Aristotle said, ‘No great mind ever existed without a touch of madness.’
We are all familiar with the idea of the tortured genius and science has begun to prove a link to this age-old belief. Victor Ponsford spoke to Doctor James McCabe of the Institute of Psychiatry, King’s College London who has found a link between high intelligence and psychiatric disorders.
Doctor McCabe conducted his research in Sweden, describing it as ‘a paradise for epidemiologists’ because of the detail in Swedish records linking a person’s health and education records with their social security number. He found that individuals with excellent school performance had a nearly fourfold increased risk of having bipolar disorder compared to those with average grades. Interestingly students with the poorest grades were also moderately at risk of having the bipolar disorder.
Victor Ponsford: What are manic depression, bipolar and schizophrenia and what is the link between the three?
James McCabe: Well, manic depression actually is a kind of old term for bipolar disorder so they’re essentially the same thing. The definition of the illness has slightly changed over time, but essentially it’s the same thing. Interestingly, there are some people who suffer from what’s now called bipolar disorder who actually prefer the term manic depression because they feel that it describes their disorder better because it emphasizes the fact that they suffer from depression for some of the time and from mania for other parts of the time.
VP: And presumably bipolar means that, if there was a spectrum, they’re on polar opposites.
JMcC: That’s right, the reason for the term bipolar is to refer to the two poles of the illness. So those are mania on the one hand, which is when your mood is very elated and you’re often very creative and excited. Often people don’t need to sleep very much when they’re in that state, they’ll often spend a lot of money; sometimes they can be aggressive when they’re in that state.
Then at the other end of the scale is depression and we all think we know what it feels like to be depressed, but people with bipolar disorder or manic depression have a much more severe form of depression than most of us would be used to, with profound sleep disturbance, with loss of appetite and they feel they have no energy. Occasionally, they might even get hallucinations and delusions associated with it.
And the third state is being of a level mood, somewhere in the middle, and so the goal of treatment for bipolar disorder is to try and maximise the amount of time that people spend in that middle range when most people find that they’re functioning the best.
VP: Okay, and what about the third one, schizophrenia?
JMcC: Schizophrenia is a separate disorder from manic depression/bipolar disorder, but it is probably genetically related. Particularly, some of the more recent work has shown that there’s quite an overlap genetically between the two disorders and so you can have families where there are some people with bipolar disorder and others with schizophrenia. The difference between bipolar and schizophrenia is that bipolar is primarily a mood disorder. In schizophrenia the person’s mood is not usually affected or, if it is, it’s not the primary problem.
The primary problem with schizophrenia is that the person suffers from delusions, which means that they have fixed false beliefs which are often of a paranoid nature, so people might believe that there are people following them, for example, people targeting them. They also often have hallucinations, particularly auditory hallucinations, in other words hearing voices.
The other symptoms that are perhaps less obvious but probably more problematic and disabling for people are the so-called negative symptoms of schizophrenia and those are a lack of energy, a lack of drive and a withdrawal from social contact. So people with schizophrenia can sometimes be very isolated and spend all of the time indoors away from other people.
VP: How many people suffer from manic depression?
JMcC: The definition of manic depression, as I said earlier, has undergone some changes recently. Particularly in America, there’s been a move recently to broaden out the criteria for bipolar disorder, thus including more people. But what’s traditionally recognized in Europe as bipolar disorder affects about half a percent to one percent of the population.
VP: How many different types of bipolar exist?
JMcC: The main type of bipolar, the core type, is sometimes called type I bipolar disorder and that’s where there are episodes of full-blown mania and depression alternating with some periods of normal mood in between. There’s a newer sub-type of bipolar disorder, which is more commonly diagnosed in America, which is called type II bipolar disorder. That involves slightly less severe mood swings, and also a pre-distribution of depression, so there’s less in the way of manic episodes and more in the way of depression.
VP: Who is susceptible to getting manic depression?
JMcC: Well, the biggest risk factor that we know of by quite a long way is having a family history of bipolar disorder, so that’s how we know that bipolar disorder is to some extent a genetic disorder. If you have an identical twin who has bipolar disorder, then your chance of developing it is about 50%; if you have a non-identical twin, it goes down to about 10 or 12%; and if you have a brother or sister, again it’s about 10%.
VP: So, your data has pointed towards both lower and higher achievers having an increased likelihood of developing manic depression. What differences are exhibited by each group?
JMcC: What we found was that people who were in the top five percent of the population (two standard deviations above the mean) are about four times more likely to develop bipolar disorder than the people with average grades; and, at the same time, we found that people that were two standard deviations below the mean – in other words they’re in roughly the bottom percent of the population in their school grades – also had an increased risk of bipolar disorder; not quite as big, but about a doubling in risk.
So this suggests that there are potentially two different mechanisms operating here that are associated with high and low scores. One possibility is that this might reflect the mood state of the children when they were actually taking their exams; so if they had already begun to develop the disorder when they were taking their exams, then you might expect that those who were feeling depressed when they took their exams might have scored poorly while those who were elated might have done very well. When people get full-blown mania, they are often quite distractible and find it quite difficult to work constructively; but when people are in what we call a hypomanic state – which means that they are on the way to developing full-blown mania – they are often very creative and often have an ability to concentrate very hard, often don’t need very much sleep, and often have access to vocabulary and seem to be very quick and very witty.
So when people are in that state, they can often achieve very great things and I think that’s one of the possibilities for this association we’ve found between getting high school grades and having bipolar disorder.
VP: How long can that state last for?
JMcC: You might think it would be great if people with bipolar disorder could be in that state all the time and of course people enjoy being in that state as well. The trouble is, it does tend to be rather transient and if somebody does go into a hypomanic state, what will often happen is that their mood will carry on getting higher and higher – particularly as they have less and less sleep as that can push their mood higher and higher – and they can then get into a fully manic state. Most people in retrospect realize this wasn’t actually a very good thing for them because, when people are manic they’re often quite reckless, often spend a lot of money; sometimes they do things that they later regret, for example being more promiscuous than usual; people often take large quantities of drugs and alcohol when they’re in that state. People have been known to die of heart attacks and things because they’ve gone for days without sleep or without eating; so it’s a difficult balance when you have bipolar disorder, to try to capitalise on the benefits of being in a hypomanic state where possible without going too far into a state of mania.
VP: Why is the link so prominent in the creative arts and not the sciences?
JMcC: Well, firstly, I don’t think it’s necessarily true that there isn’t a link in the sciences. There are quite a few examples of people who are very accomplished in the sciences who’ve also had bipolar disorder. I mean one example would be the mathematician John Nash, who many people will have heard of because of the film Beautiful Mind which, in turn, was based on a biography written by Sylvia Nasar on John Nash’s life. He was a mathematician, very very gifted, was a full professor by the age of, I think, twenty nine and around that time started to believe, for example, that he was being given secret messages in the newspapers by aliens. Ultimately he believed that he was the emperor of Antarctica. So he had some very odd beliefs and had a diagnosis of schizophrenia.
VP: Schizophrenia, not manic depression?
JMcK: No that’s true, actually, he had a diagnosis of schizophrenia rather than manic depression, but there are examples of scientists with manic depression as well.
VP: Why is there a swing in manic depression from elation to misery and does the creative aspect of artists peak at certain points on this spectrum?
JMcC: That’s an interesting question. It’s not really very well understood what underlies these mood swings from mania to depression. At the psychological level, it’s understandable in some ways because, when people have had an episode of mania, they often end up doing things which they later regret; and so, when they go into a depression, they’re often consumed with feelings of guilt about things that they’ve done when they were manic.
In terms of which mood states are associated with creativity, as I said earlier, I think the hypomanic mood state – when people are on the way to becoming manic but they don’t have full-blown mania – is when people are often very creative and are able to think very quickly and often have leaps of imagination. I think also that when people are very depressed, that can also be a creative impetus. I think perhaps people don’t often have the creative output when they’re depressed, but when they are creative, they’re often drawing on the experiences that they’ve had when they were depressed and the heightened emotions that they were feeling at that time.
VP: A visual representation of what you’re describing would be almost like a Rothco painting with depression at the bottom and mania at the top. It’s interesting how the impression is the inspiration and they can’t put it out until they hit the mania
JMcC: Yes, that’s right, a lot of people with bipolar do comment that they’re at their most creative when they’re manic, but I think the depressive phase can probably lead to creativity as well, but it comes out at a different time.
VP: Many artists have taken illicit or illegal drugs during their depression that have unlocked their creative genius after a prolonged blockage. Is this to some extent creating a synthetic mania
JMcC: One possibility is that people are taking drugs because they’re feeling depressed in an attempt to lift their mood and that it’s actually the depression that’s blocking them and the drugs are producing an artificial lift from that depression. In terms of neurobiology, there is some evidence that dopamine, which is a neurotransmitter in the brain, is associated with creativity. So people who are given drugs which increase their dopamine level – which people are sometimes given for Parkinson’s Disease – can sometimes become very creative. And we know that, when people are in a manic state particularly, their dopamine systems are increased and some illicit drugs stimulate dopamine receptors in the brain, so there is a biological possibility there for a link related to dopamine.
VP: Many bipolar sufferers have been high achievers, pushing the boundaries in their respective fields. Is there not a danger of limiting their creativity through medication?
J.McC: That’s a question that a lot of people with bipolar disorder struggle with. I think ultimately most people with bipolar disorder, if they have it severely, come to a conclusion eventually that they are better off on medication than off because that diminishes the mood swings, particularly the depressive mood swings, but also severe mania can be quite a detrimental mood state, particularly in the aftermath of overspending etc.
But I think there is a danger of stifling creativity with medication and I certainly do recall one person who I used to see in my clinic who had bipolar disorder and was a professional violinist and she actually had a very sensible approach to this. If she had a concert coming up, she would leave out her medication that day because she felt that when she was on her medication – which was lithium – she wasn’t able to play as fluently or as creatively as normal; but she also found that, if she didn’t take the lithium at all, she would become unwell and therefore not be able to go to the concert. As her psychiatrist, I was quite happy with that arrangement because I knew that she was very much in control of her illness and she knew what she was doing and she was able to then profit from the creative aspects of the illness, without having to suffer the full gamut of mood swings.
VP: So what are the implications of your research for people who suffer with bipolar?
JMcC: Well, I think it can possibly be quite a negative thing, actually, because some people with bipolar have said to me: It’s all very well finding an association with creativity or being very bright and having bipolar disorder, but I don’t have any of those benefits, so how is that going to help me? I’ve got a lot of sympathy for that view, but I think for other people it can provide a source of comfort that their illness has a positive aspect and has a plus side.
I think it can help people to understand their illness better as well in some ways. One possibility is that the downsides of the illness – I’m talking in evolutionary terms – could be balanced by the positive aspects and so I think some people will take comfort from that and I think it also allows people who haven’t perhaps allowed their creative side to blossom to say: Perhaps I should try writing some poetry or picking up a paint brush or learning an instrument and perhaps I’ll be more creative than I thought I was.
VP: There is this link between manic depression and schizophrenia and being a high achiever, which I imagine is similar to high-functioning people with autism who are renowned again for being particularly able in certain fields. Do you think, as science progresses, we’re going to find more links between what used to be considered mental illnesses and high intelligence?
JMcC: Yes, certainly we are finding more and more links between bipolar disorder, schizophrenia and autism in terms of genetics, in terms of risk factors. So it seems quite possible that there are perhaps many different manifestations of the same underlying biological process, so that you can have similar biological underpinnings for a number of different psychiatric disorders, which are basically the symptoms that are manifest.
Dr McCabe’s research is published in The British Journal of Psychiatry (2010) 196, 109–115.<http://bjp.rcpsych.org/content/196/2/109.abstract>
and his book, The The Paradoxical Brain includes more research <http://ebooks.cambridge.org/chapter.jsf?bid=CBO9780511978098&cid=CBO9780511978098A032>. Chapter 16 deals with the bi-polar disorder.
Tags: Bi-polar disorder