August 28

Creativity and mood: the ups and downs of bipolar disorder

They who dream by day are cognizant of many things which escape those who dream only by night.

–Edgar Allen Poe [1]

If the emotions are sometimes so strong that one works without knowing one works, when sometimes the strokes come with a continuity and a coherence like words in a speech or a letter, then one must remember that it has not always been so, and that in time to come there will again be hard days, empty of inspiration.

 

So one must strike while the iron is hot, and put the forged bars on one side.

Vincent Van Gogh

touchedwithfire “We of the craft are all crazy. Some are affected by gaiety, others by melancholy, but all are more or less touched.” These are the words of the poet Lord Byron, whom Kay Redfield Jamison quotes in her book Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. In this book, Jamison explores the link between so-called creative “genius” and a predisposition toward mood disorders, such as depression and, in particular, bipolar disorder (also known as manic-depressive disorder).

Jamison recounts the story of Robert Lowell, another famous poet who likely suffered from bipolar disorder. In one incident, his colleagues described him as “…excitable and talkative…behaving just as some of them hoped a famous poet would behave.” Though experiencing pleasant feelings and grandiosity is characteristic of an individual who is having a manic episode, such experiences may in fact belie the disorder. Jamison again points to Lowell’s biography: “When [his wife] became convinced that Lowell was indeed sick—over a period of two weeks his telephone calls to New York became more and more confused, lengthy and abusive—she ran up against a wall of kindly meant hostility from Lowell’s campus allies. Her version of Lowell was not theirs, even when they were discussing the same symptoms; what to her was ‘mad’ was to them another mark of Lowell’s genius.”

Even today, criteria used to diagnose bipolar disorder are subject to interpretation—there is no biological marker for the disorder, even though studies suggest it is highly heritable. Here I briefly explore the traits of the disorder before examining the propensity toward creativity and passion observed within individuals who meet criteria for this disorder.

Understanding bipolar disorder

In the U.S., mental illness is diagnosed using the DSM-5, the latest version of the Diagnostic and Statistical Manual of Mental Disorders. Though the DSM was originally created as a research tool (so that researchers had an objective way of quantifying clusters of symptoms and outcomes of disorders), a primary goal of the DSM today is to aid in diagnosing individuals who have symptoms which cause major life dysfunction so that the best treatment can be provided (which, in the case of bipolar disorder, is nearly always a medication such as lithium or, more recently, anticonvulsants and atypical antipsychotics). But individuals with a diagnosis of bipolar disorder are without symptoms for the majority of their lives (something that may contribute to medication non-compliance in a large proportion of individuals).

Diagnoses of bipolar disorder involve three primary types as currently described by the DSM-5. Cyclothymia involves the mildest symptoms of both depression and also hypomania, which is characterized by elevated mood and increased energy. Bipolar II disorder is somewhat more severe, with diagnoses requiring both (1) a hypomanic episode involving more serious symptoms and noticeable change in daily function and (2) a major depressive episode. Bipolar I is the most severe and requires only that the patient meet criteria for a manic episode—even a single such episode can land a patient with a diagnosis of bipolar I. And the criteria for a manic episode? All of the following:

  1. elevated or irritable mood lasting at least a week, including
  2. three of the following symptoms: increased self-esteem, decreased need for sleep, increased talkativeness, “racing thoughts,” distractibility, increase in goal-oriented (or purposeless) activity, and an increased engagement in activities which may have negative consequences (e.g., buying sprees);
  3. impaired social or occupational functioning or psychotic features due to mood; and
  4. an etiology that does not result from physiological effects of a substance or another medical condition.

The DSM-5 notes also that individuals with a diagnosis of bipolar I may also experience hypomanic and major depressive episodes, though these are not requirements for diagnosis. A single episode of major depression, on the other hand, leads to the diagnoses of depression, a mood disorder which is considered separately in the DSM-5’s terms.

What the DSM-5 does not do is provide an understanding of the biological and possibly genetic basis of the disorder. Twin studies place the estimates for heritability (that is, the proportion of a set of traits due to genetic, rather than environmental, factors) at about .73—suggesting that there is a strong genetic component to the disorder. Unfortunately, bipolar disorder remains largely a mystery in terms of its brain basis, though research is beginning to suggest that regulation of sleep function and circadian rhythms plays an important role.

Association of bipolar disorder and creativity

Given that the criteria for a bipolar I diagnosis require only a single manic episode lasting a week, it is perhaps not surprising that many individuals with the diagnosis may go on to be high-functioning individuals. In Touched with Fire, Kay Redfield Jamison has shown that many of history’s famous creative types, specifically poets (Dickinson, Plath), other writers (Hemingway, Faulkner), artists (Van Gogh, O’Keeffe), and composers (Handel, Tchaikovsky), are likely to have met criteria for a diagnosis of bipolar disorder. Jamison is both a prominent researcher in psychiatry who studies bipolar disorder (or manic-depressive disorder) and an individual who has a diagnosis of the disorder, lending her a unique perspective.Edgar_Allan_Poe_2_retouched_and_transparent_bg

Jamison argues that there may be a link between aspects of the disorder and creativity, particularly for writers and poets. She notes how the poet Edgar Allen Poe described his experience of heightened mood as an important component of his art: “Men have called me mad; but the question is not yet settled, whether madness is or is not the loftiest intelligence—whether much that is glorious—whether all that is profound—does not spring from disease of thought—from moods of mind exalted at the expense of the general intellect.”

This link between mood disorder and creative temperament has been observed by many other researchers and clinicians. But this link does not posit a causal role (in either direction), and only recently have systematic studies begun to examine differences in creativity between groups of artists (such as writers) and matched controls.

Empirical studies of bipolar disorder and creativity

Studying the link between a trait as nebulous as creativity and a mood disorder such as bipolar disorder, which is heterogeneous and not universally defined, poses a challenge for researchers. To do so, researchers first have to define what creativity might mean. One researcher, Nancy Andreasen, has put forth the following basic definition: “Creativity is the ability to produce something that is novel and also useful or beautiful in a very general sense.” Andreasen notes that one approach is to functionally defined creativity by choosing a specific creative group, such as writers, musicians, or artists.

A second major challenge noted by researchers is that it may be difficult to define the appropriate control group. If a “creative” group is writers, for instance, what might constitute the appropriate control? Another homogeneous group, like electricians? Or a sample from the general population? Researchers have tended to choose the latter approach.

In one study focusing only on writers, Andreasen and Canter examined rates of mood disorder in a “creative” group from the Iowa Writers Workshop compared to a control group from the nearby area matched for age and IQ. They found higher rates of both bipolar disorder (but not unipolar depression) and alcoholism in writers compared to the control group.

In another study with no control group, Jamison looked at a group of award-winning British authors. She also found high rates of individuals who had undergone treatment for a mood disorder (38% total), although poets, in particular, were the only group of writers which included individuals who had received treatment for mania.

One additional study investigating female writers compared to age- and education-matched controls found that rates of mood disorder, and bipolar disorder, in particular, were higher in the group of writers. But differences between the two groups were not constrained to mood disorder: the study reported higher rates of panic attacks, anxiety, and drug abuse in the group of writers, as well.

These studies still do not indicate any causal link between creativity and mood disorder. Moving beyond association studies, some researchers have begun to examine the mechanisms underlying functional differences in creativity in individuals with bipolar disorder. Some researchers have suggested that there are certain personality traits that might mediate this link. Individuals with bipolar disorder are more likely to exhibit openness to experience, impulsivity, and a drive to succeed. These three traits are also often associated with artistic careers—but little is known about whether individuals with bipolar disorder who are also highly creative exhibit some or all of these traits.

Bipolar disorder, creativity, and treatment

Though the link between creativity and mood disorder does not indicate that all or most artists will have bipolar disorder, there is evidence that a higher incidence rate of bipolar disorder (and other mood disorders) exists within artists, particularly writers (though also in creative professions in general), compared to the general population. While treatment for bipolar disorder has quickly advanced in the last several decades, medications used to treat the disease today are still known to have side effects ranging from extremely blunted feelings to digestion problems to lack of a sex drive. Might the use of such medicines lead to reduced creativity in high-functioning individuals with the disorder?

There is anecdotal evidence both that severe mood (mania/hypomania and depression) can enhance creativity but also that it can impair creativity. For instance, many writers from the Writers Workshop study reported that they were unable to work during periods of mania and depression. Researchers have recently suggested that the link between creativity and mood disorders may be primarily driven by individuals with milder forms of bipolar disorder, and that people with no diagnosis of a mood disorder but with a family history of bipolar disorder will also exhibit higher levels of creativity. (See also a recent NeuWrite post on the ups and downs of creativity during marijuana use.)

The evidence that bipolar disorders may be linked to creativity is compelling. Many researchers agree that this is a consideration that should be taken into account when developing treatment programs; in fact, some have speculated that “…features of bipolar illness may confer adaptive advantage to the affected individuals and/or their relatives.” Of course, bipolar disorder often comes with extremes: extreme highs may appear transcendent and beautiful, but equally intense may be feelings of lows at the opposite pole, leading, in some cases, to the irreversible consequences of suicide. Most importantly, as Jamison points out in Touched with Fire, “…there must be serious concern about any attempt to reduce what is beautiful and original to a clinical syndrome, genetic flaw, or predictable temperament.” How mood influences the complexities of the mind and creativity remains a provocative question, but an important one that could reveal great insights about our humanity.

Note: [1] Where not otherwise noted, quotes are take from Touched with Fire: Manic Depressive Illness and the Artistic Temperament.

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