Manic Depression and Creativity

Many poets such as the "McLean Poets" suffered from Manic Depression. Here is an interesting article linking creativity and mental illness...

Bipolar Disorder and the Creative Genius
HimaBindu K Krishna

Bipolar disorder, also known as manic depression, is a psychopathology that affects approximately 1% of the population. (1) Unlike unipolar disorder, also known as major affective disorder or depression, bipolar disorder is characterized by vacillating between periods of elation (either mania or hypomania) and depression. (1, 2) Bipolar disorder is also not an illness that remedies itself over time; people affected with manic depression are manic-depressives for their entire lives. (2, 3) For this reason, researchers have been struggling to, first, more quickly diagnose the onset of bipolar disorder in a patient and, second, to more effectively treat it. (4) As more and more studies have been performed on this disease, the peculiar occurrence between extreme creativity and manic depression have been uncovered, leaving scientists to deal with yet another puzzling aspect of the psychopathology. (5)

Patients with bipolar disorder swing between major depressive, mixed, hypomanic, and manic episodes. (1-9) A major depressive episode is when the patient has either a depressed mood or a loss of interest/pleasure in normal activities for a minimum of two weeks. Specifically, the patient should have (mostly): depressed mood for most of the day, nearly every day; diminished interest or pleasure in activities; weight loss or gain (a difference of 5% either way in the period of a month); insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; diminished ability to think or concentrate; feelings of worthlessness; recurrent thoughts of death or suicidal ideation or attempt. It is important to note that, except for the last symptom, all of these symptoms must be present nearly every day. (2, 7) In addition to major depressive episodes, patients with manic depression also feel periods of hypomania. A hypomanic episode must be a period of at least four days, during which the affected person feels elevated or irritated--a marked difference from the depressed period. (2, 7) The symptoms are: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual, flight of ideas or racing thoughts, distractibility, psychomotor agitation or an increase in goal-directed activity, excessive involvement in pleasurable activities that may have negative consequences. (2, 7) This change in mood is observable by others and medications, substance abuse, or another medical condition does not cause the symptoms. (7)

In contrast to hypomania is mania, which is a more extreme case of hypomania. A manic episode is a period of an elevated or irritable mood for at least one week. (2, 7) The symptoms must cause problems in daily functioning and cannot be caused by a medical condition or drugs. (7) Manic symptoms are: inflated self-esteem or grandiosity, decreased need for sleep, more talkative than usual, flight of ideas or racing thoughts, attention easily drawn to unimportant or irrelevant items, increase in goal-directed activity or psychomotor agitation, and excessive involvement in pleasurable activities which may have negative consequences. (2, 7) Lastly, bipolar disorder patients may also go through mixed episodes, which are periods when the patient meets the criteria for both a manic episode and a major depressive episode every day for at least one week. (2,7)

Due to the different mood phases, which the patient may experience, the DSM-IV (diagnostic manual of American Psychologists) has categorized two different types of bipolar disorder, I and II.

Bipolar I is characterized as any one of the following variations:
1. The patient having a manic episode without precedence of a depressive episode
2. Most recently in a hypomanic episode with at least one previous manic or mixed episode
3. Most recently in a manic episode with at least one previous major depressive episode, manic episode, or mixed episode
4. Most recently a mixed episode with at least one previous major depressive episode, manic episode, or mixed episode. (7)

Subsequently, Bipolar II is characterized as the presence or history of one or more major depressive episodes and at least one hypomanic episode, without a precedence of a manic or mixed episode. (7, 1) One of the problems with diagnosing bipolar disorder is that the symptoms may not be incredibly noticeable until the disease has progressed to a dangerous point. (4) The disorder is such that a manic phase may only last a few hours at a time. (4) That is, the episode can proceed as a few hours of mania every day for at least one week. The affected person may not mind the mania or may be in denial of the disease, and since it only lasts a few hours, no one else may even notice. (4) By the time people actually begin to notice the manic-depressive cycle (or just the mania) it has already reached a point where the patient is barely able to function normally. (4) In addition, many clinicians have difficulty first differentiating between bipolar I and bipolar II. Since the types of patients, lengths of episodes, and age of onset are very similar, the only diagnostic tool is the difference between mania and hypomania. Since the symptoms are basically the same, except for the understanding that mania is one step more severe than hypomania, many clinicians fluctuate between the two subsets before diagnosing the patient. (4) Studies are still being conducted to more accurately and quickly distinguish bipolar I patients from bipolar II patients.

Researchers are still questioning the cause of manic depression. The most popular theory is that the disorder is caused by an imbalance of norepinephrine and serotonin. (1) During manic periods there are unusually high levels of norepinephrine and serotonin while, during depressed periods, there are unusually low levels. (1) The biological explanation is also supported by strong genetic inheritance. Many twin studies have been performed which have shown a predominance of bipolar disorder among monozygotic (identical) and dizygotic (fraternal) twins, with a greater chance of inheritance in monozygotic twins. Other studies have shown that bipolar patients often have a family history of both bipolar and unipolar disorder. (2) In addition to these studies, the fact that the most common method of treatment for bipolar disorder is medication testifies to the validity of the biological theory of causation.

Treatment for manic depression consists of mood stabilizers, medications that balance the manic and depressive states experienced by patients with bipolar disorder. (6) The most common treatment, or the first medication attempted, is Lithium. Lithium increases the serotonin and norepinephrine reuptake, this causes its counterbalancing effects of mania and depression. (6, 8) Research shows that Lithium alters NA transport and may interfere with ion exchange and nerve conduction. (8) Another effect of Lithium is its ability to inhibit second-messenger systems. These systems regulate cell cycling and circadian rhythms. Cell cycling and circadian rhythms, in turn, dictate the frequency and duration of the manic-depressive moods. (6, 9) However, many patients do not respond to Lithium. Some say that this is due to the drug, while others maintain that it is due to lack of consistency in taking the drug. (6) It has been shown that Lithium in not effective for all types of bipolar disorder, so other medications have been produced to help Lithium resistant individuals. (6, 8)

Anticonvulsants are the second attempted medications to alleviate the symptoms of bipolar disorder. Valproate (VPA) and Carbamazepine (CBZ) are the two most commonly prescribed. VPA has the same efficacy as Lithium for decreasing mania as well as acting faster, which is important to some patients. (6) However, the exact mechanism of action is still unclear. Research indicates that VPA may be involved with gamma-aminobutyric acid (GABA). VPA may either enhance GABA receptor activity and/or inhibit its metabolism. (6) CBZ has similar effects as VPA. That is, CBZ is also an anticonvulsant that alleviates the symptoms of mania, and possibly depression. Unlike VPA, more is known on the mechanism of CBZ. CBZ has been associated with neurotransmitter and ion-channel systems. (6) It binds to voltage-sensitive sodium channels, decreasing the sodium influx. It promotes potassium conductance and may block dopamine receptor-mediated currents. (6) Medication seems to be the best treatment to date for bipolar disorder. Psychotherapy is also helpful, particularly cognitive-behavioral therapy, which focuses on readjusting patient's perceptions of life. (2, 3) However, patients still experience symptoms to one degree or another.

Though this psychopathology is not for one to wish, one interesting association with bipolar disorder is the creativity of those afflicted. (2, 3, 5, 7) This is not the normal creativity experienced by the above-average people (on the scale of creativity). This creativity is the creative genius, which is so rare, yet an inordinate percentage of the well-known creative people were/are afflicted with manic depression. (2, 3) Among the lengthy list are: (writers) F. Scott Fitzgerald, Ernest Hemingway, Sylvia Plath; (poets) William Blake, Sara Teasdale, Walt Whitman, Ralph Waldo Emerson; (composers) Rachmaninoff, Tchaikovsky. (10) Psychiatrists, realizing a connection greater than coincidence, have performed studies all over the world in an attempt to establish a link between bipolar disorder and creativity. (5) In the 1970s, Nancy C. Andreasen of the University of Iowa examined 30 creative writers and found 80% had experienced at least one episode of major depression, hypomania, or mania. (5) A few years later Kay Redfield Jamison studied 47 British writers, painters, and sculptors from the Royal Academy. She found that 38% had been treated for bipolar disorder. In particular, half of the poets (the largest group with manic depression) had needed medication or hospitalization. (5) Researchers at Harvard University set up a study to assess the degree of original thinking to perform creative tasks. They were going to rate creativity in a sample of manic-depressive patients. Their results showed that manic-depressives have a greater percentage of creativity than the controls. (5) There have been biographical studies of earlier generations of artists and writers which show that they have 18 times the rate of suicide (as compared to the general population), 8-10 times the rate of unipolar depression, and 10-20 times the rate of bipolar depression. (5) The additive results of these studies provide ample evidence that there is a link between bipolar disorder and creative genius. The question now is not whether or not there exists a connection between the two, but why it exists.

One common feature in mania or hypomania is the increase in unusually creative thinking and productivity. (2, 3, 5, 7) The manic factor contributes to an increased frequency and fluency of thoughts due to the cognitive difference between normalcy and mania. (2, 5) Manic people often speak and think in rhyme or alliteration more than non-manic people. (2, 5) In addition, the lifestyles of manic-depressives in their manic phase is comparable to those of creative people. Both groups function on very little sleep, restless attitudes, and they both exhibit depth and emotion beyond the norm. (2, 5) Biologically speaking, the manic state is physically alert. That is, it can respond quickly and intellectually with a range of changes (i.e. emotional, perceptual, behavioral). (5) The manic perception of life is one without bounds. This allows for creativity because the person feels capable of anything. It is as if the walls, which inhibit the general population, do not exist in manic people, allowing them to become creative geniuses. They understand a part of art, music, and literature which normal people do not attempt. The manic state is in sharp contrast to the depressive phase of bipolar patients. In their depressed phase, patients only see gloom and boundaries. They feel helpless, and out of this helplessness comes the creativity. (5) The only way bipolar patients can survive their depressed phases, oftentimes, is to unleash their despondency through some creative work. (5, 3)

Since the states of mania and depression are so different, the adjustment between the two ends up being chaotic. Looking at some works of literature or music, it can be noticed which phase the creator was in at the time of composition. In works by Sylvia Plath, for example, the readers may take notice of the sharp contrast among chapters. Some chapters she is full of hope and life, while other chapters read loneliness and desolation. Another example can be found in Tchaikovsky's music; there is a great variation among his compositions concerning their tone, tempo, rhythm, etc. In fact, some say that most actual compositions result from this in-between period because this is the only time when the patient can physically deliver something worthwhile. (3) Because the phases are so chaotic, the ideas float during the manic and depressive states, but the final, developed products are formed during the patients' "normal" phases.

However, the problem with bipolar disorder in present time is that drug treatment often vanquishes the creativity in the patient. (5) In earlier days when drug therapy was not implemented, the creativity would be free. Yet, through the attempt for affected people to cope with day to day living, their creativity must be sacrificed. It is remarkable how these "afflicted" persons exude extraordinary creativity. Therapists and researchers are on the constant search to provide treatment for the debilitating symptoms. In the case of bipolar disorder, the world benefits from the mood swings endured by a large percentage of these patients. Though their ability to function properly is of utmost concern, since the cycling between manic and depressive phases is so traumatic and energy depleting, the unusual existence of creativity of such caliber in these people is something to conserve. As more effective drug treatment is being sought after, hopefully there will be medication that will permit the creative genius of the patients and allow them to function in society as well.