A surrealism exhibit led this doctor to better understand his dementia patients — and help them

Americans are aging and that means more will be diagnosed with dementia in the coming years. And our next guest has a new way to understand the way they think and experience the world: Surrealism.

That’s right, the 20th-century avant garde art movement.

Dr. Jason Karlawish is co-director of The Penn Memory Center and writes a column for Stat called Neurotransmissions. The Show spoke with him more about it beginning with where this idea came from for him: an art museum.

Full conversation

JASON KARLAWISH: I live in Philadelphia, and just down the street from my home is the Philadelphia Museum of Art. And they have just wrapped up an exhibition called Dream World: Surrealism at 100. And I was going through that exhibition, and as I was looking at the images, I began to think about my patients' experiences when they look at images.

And to put a word to it, I think their experiences are oftentimes surreal. And I began to make this connection between my work as a physician caring for people living with diseases that cause dementia, like Alzheimer's, and my experience looking at these uncanny images that were in this exhibition.

LAUREN GILGER: Let's talk a little bit about how it is that the brain works, that consciousness works. Like, you talk about the actual mechanics of that and how this kind of applies to, you think, people experiencing dementia.

Walk us through the idea of how it is that our brain is conscious of something, and then how dementia disorders that consciousness.

KARLAWISH: Yeah, so all of us have a mind, all of us humans have a mind, and that mind is the product of the unconscious and conscious worlds. Our unconscious is constantly at work, taking in a host of sensory information. Thank God we're not aware of 99% of it, otherwise we'd go mad.

But there's this interesting border between the conscious and the unconscious where something happens, something we need to know, need to be aware of, need to hear, need to feel and we're aware of it.

And, you know, in a brain of a normally functioning, developed human brain, that generally works to allow us to see things the way they more or less are. But for persons with dementia, that can get distorted, that feed of what's perceived and then fed into conscious can be distorted and disrupted.

And I recount in the essay, a patient of mine, Nancy, who was looking at what we call the Navan figure. And the Navan figure is a giant letter, in this case, a giant letter H, constructed of multiple little tiny S's. And the question is, what do you see? And most people say, well, I see a bunch of S's and there's a big H or something like, and I see an H made-up of S's. And she could only see the S's. She couldn't see the big picture. And that's this distortion between her ability to take in sensory, put it into her consciousness, and see the whole picture.

And that's just one example of, I think, many of the distortions in mind that persons living with dementia experience and that interplay between what's constantly being taken in subconsciously and then put forward across into the border of the conscious. And for persons with dementia caused by diseases like Alzheimer's, that's oftentimes, that's typically disrupted.

GILGER: Interestingly, when you look at something that is surrealistic, I think it comes out of this time in American history, it's, you know, a 100-year anniversary show you were looking at at the Philadelphia Museum of Art there, in which we were trying to make sense of some kind of mind-blowing things, some things that were hard to wrap our heads around.

Do you think that makes sense, like it even rang true in terms of the origins of this type of art?

KARLAWISH: Yeah, yeah. I mean, surrealism was a product of early 20th century events, in particular, the horrific events of the slaughter, the mechanized slaughter that was World War I. André Breton, many other surrealists were participants in that war. Breton was in a medic, for example. And I think part of the sort of horrors of mechanized slaughter led them to want to sort of look within and try to free themselves of some of the orders of the world that led the world to that awful war.

And as I think about the 21st century, I don't like to think of dementia like a war, but I do think it presents many of those kinds of challenges that kind of a world war does to a society. So there's an interesting kind of parallel between major events that cause us great angst and looking within for World I and dementia. And I think surrealism has a new way for us to make sense of this new problem we have, which is the vast problem that is dementia.

GILGER: Right, and you write about what a vast problem it is and how we will need solutions and lenses like this because we're an aging population in this country.

Like this is the first time in which we'll have so many people of older age who will suffer from things like this?

KARLAWIS: Yeah, the fastest growing age group in America is persons over the age of 80. And the risk for developing dementia, whether it's from Alzheimer's, Lewy body disease, vascular disease, combinations thereof, takes off after about the age 75.

And the insight that I have had and I wrote about was how looking at surrealist art helps me understand what it is like to be a person living with dementia.

What it is like to, for example, I had family members who tell me, I can't stand going to the grocery store with my relative, my wife, my husband, she won't keep up with me, she just follows me. And that's a very common complaint. And I said, well, their perception of the world is not like yours and mine. They struggle to put together all these objects that make sense of them.

You know, back to my patient who couldn't see the letter H, you mean about all the S's. And that's why they're following you, because you're the one thing they can see and know what it is. It's not because they're weak, it's not because their joints hurt. It's because I'm just holding onto the one thing I can see, I can make sense of in this vast crowded grocery store with all these visual things coming at me from everywhere.

And that really hit me as I looked at these pieces at the surrealism exhibit. That's what it must be like for my patients. That's fascinating.

GILGER: That's fascinating. Yeah, that's a wow moment.

And you talk about how this surrealist aesthetic could help shed some insight on one of these debates within dementia care, which is sort of like, do we insist on the truth for people living in this kind of distorted reality? Or is it OK to sort of let people live in an unreal version of reality?

KARLAWISH: Or just not worry about reality and be surreal. Exactly. Yeah. I mean, the classic one, robotic pets, and there's a role for these pets that behave in many ways like a kind of living cat, dog, whatever. But of course, I think many of us find it extremely disturbing when we see someone playing with a robotic cat as though it was alive, and it's disturbing.

And that's why I admire, for example, robotic seals, because people don't have seals for pets. Maybe some Inuits do, but the average person in Philadelphia does not have a pet seal. And so I think it frees us of. I'm not lying to her pretending this is a cat or insisting, no, it's a toy cat. Why don't you accept it's a toy cat?

I'm just saying, Look, it's a seal. Of course, there's no seals in this nursing home in Philadelphia, but if you enjoy it and it's giving you comfort and calm, so be it. I think the surrealist aesthetic is a way to just set aside the, do I lie or do I deceive? And say, let's just enter the surreal world and not worry about whether it's true or not, but just let it be.

GILGER: You're almost saying surrealism is giving you a lens into this different kind of consciousness and just letting that be OK.

KARLAWISH: Well, accepting that that is what, that's the way this individual is, and I should meet them where they are. And yeah.