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Impact of FTD

John began to tell friends of his new ability to see not only colors but sounds ... about the same time that he began to have trouble remembering words.
—Bruce Miller, “A Passion for Painting”

In our clinic at the Memory and Aging Center, we see people who lose certain abilities, like language, while gaining new ones, like musicality and artistic expression. We have met individuals, particularly those with semantic dementia, who never created art before becoming ill and are now making wonderful, intriguing artwork. One explanation for this phenomenon is that healthier parts of the brain compensate for the areas that are no longer working. Therefore, visual expressions such as a drawing, painting or sculpture bloom as the person loses their capability for verbal language.

Behavioral variant frontotemporal dementia (bvFTD)

bvFTD is associated with atrophy of the prefrontal cortex, anterior cingulate, insula and ventral striatum. When this atrophy is predominantly right-sided, bvFTD is almost always associated with changes in behavioral and emotional function. The changes most commonly associated with bvFTD are apathy, disinhibition (disregard for social convention), aberrant motor behaviors (twitches, ticks, etc.) and eating disorders (specifically increases in appetite and strong preferences for sweets or other particular foods). Other behavioral changes in bvFTD include elation and euphoria (inappropriate or excessive happiness), aggression, irritability, sleep disturbances, depression and anxiety. Sometimes patients with bvFTD also develop addictive behaviors late in life.

People with bvFTD who develop a creative drive tend to produce simplified, less representational, bizarre, more distorted images with a disordered spatial composition. They also tend to use less variety in the types of marks made to create the artwork (shading, heavy strokes, light lines, etc.). Visual composition involves planning how the piece will look at the end, and the damage to the frontal areas impacts this planning skill. This free style may also reflect the disinhibition and lack of interest in following the rules. The distortions, particularly of the face, may derive from the growing emotional distance from other people. Despite the development of creativity in some patients with bvFTD, apathy and inertia leading to diminished creativity is more typical.

Semantic dementia (SD)

SD results from atrophy of the anterior temporal lobes (including the amygdala), insula, prefrontal cortex and anterior cingulate. Though more commonly thought of as a language disorder, SD is often associated with dramatic changes in behavioral and emotional function. Disinhibition and compulsive behaviors are the most common changes in SD. Other common changes include apathy, eating disorders, sleep disturbances, elation and euphoria, as well as depression, anxiety, irritability and aggression.

The artwork of people with SD is often described as bizarre, distorted and colorful. People with predominantly right-sided SD tend to create highly detailed images that lack overall structure or form while people with left-sided damage tend to create more abstract forms and shapes without much detail. People with right-sided SD tend to show distorted faces and expressions, which probably reflect their particular deficits in recognizing faces and emotions, as well as a loss of meaning for what those things are. The eccentric images may stem from the loss of meaning or context for the units of the composition. The elements themselves become detached from their usual roles, remain incomplete, show no activity or are reduced to merely the visual properties (pure perception without meaning). Interestingly, the content may not show much creativity (most likely due to the loss of meaning), but the visual perception and representation can be highly creative whether it's how something is represented, the perspective taken or the arrangement of the composition. Generally, the paintings are realistic or surrealistic without a significant symbolic or abstract component. The work is approached compulsively, and a painting may be repeated over and over. Patients with SD might also explore transmodal expression, meaning they create visual representations of sound or acoustic representations of color. This type of expression is not the same as "synthesia" where you might see colors when you hear sounds. Transmodal expression uses deliberate, internal associations.

Progressive nonfluent aphasia (PNFA)

PNFA develops when there is shrinking of the left perisylvian cortex (the area surrounding the deepest fold on the side of the brain - the sylvian fissure), an area of the brain more involved in language than personality. Therefore behavioral, emotional and creative changes are less common or more mild in PNFA.

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