Some people with dementia such as this patient develop or experience increased visual creativity even as their brains degenerate. The underlying mechanism, though, was unknown until a recent study led by Friedberg and others, which uncovered the potential brain structures involved and the connections between them.

Sudden development of new strengths — such as artistic creativity — and not just deficits, could be an important signal of neurodegeneration, allowing for earlier monitoring or even treatment, said neurologist Bruce Miller, the director of the UCSF Memory and Aging Center, and co-author of the study, which was published in JAMA Neurology.

The work also helps us understand different forms of creativity, Friedberg said, because it’s unclear “whether overlapping brain mechanisms are responsible for generating an inspiring art piece or inventing a transformative technology.”

Other instances of artistic development

The couple’s visit in 2018 intrigued Friedberg who was completing her residency at Tel Aviv Sourasky Medical Center. She began digging into the scientific literature, looking for evidence of links between neurodegeneration and artistic creativity.

She learned about Anne Adams, the focus of a 2008 study by neurologists Bill Seeley, Miller and their colleagues at the University of California at San Francisco.

Adams was a scientist who, in her 40s, left academia to care for her son who had been in a serious car accident. She began painting and, even after her son recovered, never returned to the laboratory. Adams fully immersed herself in her art, becoming more obsessive as signs of FTD — specifically primary progressive aphasia — emerged.

FTD is a group of neurodegenerative disorders caused by the death of neurons in the frontal and temporal lobes of the brain, regions that control social behavior and language, respectively.

Reading about this stunning surge of visual creativity in the face of neurological deterioration, Friedberg was struck by the “hidden potential that can be evoked in the setting of disease,” she said.

Friedberg, a research fellow at the UCSF Memory and Aging Center, who led the recent study with Miller, Seeley and their colleagues, now knows why it might happen.

Burst of creativity amid neurological decline

An increase in visual artistic creativity is relatively unique in neurodegenerative diseases.

“Often, it’s the opposite,” said Raquel Gutiérrez Zúñiga, a neurologist at Hospital Universitario Sanitas La Moraleja in Madrid, who was not involved in the study. Even artists, when they develop a neurodegenerative disease such as Alzheimer’s, “their styles become more simplistic,” she said.

Miller published the first case report of visual artistic creativity in a person with FTD in 1996. The patient, a man in Santa Barbara, had never been an artist, but suddenly “became obsessed with painting,” Miller said.

Miller became fascinated by the idea that something as terrible as neurodegeneration could yield something positive.

“In neurology, we’re so good at describing deficits,” he said. “For me, and I think for most people, it was a paradox. It was not something we were trained to think about.”

As his curiosity grew, Miller encountered more FTD patients with visual artistic creativity. “I started to see people coming into my office who had carved ducks out of wood or who had welded beautiful insectlike creatures or who had started painting,” he said.

For decades, case studies rolled in, as did hypotheses for how enhanced creativity could arise in patients whose brains were deteriorating. The leading theory, Miller said, was that as regions at the front of the brain break down, regions farther back in the brain, including those involved in vision, increase their activity to compensate.

With little data — partly because only a small percentage of FTD patients experience visual artistic creativity (Friedberg and Miller found 2.5 percent in their study) — teasing apart a mechanism wasn’t possible. “A group study was needed,” Friedberg said, because it would help identify patterns between and unique to those patients.

Why do only some patients with FTD show artistic creativity?

For the first group study of FTD patients with visual artistic creativity, Friedberg began by evaluating hundreds of patient records collected between 2002 and 2019. She was able to identify 17 FTD patients with visual artistic creativity and match them to both healthy control subjects and FTD patients who did not show the creativity. This allowed the research team to investigate which brain changes were related to FTD and which were unique to patients with FTD and visual artistic creativity.

The researchers used patient structural magnetic resonance imaging (MRI) data showing brain tissue structure and size to perform atrophy network mapping. It is a technique that compares a patient’s brain to a non-diseased human brain to determine what the patient’s damaged region is connected to and how those connected regions could, as a result, increase or decrease their activity.

“A simple way to think of it is, ‘damage to this location is going to do what to this other location because of connectivity?’ ” said Michael D. Fox, the director of the Center for Brain Circuit Therapeutics at Harvard University.

The other (non-degrading) brain regions that are affected might not behave so differently than normal, but their activity might be more obvious (increasing or decreasing) because they’re no longer receiving the same feedback from the region of the brain that’s deteriorating.

Atrophy network mapping revealed a connection between the frontotemporal brain region and the dorsomedial occipital region at the back of the brain that’s essential to visual processing. The researchers’ findings suggested that, for FTD patients with visual artistic creativity, frontotemporal atrophy could lead to increased activity in the visual region.

Nearly 90 percent of the FTD patients without visual artistic creativity, however, also showed the same thing, so an increase in visual processing alone could not explain a surge in visual creativity in those 17 patients.

A visual-motor connection could explain the difference

To tease out other possible reasons for visual artistic creativity in only some FTD patients, Friedberg decided to look at changes in brain tissue.

She found that the brain’s left hemisphere primary motor cortex — a region that controls right-hand movement — increases in volume in visual artistic creativity patients, in connection with an increase in volume in the dorsomedial occipital region. Even as the tissue around it is dying, Miller said, “the one area in the left hemisphere that isn’t down in volume is the part of the motor strip involved with painting itself.”

The link between the visual region and the right hand could be interpreted in a few ways. It could be innate for some people and only come to light in the face of FTD or it could be a connection that is strengthened as a consequence of spending hours every day creating art as FTD symptoms emerge.

Friedberg found the findings exciting, yet not surprising. “Art is a motor action,” she said. “To manifest this change in perceptual regions, there must be a visual-motor connection.”

The linking of right-hand movement and the brain’s visual region would have been more striking had that connection also been shown through atrophy network mapping, Fox said. But “their genius was in taking a new technique and applying it to a very interesting problem, which is emerging creativity in the setting of brain disease,” he said.

Could this shift how we diagnose neurodegeneration?

This was the largest study of FTD patients with visual artistic creativity, but it was still small. The researchers hope a larger group in a future study could reveal the importance of additional brain regions and possibly explain why more patients with FTD don’t become visual artists — something Miller is still curious about. “There are probably a lot of factors, including the way we’re wired to begin with,” he said.

The environment also could play an important role. “Some people get introduced to art in a serendipitous way,” Miller said. Other patients may not have been introduced to art, he said, or were but do not have the materials or tools available to express that creativity.

“I would love to see if these results can be replicated in another cohort, in other countries, other cultures,” Gutiérrez Zúñiga said. “And see if this is something that can be a cross-cultural phenomena.”

This work also showed that in the face of neurons dying in some regions of the brain, other regions can increase in activity and change — a process called plasticity.

Plasticity is intriguing, Friedberg said, because learning more about brain regions that thrive in the face of disease could open up the possibility for new therapeutic treatment options.