Editorial
Using artwork to better understand patients
with neurologic disorders
Self-expression through various forms of art is a
vastly underused tool in neurology. Throughout history,
persons afflicted with neurologic diseases have portrayed
their condition in vivid detail using paintings, sculpture,
and other forms of artistic expression. One has only to
recall Vincent Van GoghÕs visionary yet troubled mas-
terpieces to appreciate the depth of an artistÕs emotional
response to the realities of epilepsy. The variety of self-
expression among persons with epilepsy is evident in the
annual Expressions of Courage art contest co-sponsored
by the Epilepsy Foundation and Ortho–McNeil Phar-
maceuticals, as well as in a recently published volume
displaying the artwork of people with epilepsy [1]. Sim-
ilarly, the intense pain of migraine has been depicted by
legions of artists, including widely publicized traveling
exhibitions such as one commissioned several years
ago by the Wellcome Foundation [2]. Investigators have
explored the multifaceted dimensions of art produced by
migraineurs, deriving not only psychological and emo-
tional insights into their suffering, but also inferring
pathophysiological correlations from the drawings
(e.g., visual auras and other self-perceptions of migraine
phenomena [3–5]).
Art, however, is a great equalizer—one need not be a
professional artist to produce an artistic self-expression
worthy of our attention and analysis. Art can express
inner feelings and emotions that simmer beneath the
surface and fail to become verbalized, for various rea-
sons, yet possess an intense personal meaning for the
patient. Even children produce fascinating and insight-
ful artwork; over several years I have encouraged chil-
dren with a variety of neurologic disorders to draw
pictures of themselves as a part of their neurologic eval-
uation. The pictures often dramatically illustrate the in-
ner feelings and perceptions of these young patients.
For example, children with headaches depict their
symptoms in sufficiently specific detail that blinded
observers can differentiate those with migraine from
those with nonmigraine headaches on the basis of the
drawing alone [6]. Among children with epilepsy, self-
drawings are consistent with the syndromic diagnosis:
children with generalized tonic–clonic seizures draw
themselves shaking on the ground, while those with ab-
sence epilepsy portray staring [7]. Such drawings also
provide insight into self-image; for example, feelings
of depression are indicated by a small self-figure drawn
on an expansive background, with sad or poorly formed
facial features.
In this issue of Epilepsy & Behavior, Anschel and col-
leagues take such anecdotal studies one step further. A
group of 60 patients admitted for long-term video/
EEG monitoring were asked to participate in three art
tasks. First, they each produced a sketch of a person
picking an apple from a tree. This standardized task
was analyzed quantitatively using a well-validated scale
that considers such aspects as prominence of color, line
quality, realism, details of objects and persons, and
overall integration of parts of the drawing [8]. Second,
patients produced a ‘‘free drawing’’ of their own choice,
which was also analyzed using the quantitative art scale.
Finally, subjects were provided an outline of a human
figure and were asked to fill it in to portray how a sei-
zure makes them feel.
The study was blinded (analyzed without knowledge
of clinical history) and controlled (patients were di-
vided into groups with seizures, partial seizures, com-
plex partial seizures with a temporal lobe focus, and
nonepileptic events, as determined by video/EEG).
The results were intriguing, revealing a number of dif-
ferences between the groups. One striking finding was
that the free drawings of patients with temporal lobe
epilepsy tended to be highly detailed, but lacked cohe-
sion and integration. On the outline drawing task, pa-
tients with nonepileptic events used an excessive
number of colors, which was interpreted as an attempt
to focus attention on themselves. Additionally, the line
quality of all patients with seizures was fragmented and
incomplete, compared with that of subjects with non-
www.elsevier.com/locate/yebeh
Epilepsy & Behavior 6 (2005) 113–114
1525-5050/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2004.12.005