CREATIVITY AND BIPOLAR DISORDER 1

The Expression of Creativity in Individuals with Bipolar Disorder

Danielle M. Cregan

Wells College
CREATIVITY AND BIPOLAR DISORDER 2
CREATIVITY AND BIPOLAR DISORDER 3

Abstract

This paper examines the link between bipolar disorder and creativity. There is a definite link in

the direction of bipolar tendencies fostering creativity, although the mechanisms of this link

remain unclear. Neurology does not provide us with any clear anatomical connection between the

biological bases of bipolar disorder and creativity, though neurotransmitters may be implicated.

Treatment for bipolar disorder includes medication and therapy; certain types of therapy are

more conducive towards creativity, while certain types of medication can encourage or inhibit it.

A therapist absolutely must consider the effect on creativity of the treatment plan they set out for

a creatively inclined bipolar patient, or else they run the risk of noncompliance from the patient

and uselessness for the plan. Bipolar disorder cannot be treated as if it is separate from the

individual experiencing it; at its core, it is a human disorder, and to ignore the human experience

is to fundamentally misunderstand the disorder itself.

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Introduction

The purported link between creativity and mental illness has been widely publicized in

popular culture. The idea of the suffering artist is a popular conception of creativity, but how

much truth is there in this image? For centuries, mental illness and creativity have been

associated. The list of creative people with bipolar disorder is quite long, whether self-admitted

or diagnosed posthumously from their own writings or reported accounts from people who knew

them in life.

There are many famous creative people alive now who admit to having bipolar disorder,

including actor Russell Brand, rapper DMX, actor and author Stephen Fry, musician Macy Gray,

actress and singer Demi Lovato, musician Axl Rose, musician Pete Wentz, actor Dick Van Dyke,

and actress Catherine Zeta-Jones. The list expands upon the inclusion of deceased individuals,

such as the writers Robert Lowell, Theodore Roethke, Sylvia Plath, Anne Sexton, and Virginia

Woolf, and the actors Jeremy Brett, Vivian Leigh, and Jason Robards (Rothenberg, 2001). The

popular singer Amy Winehouse who died in 2011 is a good example of the intersectionality of

bipolar disorder and substance abuse. Many bipolar artists suffer from alcoholism or drug abuse,

including Ernest Hemingway, Jackson Pollock, and Edvard Munch (Rothenberg, 2001). Also,

many bipolar artists either took their own lives or lost them in accidents which could easily have

been prevented, robbing the world of countless potential masterpieces, including Woolf,

Hemingway, Pollock, composer Robert Schumann, and artists Vincent Van Gogh and Arshille

Gorky (Rothenberg, 2001).

The link between creativity and bipolar disorder is not simply a matter of illness

conferring creativity. A demonstrable link has been shown in several studies using many
CREATIVITY AND BIPOLAR DISORDER 5

assessments of creativity, but this link seems to only be active during hypomanic episodes

(Rybakowski & Klonowska, 2011). During a bout of depression, or at a time when experiencing

full-blown mania, the artist’s creative ability suffers (Rybakowski & Klonowska, 2011). As

Sylvia Plath said, “When you are insane, you are busy being insane—all the time… When I was

crazy, that’s all I was” (Wagner-Martin, 1987, p. 112).

Several different areas of the brain are implicated in the expression of bipolar disorder.

There are differences in size, shape, and volume of grey matter, lesions known as

hyperintensities in white matter, abnormalities in the corpus callosum and anterior limbic

network, and glial cell loss and demyelination in many locations in the brain (Brambilla, Bellani,

Yeh & Soares, 2009; Emsell & McDonald, 2009; Palaniyappan & Cousins, 2010). Scientists are

beginning to approach bipolar disorder as having its basis in the dysfunction of neural networks

or systems rather than in individual parts that act alone (Palaniyappan & Cousins, 2010).

It is harder to locate creativity in the brain, as creativity is a process, not an entity to be

isolated to a specific location in the brain. Unlike language, there are no certain areas in the brain

that are specifically associated with creativity, which could be in part because creativity is such a

broad term covering so many kinds of expression. The parts of the brain which ‘light up’ in

functional brain imaging (such as fMRI or PET scans) for a visual artist could be completely

different from the areas activated for a dancer, or an actor, or a writer. Studies examining

creativity focus on very limited expressions of creativity, like writing short poems (Fodor &

Laird, 2004) or designing a pen (Kowatari, Lee, Yamamura, Nagamori, Levy, Yamane, &

Yamamoto, 2009), or on standardized measures of creativity like the Creative Achievement

Questionnaire (Jung, Segall, Bockholt, Flores, Smith, Chavez, & Haier, 2010). The study of the
CREATIVITY AND BIPOLAR DISORDER 6

neuroanatomy of creativity is still in its infancy, however. As methods for gathering data are

refined and the criteria of creativity are redefined, the findings can and will probably change.

Creative people often find it to be a matter of great importance to preserve their creativity

when undergoing treatment for their disorders. Certain kinds of medication have more of a

negative effect on a person’s creative ability, while other types of medication can leave this

ability mostly unaffected, or perhaps even stimulate it further (Flaherty, 2011). The structures

that underlie creativity in the brain and the neurotransmitters implicated in creativity can be

positively or negatively affected by different drugs. It is important for everyone to express

creativity as a function of a healthy mind, but it is a more urgent matter for people who make a

living from their creative talents to have their ability preserved while receiving proper treatment

for their disorder. Some types of therapy, including cognitive-behavioral and play therapy, are

good for stimulating creative thought and can be particularly helpful to bipolar individuals

(Fodor & Laird, 2004; Rothenberg, 2001).

The experiences of bipolar individuals who follow creative pursuits are important to

remember when undertaking this topic of study. Delving into the brain and the science behind

bipolar disorder while forgetting about the human side of this equation would be remiss, as the

vital part of comprehending creativity and bipolar disorder is understanding the people who live

with and struggle with this disorder on a daily basis and their experiences working around or

through their inconsistent moods on a quest to create something greater than themselves. Many

bipolar people undergo pharmaceutical treatment or different kinds of therapy in the search for

relief from the symptoms of the disorder. The effects of medication strongly depend on which

medication is being used, but the effects of therapy can be demonstrated to be beneficial for both
CREATIVITY AND BIPOLAR DISORDER 7

the individual and the expression of the individual’s creativity. This paper will examine the link

between creativity and bipolar disorder, with an emphasis on the experiences of bipolar

individuals who participate in creative pursuits, and will explore the effects of medication and

therapy on how creative bipolar individuals express themselves.

Neuroscience

Neuroscience of Bipolar Disorder

Many studies have been conducted on the brains of bipolar individuals using different

types of imaging methods, such as magnetic resonance imaging (MRI), diffusion weighted

imaging (DWI), diffusion tensor imaging (DTI), and voxel-based morphometry (VBM) (Emsell

& McDonald, 2009). However, many of these studies have shown contradictory results, either

claiming an increase, decrease, or no change in volume in certain areas of the brain compared to

controls (Emsell & McDonald, 2009). There are, however, certain results which seem to be

supported by most or all studies, which will be the focus of this section.

The first result which has shown up across multiple studies is the presence of white

matter hyperintensities (WMH), which are lesions in white matter in the brain usually associated

with cardiac risk and normal ageing; however, these hyperintensities have been observed in

young and juvenile patients with bipolar disorder (Emsell & McDonald, 2009). WMH are also

observed in other types of affective disorders, including late-onset depression and suicide

(Emsell & McDonald, 2009). Subcortical WMHs are one of the most common findings in MRI

studies of bipolar patients (Brambilla, Bellani, Yeh & Soares, 2009). DWI suggests that

disruptions are found in areas of axonal loss and demyelination, and both DWI and DTI show

disruption of cortical white matter in both adult and juvenile bipolar populations (Brambilla et
CREATIVITY AND BIPOLAR DISORDER 8

al., 2009). Areas which are especially at risk for these disruptions are the frontal lobes, which

generate actions, and consciously register emotions and determine their intensity, as well as the

cingulate-paracingulate cortex, which is closely related to the limbic system and is implicated in

feeling strong emotions and to responding to the emotions of others (Brambilla et al., 2009;

Carter, Aldridge, Page & Parker, 2009). The cingulate cortex is also highly active during periods

of depression (Carter et al., 2009). The anterior cingulate cortex plays a central role in mood

regulation and cognition, making it a target for bipolar disorder studies, which have shown both

increases and decreases in grey matter, and reduced cortical thickness (Emsell & McDonald,

2009).

Another area of the brain in which differences between bipolar and healthy individuals is

found is the corpus callosum. MRI studies show a difference in size, shape, and signal intensity

in the corpus callosum of bipolar individuals in both adult and pediatric patients (Brambilla et

al., 2009). The corpus callosum is vital for inter-hemispheric communications, including the

relaying of emotions between left and right hemispheres, sustained attention, and context

processing, all of which are tasks which can be difficult for a bipolar person (Brambilla et al.,

2009; Carter et al., 2009). As definite identification of white matter composition can only happen

in a post-mortem examination, MRI studies can only reveal so much, but post-mortem studies

have shown reduced density of oligodendroglial cells in the prefrontal cortex, which results in

reduced myelination of neurons, leaving them unprotected (Brambilla et al., 2009). Reduced

myelination causes alterations in connectivity and cognition within the bipolar brain (Brambilla

et al., 2009). The cause of this reduction has not been discovered; however, it is hypothesized

that compromised immune systems affect myelination in major psychosis including

CREATIVITY AND BIPOLAR DISORDER 9

schizophrenia as well as bipolar disorder (Brambilla et al., 2009). Inflammatory cytokines in the

central nervous system have been associated with cognitive disturbance, and perivascular

inflammatory cells can lead to demyelination and axonal loss; the presence of these cells is a

telling predictor of demyelinating diseases like multiple sclerosis (Brambilla et al., 2009). If

bipolar disorder is another demyelinating disease, then it should be treatable with

anti-inflammatory therapy, and in fact, many antipsychotic drugs do modulate inflammation

(Brambilla et al., 2009).

Neuroscience of Creativity

There are several problems with trying to pinpoint the source of creativity in the brain.

Creativity is not like language or vision; there is no “creativity area” to be pointed at and neatly

labeled. Creativity itself is a sufficiently broad term to encompass visual art, verbal art, kinetic

art, musical art, gustatory art, and any other venture which could conceivably be considered

artistic. Not only that, but creativity extends its reach beyond the realm of art into science; the

definition of creativity as “the production of something both novel and useful within a given

social context” (Flaherty, 2005) captures scientific breakthroughs like Einstein’s theory of

general relativity and technical revolutions like the design and evolution of the iPod, which

triggered the rise of the tablet. Creativity is generally understood to involve the recombination of

ideas into something new, which implicates working memory, but that is only one step of a

process which involves such disparate ingredients as planning, inspiration, design, and

implementation of the creative idea.

Unfortunately, it is impossible to scan the brain of a person who is actively engaged in an

CREATIVITY AND BIPOLAR DISORDER 10

artistic endeavor. Scans like fMRI and PET require absolute stillness to acquire a clean scan,

which precludes the possibility of analyzing the brain patterns of a dancer, a sculptor, an author,

a chef, an actor, or a musician while they are working at their craft. Also, while inspiration can

be encouraged, it can rarely be predicted; it would be nice if a writer could say, “Hook me up to

the machine, I’m about to be inspired!” but it is neither realistic nor practical to sit around an

MRI machine waiting for inspiration to strike—and who’s to say that the actual moment of

inspiration would last long enough to get the artist into the scanner? Inspiration is usually

described as an instant in which everything comes together. In that case, it might make sense to

expect a moment of inspiration to light up several disparate areas of the brain, possibly ones

which seem to have little connection to each other. However, unless and until we develop

detailed brain scanners that don’t involve inserting people into massive machines, this subject

will remain a mystery.

Still, inspiration is only one very small part of creativity as a general concept; what does

the brain look like in the planning or design stage of a creative endeavor? Kowatari et al. (2009)

designed a study to find out. They compared the brains of university students trained in art and

design to the brains of novice students while both groups of students were coming up with new

designs for pens. This study discovered a difference in the neural networks used by skilled

students compared to novice students while engaged in the design task. While previous studies

found either a right-hemisphere dominance in creative tasks or that inter-hemispheric

communication was crucial, these studies were indirect assessments, and their results were

sometimes contradictory (Kowatari et al., 2009). This study used MRI scans and blood

oxygenated level-dependent (BOLD) signal changes to examine the brains of students while they
CREATIVITY AND BIPOLAR DISORDER 11

were presented with photographs of pens for four seconds each and asked to come up with new

pen designs for those four seconds. In between pictures of pens, the students were presented with

a fixation cross and asked to refrain from designing (Kowatari et al., 2009).

Regions of the brain which were activated in both novice and expert groups included the

right inferior frontal gyrus, the prefrontal cortex, the bilateral occipital cortices, bilateral inferior

temporal cortices, and bilateral hippocampus. In the expert group, only the right prefrontal cortex

and parietal cortex were activated, but the activation was bilateral in the novice group. Only the

novice group experienced activation of the anterior cingulate cortex; there was no significant

activation in that area in the expert group (Kowatari et al., 2009). One further difference was

found in the BOLD signal; the expert group showed a negative BOLD signal change in the

parietal cortex, while the novice group showed a positive signal change (Kowatari et al., 2009).

Since the anterior cingulate cortex was only activated in the novice group, that activation may

represent the difficulty of the task rather than any creative efforts; the areas of the brain which

were obviously implicated in creative efforts in both groups were the prefrontal cortex and the

parietal cortex, and the right side of each was clearly dominant over the left side in the expert

subjects (Kowatari et al., 2009). The parietal cortex is implicated in spatial awareness and

movement, and the prefrontal cortex is involved with emotional control, consciousness, the

ability to multitask, and decision-making (Carter et al., 2009). Interestingly, the anterior

cingulate cortex is activated when feeling emotional rejection or physical pain, as well as when

performing difficult tasks (Carter et al., 2009).

The only area of the brain which is activated in both bipolar disorder and during creative

endeavors (as measured by this one study) is the cingulate cortex, and in individuals with
CREATIVITY AND BIPOLAR DISORDER 12

experience in that sort of creative endeavor, the cingulate cortex does not activate. Also, the

cingulate cortex is highly active during periods of depression; creativity is actually suppressed

when depression is at its peak. What, if any, is the relationship between bipolar disorder and

creativity in this structure of the brain? Perhaps it is not the structure itself, but the chemicals

within the brain which provide the connection. Most medication does not have an effect on the

physical structure of the brain, but it does have an effect on the neurotransmitters which affect

how the brain works. If the connection is in the chemicals, then the role of medication in treating

bipolar disorder is absolutely vital in preserving creativity while controlling depression and

mania.

Effects of Medication on Creativity and the Brain

When discussing bipolar disorder, the first medication that comes to most people’s minds

is lithium, and for good reason. Lithium was the first drug approved for the treatment of bipolar

disorder, and it has been in use since the 1950s. It is effective for many people, although anyone

on lithium must have frequent blood tests to monitor the level of the drug in their system, as it

has a very narrow therapeutic index (Belmaker, 2004). The effects of lithium are partly due to its

neuroprotective qualities; it increases grey matter volume in both bipolar and healthy subjects,

particularly in the cingulate cortex, prefrontal cortex, and hippocampus (Brambilla et al., 2009).

However, the neuroprotective effects are more obvious in the brains of bipolar patients with

deficiencies in grey matter than in healthy brains which are of normal size and biochemistry

(Brambilla et al., 2009). There are suggestions that lithium and some other mood stabilizers

could promote myelination, but there has not been enough research to support this statement

conclusively (Brambilla et al., 2009). Lithium can have a positive effect on creativity by
CREATIVITY AND BIPOLAR DISORDER 13

stabilizing a bipolar person’s mood enough to allow them to be productive, but once mood

stabilization has been reached, it can have a negative effect on associational productivity and

idiosyncrasy, which are important for synthesizing unrelated ideas into new concepts (Flaherty,

2011). Still, lithium is one of the safer drugs for creativity which treats mania, along with

lamotrigine and oxcarbazepine.

The midbrain is the area of activation for driving creative motivation via

neurotransmitters sent from neurons to the cortex. Especially important in motivation and

creativity are dopamine and serotonin (Flaherty, 2011).

Dopamine. Dopamine is highly implicated in motivation and imagination and increases

approach to positive stimuli, so it is closely related to reward-based drives and curiosity

(Flaherty, 2011). It improves working memory, facilitates mental associations, and enhances

mental imagery, including hallucinations (Flaherty, 2011). The goal-directed activity of manic

patients is a result of dopaminergic activity, and dopamine agonist drugs may stimulate

creativity, but they also run the risk of causing impulse control problems, compulsive spending,

hypersexuality, and hallucinations (Flaherty, 2011). Strangely, when a dopamine agonist

stimulates creativity, it is often in a field unrelated to the original interests of the

patient—spurring poetry from an artist, or sculpture from a dancer (Flaherty, 2011). When trying

to preserve creativity, dopamine agonists are better than dopamine antagonists like neuroleptics,

but caution must be taken to keep from launching the patient into a flurry of manic high-risk

activity (Flaherty, 2011).

Serotonin. Serotonin also regulates motivation; however, unlike dopamine, it decreases

CREATIVITY AND BIPOLAR DISORDER 14

withdrawal from aversive stimuli rather than increasing approach to positive stimuli (Flaherty,

2011). Unfortunately, serotonin can inhibit dopaminergic activity, which can lead to the

inhibition of goal-oriented behavior (Flaherty, 2011). Some of the most commonly prescribed

medications for depression and anxiety are Selective Serotonin Reuptake Inhibitors, or SSRIs.

SSRIs are good for lowering avoidance motivation, making them useful in treating social anxiety

or interpersonal hypersensitivity, but they can also reduce appetitive motivations like curiosity

and libido, which has a negative effect on creativity (Flaherty, 2011). While creative persons

could benefit from caring less about other people’s opinions of them and their work, social

nuance is important for many forms of creativity, and SSRIs may numb a person’s interpersonal

sensitivity to the point where it impacts the work they produce (Flaherty, 2011). There are a few

alternatives to SSRIs which can be taken instead of or in combination with them: bupropion, an

antidepressant dopamine agonist, can improve creativity and combat SSRI apathy even if the

SSRI is continued; lamotrigine, a mood stabilizer, can replace conventional antidepressants for

bipolar patients; also, cognitive-behavioral therapy can be used to treat many of the symptoms of

anxiety and depression that SSRIs are meant to help (Flaherty, 2011).

Pharmaceutical therapy is almost always necessary for the treatment and maintenance of

bipolar disorder. It is important for a prescribing therapist to keep in mind the needs of their

patients; generally speaking, stimulating medications are more helpful for the preservation of

creativity than sedating ones, and the benefits of psychotherapy should not be forgotten in

developing a treatment plan (Flaherty, 2011). There are several kinds of therapy which could be

effective in the treatment of a bipolar person, which will be addressed in the next chapter.
CREATIVITY AND BIPOLAR DISORDER 15

Scientific Evidence of the Link between Bipolar Disorder and Creativity

Measure of Creativity in Bipolar Individuals

The link between bipolar disorder and creativity has been postulated and explored in

many studies, not only in bipolar people themselves but also in their first-degree relatives.

Creativity is strongly linked to the mood changes that are part of bipolar disorder, especially the

upswing into hypomania and mania.

A study performed by Rybakowski and Klonowska (2011) measured creativity and

schizotypy in bipolar individuals compared to healthy age-matched individuals using the Revised

Art Scale (RAS) (Barron & Welsh, 1952) and the “inventiveness” battery of the Berlin

Intelligence Structure Test (BIST) (Jäger, Süss & Beauducel, 1997). They also measured the

effects of an acute affective episode, whether manic or depressed, on an individual’s creativity.

There was little difference between bipolar and control subjects on the RAS, but markedly higher

results for bipolar individuals on the BIST. Additionally, the study did not show a significant

difference between creativity when measured during a manic episode and during remission.

However, there was a marked difference between creativity when measured during a depressive

episode and during remission, and the negative effect was directly correlated with intensity of the

depressive episode (Rybakowski & Klonowska, 2011). These findings seem to contradict the

commonly made assumption that creativity increases with a manic episode, and actually the

study found that as a manic episode deepened, creativity was slightly negatively impacted. The

time at which a bipolar person’s creativity was at its optimum was during remission of all

symptoms.

Mental Imagery
CREATIVITY AND BIPOLAR DISORDER 16

Another measure of creativity is mental imagery. When a person’s mental imagery is

more vivid and has more of an effect on their mental state, their creativity is heightened. In the

case of bipolar disorder with comorbid anxiety disorder, however, this can be a very negative

thing. Up to 90% of patients with bipolar disorder may present with a comorbid anxiety disorder

within their lifetimes, and there is a hypothesis that symptoms of anxiety may be necessary for

the development and full expression of bipolar disorder (Holmes, Geddes, Colom & Goodwin,

2008).

As mental imagery amplifies and feeds back into emotional states, it can have an effect

on both negative and positive affect. A panic attack can be heightened by a feedback cycle of

negative imagery spiraling the affected person into a deeper state of anxiety, but a hypomanic

state can also be amplified by imagery feeding into mood elevation and pushing affect into a

higher state of positivity. This can quickly rise up into a manic state fuelled by vivid imaginings

of a desired goal which may be overambitious and out of the person’s reach, because manic

people do tend to set extreme goals for themselves while in the grip of a manic episode (Holmes

et al., 2008).

Mental imagery can encompass both past events being relived in a person’s mind, and the

anticipated results of future events as they play out through imaginings; either of these has the

possibility to either elate or alarm a person, and there is evidence that bipolar individuals are

highly susceptible to the change in affect that can be brought about through imagery, especially

uncontrollable, compulsive thoughts (Holmes et al., 2008). These changes in affect can amplify

either end of the emotional spectrum, as well as contribute to the rapid mood swings which are

characteristic of certain types of bipolar disorder. Mental imagery can be contrasted to

CREATIVITY AND BIPOLAR DISORDER 17

rumination, which is a verbal process of negative thinking and consideration of implications of

negative thoughts, compared to the primarily imagistic thinking involved with mental imagery.

Rumination is a process found in both bipolar and unipolar depressive people. Imagining

negative outcomes coupled with the relative absence of imagining positive outcomes is

implicated in mood dysphoria (Holmes et al., 2008). Positively affective imagery is an important

difference between mania and depression, and it is possible that by retraining oneself to produce

positive visualization through cognitive-behavioral therapy, a person could in effect change their

own mood status and remove a depressive state. Creativity would assist greatly in this process; it

is possible that the tendency toward imagery confers creativity just as much as a tendency toward

creativity confers more vivid imagery.

Effective Therapy for Bipolar Disorder

Cognitive-behavioral therapy. One type of therapy which has often been explored in the

treatment of bipolar disorder is cognitive-behavioral therapy (CBT). In light of the poor

compliance rates for taking psychotropic medication in the bipolar community—estimates range

from 30-50% noncompliance on a regular basis—CBT can be the most effective type of therapy

a patient undergoes (Reilly-Harrington & Knauz, 2005). Also, one must take into account the

fact that even medication-compliant individuals have a 50% chance of having another mood

episode; therapy that helps the individual manage his or her own mood and recognize the

symptoms of an upswing or a downswing can be of vital importance in mitigating the effects of a

mood swing before they can develop to the point where they start negatively affecting the

individual’s life (Reilly-Harrington & Knauz, 2005). CBT combines cognitive therapy, which
CREATIVITY AND BIPOLAR DISORDER 18

restructures dysfunctional patterns of thinking and replaces irrational beliefs, with behavioral

therapy, which modifies behaviors which are maladaptive, in order to help bipolar patients

achieve several goals. These goals include understanding their disorder in order to self-monitor

and to adhere to treatment better, using coping mechanisms to manage their mood and prevent

relapse, and addressing problems which are specific to the individual which arise from the

disorder itself (Szentagotai & David, 2011).

CBT can be used in combination with other forms of therapy, like talk therapy and

medication therapy, and in fact has a positive effect on treatment adherence, clinical symptoms,

cognitive-behavioral etiopathogenic mechanisms (such as coping skills), and quality of life,

without adding anything to treatment costs (Szentagotai & David, 2011). The effect generally

falls into the “low to medium but still significant” range, except for treatment adherence, which

has a medium effect. Also, patients who undergo CBT display longer periods of euthymia

(normal, non-depressed affect), significantly fewer mood episodes, better ability to respond to

early warning signs of episodes, and better medication compliance than patients undergoing

standard care of medication and talk therapy (Reilly-Harrington & Knauz, 2005). A type of

therapy that shows benefits to such a wide range of domains without adding anything to the cost

should be more widely adopted when treating bipolar individuals. The specific arena in which

CBT would be helpful to a creative bipolar person is cognitive-behavioral etiopathogenic

mechanisms, which help to restructure thought processes. For a person who falls into the trap of

negative mental imagery, having the knowledge of how to shift to more positive imagery could

keep him or her from being pulled into a downward spiral of negative cognition. For a person

who doesn’t use mental imagery, perhaps learning to do so would help in maintaining a positive
CREATIVITY AND BIPOLAR DISORDER 19

affect for longer. The emphasis CBT places on monitoring mood state could be very helpful to a

creative bipolar person who is trying to chart the ups and downs of their mood and relate them to

creative output.

Play therapy. Another form of therapy which could be very valuable for fostering

creativity in a bipolar patient is play therapy. The “edge of chaos” theory postulates that

creativity occurs where loosely associated items and ideas come into combination, which

happens readily during mood surgency when positive affect results in defocused attention,

allowing multiple interpretations and ways of approaching the material (Fodor & Laird, 2004).

By encouraging such divergent perspectives and ideas, play therapy can result in more creative

thoughts and allow those with creative talents that might be in remission due to negative affect to

raise their mood in a controllable and stable environment.

The study conducted by Fodor and Laird (2004) compared the effects of play therapy on

creativity in college students with “bipolar inclination” (a high score on the MCMI-III Bipolar:

Manic scale, but no official DSM diagnosis) to a control group of students, and also compared

the play therapy group with a group that underwent a control which was not meant to raise their

affect. The play therapy that was used was based on techniques designed by Barnes for use with

both children and adults, and included questions like “Tell me about a “healing place” you like to

go to. Why is this place especially comforting to you?” (Fodor & Laird, 2004). The questions

were intended to have a positive effect on affect, without triggering negative memories or

unpleasant emotions. The play therapy also included various art exercises, including “Draw a

favorite thing. It can be anything, as long as it makes you happy” (Fodor & Laird, 2004). The

control group read and interpreted children’s stories from different cultures around the world.
CREATIVITY AND BIPOLAR DISORDER 20

The study measured creativity by having participants write haikus, which were then graded on

several dimensions by students who had completed a literary creativity course (Fodor & Laird,

2004).

The results of the study showed that individuals with bipolar inclination responded to the

play therapy with more creativity than individuals without the inclination, and with much more

creativity than individuals in the control group (Fodor & Laird, 2004). The higher a person’s

score on the Bipolar: Manic scale, the more creativity was revealed in their haiku after

undergoing play therapy. Also, the more a person of bipolar inclination had their mood lifted by

play therapy, the more creative their poetry, in comparison to persons of bipolar inclination

whose affect was less enhanced by the therapy. These results suggest that literary creativity can

be enhanced in bipolar patients by undergoing Barnes’s play therapy procedure (Fodor & Laird,

2004). However, the study also showed that simply having bipolar inclination did not provide a

creative advantage, as those with the inclination in the control group showed roughly the same

level of creativity as those without it in the control group, and around the same level as the

persons without the inclination who underwent play therapy. One question the study could not

answer regarded the duration of the effects of the therapy. Would the creative effect last past the

therapy session? Would a person undergoing this kind of therapy regularly see an enduring

enhancement of their creativity, or do the effects wear off after a few hours or days?

The expression of creativity can also be used as a form of therapy in and of itself. A

biography written about the poet Anne Sexton describes the importance of creative expression in

her treatment: “The sheer existence of the task of writing poetry, through which she could

describe her pain, her confusion, and her observations, provided a critical sense of self-esteem…
CREATIVITY AND BIPOLAR DISORDER 21

writing poetry, in Sexton’s case, became part of the therapy. Any work that elicited approval

would, quite obviously, assist in the repair of self-esteem” (Middlebrook, 1991). Giving a patient

a homework assignment to do some creative writing could be a valuable tool for the treatment of

bipolar disorder. Even the suggestion of keeping a diary could be helpful to a bipolar person,

combining creativity with record-keeping. “Keeping a journal and reading the previous night’s

entry helped me be objective about my mental state” (Powell, 2008). I personally have found this

to be a very helpful technique for accurate mood monitoring over any length of time.

The Experiences of Creative Bipolar Individuals

The effect of becoming medicated can be life-changing for a bipolar person. Having

sanity return to you is a wonderful experience. Finally feeling a sense of control over your own

life is almost impossible to describe to a person who has never felt a lack of it. However, it is not

an overnight process, and very often it takes trial and error to discover the right combination of

medications to keep a person stable, during which time the person is subjected to mood swings

and side effects that range from the relatively benign—shaky hands, dry mouth—to the

unpleasant—nausea, weight gain, constant sleepiness, insomnia—to the downright

life-threatening—the potential fatal rash, Stevens-Johnson Syndrome, that can be a side effect of

Lamictal. For a habitually creative bipolar person, the side effects can be pointed and damaging

to their creative expression, as Chase Twitchell (2008) describes:

Most people probably wouldn’t even notice if words came to them more slowly, or if

metaphors had to be hunted down rather than presenting themselves freely. But

for a poet, it’s crucial. For me, the most bothersome side effect of nearly every

antidepressant I’ve taken is that my metaphor-making faculty is affected. It’s as if

CREATIVITY AND BIPOLAR DISORDER 22

someone has turned off the spigot. I can still make the imaginative connections

and find the words eventually, but it takes longer and requires far more

doggedness than it did before medications. I know this to be true because, on

numerous occasions, I’ve tried to do without the drugs, whose other side effects

can be rough. Each time the withdrawal was unbearable, but during the brief

periods in which I was unmedicated, language came back to me (p. 176).

There is a high incidence of noncompliance with medication in the bipolar population when

taken as a whole; no one has examined the rates of noncompliance with specifically creative

bipolar people, but it is far from uncommon for an exasperated, well-medicated, creatively

blocked bipolar individual to go off their medication in a desperate attempt to get back that

divine spark that used to animate their days, however emotionally unbearable those days used to

be. The experiences of Kathleen Maxon, Wells Class of 2012, illustrate this point:

I feel like the medication dampers the intensity of my creativity. Instead of ideas just

coming to me in moments of brilliance, I have to put in a lot more effort and work really hard to

produce the same level of creativity. It's almost like there is a door blocking the thoughts from

getting more creative, more out of control. Sometimes I'll go off of my medication for a few

days if I have a paper to write, just because I know I can produce my best work when I'm not

on the medication. But then it gets out of control, the hypomania that makes me productive

progresses to full blown mania, hallucinations, delusions, paranoia, and not sleeping for

days. Then I crash to a deep depression. So, I feel like I am sacrificing my creativity for

stability. It's frustrating (K. Maxon, personal communication, November 12, 2011).

However, for some, it’s not worth the ease of hypomanic writing to go off medication even for a
CREATIVITY AND BIPOLAR DISORDER 23

few days. Some artists find themselves useless when they’re not properly medicated, and even

though the extremes of emotion may be blunted, at least they can put the words in some kind of

logical order rather than psychotic rambling. Ren Powell (2008) talks about her experience with

medication:

It curbed my exuberance just as it curbed the self-loathing that made me consider suicide.

I found, and find, inspiration for poetry at the edges of that emotional continuum. When

I’m on medication I do sometimes miss the fuzzy hallucinations and emotional highs. And

yet, without the clarity that medication has afforded me, I don’t think I could write the

poems. (p. 52)

As both a creative writer and a poet for the majority of my life, since well before I was

diagnosed with rapid-cycling bipolar II disorder, I have been intimately acquainted with

hypomanic writing sprees, the crash of depression, and the long stretch of writer’s block that

accompanies certain types of medication. When I went on medication for the first time in 2004, I

was in the habit of writing sestinas, which are long poems in very strict form. I have not been

able to complete a sestina since I have been medicated, though not for lack of trying. My way

with words was altered in such a way that I can still be clever, but it is harder for me to make a

pun, and I can still write rhyming poetry and adhere to forms, but my favorite form is beyond my

reach now. When I look at the poetry I wrote in 2003 and 2004 and compare it to my work in

2011, what I find is not that my current poetry is lacking in any way, but that it is clear to see that

the way I make metaphors has changed, and my focus has shifted almost entirely to formal

poetry away from free verse. I can remember the fevered nights of writing these long, older

poems, while now my poetry happens at polite hours of the afternoon and early evening.
CREATIVITY AND BIPOLAR DISORDER 24

My creative prose writing has mostly been affected in quantity—no more weekend

binges of writing 20,000 words and barely pausing to sleep or eat—rather than quality. However,

there was a definite alteration when I switched medication in 2009. I was in a deep depression

that the combination of Lamictal (lamotrigine, an anticonvulsant mood stabilizer), Lexapro

(escitalopram, an SSRI antidepressant), and Wellbutrin (bupropion, an atypical antidepressant)

just wasn’t touching, and I was writing almost nothing at all. When I went to see a new doctor

and a new therapist after moving halfway across the state, my doctor put me on Geodon

(ziprasidone, an atypical antipsychotic mood stabilizer) and Wellbutrin, and gave me Ambien

(zolpidem, a nonbenzodiazepine hypnotic) to help with the insomnia, and within three months of

starting this new combination of medication my creative output was back up to 30,000 words a

month. That was a good limit, giving me time outside of the muse’s grip to take care of myself

while also making me feel highly productive.

I also believe that my creativity has benefited from therapy. My old therapist (who was

also my psychiatrist) engaged in pure talk therapy, just letting me babble on for an hour with

brief interjections to tell me I was doing something wrong and exactly how she thought I should

fix it. She was not very helpful, and I did not trust her at all by the time I moved away. My new

therapist is a woman who does a lot of work with children; the first time I met with her, she had

me tell her about myself, and then we spent some time doing play therapy with a sandbox. She

has had me do various creative things during our sessions in an effort to express myself more

completely, and I do feel like I have benefited from these exercises. We do not do them very

often, as I find it very easy to simply talk through the entire hour I meet with her each month, but

seeing the results of the study on play therapy has encouraged me to ask her if we can
CREATIVITY AND BIPOLAR DISORDER 25

incorporate more of it into our sessions.

I believe it is important for every bipolar person to be involved in their own treatment.

Not everyone will look up or understand the direct effects of medication on the brain, and it’s not

a good idea for an uneducated person to ask for a drug simply because they have heard about it,

but with the Internet making information so readily available and discussion forums making it so

easy for bipolar people to talk to each other, anyone should be able to ask their therapist to

include cognitive-behavioral therapy in their treatment plan or to incorporate aspects of play

therapy into their sessions. If a person is being bounced from SSRI to SSRI without finding any

benefit to any of them, there are several other classes of antidepressants or mood stabilizers they

could try that may help more, and without the apathy induced by that class of drug.

Discussion

Studies have shown a definite link between bipolar disorder and creativity. However, the

mechanisms of that link remain unclear. Without a specific structure in the brain clearly

implicated in both the pathology and the process, it seems safer to say that the connection is

found in neurotransmitters, which are most often the target of psychoactive medication. The

effects of different types of medication on creativity should be considered as well as the effects

they have on affect; medication should be selected to be effective in treating the mood disorder

above all else, but one which has less of a negative effect on creativity perhaps should be

favored.

The popular image of the tortured artist may have some root in fact, but the periods of a

creative bipolar person’s life during which they are actually most creative are during remission of

all symptoms and during mild hypomanic episodes. There is a negative effect on creativity
CREATIVITY AND BIPOLAR DISORDER 26

during both depressive episodes and manic episodes, so it is in the best interest of a creative

bipolar person to remain compliant with medication therapy and to be involved in

self-monitoring of mood states in order to stop a mood episode before it has a chance to really

take off.

Other forms of therapy can be used alongside pharmaceutical therapy to great effect.

Cognitive-behavioral therapy can actually increase compliance with medication therapy and

provides the bipolar person with excellent coping strategies and mental tools to use in managing

their own mood. Play therapy can stimulate the bipolar person’s creativity during a therapy

session, although the duration of the positive effects has not been studied. Also, creative

exercises can be used as a tool in therapy; having clients write poems about how they feel or

keep a journal detailing their mood on a daily basis could be very valuable over the long term,

and even if they aren’t diagnostically helpful, the creative expression could be a very positive

experience for the bipolar person.

Although some creative bipolar individuals may be tempted to go off their medication in

order to access the levels of creativity they had before being medicated, it is important to

encourage them to stay medication-compliant at all times. Working with them to find a

combination of medications which might preserve their creativity better is one way to encourage

medication compliance; adding CBT or play therapy to their treatment plan may also help.

The neuroanatomy of creativity is a recent field of study, and the studies which have been

undertaken are so disparate that it is difficult to generalize from their findings. Perhaps if further

studies adhered to a certain measure of creativity, or a specific way of imaging the brain, this

field could develop more rapidly and with more certainty in results across the board. More
CREATIVITY AND BIPOLAR DISORDER 27

studies explicitly examining the connection between bipolar disorder and creativity could return

interesting results; perhaps a study focusing on the role of neurotransmitters could be undertaken.

From the results already shown by completed studies, a shift in commonly used therapy towards

greater inclusion of CBT principles and play therapy exercises could be greatly beneficial to

many bipolar patients.

CREATIVITY AND BIPOLAR DISORDER 28

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