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Neurodegenerative diseases, art and creativity: therapeutic implications

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Art making is a promising prism through which to appreciate the nuanced relationship between cognition, goal-directed behavior and the changing brain in the context of neurodegenerative diseases. As an area for future exploration, the value of art therapy as a potent behavioral and ultimately neurochemical, intervention has exciting potential.
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Neurodegenerative diseases, art and
creativity: therapeutic implications
Julio Alberto Perez Matos1, Alby Richard*,1, Blanca TM Spee2,3 & Matthew Pelowski2,3
1Department of Neurosciences, University of Montreal, Montreal, QC, H2X 0C1, Canada
2Department of Cognition, Faculty of Psychology, Emotion & Methods in Psychology, University of Vienna, Vienna, Austria
3Vienna Cognitive Science Hub (CogSciHub), University of Vienna, Vienna, Austria
*Author for correspondence: alby.richard.med@ssss.gouv.qc.ca
Art making is a promising prism through which to appreciate the nuanced relationship between
cognition, goal-directed behavior and the changing brain in the context of neurodegenerative
diseases. As an area for future exploration, the value of art therapy as a potent behavioral and
ultimately neurochemical, intervention has exciting potential.
First draft submitted: 19 March 2021; Accepted for publication: 18 May 2021; Published online:
3 June 2021
The recognition, characterization and development of treatment options for neurodegenerative diseases is an
important challenge. Ranging from frontotemporal degeneration, to Alzheimer’s disease (AD) and Parkinsons
disease (PD) and many more, neurodegenerative processes can manifest and progress in a panoply of different ways.
As pathophysiological entities, these processes are distinguished by specific patterns of progressive neuronal damage
and/or loss, leading to neurotransmitter disbalance and impaired cell-to-cell communication and, eventually,
disturbances in larger-scale network functioning [1]. Diseases resulting from these changes can involve a large
number of issues, including cognitive changes (e.g., impairment of episodic and semantic memory, learning and
attention [2]), motor deficiencies (e.g., slowness, rigidity or uncontrolled movements [3]) and alterations in personality
and behavior (e.g., depression, anxiety, loss of empathy and emotional regulation). These symptoms can manifest
several years or even decades before diagnosis [1]. Therapeutic and symptomatic interventions are central to elevating
the quality of life in neurodegenerative conditions, yet this element of care can be complex because many of these
diseases are diagnosed at a relatively late stage of disease progression. Besides early detection, significant effort has
gone into slowing down or perhaps even ceasing disease progression, which is especially germane in the context of
the aging global population [4,5].
One potentially fruitful area of study relating to both diagnosis and to therapeutic innovation in brain disorders is
the utility of visual creativity and artistic productivity [5]. In the past few decades, studies in the field of neuroaesthetics
have identified key regions instrumental for cognitive processing, aesthetic emotional responses, aspects of aesthetic
creativity and behavioral responses, such as a personal evaluation [6]. Interestingly, the implied regions and functional
interplay of activity patterns (and thus, differences in neurotransmitter dynamics) are also routinely impacted by
neurodegenerative diseases [7]. By stimulating and modulating neural activity in the aforementioned regions and
circuits, art making and creative endeavors may thus provide a conduit for improving cognitive and/or motor
function and general wellbeing. Similarly, the artistic output by both healthy and neurodegenerative disease-
afflicted artists, as well as salient changes, emerging now in a number of case studies and which may similarly be
matched to underlying brain regions or comorbidities, provide a fascinating possibility that similar methodologies
may serve as tools for rehabilitation and diagnosis.
Such applications for art and creative acts may be particularly relevant in PD. PD patients suffer from a loss
of dopaminergic (DA) neurons in specific regions of the brain, leading to motor dysfunction (e.g., bradykinesia,
tremor, rigidity) and psychiatric symptoms (e.g., such as apathy, depression and anxiety). In addition, as case
evidence from the last 20 years has shown, patients with PD also display changes in how they interact and
engage in creative and artistic activities at different stages of their disease and in response to different treatments,
such as dopaminergic agonists (DAA)/replacement therapy [8]. As a result, patient’s lives, personalities, disease
progression and even occupation may be impacted by art and creative acts [9]. It is thus worth considering how
Neurodegener. Dis. Manag. (Epub ahead of print) ISSN 1758-202410.2217/nmt-2021-0012 C
2021 Future Medicine Ltd
Commentary P´
erez-Matos, Richard, Spee & Pelowski
Box 1. A clinical vignette.
Consider a case of an amateur painter who underwent several changes in his art practice soon after being
diagnosed with PD [13]. The painter experienced a loss of interest in painting, along with many other activities that
previously elicited pleasure. Although his motor symptoms beneted from the initiation of levodopa therapy, his
apathy and anhedonia did not. Interestingly, after addition of a DAA (carbegoline) , the patient showed an
increased interest in painting and a notable change in both style and attitude toward his art, despite still having
generalized apathy. Over time, painting became his sole interest and started to interfere with his social life and
overall functioning to the extent that it prompted a reduction in the dose of his DAA. With every subsequent
attempt to further lower the dose; however, the patient experienced a notable decrease in his artistic output, which
rapidly increased again when the DAA was re-augmented.
DAA: Dopaminergic agonist.
PD may provide insight into the neurological substrates of creative processes, which can be conditioned by such
medications or by the disease itself. Alternatively, a creative environment that promotes implication in artistic
activities could influence a patient’s perception of the disease, remove unwanted side effects – such as impulse
control disorders ([ICDs], a major issue associated with DAA) or have applications in neurorehabilitation [10] and
disease prevention. The neurochemical basis for many such speculations in PD, as suggested by the past evidence
linking PD-related modulations in creativity or arts interest to medication, is centered on the DA system [11].As
this system is implicated in reward-based behavior, motivation, emotion and may even be substantial for feeling of
being creative or the creative process itself, functional alterations due to disease can modify the way these patients
perceive and interact with art. Art and creativity are therefore of interest in PD from multiple perspectives, including
diagnosis, disease progression, management of unwanted symptoms of treatment and therapy.
Artistic changes in PD
Given that PD is the world’s fastest growing neurodegenerative disease [10], considerable work has been done
to explore the observed increased drive to engage in creative activities and art making at various stages of the
disease [8,10–12]. However, increased artistic drive is only one of the aspects that these patients can manifest. It is
also suggested that certain patients exhibit changes in the quantity, quality and style of the produced art, along
with differences in level of motivation for creative undertakings, as reflected in the cases above [8]. Interestingly,
this is not only limited to previously known artists or patients that had previous artistic hobbies, as de novo artistic
drive has also been reported in PD patients that had not ever shown any interest in art making whatsoever [8]
(see Box 1). Since DA plays the central role in PD progression and symptomatology, DA signaling – or rather its
dysbalanced transmission in different areas of the brain – is thought to be the key in the neurobiology of these
observations.
DA-mediated signaling is thought to produce different responses in key brain areas of PD patients from what
would be expected in an otherwise healthy individual [8,11]. An intriguing (and open) question relating to the nature
of the PD afflicted versus artistic brain is whether these differences are indeed deviations from regular activity or,
rather, exacerbations of normal responses. One approach toward an answer involves a closer examination of how
DA signaling is organized in the brain. Functionally, the DA system is involved in reward contingencies at the
neuronal level, specifically the mesolimbic pathway. This pathway, which links the ventral tegmental area to the
nucleus accumbens and amygdala, has been implicated in addiction, working memory and emotional regulation [6].
Furthermore, connections between the ventral striatum, ventromedial prefrontal cortex and orbitofrontal cortex
have been implicated in reward-based behavior and motivation [8]. As such, disease-related changes in the availability
of DA (i.e., a dearth leading up to the diagnosis of PD or an excess after treatment) can produce an imbalance
throughout the mesolimbic network and have important consequences on behavior and motivation [14].
One explanation for why PD patients are especially vulnerable to the behavioral effects of DA replacement
therapy relates to the imbalance between the motor-related and reward-related DA pathways, mainly associated
with nigrostriatal and mesolimbic projections, respectively. While neurodegeneration occurs in both of these
circuits, the latter may be somewhat spared in the initial stages of the disease (see [3] regarding the generally accepted
theory of ascending alpha-synuclein deposition). Moreover, while DA drugs are intended to be used at a dose that
is adequate to treat motor functions (i.e., correct the nigrostriatal disbalance), it is easy to ignore the net effect of
that dose over the nonmotor DA pathways. If the mesolimbic system is sensitized in order to compensate for the
10.2217/nmt-2021-0012 Neurodegener. Dis. Manag. (Epub ahead of print) future science group
Neurodegenerative diseases, art & creativity Commentary
PD related denervation, reward seeking behaviors (i.e., art making) may be potentiated, in a manner analogous what
is observed in the nigrostriatal system for dyskinesias (i.e., too much/uncontrolled movement [11]). A given dose of
a DA agent would therefore normalize motor functions, while at the same time over activating the (relatively intact)
reward circuitry [8]. Analogously, other nonmotor DA pathways might also be over stimulated. More specifically,
the mesocortical pathway. This is important as moderately elevated prefrontal levels of DA are related to cognitive
rigidity and persistent thinking, as opposed to a flexible and divergent thinking which has been associated with
increased levels of DA in the striatum [15]. Both flexible and persistent thinking are important to creativity and
their balance is essential. In this organizational motif, mesocortical pathway overstimulation would block creative
ideation, while nigrostriatal pathway overstimulation would lead to easy distractibility (i.e., too much flexibility
and divergence of thought).
The positive side of being creative: a counterpoint to ICDs
Altered DA reward signaling is also thought to be the basis of one of the most recognizable and clinically
salient behavioral consequences of DA replacement therapy in PD: ICDs [14]. These collectively refer to a variety
of symptoms that include compulsive gambling, buying, sexual behavior, hobbyism, hoarding and punding –
repetitive, purposeless behaviors characterized by an intense preoccupation with specific items or activities such
as arranging or taking apart objects [12,14]. Often observed in the context of DA-replacement therapy with DAA,
ICDs are thought to be mediated by excessive stimulation of DA D3 receptors within the mesolimbic pathway [16].
Based on what is currently known about ICDs, it is reasonable to speculate that the alterations in artistic drive
and creativity observed in PD are related at a pathophysiological level. One study investigated the association
between an increase in artistic production and ICDs in patients under DA therapy [17], and found no differences
in impulsivity or frequency of ICDs (including punding) among PD patients with and without increased artistic
production. Therefore according to these results, increased creative drive and ICDs could be two separate entities.
This would reinforce the distinction between creativity and punding, where the former involves both novelty and
usefulness, as opposed to the latter, which is defined by repetitiveness and aimlessness [11]. However, we must not
overlook the fact that concepts such as usefulness, creativity and meaningfulness are inherently subjective, with no
recognized metrics that allow easy comparisons between studies. If one patient dedicates most of their time to a
given activity with classically negative valence (e.g., gambling), how would it be any different from another one
who devotes most of his time to art? At what point does an acceptable amount of time become devoted to a given
goal-directed activity become compulsive? The limits are, often, in what is considered to be socially acceptable. As
opposed to ICDs, enhanced creativity/creative drive is generally considered to be desirable and rarely disruptive for
both patients and their families [18]. However from a pathophysiological perspective, it is difficult to provide a clear
distinction between these different activity types in order to answer these questions. Thus far at least, the relatively
positive valence of flexibility and divergence of thought has only been associated with creativity [15] and not with
ICDs. It is worth asking whether a shift in the balance between the nigrostriatal, mesolimbic or mesocortical
pathways could perhaps lead the patient to opt for one type of activity over another.
Creativity changes in other degenerative disease states
Considering the postulated relationship between DA and artistic production in PD, the question arises as to
whether analogous responses are seen in other disorders where DAA are commonly used. Indeed, a similar tendency
toward artistic production has been suggested in patients with restless legs syndrome treated with DAA [12,18].
However, these results should be interpreted with caution, since there were subjective observations (mostly by
study authors) that restless legs syndrome patients’ artistic output was more mechanistic and impulsive, lacking the
distinctive creative elements attributed to art such as novelty or viability. Incongruencies such as these reinforce the
aforementioned need for more objective metrics that allow comparisons of produced work across patient cohorts
and diseases. An important element going forward will thus involve a systematic methodology for assessing both
subjective/felt and objective/measurable aspects of art in the context of neurodegeneration.
From a behavioral perspective, artistic output involves integrating multiple individual systems, including percep-
tion, cognition and motor skills. In the context of neurological disease, different neurodegenerative processes affect
these systems in distinctive ways and to varying extents. As a result, changes in the artworks produced by a patient
with a given disease process may differ significantly compared with another. Artistic signatures of different dementia
subtypes have been suggested [2], where specific technical differences could be objectively described. For example,
PD patients being treated with DAA may experience an increase in quantity/production, along with changes to
future science group 10.2217/nmt-2021-0012
Commentary P´
erez-Matos, Richard, Spee & Pelowski
January 2017 2018 2019 2020 May 2020
Stopped painting
Continued painting
Artist showed no interest
or had any practice in
painting before
Operation bilateral SN
DBS, Pramipexol 0.7 mg
1/2co 3x daily
Increase in DAA-dosage to
Pramipexol 0.7 mg 1co
3x daily
Increase in DAA-dosage to
Pramipexol 1.23 mg 1co
3x daily
Re-operated (change battery) with
concomitant decrease in DAA-dosage
from 1.23 mg 1co 3x daily to Pramipexol
0.7 mg 1co 2x daily
Started regular
painting from 2018
Paintings from an individual with Parkinson’s disease: Parkinson symptoms started in 2010 at the age of 49. Diagnosis 2011. Response to levodopa was
excellent but she developed moderate to severe dyskinesias within 2 years of initial diagnosis. No impulse control disorder. No cognitive decline.
SN DBS = Subthalamic nucleus deep brain stimulation. DAA = Dopamine agonist.
Figure 1. Paintings from an individual with Parkinson’s disease.
technical attributes of the work itself, such as a trend toward abstraction, more vibrant colors and increased use of
crosshatching [8]. Importantly; however, these trends are not always consistent (see [8] for discussion of an increased
drive toward abstraction in the context of deep brain stimulation), highlighting the above mentioned importance
of more systematic methods to compare across studies. By contrast, AD patients have notable changes in spatial
constructional quality, loss of detail and simplification of drawing [8]. Patients with frontotemporal dementia may
show preserved spatial organization and proportions, albeit with obsessively repeated figures, patterns and a style
shifted toward realism and away from emotion and symbolism [2]. The relationship between art and other neu-
rodegenerative diseases, which also show similar relations to DA agonist/antagonist therapy, such as Huntingtons
disease, is less studied. In contrast to PD, there have only been scattered case reports in Huntingtons disease to
suggest that artists tended to be more creative in the years preceding the onset of motor symptoms [19].Figure 1
shows paintings made by a patient with PD within a given period of the disease.
Art as a therapeutic intervention
The notion that altered neurotransmission in neurodegenerative disease may induce observable behavioral changes
animates a number of questions regarding the analysis of produced artistic works as markers for early diagnosis [8].
It may also open new avenues for the use of art as therapy [4]. The importance of nonpharmacological interventions
in the management and symptomatic treatment of neurodegenerative diseases is emerging. A popular example
is the use of music therapy in AD, considered to be protective against age related cognitive decline, which has
also been shown to improve quality of life [20]. Similarly, there is evidence that art therapy can be associated with
neuroplasticity and has been shown to influence both cognitive outcomes (i.e., immediate memory and attention)
and cortical thickness in memory-related regions (right middle frontal gyrus) in patients with mild cognitive
impairment [1,5]. These results suggest a potential neuroplastic effect, raising questions about potential applications
as a stand alone therapy. Evidence for art therapy in PD is limited; although, engaging in creative activities is known
to reduce apathy, depression, stress and anxiety; all of these are highly comorbid with PD [4].
One context where art therapy may also be particularly applicable involves PD patients struggling with ICDs.
As noted, the incidence of ICDs has not, to date, been systematically linked to increased art production [17].
These behaviors may; however, share common triggers, such as DA-replacement therapy, alluding to a common
neurobiological explanation involving DA tone in the mesolimbic pathway [18]. The question thus arises: could a
creative environment facilitate the engagement in artistic pursuits rather than destructive ICDs behavior? Could we
redirect the socially disruptive urges of ICDs toward a less debilitating and potentially hazardous, ‘healthier’ outlet?
10.2217/nmt-2021-0012 Neurodegener. Dis. Manag. (Epub ahead of print) future science group
Neurodegenerative diseases, art & creativity Commentary
Ultimately, could art therapy have a role in the prevention or treatment of ICDs? If the manifestation of activities
consideredtofallundertherubricICDs versus those related to creativity determined by the relative balance of the
different DA pathways, it would be most desirable to find external factors that would shift this balance toward
creativity. Nurturing a creative environment with interventions such as art therapy or promoting positive feedback
for artistic endeavors could lead to preferential reward (mesolimbic) circuit activation. This, in turn, could help
modify/facilitate patient behavior toward creative activities rather than ‘disruptive’ ones that are more classically
associated with deleterious consequences, such as ICDs. It is tantalizing to imagine that such an elegant, cost-
effective intervention could potentially manage ICDs as one of the most notorious and undesirable side effects of
DAA, whose use is often limited in many patient populations (e.g., those with comorbid substance abuse issues).
A granular understanding of the relationship between brain diseases and their impact on behavior remains an
important and relatively uncharted frontier in neuroscience and in medicine, with large implications for society at
large. Art making is a promising prism through which to appreciate the nuanced relationship between cognition,
goal-directed behavior and the changing brain in the context of neurodegenerative diseases. As an area for future
exploration, the value of art therapy as a potent behavioral and ultimately neurochemical, intervention has exciting
potential.
Financial & competing interests disclosure
This work was not funded by any granting agencies. The writing of this paper was partially supported by a grant to MP from
EU Horizon 2020-SC6-TRANSFORMATIONS, Societal Challenges and the Arts (no 870827). The authors have no other relevant
afliations or nancial involvement with any organization or entity with a nancial interest in or nancial conict with the subject
matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.
Ethical conduct of research
The authors state that informed consent has been obtained from the participants involved.
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Creative cognition is key to human functioning yet the underlying neurobiological mechanisms are sparsely addressed and poorly understood. Here we address the possibility that creative cognition is a function of dopaminergic modulation in fronto-striatal brain circuitries. It is proposed that (i) creative cognition benefits from both flexible and persistent processing, (ii) striatal dopamine and the integrity of the nigrostriatal dopaminergic pathway is associated with flexible processing, while (iii) prefrontal dopamine and the integrity of the mesocortical dopaminergic pathway is associated with persistent processing. We examine this possibility in light of studies linking creative ideation, divergent thinking, and creative problem-solving to polymorphisms in dopamine receptor genes, indirect markers and manipulations of the dopaminergic system, and clinical populations with dysregulated dopaminergic activity. Combined, studies suggest a functional differentiation between striatal and prefrontal dopamine: moderate (but not low or high) levels of striatal dopamine benefit creative cognition by facilitating flexible processes, and moderate (but not low or high) levels of prefrontal dopamine enable persistence-driven creativity.
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This paper has a rather audacious purpose: to present a comprehensive theory explaining, and further providing hypotheses for the empirical study of, the multiple ways by which people respond to art. Despite common agreement that interaction with art can be based on a compelling, and occasionally profound, psychological experience, the nature of these interactions is still under debate. We propose a model, The Vienna Integrated Model of Art Perception (VIMAP), with the goal of resolving the multifarious processes that can occur when we perceive and interact with visual art. Specifically, we focus on the need to integrate bottom-up, artwork-derived processes, which have formed the bulk of previous theoretical and empirical assessments, with top-down mechanisms which can describe how individuals adapt or change within their processing experience, and thus how individuals may come to particularly profound, moving, disturbing, transformative, as well as mundane, results. This is achieved by combining recent theoretical research into a new integrated approach built around three processing checks, which we argue can be used to systematically delineate the possible outcomes in art experience. We also connect our model's processing stages to specific hypotheses for emotional, evaluative, and physiological factors, and address main topics in psychological aesthetics including provocative reactions—chills, awe, thrills, sublime—and difference between “aesthetic” and “everyday” emotional response. Finally, we take the needed step of connecting stages to functional regions in the brain, as well as broader core networks that may coincide with the proposed cognitive checks, and which, it is our hope, taken together can serve as a basis for future empirical and theoretical art research.