Bipolar Illness, Creativity, and Treatment - Springer Link

P1: FhN Psychiatric Quarterly [psaq]

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Style file version Nov. 19th, 1999

Psychiatric Quarterly, Vol. 72, No. 2, 2001

BIPOLAR ILLNESS, CREATIVITY, AND TREATMENT Albert Rothenberg, M.D.

There have been in recent years increasing claims in both popular and professional literature for a connection between bipolar illness and creativity. A review of studies supporting this claim reveals serious flaws in sampling, methodology, presentation of results, and conclusions. Although there is therefore no evidence for etiological or genetic linkages, it is still necessary to explain interrelationships in those creative persons suffering from the illness. Examples of the work in progress of artists with bipolar disorder, Jackson Pollock and Edvard Munch, illustrate the use of healthy and adaptive creative cognition—janusian and homospatial processes—in the former’s breakthrough conception during an improvement phase in treatment leading to the development of the Abstract Expressionist Movement and in the latter’s transformation of an hallucination into his famous artwork “The Scream.” Treatment options that do not produce cognitive effects are important for creative persons with bipolar disorder. KEY WORDS: creativity; bipolar illness; Jackson Pollock; Edvard Munch; homospatial process.

A number of creative people in the arts have been reliably diagnosed as having bipolar disorder (formerly manic depressive illness) such as writers Ernest Hemingway, Robert Lowell, Theodore Roethke, and Albert Rothenberg, M.D., is with the Department of Psychiatry, Harvard University. Address correspondence to Albert Rothenberg, M.D., Box 1001, Canaan, NY 12029; e-mail: albert [email protected]. 131 C 2001 Human Sciences Press, Inc. 0033-2720/01/0600-0131$19.50/0 °


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Virginia Woolf, composers Robert Schumann and Hugo Wolf, artists Jackson Pollock, probably Vincent Van Gogh, Edvard Munch, and Arshille Gorky, and actors Vivian Leigh, Dick Van Dyke, and Jason Robards. To know that such highly valued achievement is possible should therefore be encouraging for people suffering from the disorder and, as some have argued, might even help dispel some of the heavy layer of stigma connected with mental illness in general. On the other hand, it has been alleged that the illness makes creative persons more sensitive because of depressive diatheses (1) and more productive while undergoing manic episodes (2). These allegations represent a romantic notion about creativity—the saga of the suffering artist—with little evidence to support them. Only comedians such as Jackie Gleason and Dick Van Dyke have seemed to derive direct benefit in their work from manic and hypomanic tendencies. Artistic products containing depressive or manic flight of ideas content have, only at particular times in history, been of social and aesthetic interest. Despite the erroneous emphasis on the advantages of bipolar illness, its presence and effects among highly creative persons are of medical and social importance. For instance, several of the eminent creators I mentioned—Schumann, Woolf, Hemingway, Van Gogh, Gorky, Pollock—reached premature deaths through suicide or preventable accident, at a great loss to society. Mental suffering and debilitation are intrinsic factors in such illness and appropriate treatment and treatment approaches are required. Such treatment and approaches, however, are a challenge requiring knowledge of creativity and the creative processes in conjunction with the course and permutations of the disorder. Moreover, it is important to emphasize that creativity is something all prize very highly. In a special recent issue of the New York Times Magazine on the next millennium, a feature article asks “What separates humans from animals and ever more advanced machines?” and gives the answer: “We make art.” The production of art, literature, music of all types, dance, motion pictures, great inventions, scientific discoveries, political breakthroughs, exceptional business enterprise, all are due in large degree to creativity. Creative people are admired and prized, and creative achievement is widely appreciated. The creative process inspires awe and is sometimes considered virtually miraculous—many people believe it to be totally mysterious. Therefore, as the discussion to follow shall pertain to all levels of creativity, from everyday creativity in living, cooking, spare time painting and writing all the way to the achievements of Einstein and Shakespeare, it shall be focused on a highly valued and complicated process.


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REVIEW OF STUDIES OF BIPOLAR DISORDER AND CREATIVITY Presumed support for the idea of an intrinsic connection between bipolar illness and creativity has come primarily from a handful of studies. Andreasen (3,4) carried out psychiatric interviews with 30 Writers-inResidence at the University of Iowa Program in Creative Writing and with 30 controls. An incidence of 43% bipolar illness was reported in the writer group and 10% in the controls. This investigator has stated that several well-known writers such as “Philip Roth, Kurt Vonnegut, John Irving, Robert Lowell, Flannery O’Connor and John Cheever” (p. 1288) had at one time been visiting faculty in the program. Although the writer group she interviewed were matched for age, sex, and educational status with controls, the latter group consisted of the following: “hospital administrators, businessmen, social workers, lawyers, medical and computer science students” (p. 125) (4). Variables pertinent to creativity such as socio-economic class, academic or peer recognition and success, were not at all compared for the control and subject groups. Intelligence, an important variable, was only matched in a non-randomly selected second later half of the subject groups, the test period covering a span of fifteen years. Moreover, as the investigator carried out all interviews herself and no independent ratings or evaluations were carried out, investigator “blindness” was absent regarding assessments of both subjects and controls. Another confounding factor influencing the type of group selected and the diagnosis of depressive features is that the Iowa Program has long served as a retreat for writers at times of career shifts or setbacks. Jamison (5) studied a British group of 47 prizewinning artists and writers. Stating that the design of the study could not allow for systematic diagnostic inquiry regarding mania and hypomania, Jamison reported that 38% of the sample had been treated for an “affective” illness. No controls, however, were used in the study. Investigator interviews here also were not “blind” and no attempt at differential diagnosis was made. Subjects were asked only “whether or not they had received treatment, and the nature of that treatment, for a mood disorder” (p. 126), and no further diagnostic assessment was reported. This problem was compounded by the fact that subjects were self-selected which, in the absence of controls, introduces the possibility of an overrepresentation of psychiatric illness in the group. In addition, reported results were primarily only applicable to the playwright and poet subjects because numbers of designated mood disordered subjects in other categories were too


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small, e.g. 1 biographer, 1 artist, 2 novelists (calculated from given percentages). Ludwig (6) carried out an investigation of individual biographies (primarily English language) of 1004 persons reviewed in the New York Times during the period 1960–1990. The New York Times list was cross-checked with other popular biography listings. Subjects in the sample ranged from Albert Einstein and William Faulkner to Mae West and Casey Stengel. Three percent of all subjects and 10% of artists (including writers and others) were assessed as having at least one episode of mania during their lives compared with a cited U.S. sampling incidence of manic illness of 0.4 to 1.2%. Despite the large number of subjects studied, the Ludwig sampling of primarily popular and celebrity biographies, exclusive reliance on single biographical sources, and use of nonprofessional assessors for constructing psychiatric diagnoses, limit the validity of the investigatory conclusions. Although biographies may provide reliable information of various types, they are primarily non-professional secondary sources which often tend to include, even emphasize, the disabilities and foibles of famous people. For diagnostic purposes, therefore, they are often misleading. Major biographers refused over several years to write a biography of the comedian Jack Benny because he lived what was considered an uninteresting happy life. Biographies (English language) have been published for 100% of American and English Nobel Laureates in Literature but for only 6% of all American and English Nobel Laureates in Economics, Peace, Physics, Chemistry, and Medicine (Physiology) combined (7). Famous writers are clearly popular as biographical subject and anecdotal and hearsay accounts of flamboyant or aberrant behavior, often richly elaborated, may be prima facie construed as evidence for psychopathology. In a survey claiming published evidence for a connection between bipolar illness and creativity, Andreasen and Glick cited studies by Juda (8), Ellis (9), and McNeill (10). Juda (8) investigated, primarily through psychiatric interviews, 294 German artists and scientists. She, however, reported an incidence of only 1.3% manic-depressive psychosis and, for her overall results, concluded the following: “There is no definite relationship between highest mental capacity and psychic health or illness, and no evidence to support the assumption that the genesis of highest intellectual ability depends on psychic abnormalities” (p. 306). Ellis (9) studied the biographies of 1,020 eminent persons listed in the British Dictionary of National Biography and diagnosed the following: 4.2% insane, 8% melancholic, 5% with traits suggestive of a personality disorder. No bipolar or manic-depressive


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illness was diagnosed in this early account and no behavior suggestive of that condition was described. In his study attempting to determine familial and genetic associations between creativity and mental illness, McNeill (10) assessed 72 Danish adopted subjects and their relatives, the subjects being designated as highly creative on the basis of having had official recognition in the fields of performing arts, graphic arts, literary pursuits, science, and commerce/business. He found only one subject with manic depressive psychosis, and one and two subjects respectively in the possibly related categories of affective reaction and reactive psychosis. Richards, Kinney, Lunde et al (11) also drew their subjects from a Danish adoption study, using documented diagnostic assessments of 77 adoptee relatives and then assessing creative accomplishments. Three levels each of vocational and avocational creativity were defined. The following example presented of the vocational category of “high peak creativity” indicates different types of criteria for creativity or eminence than those considered in data from the studies already cited: “Entrepreneur who advanced from chemist’s apprentice to independent researcher of new products before starting a major paint manufacturing company, and whose operation surreptitiously manufactured and smuggled explosives for the Danish Resistance during World War II” (p. 285). Results failed to demonstrate a connection between such presumably peak creativity and manic depressive illness but instead did show an association with cyclothymic disorder (chronic fluctuating mood disturbance involving numerous periods of hypomanic symptoms and of mild depressive ones). Richards, Kinney, Lunde et al interpreted this result as suggesting that the creative subjects had a “bipolar liability” (p. 287) rather than manifest bipolar illness. Overall, therefore, there is little evidence for an association between bipolar or manic-depressive illness and creativity. Because of the possibly highly detrimental effects when the disorder does occur in creative people, however, it is necessary to attempt to understand and explain interrelationships. To do this, some clarification of the empirically defined nature of creative thought processes is required. JANUSIAN AND HOMOSPATIAL PROCESSES In previous investigations, I have found evidence for specific forms of creative cognition, the janusian (12–16) and homospatial (12–26) processes. The janusian process (the name derives from the Roman god Janus whose multiple faces looked simultaneously in 4–6 opposite directions) consists of actively conceiving multiple opposites or antitheses


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simultaneously. During the course of the creative process, opposite or antithetical ideas, concepts, or propositions are consciously conceptualized as simultaneously co-existing. Although seemingly illogical and self-contradictory, these formulations are constructed in clearly logical and rational states of mind in order to produce creative effects. They occur as early conceptions in the development of artworks and scientific theories and at critical junctures at middle and later stages as well. Because they serve generative functions during both formative and critical stages of the creative process, these simultaneous antitheses or simultaneous opposites usually undergo transformation and modification and are seldom directly discernible in final created products. They are formulated by the creative thinker as central ideas for an artwork and solutions in working out practical and scientific tasks. The homospatial process (the name derives from the Greek homiois, meaning the same) consists of actively conceiving two or more discrete entities occupying the same space, a conception leading to the articulation of new identities. In this process, concrete entities such as rivers, houses, human faces, as well as sound patterns and written words, are superimposed, interposed, or otherwise brought together in the mind and totally fill its perceptual space—the subjective or imaginary space experienced in consciousness. Superimposed images may be derived from the visual, auditory, gustatory, olfactory, or tactile sensory modes. These processes have been identified in the creative work of Nobel laureates (15,16) in science and literature and other outstanding creative people. Although they are unusual and difficult to use, the evidence indicates that they are adaptive and conscious healthy processes. Despite a given artist’s mental illness, therefore, and despite the suffering it may cause, creative production is carried out by healthy mental processes during periods of lowered symptom activity and anxiety. I shall illustrate the operation of these healthy processes in the work of two artists who have suffered from bipolar disorder. In one case, the Norwegian Edvard Munch, a product of the illness underwent transformation into a work of art and in the other, the American Jackson Pollock, psychiatric treatment brought about a period of improvement during which a creative breakthrough occurred. CREATION OF EDVARD MUNCH’S “THE SCREAM” Edvard Munch (1863–1944) was one of the founders of the Expressionist Movement in art. A diagnosis of bipolar disorder with psychosis is based on his own diary descriptions of visual and auditory hallucinations, a multiply documented instance of his travelling throughout Europe


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manifesting manic disrupted behavior that culminated in his shooting two joints off the ring finger of his left hand, and his psychiatric hospitalization in 1908 for an intensification of auditory hallucinations, depression, and suicidal urges (23,24). He also suffered from bouts of alcoholism. In his diary, Munch recorded his initial conception in 1891 for his most famous artwork, titled in translation as “The Scream” or “The Screech” (Figure 1) as follows: “I was walking along the road with two of my friends. Then the sun set. The sky suddenly turned into blood, and I felt something akin to a touch of melancholy. I stood still, leaned against the railing, dead tired. Above the blue black fjord and city hung clouds of dripping, rippling blood. My friends went on and again I stood, frightened with an open wound in my breast. A great scream pierced through nature.” (p. 109) (25)

This experience, clearly a visual hallucination, was creatively transformed by Munch over a period of eighteen months into a work of art. The phases of that transformation are illustrated in the accompanying Figures 2–5. In his first drawing right after the hallucination, Munch showed a solitary man far in the distance leaning in profile over a bridge and looking at the sky and a boat on a small lake (Figure 2). As an observer of the scene, the man was quite separate from the elements of nature depicted. In the next version, a painting (Figure 3), the still-profiled leaning solitary man was by Munch portrayed in the front portion of the scene where he then appeared closer both to the lake and the viewer of the artwork. Introduced into the next charcoal drawing (Figure 4) was a round bowler hat on the man as he continued to look in profile at the lake. This rounded shape of the hat eventually became emphasized in the curved lines of both sky and man’s body in the completed artwork. Following this drawing, he did two more pen and ink sketches, one (Figure 5, left) depicted a round-hatted man in the same position as previously and the other showed the man, for the first time, looking frontward (Figure 5, right). This shift constituted a critical and creative change of presenting the man within and connected to the nature scene rather than turned in profile and separately observing it. In the final version (Figure 1), first done as a lithograph and later as a painting, the hatless but round headed forward facing man is portrayed with an oval open screaming mouth and with differently oriented but similarly rounded shapes in both the red sky and the man’s body. Munch had thereby visually integrated the screaming man with the scene and produced what has been described as a universal


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FIGURE 1. Edvard Munch, The Scream 1893. Oil pastel and casein on cardboard. Oslo National Gallery, Oslo. Reproduced with permission.

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FIGURE 3. Edvard Munch, Despair 1892. Oil on canvas. Thiel Gallery, Stockholm. Reproduced with permission.

FIGURE 2. Edvard Munch, Study c.1891-2. Pencil C 2001 The Munch on paper. Munch Museum, Oslo. ° Museum/The Munch-Ellingsen Group/Artists Rights Society (ARS), New York. Reproduced with permission.

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FIGURE 4. Edvard Munch, Despair 1892. Charcoal and oil on paper. C Munch Museum, Oslo. ° 2001 The Munch Museum/The Munch-Ellingsen Group/Artists Rights Society (ARS), New York. Reproduced with permission.

type of metaphor, an artwork displaying a “scream of nature” or “the scream of man and nature.” The last two steps indicate the use of a homospatial process. The artist juxtaposed the front facing round hatted man with the nature vista and, as indicated by the composition, he then mentally superimposed an image of that man upon the scene. In this way, he developed the rounded shapes of head, mouth, sky, and body and the expressive images integrating the man with nature. Although the artwork began with the psychotic experience of a visual hallucination, it was necessary for the artist to transform his initial image in work and thought over the period of more than a year to produce a creative work of art. Visual hallucinations such as Munch’s


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FIGURE 5. Edvard Munch, Despair c.1892 (both). Pen and ink. Munch Museum, Oslo. (Right: Facing C 2001 The Munch Museum/The Munch-Ellingsen viewer). ° Group/Artists Rights Society (ARS), New York. Reproduced with permission.

commonly occur in psychotic illnesses but creative processes are necessary to transform them into art. The homospatial process involving superimposition of images is a conscious, intentional form of cognition and not a product of the pathological condition. It is used to bring about innovations and unifications and, as in the case of “The Scream,” to articulate the emotional underpinnings of ideas and experiences. POLLOCK’S CREATIVE BREAKTHROUGH Jackson Pollock (1912–1956) is credited with the founding of the Abstract Expressionist Movement in art. This was the first truly American artform and its development had worldwide repercussions. Whereas up to the time of the artform’s appearance, France had been considered the


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art center of the world, abstract impressionism moved the focus of the art world to the United States where it has remained ever since. Pollock ushered in the abstract expressionist form with the genesis of a dramatic new style of painting which has been given such names as “drip painting” or “action painting.” An example drawn from his works, entitled “Number Three, Tiger, 1949” is shown in Figure 6. The initial formulations leading to the creation of this form of painting occurred while the artist was in psychiatric treatment and at a point when his bipolar illness was showing improvement. Evidence for the diagnosis of Pollock’s bipolar illness is based on the report by his treating psychiatrist Dr. Richard Hendersen of periods of “violent agitation” alternating with “paralysis or withdrawal” (p. 14) (26), another therapist Dr. Violet de Laszlo’s direct assessment that Pollock was “manic depressive” (p. 852) (27), and his wife Lee Krasner’s description of his extremes of temperament and behavior as follows: “Whatever Jackson felt, he felt more intensely than anyone I’ve known; when he was angry, he was angrier; when he was happy, he was happier; when he was quiet, he was quieter” (pp. 9–10) (26). Like Munch, Pollock also used alcohol in excess to deal with his mood upheavals. In an unusual public presentation of psychiatric treatment, Dr. Hendersen, who became Founder of the Jungian Institute in San Francisco, gave an open lecture to colleagues about his therapy of Jackson Pollock from late 1938 to September, 1940 (28). In this therapy, as is commonly practiced by Jungians, the patient Pollock regularly delivered drawings and other artwork to his sessions for analysis. Eighty three of these works were preserved by Dr. Hendersen (29). Although the exact sequence of the creation of the artworks is not known, a distinctly early one is shown in Figure 7. This and many subsequent works show the influence of his mentors, Thomas Hart Benton, Diego Rivera, Jose Clemente Orosco and other Mexican muralists. It is a large, brightly colored drawing with a suggestion of an Aztec or other native Mexican icon. There is also an otherworldliness that indicates Pollock’s known interest in surrealism at the time. In numerous other drawings done around the same period, he adopted both the styles of Picasso, portraying that artist’s earmark bull and horse, and Miro, with the frequent use of decorative seemingly suspended symbols. There was little in the early group of drawings of the generative originality of his late abstract expressionistic work. As the treatment progressed, the symbolism in Pollock’s artwork became more obscured and he began to produce the type of expressive compositions that characterized his eventual breakthrough. At this point,


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FIGURE 6. Jackson Pollock, Number Three, 1949, Tiger. Oil, enamel, aluminum, paint, string and cigarette fragement on canvas. Hirshhorn Museum and Sculpture Garden, Smithsonian Institution, Gift of Joseph H. Hirshhorn, 1972. Photographer: Lee Stalsworth. Reproduced with permission.

FIGURE 7. Jackson Pollock, Untitled. Colored pencil, lead pencil. Nielsen Gallery, Boston. ° C 2001 The Pollock-Krasner Foundation/Artists Rights Society (ARS), New York. Reproduced with permission.


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he had also sustained definite albeit temporary improvement in his illness. During the summer of 1939, he was devoid of moodiness and anxiety, attending parties where he was the only person abstaining from drinking (27). His artworks of this time, as described by curator and art critic C.L. Wysuph, showed “automatic drawing to elicit unconscious imagery; [together with] obscuring or veiling this imagery” (p. 20) (26). Pollock spoke explicitly later of working to obscure images and symbols and to express them at the same time (p. 537) (27). This breakthrough idea, which achieved representation in the drip paintings (see Figure 6 where formed images can be vaguely discerned), is an instance of the janusian process described above. Opposites of obscuring and expressing were by Pollock actively conceived simultaneously in the drawings done during 1939. The janusian process is not a matter of dialectical thinking where opposites are posited sequentially and contradictions are superseded or resolved, nor is it a matter of Jungian fusing of opposites. Opposites and contradictions such as obscuring and revealing are posited or presented simultaneously and developed into a final product. It is a conscious process and, unlike psychopathological processes, which involve rigidity, irrationality, exteme self-absorption and self-focus, the janusian process is flexible and rationally based as well as directed toward other human beings and the environment (as is the homospatial process as well). As the therapy with Dr. Hendersen progressed further, Pollock began a period of intense activity. A year later, his artist brother Sanford wrote to another artist brother Charles as follows: “[Jackson] is doing work which is creative in the most general sense of the word. . . . Although I ‘feel’ its meaning and implication, I am not qualified to present it in terms of words. We are sure that if he is able to hold himself together his work will become of real significance. His painting is abstract, intense, evocative in quality” (30). The breakthrough had occurred during the therapy with Dr. Henderson, a therapy Pollock spoke of positively for the rest of his life. Bipolar disorder, although it may exist concurrently with creativity, does not convey a special gift. Creative persons must struggle to deal with or overcome the effects of illness through psychological creative processes which are in themselves healthy and adaptive. The disorder itself, like any mental illness, brings suffering rather than accomplishment. Further testimony for this point comes from the experiences of two outstanding American poets, Robert Lowell and Theodore Roethke, both of whom had well documented bipolar illness. Lowell told an interviewer, Ian Hamilton: “One wakes, is happy for about two minutes,


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probably less, then fades into dread of the day. [Depression being] no gift from the muse, [I was unable at all to write]” (p. 40) (31). For Theodore Roethke, his wife Beatrice reported: “when Ted and I were first married he thought it [mental illness] might be a requisite, but over a period of years he revised his thinking about this, I believe. What are generally thought of as his best poems were written when he was well and out of the hospital” (p. 290) (32).

TREATMENT AND TREATMENT APPROACHES In the case of both artists suffering from bipolar disorder, a struggle away from illness seems to have given power to their art; this is sometimes true for emotionally ill creative persons in general. However, such illness itself is neither causative nor facilitative of creativity and it incurs a serious loss to society. Effective psychiatric treatment is therefore vital. One of the impediments to such treatment is that creative people themselves often erroneously believe in an intrinsic connection between suffering and mental illness. They too have followed the romantic myth of Western society that tampering with or ameliorating their illness will damage their creative talent. As a result, they often resist seeking treatment or if they eventually accept it, they are openly or covertly non-compliant. Robert Lowell, for example, frequently stopped taking lithium carbonate for extended periods of time, with resulting severe manic episodes (33). One approach to such non-compliance, either with medication regimens or with psychotherapy or both, is to apprise such patients of the evidence discussed above. By and large, creativity is improved with proper treatment rather than impeded. Another type of treatment issue is the tendency for practitioners either to overestimate or to underestimate the creative patient. Underestimation occurs when there is lack of appreciation for the complexities of creative work, the special difficulties in achieving success in artistic fields, the patient’s need for extraordinary persistence, or simply an absent aesthetic sensibility. This underestimation results in biases and faulty or even destructive therapeutic intervention and support. Overestimation may also be destructive when a therapist withholds needed interventions and courses of treatment or otherwise suspends sound clinical judgment either out of excessive fear of undermining creative work or because of awe or misassessment of the patient’s accomplishments. For example, the famous Ernest Hemingway was apparently prematurely discharged from the Mayo Clinic because of an


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overestimation of his judgment and capacities. Shortly after the author returned home, he shot himself (34). Intercurrent substance abuse, especially the abuse of alcohol, is not uncommon with creative persons suffering from bipolar disorder. The dual diagnosis of alcohol abuse, probable in the cases of the two artists discussed here, requires separate treatment in its own right. Use of substances is probably more common with creative people than in the population as a whole, the complex reasons for which are discussed elsewhere (35). One factor is that creative work itself arouses anxiety and substances are used for anxiety relief. Self-medicating use of substances is also often present in persons suffering from bipolar disorder, whether creative or not, as a way of reducing the severity of cyclical disturbances. A major treatment issue for creative persons with bipolar disorder is the risk of cognitive impairment resulting from otherwise effective treatment modalities. By and large, high levels of cognitive capacity are required for creative activities and some possible deleterious effects to this capacity result both from ECT and lithium carbonate treatment. With ECT, sometimes a critically important and life saving treatment in bipolar disorder, there is an attendant memory loss and dysfunction which is usually shortlived but may become prolonged and to some degree permanent. With lithium carbonate, Shaw and associates have assessed presumed creativity factors of associative productivity and idiosyncrasy in patients receiving that medication for mood disorder and showed a decrease in both factors (36). Judd et al have shown slower rates of cognitive processing in a population of normal persons receiving lithium carbonate for assessment purposes (37). Schou, an early pioneer in the use of this medication, qualitatively reported variable lithium effects with creative patients: some improvement in the severely ill, a decline in productivity in those who believed their creativity depended on mania, no decrease in productivity but some qualitative changes in their work in a small number of patients (38). Unless lithium carbonate and ECT are necessary for the treatment, it is usually preferable to use anticonvulsants for bipolar disorder in creative people. Carbamazapine and valproate have, over a considerable period of time at this point, clinically demonstrated high levels of effectiveness in patients with both rapid and slower cycling conditions with no definite evidence of accompanying cognitive impairment with either medication. Calcium channel blockers such as verapamil have been used with some benefit and little side effect but the greatest promise for treatment are with newer anticonvulsants such as lamotrigine, gabapentin, tiagabine. Recent studies have demonstrated the


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efficacy both of lamotrigine and gabapentin (39) in bipolar disorder with a generally high margin of safety. These medications may be effectively used alone or in combination with lower and consequently less impairing doses of lithium carbonate. Psychotherapy, with or without medication use, remains a treatment of choice for creative patients with bipolar disorder. This was illustrated above with regard to the facilitation of a creative breakthrough in the case of Jackson Pollock. Once myths about connections between creativity and mental illness are dispelled, creative persons do especially well in psychotherapy. They generally prize exploratory activity and are independent minded and therefore benefit both from the opportunity for self exploration and the intrinsic and detailed freedom of choice about change. For both highly creative persons as well as lesser ones, psychotherapy helps to resolve the conflicts and anxiety connected with creative work, bipolar disorder, and everyday life; it promotes medication compliance when necessary, and also may function as a support for the development and maintenance of a creative identity, the inner confidence and belief in one’s creative capacities, an all important factor in creativity. REFERENCES 1. Schildkraut JJ, Hirschfeld AJ, Murphy JM: Mind and mood in modern art II: Depressive disorders, spirituality, and early deaths in the abstract expressionist artists of the New York school. American Journal of Psychiatry 151:482–487, 1994. 2. Jamison K: Touched With Fire. New York, Free Press, 1993. 3. Andreasen NC: Creativity and mental illness: Prevalence rates in writers and their first degree relatives. American Journal of Psychiatry 144:1288–1292, 1987. 4. Andreasen NC, Canter A: The creative writer: Psychiatric symptoms and family history. Comprehensive Psychiatry 15:123–131, 1974. 5. Jamison KR: Mood disorders and patterns of creativity in British writers and artists. Psychiatry 52:125–133, 1989. 6. Ludwig AM: The Price of Greatness. New York, Guilford Press, 1995. 7. Rothenberg A: Unpublished manuscript. 8. Juda A: The relationship between highest mental capacity and psychic abnormalities. American Journal of Psychiatry 106:296–307, 1949. 9. Eliis HA: A Study of British Genius. London, Grant Richards, 1926. 10. McNeill TF: Prebirth and postbirth influence on the relationship between creative ability and mental illness. Journal of Personality 39:391–406, 1971. 11. Richards R, Kinney DK, Lunde I, et al: Creativity in manic-depressives, cyclothymes, their normal relatives, and control subjects. Journal of Abnormal Psychology 97:281– 288, 1988. 12. Rothenberg A: The process of janusian thinking in creativity. Archives of General Psychiatry 24:195–205, 1971. 13. Rothenberg A: Word association and creativity. Psychological Reports 33:3–12, 1973.


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