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From Scientific American:

Manic-Depressive Illness and Creativity


Does some fine madness plague great artists? Several studies now show that
creativity and mood disorders are linked

by Kay Redfield Jamison

"Men have called me mad," wrote Edgar Allan Poe, "but thequestion is not yet
settled, whether madness is or is not the loftiest intelligence--whethermuch
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."

Many people have long shared Poe's suspicion that genius and insanity are
entwined. Indeed, history holds countless examples of "that fine madness."
Scores of influential 18th- and 19th-century poets, notably William Blake,
Lord Byron and Alfred, Lord Tennyson, wrote about the extreme mood swings
they endured. Modern American poets John Berryman, Randall Jarrell, Robert
Lowell, Sylvia Plath, Theodore Roethke, Delmore Schwartz and Anne Sextonwere
all hospitalized for either mania or depression during their lives. Andmany
painters and composers, among them Vincent van Gogh, Georgia O'Keeffe,
Charles Mingus and Robert Schumann, have been similarly afflicted.

Judging by current diagnostic criteria, it seems that most of these
artists--and many others besides--suffered from one of the major mood
disorders, namely, manic-depressive illness or major depression. Both are
fairly common, very treatable and yet frequently lethal diseases. Major
depression induces intense melancholic spells, whereas manic-depression,a
strongly genetic disease, pitches patients repeatedly from depressed to
hyperactive and euphoric, or intensely irritable, states. In its milderform,
termed cyclothymia, manic-depression causes pronounced but not totally
debilitating changes in mood, behavior, sleep, thought patterns and energy
levels. Advanced cases are marked by dramatic, cyclic shifts.

Could such disruptive diseases convey certain creative advantages? Many
people find that proposition counterintuitive. Most manic-depressives donot
possess extraordinary imagination, and most accomplished artists do not
suffer from recurring mood swings. To assume, then, that such diseases
usually promote artistic talent wrongly reinforces simplistic notions ofthe
"mad genius." Worse yet, such a generalization trivializes a veryserious
medical condition and, to some degree, discredits individuality in the arts
as well. It would be wrong to label anyone who is unusually accomplished,
energetic, intense, moody or eccentric as manic-depressive.

All the same, recent studies indicate that a high number of established
artists--far more than could be expected by chance--meet the diagnostic
criteria for manic-depression or major depression given in the fourth edition
of the "Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)."In
fact, it seems that these diseases can sometimes enhance or otherwise
contribute to creativity in some people.

Diagnosing Mood Disorders


By virtue of their prevalence alone, it is clear that mood disorders donot
necessarily breed genius. Indeed, 1 percent of the general population suffer
from manic-depression, also called bipolar disorder, and 5 percent froma
major depression, or unipolar disorder, during their lifetime. Depression
affects twice as many women as men and most often, but not always, strikes
later in life. Bipolar disorder afflicts equal numbers of women and men,and
more than a third of all cases surface before age 20. Some 60 to 80 percent
of all adolescents and adults who commit suicide have a history of bipolaror
unipolar illness. Before the late 1970s, when the drug lithium first became
widely available, one person in five with manic-depression committed suicide.

Major depression in both unipolar and bipolar disorders manifests itself
through apathy, lethargy, hopelessness, sleep disturbances, slowed physical
movements and thinking, impaired memory and concentration, and a loss of
pleasure in typically enjoyable events. The diagnostic criteria also include
suicidal thinking, self-blame and inappropriate guilt. To distinguish
clinical depression from normal periods of unhappiness, the common guidelines
further require that these symptoms persist for a minimum of two to four
weeks and also that they significantly interfere with a person's everyday
functioning.

During episodes of mania or hypomania (mild mania), bipolar patients
experience symptoms that are in many ways the opposite of those associated
with depression. Their mood and self-esteem are elevated. They sleep lessand
have abundant energy; their productivity increases. Manics frequently become
paranoid and irritable. Moreover, their speech is often rapid, excitableand
intrusive, and their thoughts move quickly and fluidly from one topic to
another. They usually hold tremendous conviction about the correctness and
importance of their own ideas as well. This grandiosity can contribute to
poor judgment and impulsive behavior.

Hypomanics and manics generally have chaotic personal and professional
relationships. They may spend large sums of money, drive recklessly or pursue
questionable business ventures or sexual liaisons. In some cases, manics
suffer from violent agitation and delusional thoughts as well as visualand
auditory hallucinations.

Rates of Mood Disorders


For years, scientists have documented some kind of connection between mania,
depression and creative output. In the late 19th and early 20th centuries,
researchers turned to accounts of mood disorders written by prominent
artists, their physicians and friends. Although largely anecdotal, thiswork
strongly suggested that renowned writers, artists and composers--and their
first-degree relatives--were far more likely to experience mood disordersand
to commit suicide than was the general population. During the past 20 years,
more systematic studies of artistic populations have confirmed these
findings. Diagnostic and psychological analyses of living writers and artists
can give quite meaningful estimates of the rates and types of psychopathology
they experience.

In the 1970s Nancy C. Andreasen of the University of Iowa completed thefirst
of these rigorous studies, which made use of structured interviews, matched
control groups and strict diagnostic criteria. She examined 30 creative
writers and found an extraordinarily high occurrence of mood disorders and
alcoholism among them. Eighty percent had experienced at least one episodeof
major depression, hypomania or mania; 43 percent reported a history of
hypomania or mania. Also, the relatives of these writers, compared withthe
relatives of the control subjects, generally performed more creative workand
more often had a mood disorder.

A few years later, while on sabbatical in England from the University of
California at Los Angeles, I began a study of 47 distinguished British
writers and visual artists. To select the group as best I could for
creativity, I purposefully chose painters and sculptors who were Royal
Academicians or Associates of the Royal Academy. All the playwrights hadwon
the New York Drama Critics Award or the Evening Standard Drama (London
Critics) Award, or both. Half of the poets were already represented in the
"Oxford Book of Twentieth Century English Verse." I found that38 percent of
these artists and writers had in fact been previously treated for a mood
disorder; three fourths of those treated had required medication or
hospitalization, or both. And half of the poets--the largest fraction from
any one group--had needed such extensive care.

Hagop S. Akiskal of the University of California at San Diego, also
affiliated with the University of Tennessee at Memphis, and his wife, Kareen
Akiskal, subsequently interviewed 20 award-winning European writers, poets,
painters and sculptors. Some two thirds of their subjects exhibited recurrent
cyclothymic or hypomanic tendencies, and half had at one time suffered froma
major depression. In collaboration with David H. Evans of the Universityof
Memphis, the Akiskals noted the same trends among living blues musicians.
More recently Stuart A. Montgomery and his wife, Deirdre B. Montgomery,of
St. Mary's Hospital in London examined 50 modern British poets. One fourth
met current diagnostic criteria for depression or manic-depression; suicide
was six times more frequent in this community than in the general population.

Ruth L. Richards and her colleagues at Harvard University set up a systemfor
assessing the degree of original thinking required to perform certain
creative tasks. Then, rather than screening for mood disorders among those
already deemed highly inventive, they attempted to rate creativity in a
sample of manic-depressive patients. Based on their scale, they found that
compared with individuals having no personal or family history of psychiatric
disorders, manic-depressive and cyclothymic patients (as well as their
unaffected relatives) showed greater creativity.

Biographical studies of earlier generations of artists and writers alsoshow
consistently high rates of suicide, depression and manic-depression--upto 18
times the rate of suicide seen in the general population, eight to 10 times
that of depression and 10 to 20 times that of manic-depressive illness and
its milder variants. Joseph J. Schildkraut and his co-workers at Harvard
concluded that approximately half of the 15 20th-century
abstract-expressionist artists they studied suffered from depressive or
manic-depressive illness; the suicide rate in this group was at least 13
times the current U.S. national rate.

In 1992 Arnold M. Ludwig of the University of Kentucky published an extensive
biographical survey of 1,005 famous 20th-century artists, writers and other
professionals, some of whom had been in treatment for a mood disorder. He
discovered that the artists and writers experienced two to three times the
rate of psychosis, suicide attempts, mood disorders and substance abusethan
did comparably successful people in business, science and public life. The
poets in this sample had most often been manic or psychotic and hospitalized;
they also proved to be some 18 times more likely to commit suicide thanis
the general public. In a comprehensive biographical study of 36 major British
poets born between 1705 and 1805, I found similarly elevated rates of
psychosis and severe psychopathology. These poets were 30 times more likely
to have had manic-depressive illness than were their contemporaries, atleast
20 times more likely to have been committed to an asylum and some five times
more likely to have taken their own life.

Cycles of Creative Accomplishment


These corroborative studies have confirmed that highly creative individuals
experience major mood disorders more often than do other groups in the
general population. But what does this mean for their work? How does a
psychiatric illness actually contribute to creative achievement? First,the
common features of hypomania seem highly conducive to original thinking;the
diagnostic criteria for this phase of the disorder include "sharpenedand
unusually creative thinking and increased productivity." And accumulating
evidence suggests that the cognitive styles associated with hypomania
(namely, expansive thought and grandiose moods) can lead to increased fluency
and frequency of thoughts.

Studying the speech of hypomanic patients has revealed that they tend to
rhyme and use other sound associations, such as alliteration, far more often
than do unaffected individuals. They also use idiosyncratic words nearly
three times as often as do control subjects. Moreover, in specific drills,
they can list synonyms or form other word associations much more rapidlythan
is considered normal. It seems, then, that both the quantity and qualityof
thoughts build during hypomania. This speed increase may range from a very
mild quickening to complete psychotic incoherence. It is not yet clear what
causes this qualitative change in mental processing. Nevertheless, this
altered cognitive state may well facilitate the formation of unique ideasand
associations.

Manic-depressive illness and creative accomplishment share certain
noncognitive features: the ability to function well on a few hours of sleep,
the focus needed to work intensively, bold and restless attitudes, and an
ability to experience a profound depth and variety of emotions. The less
dramatic daily aspects of manic-depression might also provide creative
advantage to some individuals. The manic-depressive temperament is, in a
biological sense, an alert, sensitive system that reacts strongly and
swiftly. It responds to the world with a wide range of emotional, perceptual,
intellectual, behavioral and energy changes. In a sense, depression is aview
of the world through a dark glass, and mania is that seen through a
kaleidoscope--often brilliant but fractured.

Where depression questions, ruminates and hesitates, mania answers withvigor
and certainty. The constant transitions in and out of constricted and then
expansive thoughts, subdued and then violent responses, grim and then
ebullient moods, withdrawn and then outgoing stances, cold and then fiery
states--and the rapidity and fluidity of moves through such contrasting
experiences--can be painful and confusing. Ideally, though, such chaos in
those able to transcend it or shape it to their will can provide a
familiarity with transitions that is probably useful in artistic endeavors.
This vantage readily accepts ambiguities and the counteracting forces in
nature.

Extreme changes in mood exaggerate the normal tendency to have conflicting
selves; the undulating, rhythmic and transitional moods and cognitive changes
so characteristic of manic-depressive illness can blend or harness seemingly
contradictory moods, observations and perceptions. Ultimately, these fluxes
and yokings may reflect truth in humanity and nature more accurately than
could a more fixed viewpoint. The "consistent attitude toward life,"may not,
as Byron scholar Jerome J. McGann of the University of Virginia points out,
be as insightful as an ability to live with, and portray, constant change.

The ethical and societal implications of the association between mood
disorders and creativity are important but poorly understood. Some treatment
strategies pay insufficient heed to the benefits manic-depressive illnesscan
bestow on some individuals. Certainly most manic-depressives seek relieffrom
the disease, and lithium and anticonvulsant drugs are very effective
therapies for manias and depressions. Nevertheless, these drugs can dampena
person's general intellect and limit his or her emotional and perceptual
range. For this reason, many manic-depressive patients stop taking these
medications.

Left untreated, however, manic-depressive illness often worsens over
time--and no one is creative when severely depressed, psychotic or dead.The
attacks of both mania and depression tend to grow more frequent and more
severe. Without regular treatment the disease eventually becomes less
responsive to medication. In addition, bipolar and unipolar patients
frequently abuse mood-altering substances, such as alcohol and illicit drugs,
both of which can cause secondary medical and emotional burdens for
manic-depressive and depressed patients.

The Goal of Treatment


The real task of imaginative, compassionate and effective treatment,
therefore, is to give patients more meaningful choices than they are now
afforded. Useful intervention must control the extremes of depression and
psychosis without sacrificing crucial human emotions and experiences. Given
time and increasingly sophisticated research, psychiatrists will likelygain
a better understanding of the complex biological basis for mood disorders.
Eventually, the development of new drugs should make it possible to treat
manic-depressive individuals so that those aspects of temperament and
cognition that are essential to the creative process remain intact.

The development of more specific and less problematic therapies should be
swift once scientists find the gene, or genes, responsible for the disease.
Prenatal tests and other diagnostic measures may then become available;these
possibilities raise a host of complicated ethical issues. It would be
irresponsible to romanticize such a painful, destructive and all too often
deadly disease. Hence, 3 to 5 percent of the Human Genome Project's total
budget (which is conservatively estimated at $3 billion) has been set aside
for studies of the social, ethical and legal implications of genetic
research. It is hoped that these investigations will examine the troubling
issues surrounding manic-depression and major depression at length. To help
those who have manic-depressive illness, or who are at risk for it, mustbe a
major public health priority.

BOX I: The Tainted Blood of the Tennysons


Alfred, Lord Tennyson, who experienced recurrent, debilitating depressions
and probable hypomanic spells, often expressed fear that he might inheritthe
madness, or "taint of blood," in his family. His father, grandfather,two of
his great-grandfathers as well as five of his seven brothers suffered from
insanity, melancholia, uncontrollable rage or what is today known as
manic-depressive illness. His brother Edward was confined to an asylum for
nearly 60 years before he died from manic exhaustion. Lionel Tennyson, oneof
Alfred's two sons, displayed a mercurial temperament, as did one of histhree
grandsons.

Modern medicine has confirmed that manic-depression and creativity tendto
run in certain families. Studies of twins provide strong evidence for the
heritability of manic-depressive illness. If an identical twin has
manic-depressive illness, the other twin has a 70 to 100 percent chanceof
also having the disease; if the other twin is fraternal, the chances are
considerably lower (approximately 20 percent). A review of identical twins
reared apart from birth--in which at least one of the twins had been
diagnosed as manic-depressive--found that two thirds or more of the setswere
concordant for the illness.

BOX II: The Case of Vincent van Gogh


Many clinicians have reviewed the medical and psychiatric problems of the
painter Vincent van Gogh posthumously, diagnosing him with a range of
disorders, including epilepsy, schizophrenia, digitalis and absinthe
poisoning, manic-depressive psychosis, acute intermittent porphyria and
Meniere's disease. Richard Jed Wyatt of the National Institute of Mental
Health and the author have argued in detail that van Gogh's symptoms, the
natural course of his illness and his family psychiatric history strongly
indicate manic-depressive illness. The extent of the artist's purported
absinthe use and convulsive behavior remains unclear; in any event, his
psychiatric symptoms long predate any possible history of seizures. It is
possible that he suffered from both epilepsy and manic-depressive illness.


KAY REDFIELD JAMISON is professor of psychiatry at the Johns Hopkins
University School of Medicine. She wrote "Touched with Fire: Manic-Depressive
Illness and the Artistic Temperament" and co-authored the medical text
"Manic-Depressive Illness." Jamison is a member of the NationalAdvisory
Council for Human Genome Research and clinical director of the Dana
Consortium on the Genetic Basis of Manic-Depressive Illness. She has also
written and produced a series of public television specials about
manic-depressive illness and the arts (and has talked openly and honestlyabout her own
manic depression. In 1996, she won the Consumer of the Year Award from AMI/FAMI-dj)

TOUCHED WITH FIRE: MANIC-DEPRESSIVE ILLNESS AND THE ARTISTIC TEMPERAMENT.Kay
R. Jamison. Free Press/Macmillan, 1993.

SCIENTIFIC AMERICAN February 1995 Volume 272 Number 2 Pages 62-67


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