities. His pre-morbid art works were compared to those produced during the disease; the comparison indicated no enhancement, nor loss of talent or major alteration in genre, but no increase in creativity. If anything there was deterioration in his art: “representational-visuospatial skills diminished as the result of his disease. We also found that other qualities of his painting diminished including aesthetic value, closure, and evocative impact” (Drago et al., 2006, p. 3014).

Neurofilament intermediate inclusions disease (NIFID)

VV

This dementia case was a professional artist who developed a variant of FTD with an early onset and rapid course of deterioration leading to death (Budrys, Skullerud, Petroska, Lengveniene, & Kaubrys, 2007). She was 40 years old when diagnosed and 44 when she died. VV was a professional painter, engraver, poet, and theater performer. She was the creator and director of a modern Lithuanian puppet theater. Her education included graduation from the Lithuanian Art Academy, and it is perhaps worth noting that her family background included other artists as well. MRI and CT scans revealed rapidly progressive bilateral atrophy of the temporal and frontal lobes, with greater atrophy in the left hemisphere. Post-mortem examination of her brain confirmed the bilateral atrophy in the frontal and temporal lobes, and in addition showed atrophy in the corpus callosum. Microscopic intermediate neuronal inclusions (cytoskeletal proteins) were found in several brain regions together with spongiform changes. The occipital and parietal lobes appeared unchanged. Her neuropsychological profile consisted of aphasia, echolalia, retrograde amnesia, difficulties with abstract cognition, disorientation with respect to place and time, and personality changes (including several forms of disinhibition). Her disease course was rapid and her multiple artistic expressions declined rapidly. Poetry showed the most pronounced decline right at the start of the disease, not unexpectedly given the more pronounced atrophy in the left hemisphere. VV’s visual art deteriorated least with the disease progression although the artistic quality was much reduced compared to prior to the disease.

The authors summarize her visual art thus:

A few characteristic changes of V. V.’s art probably related to NIFID could be noticed in her paintings and drawings created during the course of the disease: turn from abstract to symbolic concreteness and “return” to the child’s “realistic” primitivism at the advanced stage of the disease …; shift of color spectrum to predominantly “primary” colors…; appearance of aggressiveness and disquietude; drawing perseveration…; visual expression of inner fear and silent cry for help.

(Budrys et al., 2007, p. 143)

Only a few samples of her paintings are illustrated in the published article. They appear bizarre and not especially aesthetically pleasing.

Pick’s disease with semantic dementia

This neurodegenerative disease is another variant of FTLD dementia. It is characterized by profound loss of memory for the meaning of spoken or read words (semantic dementia) and in naming or word-finding difficulties. Grammar and phonology appear unimpaired. In addition, certain aspects of episodic memory remain unimpaired, typically visual recognition memory and recent autobiographical details. KT, a 58-year-old man living in Japan, developed the disease about eight years prior to his case being reported. MRI scans showed pronounced atrophy in the left anterior temporal lobe as well as some atrophy in the right anterior temporal lobe (Tanabe et al., 1996). The atrophied medial areas included the hippocampus and parahippocampal gyrus. Posterior regions of the brain were spared. Neuropsychological assessment indicated episodic memory for daily events was relatively unaffected. KT’s principal impairment was in semantic memory, specifically in word-finding and in understanding the meaning of words. His money-earning profession was that of a high school teacher but his lifelong occupation (hobby) was art, specifically painting. He had several exhibitions of his works prior to disease onset. A limited number of works (two pre-morbid and two post-morbid) were illustrated in the publication of this case; what they show are fuzzy, Impressionist-style paintings of realistic scenery (not abstract) prior to the disease and loss of the fuzzy touches of similar scenery after the disease process set in. The latter paintings have strong colors and display convergent perspective, good spatial layout, and highly pleasing aesthetics.

Rankin and associates (2007) showed that the effects of dementia on drawings and paintings in non-artists are not uniform across most of the forms of the disease covered above. Importantly, none of the forms obliterated the ability to create pictorial representations. This reinforces the notion that pictorial art represents a communicative system without a single circumscribed specialized region in the brain. While the language and social communicative systems deteriorate substantially with neurodegenerative dementia, pictorial representation is still possible.

Other writers and visual artists

Additional established literary artists produced their literary craft following brain damage, without noticeable alteration in oeuvre, notably novelist Charles-Ferdinand Ramuz, who suffered left hemisphere stroke (Bogousslavsky, 2009), and poet and writer Guillaume Apollinaire, who suffered a right temporal lobe gunshot wound in World War I (Bogousslavsky, 2003). The famous Russian writer Fyodor Dostoyevsky suffered from temporal lobe epilepsy with preceding aura (laterality focus is not known) for most of his life and in spite of that continued to produce enormously influential novels and stories (Alajouanine, 1963; Iniesta, 2014).

Artists adjust to brain damage in their own unique ways (see the discussion of functional reorganization in Chapter 4). Importantly, certain regular post-damage artistic patterns emerge and they consist of preservation of skills, creativity, talent, aesthetic appeal, and motivation to produce art (see also Chapters 3, 4, 5, 6, 11, and 12). Further, it would seem that damage to either the right or the left hemispheres does not lead to cessation of art production. Bäzner and Hennerici (2007) described 13 artists with right hemisphere damage and noted that all continued to produce art post-damage. As would be expected, some displayed their hemi-neglect symptoms and visuospatial distortions for a short time after the damage occurred, but with time these symptoms diminished. The content of the art works and the artistic capability, knowledge, and talent remained intact.

Dance choreography and the brain

Agnes de Mille

Of interest in this book is the creation of art, which includes the choreography of a staged dance. The well-known American choreographer (and dancer) Agnes de Mille suffered a left hemisphere stroke (hemorrhage) in 1975 in Hunter College auditorium, New York City, just as her dance company was about to go on stage (de Mille, 1981). She lost motor control and sensory perception in the right side of the body. Her speech was affected only briefly (slurred, hoarse). The site of the hemorrhage was the thalamus, which might explain in part why her language abilities were largely spared. Most language abilities recovered within a month, but there was some anomia (word-finding difficulties), some acalculia (inability to do arithmetic), and some immediate memory impairments. All of these symptoms improved with time. Because her right hand was paralyzed she learned to write with her left hand. She wrote longhand and through dictation. Despite the damage caused by the stroke she was able to write and publish several books. In terms of her choreography, within less than two years post-stroke and together with Robert Joffrey of the Joffrey Ballet, she continued to work on the ballet she had begun to compose before the stroke, Conversations About the Dance. Although in its post-stroke structure it was not composed from scratch, it nevertheless required her artistic choreography skills to see it through successfully. She was limited by her right-sided paralysis; choreographers need to physically demonstrate dance moves to their dancers and she could not. She had to resort to verbal instructions and assistance from others. Thus, although her artistic talent, skills, and creativity were expressed after the stroke, there were limitations dictated by the very nature of her art.

Summary

The established professional artists described here continued to be artistically expressive despite the presence of various severe neurological conditions. The etiologies of these artists, including both visual artists (painters, sculptors, film directors) and literary artists (poets, novelists), differed and ranged from left hemisphere stroke to right hemisphere stroke, several types of dementia (Alzheimer’s disease, Pick’s disease, and more), and Parkinson’s disease. Importantly, hemispheric laterality of damage did not seem to interfere with either creativity or productivity post-damage. Moreover, individual artistic style (defined in the introduction to this chapter), worked out and perfected by these artists prior to the acquired brain damage, by and large survived the damage. Artists who specialized in figurative and representational art did not suddenly start producing abstract art in their post-damage years. Literary artists retained their oeuvre. Preservation of skill and talent probably reflects the effects of damaged tissue in combination with healthy tissue. Both mechanisms interact with each other in the production of art. The presence of alterations in artistic techniques can be explained in terms of basic sensory, perceptual, or motoric impairments, the kind seen in non-artists suffering from similar brain damage. Furthermore, these artists appear to have retained their motivation and expressive capabilities independently of language impairments, hemispheric laterality of damage, disease etiology, or artistic format.