Many people with psychiatric disorders engage in creative activities, from informal hobbies to highly accomplished careers, but some avoid treatment entirely. Two cases illustrate a nuanced approach that integrates medical knowledge with patients’ perspectives.
Many people with psychiatric disorders engage in creative activities, from informal hobbies to highly accomplished careers. While some distinguish their symptoms from their creative talents, others avoid treatment, fearing it will impair mental and emotional processes they value. After a brief summary of the complex relationship between creativity and psychiatric illness, this article focuses on the treatment of such patients. Two cases-the mathematician John Nash and the author David Foster Wallace-are presented to illustrate a nuanced approach that integrates medical knowledge with patients’ perspectives.
A few years after the groundbreaking work that earned him a Nobel Prize, John Nash began to experience signs of schizophrenia. About his delusions, he explained, “the ideas I had about supernatural beings came to me the same way my mathematical ideas did. So I took them seriously.”1 Nash avoided psychiatric treatment, and the only productive mathematical work he accomplished after his first psychotic episode occurred during several months when he took trifluoperazine.
David Foster Wallace, a MacArthur Fellow whose fiction and essays caught the experience of a generation, suffered from recurrent depression. In 2007 he discontinued longstanding treatment with phenelzine in part because he thought it was interfering with his ability to finish a novel. Tragically, his depression relapsed, and he committed suicide without completing the book.2 While it is impossible to determine the validity of Nash’s and Wallace’s ideas about their illnesses, medication, and creative abilities, their beliefs that they were linked contributed to decisions that ended their productive careers and, in Wallace’s case, his life.
A century of biographical research has documented mental illness in the lives of individuals like Nash and Wallace; a recent example is a study of the poet Robert Lowell by Kay Redfield Jamison, PhD. Lowell’s racing thoughts, flight of ideas, and divergent thinking during times of rising mania generated highly original language, which required extensive revision during euthymic periods.3
Older case reports have explored these issues as well. Mogens Schou, MD,4 described varying effects of lithium on artistic productivity in 24 lithium responders. Half reported benefit, but several discontinued the medication, believing it interfered with their creativity. Schou attributed the variations to type and severity of illness, individual sensitivity, and whether the artist tended to use manic symptoms productively.
Modern research using psychological tests, population surveys, and genetics has looked both at psychiatric illness in creative individuals and at creativity in people with diagnosed psychiatric disorders. The results indicate modestly higher rates of bipolar disorders in creative individuals, as well as elevated psychological traits associated with creativity in people who have bipolar illness.
These associations are found in the visual arts, literature, music, performing arts, business, politics, religion, and science. The connection is strongest for milder conditions like cyclothymic and bipolar II disorders, since the functional impairment associated with florid mania can interfere with creative work.5
Because it is difficult to study symptomatic individuals, most research looks at creative traits during euthymic periods: the limited evidence documenting creative work during symptomatic periods, usually hypomania, comes from patient accounts and case reports. Divergent thinking, high verbal productivity, and intense or contrasting mood states can generate original work, and grandiosity, high energy, and reduced sleep can increase productivity. Manic ambition and sociability can enhance public recognition.6 The relationship of creativity to depression is less clear.
Creativity shares genetic roots with both bipolar disorder and schizophrenia, and symptoms associated with schizophrenia can contribute to creativity.7,8 Flattened affect, apathy, and a sense of strangeness may manifest themselves in creative irony, rule-breaking, self-reference, and temporal and spatial dislocations. Psychotic symptoms can also impede creative work, which may account for higher rates of avocational creative activities like poetry and photography in people with schizophrenia.9
Creativity carries mental health risks. And artistic exploration can intensify mood states. The uncertainties of a creative career can worsen psychiatric symptoms. Creative peers may promote one another’s substance abuse. Irregular sleep and activity schedules can be destabilizing. And mood disorders are associated with heightened reactivity-success can trigger manic symptoms, and people with bipolar disorder experience more frustration than others when goals are not met.10
Psychiatric disorders, then, have a complex relationship with creativity. Some mild to moderate traits and symptoms can enhance original thinking, problem solving, productivity, and recognition, but confusion, depression, mania, bizarre behavior, and social isolation get in the way. Many psychiatric patients value their creativity, and some, like Nash and Wallace, believe it is connected to their symptoms and treatment.
One of psychiatry’s creative skills is the ability to think in more than one way at the same time-to maintain one’s medical perspective while exploring a patient’s experiences and beliefs. This is not always easy: a narrow focus on symptoms can jeopardize the treatment alliance by ignoring a patient’s concerns that treatment will interfere with creativity, but blind acceptance of a patient’s views can overestimate creative abilities, their importance in the patient’s life, or their connection to the patient’s symptoms.
Many patients, particularly those with depression, recognize that their symptoms interfere with creative activities and welcome relief, although some, as appears to have been the case for Wallace, complain that medication limits their emotional responsiveness. Others value symptoms like rapid thinking and unusual mental associations. And a few, like Nash, believe their symptoms and creativity arise from the same source. When patients identify such connections, it is helpful to look at when and under what circumstances psychiatric symptoms and creative thinking occur and at what factors, including medication, heighten or diminish them. The goal is a clearer understanding of any possible connection.
A patient’s concern that treatment will interfere with creativity may point toward treatment options to which he or she is more likely to be adherent. Patients with bipolar disorder, for example, may be more comfortable with anticonvulsant mood stabilizers such as valproate or lamotrigine than with lithium or ECT, which may have adverse cognitive effects (although, with lithium, these can usually be managed by careful dosing). As treatment unfolds, it is worthwhile to ask about changes in creativity along with symptom levels and functioning. Clinicians who use rating scales may find a self-report questionnaire such as the Inventory of Creative Activities and Achievements useful.11
After his third hospitalization, John Nash agreed to take trifluoperazine. He worried that the drug would prevent him from thinking clearly enough to resume mathematical work. His psychiatrist was sympathetic and kept the dose low. Months later he relapsed to florid psychosis. It is unclear whether he had discontinued the medication or whether the dose was simply too low. In his discussion of Nash’s treatment, Peter Weiden, MD,1 recommends taking a patient’s concerns seriously, trying to persuade the patient that his intellect is strongest when his preoccupations are at a low level, and developing a treatment goal for avoiding hospitalizations. Then, reviewing evidence that medication maintenance reduces the risk of relapse might persuade the patient to accept ongoing treatment.1 A patient like Nash might also agree to monitor his symptoms and creativity with rating scales so dose adjustments can be based on data rather than on the patient’s fears or the clinician’s assumptions.
The nature of David Foster Wallace’s treatment alliance when he discontinued phenelzine is unknown, nor is it clear whether he was receiving psychotherapy. In retrospect, it would have been best to see him regularly; include input from his wife; discuss the risks and possible benefits of treatment discontinuation as well as early signs of relapse; taper the medication with monitoring by the patient, family, and psychiatrist; and intervene early if depression returned. A few months after he stopped taking phenelzine, Wallace was hospitalized for severe depression. Other antidepressants were prescribed, but his anxiety about adverse effects led to early discontinuation. After an unsuccessful course of ECT, he asked to restart phenelzine. Despite some signs of early response, he hanged himself. Wallace’s story illustrates both the benefits of treatment-on medication, he had 22 productive years-and the complexities of treating a highly creative individual.
Patients’ experiences with their creativity, symptoms, and treatment follow many paths. Some are grateful to have their symptoms controlled so they can live and create more fully. Others are ambivalent, associating their illnesses with creativity out of a romantic fantasy or, as with Nash, from personal observation. Even when creativity is closely related to psychiatric symptoms, treatment may facilitate creative work. An inquiring attitude toward patients’ creative aspirations and activities-grounded in medical evidence but encompassing the complexities of their experiences and beliefs-can be rewarding for the clinician and facilitate patients’ creative work.
Dr. Woodward is Assistant Clinical Professor of Psychiatry, Boston University School of Medicine. He is in private practice in Newton, MA.
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