• Morgana Aurielle Sciorilli

Bipolar spectrum disorder and creativity

Updated: Jun 20

Bipolar spectrum disorder (BD) – previously known as manic depression – is a mood disorder that causes extreme shifts in mood. Individuals living with the condition experience periodic cycling between mania and depression, and many share indications of enhanced creativity. Symptoms typically appear as periods of 'mania' characterised by euphoria, creativity, irritability and risk-taking, and periods of 'depression' characterised by severe lethargy, despair and feelings of hopelessness (Katz et al., 2021). Occasionally, individuals may experience rapid cycling between the two or experience both states simultaneously. This article examines the symptoms and possible causes of BD, its correlation with high levels of creativity and the various treatment options available today. In this article, established symptoms and risk factors for the disorder will be introduced adjacent to novel hypotheses. Furthermore, investigations into the links between creativity and the positive traits of BD may provide deeper insight into the genetic architecture of the illness and propose innovative strength-based approaches to treatment.

Essentially, the bipolar spectrum involves periodic experiencing of emotional extremes (American Psychiatric Association, 2013), although this can vary significantly between individuals depending on the type and severity of their condition. BD affects approximately 6% of the population when considered a spectrum disorder, with only 1% severely affected by symptoms (Greenwood, 2016). A diagnosis of Bipolar I requires that an individual has experienced at least one manic episode (American Psychiatric Association, 2013); however, the vast majority of individuals with Bipolar I have experienced at least one depressive episode as well (Katz et al., 2021). A diagnosis of Bipolar II requires a history of less severe manic episodes known as 'hypomania' accompanying at least one major depressive episode (American Psychiatric Association, 2013). Cyclothymic disorder involves rapid cycling between less severe manic and depressive episodes and is applied to describe chronic mood instability (Katz et al., 2021). Severe psychological impairment is more prevalent among those with Bipolar type I, while severe depression is more prevalent among those with Bipolar type II (Katz et al., 2021). Although the severity of symptoms may shift based on type, Bipolar spectrum disorders share the fundamental experience of alternating emotional extremes (Katz et al., 2021).

The specific causes of BD are still unknown. Although the precise reasons for developing the disorder remain unclear, numerous factors are associated with the condition. Identified risk factors for the onset of BD include having a first-degree relative with the disorder, periods of extreme stress, traumatic life events, and drug or alcohol abuse (Greenwood, 2020). There is strong evidence to suggest that mania is triggered by an excess of dopamine whereas depression is correlated with dopamine deficiency (Greenwood, 2016). Early-life trauma is also associated with an increased risk of developing BD later in life (Rantala et al., 2021). BD is thought to be largely familial, with an estimated heritability of up to 93% (Greenwood, 2016). However, despite the apparent participation of genetics, the genes associated with BD are not yet fully understood. Specifically, enhanced creative abilities also appear to exist within the bipolar spectrum and in unaffected relatives. This may suggest that substantial amounts of risk variants cause illness, but moderate amounts may hold advantages (Greenwood, 2016). It has also been observed that individuals living with BD appear to have biological variations in their brains; however, the significance of these differences is still unexplained. In the most extensive study of its kind to date, MRI scans revealed that both brain hemispheres' frontal, temporal, and parietal regions were thinner in BD patients (Hibar et al., 2017). Ultimately, further understanding of these brain variations may help researchers identify physiological causes. Interestingly, recent studies have correlated BD with low-grade neuroinflammation (Rantala et al., 2021). These findings show how stress produces inflammation and disrupts circadian rhythms, frequently resulting in mania. Given that stress is a known triggering factor for both manic and depressive episodes and a known cause of neuroinflammation (Rantala et al., 2021), reducing chronic stress could provide a protective effect. Further studies are required to establish the physiological causes of BD and more fully understand its genetic components, particularly regarding its links to creativity.

Notions of the 'creative genius' and the problematic 'artistic temperament' date back to Aristotle, and both formal and anecdotal evidence supports these notions (Jamison, 1994). Studies suggest that artists are ten times more likely to suffer from BD than the general population (Greenwood, 2016) and that both creative individuals and individuals with BD have higher mood instability, depression, and irritable temperament scores than noncreative controls (Nowakowska et al., 2005). The correlation between creativity and BD is frequently driven by biographical reports of artists who have displayed signs of being on the bipolar spectrum. It is believed that Hemingway, Faulkner, Fitzgerald, Dickens, Woolf, Handel, Rachmaninoff, Tchaikovsky, Mingus, Charlie Parker, Lord Byron, Dickenson, Plath, O'Keefe and Pollock (to name a few) were all on the bipolar spectrum (Johnson et al., 2012). No other mental illness has been so profoundly romanticised throughout history. Interestingly, a romanticised view of the illness may actually benefit patients – evidence of enhanced creativity may help improve attitudes towards the disorder when coping with its more challenging aspects. Research confirms that strengths-focused therapy can improve outcomes for patients living with chronic mental illness (Johnson et al., 2012). Recognising the positive aspects of BD may not only help patients view their illness in a more positive light, but also help reduce the stigma attached to the illness. Recognising positive aspects could be particularly useful within patients' families – creativity is significantly enhanced among first-degree relatives of those with bipolar spectrum traits (Greenwood, 2016), suggesting that some genetic features of the bipolar spectrum produce positive traits. Although creativity is highly complex and difficult to study, many of its cognitive and physiological elements resemble a shared genetic vulnerability with BD (Greenwood, 2016). It must be noted that not everyone with BD is highly creative. Additionally, a more severe manifestation of the illness may prevent an individual with BD from actualising their creative potential. However, given the overrepresentation of mood disorders among artists and creatives, further research into the correlation between creativity and BD could examine its biological causes and underlying neural networks. Creative expression is recognised to promote wellbeing, and many individuals struggling with BD consider enhanced creativity a genuinely positive aspect of their illness (Parker et al., 2012). Psychiatrists confirm that BD patients frequently abandon their medications due to self-reports of decreased creativity (Jamison, 1994). Although this discussion dates back to the time of Aristotle, research in this area is relatively new. Nevertheless, studies now provide empirical evidence to reinforce and legitimise what was once just a collection of anecdotal stories surrounding the 'temperamental artist'. A deeper understanding of these shared genetic mechanisms may provide indications towards more reliable, evidence-based treatments.

Depending on the severity of the disorder, treatment with pharmaceuticals may be necessary; however, many patients may be resistant to the notion of taking medication for the rest of their lives, and alternatives should be made available to them. Lithium has been administered as a standard treatment for BD since 1949 (Malhi and Gershon, 2009), and yet its effectiveness was largely unexplained. Recently, studies have revealed that lithium reduces low-grade inflammation, further supporting the neuroinflammation hypotheses (Rantala et al., 2021). Regrettably, one-third of patients continue to relapse despite lithium treatment (Jones, 2004), suggesting that pharmacological intervention alone is not always adequate. Numerous lifestyle interventions known to reduce stress and inflammation could be utilised in addition (or as an alternative) to medication for patients living with BD. Established lifestyle interventions include adopting a ketogenic diet (Phelps et al., 2013), maintaining a regular sleep/wake cycle, limiting alcohol, avoiding smoking, exercise, meditation, and connecting with nature (Rantala et al., 2021). The ketogenic diet has successfully treated epilepsy for decades and shows promise as a potential drug-free alternative for mood stabilisation (Phelps et al., 2013), although further studies on its efficacy are required. Additionally, stressful life events impact both the risks of initial onset and future relapses (Jones, 2004). Consequently, psychotherapy and learned coping strategies are essential tools in the management of BD. Although there is little published research concerning psychodynamic psychotherapy specifically for BD, substantial evidence shows the effectiveness of cognitive behavioural therapy for managing depressive episodes (Mace, 2005). Cognitive-behavioural therapy and self-monitoring techniques can assist patients to correct cognitive disorganisation and function better in their daily lives (Greenwood, 2016).

In summary, BD is a complex, lifelong disorder that exists on a spectrum, manifesting itself with varying degrees of severity. There is still only a limited understanding of BD's genetic mechanisms, and current treatments are far from adequate. To date, psychiatrists have predominantly managed symptoms with medication – regardless of where patients are on the spectrum – with limited efficacy and high relapse rates. The prevailing practice in psychiatry focuses on managing a patient's symptoms of BD rather than understanding a patient's actual needs and potentials (Greenwood, 2016). It is crucial to develop more effective, biopsychosocial treatments for the long-term management of BD. Treatment methods must consider the genetic and stress features of the disorder. Patients should be educated on the importance of implementing effective stress management techniques alongside medication and psychotherapy. Furthermore, strengths-based psycho-education should be made available to patients and their families to reduce stigma and foster hope. The cyclical nature of BD should be conceptualised as containing both positive and negative aspects. Mental health workers should emphasise the positive traits of the disorder to encourage patients to view their illness as a gift rather than solely a challenge. Additionally, lifestyle and dietary interventions should be proposed to patients as a self-determined means of managing symptoms. A more holistic approach toward treatment could offer patients a more empowered way to view and manage their lifelong condition. The value of research into creativity and BD is to understand the genetic pathways contributing to risk, thus facilitating better treatment options. Ideally, a holistic treatment method should include, support and maintain the advantages of creative expression whilst supporting the patient in achieving long-term mood stability. A deeper understanding of this relationship could also improve psychotherapy techniques to help patients take advantage of their illness's more positive aspects whilst supporting their daily functioning. Fundamentally, further research in this area is a significant step towards developing better patient care and understanding this complex and frequently misunderstood disorder.

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