An n=1 trial into how a patient’s drawings reveal his underlying mood and maybe treat his depression

A man with vascular dementia was admitted following a suicide attempt. The Crisis consultant felt it was high risk, and recommended him to be admitted.

There’s “oh, dementia” and “oh…dementia”. This patient belonged in the first category. He looked after his house alone, and kept it in immaculate condition. He self-cared better than most students.  He had the air of an aged rock star, looking back over his life with pride and no regrets yet probably quite looking forward to living in a gentler gear.  The only time his dementia surfaced in our conversation was when he would freeze mid sentence, suddenly unaware of what he was talking about and as much embarrassed as frustrated by this.

I noticed how he used tricks to work around his memory problems which were quite similar to the memory tricks I use for learning medicine.  If he could not remember the name of someone, he would find a picture to remind him of them, and flood the picture with as many details as he could which would trigger off his memory.

When I can’t remember the features of a medical problem, I try and create an image to link them all together. I think that the reason this works so well is not so much the image, but that the very process of creating them forces you to engage with the material that much more.  Have a look at this totally not peer reviewed summary.

It seems this man was self-administering cognitive rehabilitation. Cognitive rehabilitation is defined as “any intervention strategy or technique which intends to enable clients or patients, and their families, to live with, manage, by-pass, reduce or come to terms with deficits precipitated by injury to the brain.” Examples of cognitive rehabilitation strategies include:

  • Build on the memory skills the patient already has using prompts to achieve whatever you need. Then fade the prompts. This video on errorless learning demonstrates it really well.
  • Use alternative skills to compensate e.g. pictures of clothes to remind you what the washing machine is used for.

This patient enjoyed drawing throughout his life. It seems he was using his presumably well developed visual neural circuitry to compensate for his short term declarative memory problems.

He wanted to show me his sketches. The first one was of Elvis Presley. It was quite impressive, especially given he did it at 3am.

Done at 3am. Quite impressive for an inpatient on a dementia ward.
Done at 3am. Quite impressive for an inpatient on a dementia ward.

Then he asked me something which caught me off guard:

“Can you see the anger?”

I looked at the drawing with my anger-filter switched on to maximum.

“His expression?” I suggested initially pointing to the face, and then further outwards looking optimistically for any signs of agreement.

“You’re nearly there. It’s all these lines.”

He pointed to the strokes towards the edge of the drawing.

“You see these lines? They are much darker. When someone makes me angry, or I’m getting frustrated, I don’t draw delicate lines. Can you see the anger in those lines?”

The angry bits are highlighted in red. Note how the lines are darker.
The angry bits are highlighted in red. Note how the lines are darker.

I could. It’s how I feel with Adobe Illustrator and the Image Trace function has been butchering my sketches. Sometimes I just give up and make the whole thing MS Paint-y. That’s a sign I got angry.

“Every time I’m angry, I remember it in my drawings. I remember what made me make those lines darker. It’s usually a loud noise, or someone disturbing me.”

I then realised his drawings might be one of the best ways of assessing his mood. This patient was giving us something that most advanced brain scan could never pick up. It was actually a pretty good functional assessment of his mood, recorded as is and without any attempt to pigeon hole his thoughts and feelings into any questionnaire criteria.

I looked at his old sketches with him. He could tell me exactly what he was feeling at the time, where he was and what he was thinking when he drew them. You could argue we do not know that he was not confabulating for the old sketches. However, the events he described surrounding the recent sketches done whilst an inpatient had actions associated with them that were verifiable with other members of staff e.g. a patient walking into him one evening. This is a man who was normally unable to recall events of the day before. It seems his drawings allow him to access memories of the recent past by coding emotionally significant events into their very structure.

Could this skill be used for his benefit? One of his greatest frustrations was not knowing what happened in the ‘in between time’. This was the time between the last few hours and the olden days, such as one week ago. Not knowing what happened depresses him. I could see why, given how well his other cognitive functions were and his high level of insight.

I wanted to see if we could help him help himself. I suggested keeping a drawing diary, and that when significant events happen that he wants to remember, perhaps he could sketch whatever he feels would capture it best. Although this would not capture all the details such as what he had for breakfast three days ago, it would capture the most significant memories. If we could capture those memories, I felt he would be less depressed.

He has decided to give it a go. He is also on mirtazapine 30mg NOCTE.

14/5/13: He has improved considerably, and his newer drawings reflect this.