Manic-Depressive Illness and Creativity

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Manic-Depressive Illness and Creativity Does some ﬁne madness plague great artists? Several studies now show that creativity and mood disorders are linked by Kay Redﬁeld Jamison

en have called me mad,” wrote Edgar Allan Poe, “but the question is not yet settled, whether madness is or is not the loftiest intelligence— The Author whether much that is glorious—whether all that is profound—does not spring from disease of thought—from moods of mind exalted at KAY REDFIELD JAMISON the expense of the general intellect.” is professor of psychiatry at M the Johns Hopkins University Many people have long shared Poe’s suspicion that genius and insanity are entwined. In- School of Medicine. She deed, history holds countless examples of “that ﬁne madness.” Scores of inﬂuential 18th- wrote Touched with Fire: and 19th-century poets, notably William Blake, Lord Byron and Alfred, Lord Tennyson, Manic-Depressive Illness and wrote about the extreme mood swings they endured. Modern American poets John Berry- the Artistic Temperament and man, Randall Jarrell, Robert Lowell, Sylvia Plath, Theodore Roethke, Delmore Schwartz co-authored the medical text and Anne Sexton were all hospitalized for either mania or depression during their lives. Manic-Depressive Illness. Jamison is a member of the And many painters and composers, among them Vincent van Gogh, Georgia O’Keeffe, National Advisory Council Charles Mingus and Robert Schumann, have been similarly afflicted. for Human Genome Re- Judging by current diagnostic criteria, it seems that most of these artists—and many oth- search and clinical director of ers besides—suffered from one of the major mood disorders, namely, manic-depressive ill- the Dana Consortium on the ness or major depression. Both are fairly common, very treatable and yet frequently lethal Genetic Basis of Manic-De- diseases. Major depression induces intense melancholic spells, whereas manic-depression, pressive Illness. She has also written and produced a series of public television specials about manic-depressive ill- Tennessee Williams ness and the arts.

Van Gogh painted flowers while in the asylum at Saint-Rémy.

Vincent van Gogh AP/WIDE WORLD PHOTOS

a strongly genetic disease, pitches pa- tuitive. Most manic-depressives do not eccentric as manic-depressive. All the tients repeatedly from depressed to hy- possess extraordinary imagination, and same, recent studies indicate that a high peractive and euphoric, or intensely ir- most accomplished artists do not suffer number of established artists—far more ritable, states. In its milder form, from recurring mood swings. To assume, than could be expected by chance— termed cyclothymia, manic-depression then, that such diseases usually promote meet the diagnostic criteria for manic- causes pronounced but not totally de- artistic talent wrongly reinforces simplis- depression or major depression given in bilitating changes in mood, behavior, tic notions of the “mad genius.” Worse the fourth edition of the Diagnostic and sleep, thought patterns and energy lev- yet, such a generalization trivializes a Statistical Manual of Mental Disorders els. Advanced cases are marked by dra- very serious medical condition and, to (DSM-IV). In fact, it seems that these matic, cyclic shifts. some degree, discredits individuality in diseases can sometimes enhance or oth- Could such disruptive diseases con- the arts as well. It would be wrong to erwise contribute to creativity in some vey certain creative advantages? Many label anyone who is unusually accom- people. people ﬁnd that proposition counterin- plished, energetic, intense, moody or By virtue of their prevalence alone, it is clear that mood disorders do not nec-

OS essarily breed genius. Indeed, 1 percent T

Charles Mingus HO of the general population suffer from manic-depression, also called bipolar ORLD P disorder, and 5 percent from a major depression, or unipolar disorder, during AP/WIDE W their lifetime. Depression affects twice as many women as men and most often, but not always, strikes later in life. Bipolar disorder afflicts equal numbers of women and men, and more than a third of all cases surface before age 20. Some 60 to 80 percent of all adoles-

ARTISTS, writers and composers shown on these pages all most likely suffered from manic-depressive illness or major depressive illness, according to their letters and journals, medical records and accounts by their families and friends. Re-

CHIVE cent studies indicate that the tempera- ments and cognitive styles associated with mood disorders can in fact enhance cre- MANN AR T ativity in some individuals. BET

lfred, Lord Tennyson (right), who experienced Modern medicine has confirmed that manic-de- A recurrent, debilitating depressions and pression and creativity tend to run in certain fami- probable hypomanic spells, often expressed fear lies. Studies of twins provide strong evidence that he might inherit the madness, or “taint of for the heritability of manic-depressive illness. blood,” in his family. His father, grandfather, If an identical twin has manic-depressive ill- two of his great-grandfathers as well as five ness, the other twin typically has a 70 to 100 of his seven brothers suffered from insanity, percent chance of also having the disease; if melancholia, uncontrollable rage or what is the other twin is fraternal, the chances are today known as manic-depressive illness. considerably lower (approximately 20 per- His brother Edward was confined to an asy- cent). A review of pairs of identical twins lum for nearly 60 years before he died from reared apart from birth—in which at least one MANN manic exhaustion. Lionel Tennyson, one of Al- had been diagnosed as manic-depressive— T fred’s two sons, displayed a mercurial tempera- found that in two thirds or more of the sets, the ill- ORBIS-BET

ment, as did one of his three grandsons. ness was present in both twins. —K. R. J. C

ELIZABETH MARY CHARLES (D'EYNCOURT) b. 1776 b. 1777 1784–1861 Recurrent bouts “Ferocious pessimism”; “Inherited his father’s instability of depression constant quarreling and fretfulness”; spendthrift and gloominess tendencies; expansive, grandiose activities and interests

ELIZABETH FYTCHE GEORGE CLAYTON TENNYSON 1781–1865 1778–1831 Recurrent depressive illness Manic-depressive illness “Easy-going” and Vacillating moods “between frenzy and lethargy”; Rage, unstable moods and/or insanity “sweet tempered” spendthrift; alcoholic; “fits”; insanity

GEORGE CHARLES MARY EDWARD SEPTIMUS CECILIA Died in 1808 –1879 1810 –1884 1813–1890 1815–1866 1817–1909 infancy, Addicted to laudanum; “...of a wild sort Confined in insane “Suffered from ner- “Mental disturbance 1806 “complete nervous break- of countenance”; asylum for almost 60 vous depression”; fre- and depression”; down”; had to be segregated obsessed with years; severe quent treatments for eccentric from outside world; extreme spiritualism melancholia; death melancholia; “the mood swings and from manic most morbid “recurrent fits of exhaustion of all the psychopathic Tennysons” depression” FREDERICK ALFRED EMILY ARTHUR MATILDA HORATIO 1807–1898 1809–1892 1811–1889 1814–1899 1816–1913 1819–1899 Irritability; eccentric; Recurrent depression that re- “Suffered much “Some mental derangement,” “Strange personality was violent temper and quired treatment; trances, possibly from depression”; occasionally attributed to legendary”; “rather unused volatile; obsessed epileptic but not thought so by one year in childhood accident; religious to this planet”; per- with spiritualism physician; possibly transient Crichton obsessions; “did not entirely ceived himself as vulner-

hypomanic episodes; “dwelling Institution escape the black-blooded- able to the “weakness of the T in an element of gloom” for the Insane ness of the Tennysons” Tennysonian temperament”

SOURCE: Adapted from Touched with Fire: Manic-Depressive Illness and the Artistic Temperament; based on biographies, autobiographical writings and letters. URNET LISA B cents and adults who commit suicide pression from normal periods of unhap- ductivity increases. Manics frequently have a history of bipolar or unipolar ill- piness, the common guidelines further become paranoid and irritable. More- ness. Before the late 1970s, when the require that these symptoms persist for over, their speech is often rapid, excit- drug lithium first became widely avail- a minimum of two to four weeks and able and intrusive, and their thoughts able, one person in five with manic-de- also that they significantly interfere with move quickly and fluidly from one topic pression committed suicide. a person’s everyday functioning. to another. They usually hold tremen- Major depression in both unipolar dous conviction about the correctness and bipolar disorders manifests itself Mood Elevation and importance of their own ideas as through apathy, lethargy, hopelessness, well. This grandiosity can contribute to sleep disturbances, slowed physical uring episodes of mania or hypo- poor judgment and impulsive behavior. movements and thinking, impaired Dmania (mild mania), bipolar pa- Hypomanics and manics generally memory and concentration, and a loss tients experience symptoms that are in have chaotic personal and professional of pleasure in typically enjoyable events. many ways the opposite of those asso- relationships. They may spend large The diagnostic criteria also include sui- ciated with depression. Their mood and sums of money, drive recklessly or pur- cidal thinking, self-blame and inappro- self-esteem are elevated. They sleep less sue questionable business ventures or priate guilt. To distinguish clinical de- and have abundant energy; their pro- sexual liaisons. In some cases, manics

46 Mysteries of the Mind Manic-Depressive Illness and Creativity Copyright 1997 Scientific American, Inc. suffer from violent agitation and delu- percent reported a history of hypoma- jor depression. In collaboration with Da- sional thoughts as well as visual and nia or mania. Also, the relatives of these vid H. Evans of the University of Mem- auditory hallucinations. writers, compared with the relatives of phis, the Akiskals noted the same trends the control subjects, generally performed among living blues musicians. More re- Rates of Mood Disorders more creative work and more often had cently Stuart A. Montgomery and his a mood disorder. wife, Deirdre B. Montgomery, of St. or years, scientists have documented A few years later, while on sabbatical Mary’s Hospital in London examined Fsome kind of connection between in England from the University of Cali- 50 modern British poets. One fourth met mania, depression and creative output. fornia at Los Angeles, I began a study current diagnostic criteria for depres- In the late 19th and early 20th centuries, of 47 distinguished British writers and sion or manic-depression; suicide was researchers turned to accounts of mood visual artists. To select the group as best six times more frequent in this commu- disorders written by prominent artists, I could for creativity, I purposefully nity than in the general population. their physicians and friends. Although chose painters and sculptors who were Ruth L. Richards and her colleagues largely anecdotal, this work strongly Royal Academicians or Associates of at Harvard University set up a system suggested that renowned writers, artists the Royal Academy. All the playwrights for assessing the degree of original think- and composers—and their first-degree had won the New York Drama Critics ing required to perform certain creative relatives—were far more likely to expe- Award or the Evening Standard Drama tasks. Then, rather than screening for rience mood disorders and to commit (London Critics) Award, or both. Half mood disorders among those already suicide than was the general population. of the poets were already represented in deemed highly inventive, they attempt- During the past 20 years, more system- the Oxford Book of Twentieth Century ed to rate creativity in a sample of man- atic studies of artistic populations have English Verse. I found that 38 percent ic-depressive patients. Based on their confirmed these findings [see illustra- of these artists and writers had in fact scale, they found that compared with tion below]. Diagnostic and psycholog- been previously treated for a mood dis- individuals having no personal or fami- ical analyses of living writers and artists order; three fourths of those treated had ly history of psychiatric disorders, man- can give quite meaningful estimates of required medication or hospitalization, ic-depressive and cyclothymic patients the rates and types of psychopathology or both. And half of the poets—the (as well as their unaffected relatives) they experience. largest fraction from any one group— showed greater creativity. In the 1970s Nancy C. Andreasen of had needed such extensive care. Biographical studies of earlier genera- the University of Iowa completed the first Hagop S. Akiskal of the University of tions of artists and writers also show of these rigorous studies, which made California at San Diego, also affiliated consistently high rates of suicide, depres- use of structured interviews, matched with the University of Tennessee at sion and manic-depression—up to 18 control groups and strict diagnostic cri- Memphis, and his wife, Kareen Akis- times the rate of suicide seen in the gen- teria. She examined 30 creative writers kal, subsequently interviewed 20 award- eral population, eight to 10 times that and found an extraordinarily high oc- winning European writers, poets, paint- of depression and 10 to 20 times that of currence of mood disorders and alco- ers and sculptors. Some two thirds of manic-depressive illness and its milder holism among them. Eighty percent had their subjects exhibited recurrent cyclo- variants. Joseph J. Schildkraut and his experienced at least one episode of ma- thymic or hypomanic tendencies, and co-workers at Harvard concluded that jor depression, hypomania or mania; 43 half had at one time suffered from a ma- approximately half of the 15 20th-cen-

EXPECTED RATE MAJOR DEPRESSIVE ILLNESS IN GENERAL POPULATION MANIC-DEPRESSIVE ILLNESS CYCLOTHYMIA ANDREASEN’S STUDY SUICIDE OF WRITERS (1987)

JAMISON’S STUDY OF ARTISTS AND WRITERS (1989) SCHILDKRAUT AND HIRSHFELD’S STUDY OF ARTISTS (1990) AKISKAL AND AKISKAL’S STUDY OF ARTISTS AND WRITERS (UNPUBLISHED) JAMISON’S STUDY OF BRITISH POETS BORN BETWEEN 1705 AND 1805 (1989)

MONTGOMERY AND MONTGOMERY’S STUDY OF POETS (1993)

LUDWIG’S STUDY OF POETS (1992) T 0 10 20 30 40 50 60 70 80 URNET PERCENT LISA B INCREASED RATES OF SUICIDE, depression and manic-de- 18 times the rate of suicide seen in the general population, eight pression among artists have been established by many separate to 10 times the rate of depression and 10 to 20 times the rate of studies. These investigations show that artists experience up to manic-depression and its milder form, cyclothymia.

Manic-Depressive Illness and Creativity Mysteries of the Mind 47 Copyright 1997 Scientific American, Inc. tury abstract-expressionist artists they cognitive styles associated with hypo- tures: the ability to function well on a studied suffered from depressive or man- mania (expansive thought and grandi- few hours of sleep, the focus needed to ic-depressive illness; the suicide rate in ose moods) can lead to increased fluen- work intensively, bold and restless atti- this group was at least 13 times the cur- cy and frequency of thoughts. tudes, and an ability to experience a rent U.S. national rate. profound depth and variety of emo- In 1992 Arnold M. Ludwig of the Mania and Creativity tions. The less dramatic daily aspects of University of Kentucky published an ex- manic-depression might also provide tensive biographical survey of 1,005 fa- tudying the speech of hypomanic creative advantage to some individuals. mous 20th-century artists, writers and Spatients has revealed that they tend The manic-depressive temperament is, other professionals, some of whom had to rhyme and use other sound associa- in a biological sense, an alert, sensitive been in treatment for a mood disorder. tions, such as alliteration, far more of- system that reacts strongly and swiftly. He discovered that the artists and written than do unaffected individuals. They It responds to the world with a wide ers experienced two to three times the also use idiosyncratic words nearly three range of emotional, perceptual, intellec- rate of psychosis, suicide attempts, mood times as often as do control subjects. tual, behavioral and energy changes. In disorders and substance abuse that com- Moreover, in specific drills, they can list a sense, depression is a view of the parably successful people in business, synonyms or form other word associa- world through a dark glass, and mania science and public life did. The poets in tions much more rapidly than is consid- is that seen through a kaleidoscope—of- this sample had most often been manic ered normal. It seems, then, that both the ten brilliant but fractured. or psychotic and hospitalized; they also quantity and quality of thoughts build Where depression questions, rumi- proved to be some 18 times more likely during hypomania. This speed increase nates and hesitates, mania answers with to commit suicide than is the general may range from a very mild quickening vigor and certainty. The constant tran- public. In a comprehensive biographi- to complete psychotic incoherence. It is sitions in and out of constricted and then cal study of 36 major British poets born not yet clear what causes this qualita- expansive thoughts, subdued and then between 1705 and 1805, I found simi- tive change in mental processing. Nev- violent responses, grim and then ebul- larly elevated rates of psychosis and se- ertheless, this altered cognitive state lient moods, withdrawn and then out- vere psychopathology. These poets were may well facilitate the formation of going stances, cold and then fiery states— 30 times more likely to have had man- unique ideas and associations. and the rapidity and fluidity of moves ic-depressive illness than were their con- People with manic-depressive illness through such contrasting experiences— temporaries, at least 20 times more like- and those who are creatively accom- can be painful and confusing. Ideally, ly to have been committed to an asylum plished share certain noncognitive fea- though, such chaos in those able to and some five times more likely to have taken their own life. 146 These corroborative studies have con- 145 141 YER,1959 firmed that highly creative individuals 142 138 experience major mood disorders more 127 137 often than do other groups in the gener- 077 108 TER AND A. ME al population. But what does this mean 057 106 A

053 102 . SL for their work? How does a psychiatric 051 101 illness contribute to creative achieve- 049 098 OM E ment? First, the common features of 048 095 045 094 hypomania seem highly conducive to 043 093 136 ADAPTED FR original thinking; the diagnostic criteria 042 092 128 040 091 121

for this phase of the disorder include OS 039 T 086 119 “sharpened and unusually creative think- HO 036 085 144 117 ing and increased productivity.” And 035 082 130 113 CHIVE P

accumulating evidence suggests that the 034 AR 079 129 112 143 033 Robert Schumann 078 125 111 134 031 076 097 110 133 030 120 075 096 109 148 132 032 029 064 072 084 115 074 090 107 147 131 124 021 028 027 054 060 080 081 073 089 105 140 126 004 022 017 018 023 026 052 047 058 065 071 070 088 104 139 123 003 010 011 014 012 016 020 025 038 044 050 056 061 063 068 069 087 103 135 118 007 001 008 002 005 099 009 013 006 015 019 024 037 041 046 055 059 062 066 067 083 100 122 114 1829 ’30 ’31 ’32 ’33 ’34 ’35 ’36 ’37 ’38 ’39 ’40 ’41 ’42 ’43 ’44 ’45 ’46 ’47 ’48 ’49 ’50 ’51 ’52 ’53 ’54 ’55 1856

DIED IN ASYLUM SUICIDE SEVERE DEPRESSION (SELF- ATTEMPT THROUGHOUT 1844 STARVATION) HYPOMANIC HYPOMANIC SUICIDE THROUGHOUT 1840 THROUGHOUT 1849 ATTEMPT

ROBERT SCHUMANN’S MUSICAL WORKS, charted by mann’s parents were clinically depressed, and two other ﬁrst-de- year and opus number (above), show a striking relation between gree relatives committed suicide. Schumann himself attempted his mood states and his productivity. He composed the most suicide twice and died in an insane asylum. One of his sons when hypomanic and the least when depressed. Both of Schu- spent more than 30 years in a mental institution.

any clinicians have reviewed the medi- Mcal and psychiatric problems of the painter Vincent van Gogh posthumously, diag- nosing him with a range of disorders, including epilepsy, schizophrenia, digitalis and absinthe

poisoning, manic-depressive psychosis, acute in- , 1958 VY termittent porphyria and Ménière’s disease. Richard Jed Wyatt of the National Institute of Mental Health and I have argued in detail that van Gogh’s symptoms, the natural course of his , GIFT OF ADELE R. LE illness and his family psychiatric history strongly T indicate manic-depressive illness. The extent of the artist’s purported use of absinthe and con- vulsive behavior remains unclear; in any event, AN MUSEUM OF AR his psychiatric symptoms long predate any possible history of seizures. It is possible that he suf- OPOLIT

fered from both an epileptic disorder and manic- METR depressive illness. —K. R. J. Irises, 1889

transcend it or shape it to their will can pressive illness often worsens over time— bilities raise a host of complicated ethi- provide a familiarity with transitions and no one is creative when severely de- cal issues. It would be irresponsible to that is probably useful in artistic endeav- pressed, psychotic or dead. The attacks romanticize such a painful, destructive ors. This vantage readily accepts ambi- of both mania and depression tend to and all too often deadly disease. Hence, guities and the counteracting forces in grow more frequent and more severe. 3 to 5 percent of the Human Genome nature. Without regular treatment the disease Project’s total budget (which is conser- Extreme changes in mood exaggerate eventually becomes less responsive to vatively estimated at $3 billion) has the normal tendency to have conflicting medication. In addition, bipolar and uni- been set aside for studies of the social, selves; the undulating, rhythmic and polar patients frequently abuse mood- ethical and legal implications of genetic transitional moods and cognitive chang- altering substances, such as alcohol and research. It is hoped that these investi- es so characteristic of manic-depressive illicit drugs, which can cause secondary gations will examine the troubling is- illness can blend or harness seemingly medical and emotional burdens for sues surrounding manic-depression and contradictory moods, observations and manic-depressive and depressed patients. major depression at length. To help those perceptions. Ultimately, these fluxes and who have manic-depressive illness, or yokings may reflect truth in humanity The Goal of Treatment who are at risk for it, must be a major and nature more accurately than could public health priority. SA a more fixed viewpoint. The “consis- he real task of imaginative, com- tent attitude toward life” may not, as Tpassionate and effective treatment, Byron scholar Jerome J. McGann of the therefore, is to give patients more mean- University of Virginia points out, be as ingful choices than they are now afford- Further Reading insightful as an ability to live with, and ed. Useful intervention must control the portray, constant change. extremes of depression and psychosis Tennyson: The Unquiet Heart. R. B. The ethical and societal implications without sacrificing crucial human emo- Martin. Oxford University Press, 1980. Creativity and Mental Illness: Preva- of the association between mood disor- tions and experiences. Given time and lence Rates in Writers and Their ders and creativity are important but increasingly sophisticated research, psy- First-Degree Relatives. Nancy C. An- poorly understood. Some treatment stra- chiatrists will likely gain a better under- dreasen in American Journal of Psychia- tegies pay insufficient heed to the bene- standing of the complex biological ba- try, Vol. 144, No. 10, pages 1288-1292; fits manic-depressive illness can bestow sis for mood disorders. Eventually, the October 1987. on some individuals. Certainly most development of new drugs should make Manic Depressive Illness. Frederick K. manic-depressives seek relief from the it possible to treat manic-depressive in- Goodwin and Kay R. Jamison. Oxford University Press, 1990. disease, and lithium and anticonvulsant dividuals so that those aspects of tem- Creative Achievement and Psycho- drugs are very effective therapies for perament and cognition that are essen- pathology: Comparison among Pro- manias and depressions. Nevertheless, tial to the creative process remain intact. fessions. Arnold M. Ludwig in American these drugs can dampen a person’s gen- The development of more specific and Journal of Psychiatry, Vol. 46, No. 3, eral intellect and limit his or her emo- less problematic therapies should be pages 330–356; July 1992. tional and perceptual range. For this swift once scientists find the gene, or Touched with Fire: Manic-Depressive Illness and the Artistic Temperament. reason, many manic-depressive patients genes, responsible for the disease. Pre- Kay R. Jamison. Free Press/Macmillan, stop taking these medications. natal tests and other diagnostic measures 1993. Left untreated, however, manic-de- may then become available; these possi-