Research on the human brain’s sensitivity to symmetry, proportionality, and regularity in visual inputs lends credence to the notion that perception and evaluation are linked because symmetry and proportionality cannot be observed before being evaluated (Keefe et al., 2018). While probabilistic preferences for symmetry and proportionality are widely observed, their expression is shaped by cultural learning, genre conventions, and task context; claims of universality are therefore hypotheses to be tested against cross-cultural data. Not only do humans like symmetry in visual stimuli, but non-human primates also prefer such stimuli, implying that a mechanism for detecting and appreciating visual harmony has survived evolution (Sasaki et al., 2005; Little and Griffey, 2020). Cross-cultural and evolutionary psychology research has shown that the preference for specific face and body traits is universal across the human race, implying that aesthetic preference is, to some extent, biologically derived (Little et al., 2011; Fiala et al., 2021). Beyond that, neuroimaging has also found that the insular cortex and anterior cingulate cortex get turned on during moments of particularly strong aesthetic experience, particularly when art provokes deep personal emotional responses (Morita et al., 2014). These areas are involved not only in reward but also in emotion awareness and interoceptive states, highlighting the dual nature of the aesthetic experience as an interoceptive and sensory phenomenon (Brown et al., 2011). Curiously, these networks are more active in people with greater openness to experience or training in the arts, implying a level of plasticity in how the brain attends to beauty (Medford and Critchley, 2010). Recent findings suggest that aesthetic pleasure can also benefit memory and learning, potentially due to its recruiting of attention and emotional arousal, which promote the encoding and consolidation of visual information (Mansueto et al., 2025; Ponzio and Mather, 2014; Belfi et al., 2019).

Yet, this emerging research is not free from conceptual and methodological difficulties. Some have worried about the potential for reductionism, for instance, to reduce complex, culturally embedded experiences with art to just another kind of neural activation or preference rating (Bilsky, 2017). Indeed, because as immensely helpful as the quantitative neuroaesthetic approaches are as indicators and as neural correlates, they should be part and parcel of a general and nuanced understanding of what we can call the contextual, symbolic, and subjective/cognitive dimensions of aesthetic experiences (Pearce et al., 2016). A central challenge for the field, as it continues to grow and evolve, will be to strike the balance between these two extremes, ensuring that the neurobiological perspective not only enriches other, variously informed views of the profound and multilayered nature of art but also enriches them in return. From this vantage, symmetry and proportionality do not merely please because they are regular; they scaffold the predictive models that allow meaningful surprise. Cadential delays, motif recurrences, or perspectival reveals work precisely because the brain has inferred structure and is primed to register precision-weighted violations, a sequence that culminates in chills and durable encoding (Schoeller et al., 2024; Blood and Zatorre, 2001). Methodologically, isolating chills requires convergent markers, time-locked self-report, piloerection sensors, electrodermal activity, and stimuli with controlled expectation profiles to distinguish peak aesthetic response from generic arousal.

AD, which has been acknowledged as a prototype of progressive cognitive impairment, also provides a striking example of loss of aesthetic experience. At the earliest stages, AD focuses on the medial temporal lobes, including the hippocampus and entorhinal cortex, before progressively spreading into the temporo-parietal association cortices and frontal lobes. These are, after all, the substrates on which memory, meaning, and affect are organized, central also to the aesthetic triad (Menon and Levitin, 2005). The aesthetic existence of patients with AD is clinically characterized by an insidious and gradual stripping away. Neuroimaging investigations indicate that when patients are exposed to art or music, they have reduced activation of the ventral visual stream and medial orbitofrontal cortex, as well as a reduction of subjective reports of pleasure and an impairment of their ability to make aesthetic judgments (Chaudhary et al., 2022; Menon and Levitin, 2005; Silveri et al., 2015). This appears not just as “not liking art” but as a fracturing of the capability to engage with artistic complexity. Indeed, patients’ responses tend to favor simplicity, formality, and familiar stimuli, compensating little for abstraction or novelty (Leder et al., 2004; Zaidel, 2015). Nonetheless, the emotional power of art can still be reached. A growing literature indicates that aspects of musical memory can remain relatively resilient in AD, particularly recognition of familiar melodies and affective responses to personally salient music, despite severe episodic memory deficits, supporting patient-tailored playlists and caregiver-led music engagement (Cuddy and Duffin, 2005; Jacobsen et al., 2015; Vanstone and Cuddy, 2010). In line with individualized music evidence, personalized listening reduces agitation more reliably than generic ‘relaxation’ music, underscoring the need to calibrate familiarity, tempo, and arousal and to monitor for rare agitation spikes (Park and Pringle Specht, 2009; Belenchia, 2023; Gerdner, 2000). Through observational studies, some patients with early-stage AD can even be reached with music they once knew or even just familiar artwork (Cuddy and Duffin, 2005; Vanstone et al., 2009). Recent papers suggest that although a change in music experience is often reported by patients and carers, music perception can be preserved for well-known music as well as more global affective response to music and known visual art in the early to mid-stages of the disease, despite widespread high-level cognitive deficits that prevent the spontaneous interpretation or analysis of complex artistic material‘s meaning (Arroyo-Anlló et al., 2019). For instance, quantitative data from behavioral and physiological research have supported the notion that, when they listen to personal music, patients with AD express similar affective reactions (e.g., artificial movements, vocalization, or physiological arousal) independently from the presence of verbal recall or recognition deficits (Cuddy et al., 2015; Baird and Samson, 2015; Vink et al., 2013; Särkämö et al., 2013).

The persistent central nervous system awakening response to the negative, noxious events accordingly highlights the relative independence of the cognitive from the emotional processing systems (McKhann et al., 2011). As AD progresses, there is a decrease in generative creativity. Art generated by formerly capable artists is diminished in complexity, nuance, and repetitiousness, which, respectively, are indicative of the loss of executive function and/or semantic memory (Fornazzari, 2005; Miller, 2005). However, procedural memory, the memory for how one performs well-learned activities, can last unusually long, such that an amnesiac can still play a familiar tune even if other abilities are lost (Cavaco et al., 2004). This dissociation highlights the hierarchical arrangement of artistic cognition. Set against this backdrop, selective vulnerability of ventral tegmental area (VTA) dopaminergic neurons in AD models suggests that deficits in reward prediction and motivational drive may emerge before widespread cortical failure (Krashia et al., 2022). Because chills engage VTA-striatal loops and amplify precision-weighted prediction errors, familiar-but-surprising musical or visual sequences may transiently lift hedonic tone and enhance consolidation in mild stages, leveraging preserved affective and procedural channels while limiting cognitive load (Schoeller et al., 2024; Blood and Zatorre, 2001). Practically, this argues for session designs built around personalized playlists with graded tension-release and objective chill markers to titrate difficulty and prevent habituation.

PD, a common neurodegenerative movement disorder, is not merely a physiological disorder. The essential pathology, degeneration of dopaminergic neurons in the substantia nigra with resulting depletion of dopamine from basal ganglia and interconnected fronto-striatal circuits, not only affects movement control but also impairs motivation, hedonic tone, and emotional expressiveness (Kalia and Lang, 2015; Weintraub and Mamikonyan, 2019; Radad et al., 2023). Aesthetic participation in PD is thus doubly constrained. On one hand, motor symptoms interfere directly with the production of art: tremor, rigidity, and bradykinesia disrupt the flow of brush, bow, or pen (Thaut and Abiru, 2010; Bologna et al., 2016; Rios-Urrego et al., 2019). On the other hand, non-motor symptoms such as apathy and anhedonia sap the will to engage with beauty at all (Sipos-Lascu et al., 2021; Skorvanek et al., 2015). Neurophysiological studies indicate a muted response in the ventral striatum when individuals with PD are exposed to rewarding or aesthetically pleasing stimuli, a neural correlate of the diminished “reward” response to art (Martínez-Horta et al., 2014; Muhammed et al., 2016). However, the outlook is not entirely negative. Some patients who are treated for pharmacological restoration with dopaminergic tone, particularly dopamine agonists, have paradoxical episodes in which they find themselves flooded with creative energy, which they may manifest compulsively. Reports detail people who, after starting such medications, suddenly develop a newfound interest in an art form or start producing notably more work, sometimes to an obsessional degree (Marafioti et al., 2025; Lhommée et al., 2014; Schwingenschuh et al., 2010). While the condition, which researchers have dubbed “dopaminergic artistic emergence,” has been associated with the neurochemical pathways involved in impulse control disorders, it provides an extraordinary example of the fragile chemical tightrope that underpins the creative urge (Muhammed et al., 2016; Marafioti et al., 2025). Reviews document medication-associated surges in artistic output in a subset of patients, underscoring the narrow therapeutic window between restored motivation and impulse-control risk and the need for systematic monitoring in high-salience interventions (Inzelberg, 2013; Voon et al., 2011). On the phenomenological level, persons with PD commonly report a powerful, if not painful, experience of frustration and loss, as the vivid pictures or music that populate their minds fail to translate themselves faithfully into the gross extent of the motor domain (Gökçal et al., 2017). Many patients describe a continued internal world of artistic vision or music even as the body’s ability to translate those visions into action was progressively eroded (Canesi et al., 2012). If there is a gap between internal creativity and external performance, emotional responses will span from anger to sadness and may result in creative responses such as moving from performance to appreciating passively or finding new alternative, less physically demanding vehicles to come to expression (Spee et al., 2025).

Furthermore, our investigation is in line with others in that, in certain instances, motor deficiency is responsible for limiting creative output, but not beauty perception and emotion, when participants are exposed to familiar melodies, visual art, or poetry (Humphries et al., 2021; Lauring et al., 2019). The fact that the visual pleasure response persevered in the presence of physical limitations is evidence of the multi-level nature of the human brain, on which sensory, emotional, and cognitive networks are deeply entwined but can also at least partly function with great independence. Within this framework, peak aesthetic responses can be used to restore reward learning in sessions that explicitly manipulate expectancy, tempo ramps, rhythmic syncopations, and cadential delays, to drive dorsal-then-ventral striatal phases and counter ventral hyporesponsivity (Blood and Zatorre, 2001). Meta-analytic and clinical evidence confirms high rates of apathy and reward-learning alterations in PD, aligning with blunted ventral striatal responses to incentives and supporting mechanistic rationales for aesthetic protocols that manipulate expectancy and salience (den Brok et al., 2015). Converging evidence from anhedonic depression shows chills-evoked improvements in reward learning and approach motivation, motivating parallel protocols in PD with outcomes spanning apathy, effort-based decision-making, and computational learning metrics (Jain et al., 2025). Because dopaminergic therapy can lower thresholds for impulsive reward seeking, monitoring for impulse-control symptoms should be integrated when designing high-salience aesthetic sessions.

In the field of the neuroscience of creativity and aesthetics, FTD, comprising a heterogeneous group of disorders involving the frontotemporal lobes bilaterally, profiles as one of the most fascinating clinical entities studied to date (Bang et al., 2015; Seeley et al., 2008). The clinical patterns, behavioral, semantic, and non-fluent aphasias, they disassemble separate components of the aesthetic brain (Rascovsky et al., 2011; Gorno-Tempini et al., 2011). Nowhere is the interrelationship between neural degeneration and creativity more starkly portrayed than in the phenomenon of paradoxical artistic emergence observed in behavioral FTD. Clinical observations and imaging work have characterized artistic behavior in FTD, often with right-hemisphere visuospatial disinhibition and prefrontal atrophy, yielding prolific yet affectively flattened output (Friedberg et al., 2023; Miller and Miller, 2013; Peet et al., 2021; Erkkinen et al., 2018b). Patients who had previously shown little or no interest in the arts can become so absorbed in painting, sculpture, music, and poetry that the artwork itself becomes obsessive, the images vivid or delicately detailed, or the composition compulsively repeated (Rankin et al., 2007). Functional imaging suggests an explanation in the form of disinhibition of posterior right-hemisphere visuospatial regions ‘released’ from the metaplastic control of the atrophic prefrontal cortex. These individuals may stand for hours before the easel with a mixture of creative and pathological compulsion (Ward et al., 2023; Agosta et al., 2012). Their work frequently is not coherent narratively but instead is more emotionally salient or visually complex, marking a move away from goal-oriented construction to a less conscious, more procedural, mode of expression (Antonioni et al., 2023). What caregivers and families often express, with some combination of awe and alarm, is this artistic transformation. And these accounts are evocative precisely because they capture the paradox of FTD, in which the degradation of frontal regulatory circuits unleashes new species of artistic behavior even as it impairs judgment and run-of-the-mill creativity (Miller et al., 1998; Carlsson et al., 2000).

Nonetheless, it is important to point out that this is not a general observation in FTD. Especially the semantic variant, where conceptual knowledge is consistently eroded, distorts the texture of aesthetic experience. People with semantic dementia might begin to find it difficult to recognize familiar objects, faces, or the symbolic content in paintings or sculptures and subsequently disengage with narrative or contextual aspects of art that evoked personal significance (Snowden, 1999). This dissociation, formal exploration with diminished semantic appraisal, motivates stimulus sets that orthogonally manipulate content semantics and low-level structure to parse which components of peak aesthetic responses are preserved across FTD phenotypes (Rouse et al., 2024). What’s more, their interaction with art is primarily concerned with its formal aspects (color, pattern, and texture) isolated from its more profound emotional or representational context. The works that ensued were sometimes successful for their technical brilliance but more often felt emotionally flat or repetitive, the divide between intellectual intent and affective response clearly visible (Drago et al., 2006). This change provides a striking example of the experiential and generative role of art, a product of the bedrock interaction between perceptual, cognitive, and affective networks. The extent to which damage to these networks can both lead to extraordinary bursts of creativity and the utter impoverishment of meaning in FTD indicates the subtle balance that underpins our unique ability to feel and form aesthetic experiences (Ilchovska et al., 2025). Because chills depend on the integration of prediction, violation, and meaning, behavioral-variant FTD may preserve sensory surprise yet distort narrative appraisal, whereas semantic-variant presentations may blunt chills by severing symbolic links that imbue patterns with significance (Schoeller and Perlovsky, 2016). Future studies should pair content-manipulated stimuli with piloerection sensors to parse formal versus semantic contributions to peak responses and to explain why some FTD phenotypes show prolific output that is affectively “flat.”

HD, an autosomal-dominant neurodegenerative disease involving progressive degeneration of the striatum that eventually includes the cortex, offers a unique problem for the neural circuits that support aesthetic experience (Ross and Tabrizi, 2011; Novak and Tabrizi, 2010). The inexorable spread of HD-mediated neuronal death disrupts not only the sensory-motor networks that are required for artistic production but also the affective-appraisal networks that create emotional reactions to beauty and creativity (Kirkwood et al., 1999; Niccolini and Politis, 2014). Motor symptoms like chorea, dystonia, and severe incoordination can extremely affect the exercise of painting, music playing, or any other artistic expression (Schwartz et al., 2019). But the aesthetic consequences of HD are not limited to motor rendering; they penetrate deep into the patient’s emotional, motivational landscape. Clinically, patients affected by HD often recall a slow reduction of their participation in creative activities and enjoyments. This disconnection is not just a consequence of the effects of physical disability on the mind, but all too frequently it expresses a deeper attrition of desire and pleasure in artistic participation (Atkins et al., 2024). This subjective finding is supported by functional neuroimaging that reveals lower activation of the ventral striatum and orbitofrontal cortex upon reward in patients compared to control subjects (Pardina-Torner et al., 2024; Eidelberg and Surmeier, 2011). These data share some clinical features with the core apathy and anhedonia symptoms (Atkins et al., 2024). Large-scale clinical and imaging syntheses emphasize motivational syndromes as core features of HD and implicate striatal-orbitofrontal circuit compromise during reward processing, supporting short, personalized, high-salience aesthetic blocks with objective engagement markers (Ross et al., 2014; van Duijn et al., 2010). So while a patient does not lose the ability to perceive beauty in the world, in music, art, or nature, often the emotional response is lost that produces the sense of wonder or joy at having the privilege to experience it. On the cognitive front, the very executive deficits that define HD add yet another layer of complexity to life with aesthetics. Deficits in planning, organization, and abstraction could restrict understanding of the complexity of artistic creations, musical narratives, or symbolic content (Schwartz, 2010). This flattening or blunting, an inability to connect deeply to the sources of beauty, for many is one of the most distressing aspects of the disorder, not only because it means pleasure is lost, but also because it means a vital aspect of selfhood is gone (Atkins et al., 2024).

Moreover, it is important to recognize that people living with HD may perceive and respond to art in many ways. In those who have strong family support and/or a good therapist, simply being around good music, pictures, and aesthetically friendly environments can be a kind of comfort. Such moments may be helpful to intentionally foster from a clinical and research perspective, for even the briefest and subtlest connections to a larger sense of personhood have the potential to support dignity and emotional wellbeing among those with HD (Schwartz et al., 2019). Given striatal degeneration, HD constitutes a stringent test for chills-based strategies: if expectancy-driven sequences still elicit phasic dopaminergic responses, transient gains in engagement and mood may be achievable; however, effects are likely smaller and more fatiguable than in PD/AD, warranting short, highly personalized blocks with objective chill detection and effort-based decision tasks to separate hedonic from motor effects. In light of striatal compromise and fatigue liability, short, personalized aesthetic blocks with embedded chill detection and adverse-event logging are advisable to separate hedonic from motor limits (Lundin et al., 2023; Simón-Vicente et al., 2024). These attempts illustrate the importance of ‘person-centered’ interventions that respect and encourage the remaining modes of expression and communication that may be present even as the disease progresses. For a better understanding of the topic Figure 2 maps the Aesthetic Triad onto syndrome-specific vulnerabilities in neurodegenerative disease (e.g., medial temporal/valuation in AD; dorsal-ventral striatal phases in PD; semantic/narrative integration in FTD; striatal-orbitofrontal reward in HD).

The “Michelangelo effect” refers to the fact that being involved in an aesthetically meaningful activity (such as making or observing art) positively influences skill learning and execution, motivation, and perception of effort (Iosa et al., 2022). Clinical findings, especially based on recent work conducted in stroke populations, emphasize the effectiveness of immersive virtual art therapy protocols based on neuroaesthetic guidelines. For example, De Giorgi et al. (2023), exemplify this strategy with a study where stroke patients engaged in virtual art therapy (VAT), where patients were presented with environments that resembled the ones in which masterpieces of art were painted. Compared with an age-matched group who received standard rehabilitation only, the VAT group made significantly greater gains on upper extremity function, including both Barthel Index (a measure of independence in activities of daily living) and pinch strength (which doubled). Moreover, participants in the virtual art therapy group reported lower rates of muscle fatigue and greater engagement on therapy days, and quantitative findings supported the association between participation in therapy and functional outcomes (De Giorgi et al., 2023). This was supported by preliminary pilot studies (Iosa et al., 2022), suggesting that artistic stimuli presented in a virtual environment would improve not only the kinematics of movements but also the physical demand required by the patients and the task accuracy, as compared with control conditions. To strengthen causal inference, future ‘Michelangelo’ protocols should incorporate preregistered control arms matched on therapist contact and task difficulty, physiological peak-response markers (e.g., piloerection, electrodermal activity), and blinded ratings of movement quality, thereby isolating aesthetic-specific mechanisms from generic attentional arousal (Wassiliwizky et al., 2015; Grewe et al., 2007).

It is worth mentioning that the significance and emotional valence of the aesthetic stimulus seem to play an important role: patients operate with more involvement and better memory, more peacefulness, and less anxiousness when exposed to known or personally meaningful works of art (Kliem et al., 2022). This claim of the Michelangelo effect has been extended beyond painting or even 2D tasks to 3D digital sculpting tasks. Participants sculpting famous works, such as Michelangelo’s David or the Venus de Milo, in VR showed lower jerk and more coordinated bimanual movements relative to those sculpting highly irregular non-artistic shapes, especially during first exposures (Pascucci et al., 2024). While total times for the completed sets of these taxing sculptures were greater, the experience of fatigue was not higher, indicating the role that beauty and aesthetic engagement can play in buffering declining effort over a longer or more challenging task (Iosa et al., 2022). Furthermore, relationships between performance, perceived beauty, and the enjoyment of the task indicate that the art-related motivational “lift” is driven by a combination of neural-sensory priming, emotional arousal, and cognitive involvement (Kirsch and Cross, 2018; Sturm et al., 2023).

Evidence from immersive VR and virtual embodiment shows that body-ownership illusions and agency can modulate motivation and neurorehabilitative outcomes, providing a principled route to personalize aesthetic engagement and effort allocation (Slater and Sanchez-Vives, 2016; Buetler et al., 2022). At the mechanistic level, protocols can also be engineered to elicit chills by shaping expectancy, controlled repetition, harmonic tension, and motif return in order to engage dorsal-then-ventral striatal phases that support learning and pleasure (Blood and Zatorre, 2001). Personalization is now feasible: predictive models can estimate, from brief calibration and person-level features, the probability of a peak response and adapt stimulus parameters in real time to maximize chills while maintaining safety and tolerability (Schoeller et al., 2024). Embedding objective chill markers (e.g., piloerection, electrodermal activity) and preregistered control conditions will help distinguish specific aesthetic mechanisms from novelty or generic arousal. Direct evidence of dopaminergic involvement in peak aesthetic pleasure, via striatal dopamine release during music-evoked chills, supports phase-specific designs that leverage anticipation and tension-release to drive learning signals (Salimpoor et al., 2011). Figure 3 distills the Michelangelo effect: aesthetic engagement, delivered through art and digital tools, increases motivation (functional gains), improves performance, and reduces perceived fatigue via emotion-movement-brain loops. In conclusion, the Michelangelo effect reflects a most promising neural rehabilitation strategy with scientific and clinical relevance in neurorehabilitation. By incorporating aesthetic experience into a patient’s personal therapeutic journey, clinicians may assist patients in addressing their composite needs, promoting neuroplastic facilitation of function and the experience of joy, dignity, and self.

A rapidly growing literature in art therapy documents psychophysiological benefits that are mechanistically aligned with our framework. In healthy and clinical populations, 45–60 min of visual art-making is associated with significant reductions in salivary cortisol and self-reported stress (Kaimal et al., 2016). Quantitative EEG and meta-analytic syntheses indicate post-drawing shifts in alpha (and in some tasks beta) activity consistent with relaxed alertness and self-regulation (Belkofer et al., 2014). Extending beyond traditional media, a pilot mixed-methods program of virtual drawing reported improvements in affect, creative agency, and wellbeing, suggesting that immersive and multisensory parameters can be tuned to support motivation (Kaimal et al., 2020). Integrative reviews also chart the rapid uptake of digital tools by art therapists (synchronous online work, digital drawing, VR), including practice guidance around competencies, consent, and data governance (Zubala et al., 2021). Finally, museum-based ‘social prescribing’ shows clinically relevant effects on mood and engagement in older adults, bolstering ecological models of cultural participation in care pathways (Thomson et al., 2018). Methodologically, future trials should pair art-making (physical or virtual) with convergent psychophysiology, pre-registered outcomes, and equitable access provisions (device fit, digital literacy) to isolate aesthetic-specific mechanisms from generic arousal (Haiblum-Itskovitch et al., 2018; Czamanski-Cohen and Weihs, 2016).

Ethical and safety considerations are integral to neuroaesthetic protocols. First, consent must be adapted to cognitive vulnerability: a process-consent approach emphasizes ongoing assent, capacity checks, and the right to pause/withdraw without penalty (Hendriks S. et al., 2019). Second, professional codes in art therapy provide concrete guardrails for beneficence, non-maleficence, confidentiality, boundaries, and cultural humility when working with creative content and digital artifacts. Third, immersive technologies warrant explicit risk management. VR can induce cybersickness (nausea, disorientation, and visual discomfort); incidence varies with content and hardware, and protocols should incorporate screening, graduated exposure, rest breaks, seated options, and device-level mitigations (Chang et al., 2020; Ng et al., 2025). Fourth, overstimulation and agitation can occur in a minority of people with dementia during group music/art; personalization and real-time observation reduce risk and support safe cessation when needed (Ridder et al., 2013; Pedersen et al., 2017). Fifth, biosignals used to detect peak responses (e.g., electrodermal activity, piloerection images) constitute sensitive health/biometric data; governance should align with privacy-by-design and emerging ‘neurorights’ discussions addressing mental privacy and cognitive liberty (Ienca and Andorno, 2017). Finally, VR research should follow published ethical recommendations for minimizing harm and reporting adverse events (Madary and Metzinger, 2016). Collectively, these frameworks make explicit how dignity, autonomy, and safety remain primary outcomes alongside efficacy.