HONOLULU— Cognitive psychologists have long recognized the importance of the right parietal lobe in shaping our internal representation of the world at large. When this region of the brain is harmed, whether due to injury from a stroke or by degenerative decay, individuals can lose the ability to perform such simple cognitive functions as drawing and copying.

Now a more recently observed phenomenon has behavioral and cognitive neurologists marveling at the visual creativity of patients whose progressive cognitive decline should, based on these earlier findings, render them artistically impotent.

Call it the “parietal paradox”: Patients with a variant of frontotemporal dementia—in which selective involvement of the left anterior temporal lobe has been detected—suddenly exhibit an ability to create startling works of art when no previous talent or even interest had been documented. In other cases, experienced artists go on to produce paintings that are as striking as anything found in their entire body of work. Often, patients with the temporal lobe variant do their creating while in the grip of another subtype of frontotemporal dementia—semantic dementia—where individuals lose the ability to use words and symbols and the concepts they represent.

What is the explanation for this paradox? Is the answer merely a matter of arriving at a better understanding of brain anatomy, including the left brain/right brain dichotomy that has been used to differentiate the source of creativity from that of more strictly “rational” abilities? Or is the answer something deeper—something found in the missing evolutionary link between nonhuman primates, who were apparently devoid of artistic impulses, and the first outpourings of visual representation by humans as evidenced by extant cave paintings?

Bruce L. Miller, MD, admits to leaning toward the “Romantic view.” During his fellowship training in behavioral neurology with D. Frank Benson, MD, and Jeffrey Cummings, MD, at the University of California, Los Angeles, Dr. Miller developed a special interest in frontotemporal dementia that has carried through to his clinical work at the bedside with a series of patients who have displayed this remarkable artistic temperament.

“Even in the setting of autism and degenerative dementia, visual creativity is possible—and sometimes it looks almost mandatory,” said Dr. Miller, who is now A.W. and Mary Margaret Clausen Distinguished Professor of Neurology at the University of California, San Francisco. “What these patients, in a general way, have taught me is that we need to focus on both the strengths and weaknesses of our patients.”

In a wide-ranging lecture delivered at the 55th Annual Meeting of the American Academy of Neurology (AAN), Dr. Miller speculated on the relationship between art and brain evolution and surveyed the research that has been done on regions of the brain, dementia, and linguistic and artistic functions. At the core of his presentation were several case studies culled from his clinical work—a singular approach based on the view, fomented by one of his mentors, Dr. Benson, that what occurs at the bedside between a patient and a physician is a valuable component of research.

A NEWFOUND TALENT, A LIBERATED IMAGINATION

Dr. Miller described the discovery of his frontotemporal dementia patients’ hidden talents as a “serendipitous finding.” It started with a patient named Jack who—according to the man’s son—painted. Naturally, Dr. Miller presumed Jack’s paintings got worse as his disease progressed. “Up to that point, I approached patients thinking about their weaknesses rather than their strengths,” he recalled. “And the son said, ‘Oh, no, he got much better as the disease progressed.’”

Doubting this, Dr. Miller asked Jack’s son to send him 10 paintings completed during the course of 10 years. Sure enough, the son’s report was true. As Jack’s dementia progressed and his language skills deteriorated, his visual creativity blossomed. “He started off with no talent and developed the idea that he could feel and see colors better than he had before,” Dr. Miller reported. “He became very eccentric: wore a purple shirt and yellow pants every time I saw him. You see purple and yellow in all of his paintings.”

Jack’s urge to paint took on an obsessive-compulsive quality. He did paintings over and over again. Dr. Miller recounted visiting Jack’s home where, for each of the paintings he showed the AAN audience, the doctor encountered 20 or 30 others that were almost identical. Fairly late in the disease, Jack went through an especially notable phase in his art—an intensification of his “purple and yellow period.” Almost completely aphasic, unable to name something so basic as a bird, Jack could still draw a bird from his imagination with indescribable beauty. Eventually, the ravages of frontotemporal dementia led to the deterioration of his visual creativity as well, and Jack lost the ability to draw altogether. He is still alive, Dr. Miller reported. “But this artistic phase, which in retrospect heralded the onset of his dementia, is over,” he said.

A second patient Dr. Miller described is the first patient with frontotemporal dementia he worked with who was a working artist before the illness began. A native of China who came to the United States as a teenager, this painter sought to combine a more traditional Asian sensibility with Western abstract-expressionism in the Jackson Pollock mode. As her progressive aphasia became more evident, the woman’s visual output changed. Among 12 pictures painted during the course of a year from the Chinese calendar, Dr. Miller showed her dragon. “Wilder, freer, more beautiful, I think, than anything she had done before,” he said.

In her last year of working, this artist painted a series of nudes that were all conjured up from her imagination. Her last few paintings, created when she had almost no language at all, betray some distortion of faces, of emotion. Like Jack, her painting has stopped. Yet, Dr. Miller observed, “she had this extraordinary five years of wonderful visual creativity in the setting of progressive aphasia.”

WHEN THE DOMINANT BRAIN IS DOMINATED BY DISEASE

Why does true art rise out of semantic dementia? It remains an open question, according to Dr. Miller. There appears to be a disinhibition effect that allows people to do things they have never done before. Such art may be due to the negation of linguistic concepts that normally block visual creativity in some individuals. Evidence also exists that a slow “rewiring” of the cortex takes place during the course of this illness. Finally, there is one theorist’s concept of paradoxical functional facilitation. “Injure one part of the brain, release another part of the brain, and see increased function in that area,” Dr. Miller explained.

Much of what the field has learned about art and the brain has come from lesion studies. Although it is thought that our greatest artists used multiple brain regions, the principal region of the brain for visual artistry appears to be the nondominant, or right, hemisphere. “We have an internal representation of the world that we carry, and when we produce a great piece of work we’re able to put that [view] onto a canvas,” Dr. Miller observed.

This internal representation appears to be regulated by the right hemisphere, he suggested; yet, the left or dominant hemisphere, where language originates, also contributes to artistic ability, particularly the linguistic-symbolic components of art. That’s why patients with certain types of degenerative brain disorders can lose the ability to make a simple copy. Some patients with Alzheimer’s disease have symmetric involvement of the parietal lobes, where both visuospatial and linguistic ability are affected.

Dr. Miller showed some works by a woman who produced beautiful landscapes before suffering a stroke, and soon after her recovery attempted to paint. “Rather than being able to draw these beautiful complex scenes, with lots of detail, she was left with these very restricted images of just tiny pieces of her world,” he said.

Such individuals are in marked contrast to Dr. Miller’s patients with the temporal lobe variant of frontotemporal dementia. As their disease progresses, many of these patients lose the semantic/ symbolic concepts of items in their world, he emphasized. They cannot name a dog or a bird yet can draw in detail “a prototypic animal that looks like it came out of evolution.”

Dr. Miller cited one other characteristic that many of these patients have in common—the compulsion to draw.

THAT WHICH MAKES US HUMAN

Why are they compelled to draw? The anatomical explanation is that these individuals tend to have bilateral temporal involvement, where the left hemisphere is worse than the right. The frontal lobes are relatively spared, which helps to explain why these artists can plan and organize such beautiful pieces.

The other explanation is evolutionary. One of the reasons art is so interesting to Dr. Miller is that it appeared shortly before the rapid evolution of our civilization, before the appearance of music and written language. The ability to imagine something and then put it on a canvas—or a cave wall—appears to be part of our genetic makeup, the essence of what makes us human.

At the close of his lecture, drawing a parallel between frontotemporal dementia and the savant syndrome, Dr. Miller cited the case of a boy who, at age 18 months, began to withdraw linguistically and socially but became compelled to draw. Dane had an extraordinary talent for internal representation and for a time was obsessed with drawing horses. It was one of Dane’s horses, done at age 2, that led Dr. Miller to his “wild” Romantic speculation.

“Who were the people who made these wonderful cave paintings at the beginnings of human evolution?” he asked. “Perhaps it was a child like Dane who had linguistic problems but an intense visual preoccupation and an intense need to draw.

“We’ll never know, but I think the first human artists were undoubtedly asymmetric—they were different, there was something about their brain organization that allowed this extraordinary visual creativity.”

—Fred Balzac

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