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Lithium, Creativity, and Manic-Depressive illness: Review and Prospectus
Lithium, Creativity, and Manic-Depressive Dlness: REVIEW AND PROSPECTUS MYRON
H.
MARSHALL,
M.D.,
CHARLES
P.
NEUMANN, M.D.,
A definite relationship links lithium, creativity, and manic-depressive iIIness. t It is the nature of the connection that demands attention. A simple cause and effect explanation is insufficient, since, though we can see the manic-depressive state and creativity co-existing. we cannot determine that either caused the other. We do have proof that lithium can be instrumental in countering the manic or hypomanic phase.2-6 Current investigation using lithium in the treatment of manicdepressive patients who are creative in their fields will uncover the actual association. Lithium, working selectively, probably alleviates only the manic phase of the illness. By detennining the qualitative level of creativity in manic-depressives and then administering lithium, we will have controlled data that can show the relationship between creativity and the manic phase of this illness. Varying periods of increased productivity and creativity are associated with the mood swings of severe cyclothymic illness. The relationship of this extreme creativity to manic depressive illness has been noted, for example, by Arieti: 7 " • • • in creative work there is a fusion of primary and secondary processes with the inner world providing motivation." He calls this the principle of "active concretization to give a tertiary proc·ess. One sees the hidden order of the tertiary process in creativitv."
The tie between creativity and psychiatric illness has been discussed for many years. In the present decade, the conceptualization has been that creativity not only may be associated with particular personality diagnoses, but that creativity may be managed in a particular way so as to produce more of it at a lower economic cost. 8-9 This has led to a cult of creativity management prevalent in American industry. Industrial management is being alerted to the "problems" in managing and motivating creativity especially in cases where persons who are creative may also be considered "odd". This is visualized as quite a Dr. Marshall is Consultant in Resl'arch, the Silver Hill Foundation and in private praclice in Wt'stl'rn New York. Dr. Nt'umann is Medical Dirl'clor. The Silvl'r Hill Foun,lation. N.·w Canaan. Conn. Dr. Robinson wbo preSl'ntl't1 this paper is Hl'ad of the Division of Psychialry. Nial!ara Falls Memorial Medical Centl'r, Niagara Falls, N. Y.
406
and
MILTON ROBINSON, M.D.
challenge. It has become fertile ground for social scientist~ to sell their expertise on the management of creativity by enumerating to administrative personnel the characteristics of creative persons, some of which sound quite abnormal to the psychiatrist. Much thought is given to the stimulation of creative scientist~; this is considered to be a rather well-defined area. Such articles as "Sure Steps to Foster Creativity" advise administrators that many creative people have "odd personalities", but add that "... the creative process really arises from the conflict and coalition of personalities." Industry, then, has recognized that creativity may come at the expense of a more "nonnal personality adjustment." Industry may differ from psychiatry in the definition of concepts. Offer and Sabshin,IO in their scholarly book Normality, have shown how difficult it is to define an idea such as nonnality and how various diSciplines explain it in their own tenns. This is no doubt being done with the concept of "mental illness". Even within the profession, individual psychiatrists take varying stands: Thomas Szasz l l branches off from the basic definition of mental illness in his concept of the "myth of mental illness"; the present paper offers a variant in suggesting that mental illness might confer a benefit in creativity. Lindsley t2 raised the point that deficiency might produce specific superiority. Here is the suggestion that because of a serious definable illness, one may have an over-competence to do particular tasks. There are many instances in which a high level of creativity is found in manic depressive persons. In the Gennan literature, KUiper,13 in writing about the psychoanalytic histories of creative personalities, reviews Eissler's biography of Goethe. He is struck by the personalities of creative people, finding in them traits frequently associated with mental illness. The French literature is slanted toward the artist and the writer as examples of creative, productive persons. Benn 14 suggests that mental illness must be contrasted with genius. In his article, "genius" is loosely defined as equivalent to creative, and previous findings of mental illness in very creative individuals are enumerated. Benn's point is that madness is not equivalent to genius, but that the environment often creates the Volume XI
LITHIUM AND CREATIVITY
genius from a mentally unbalanced, gifted individual. \Vhat in the environment contributes to creativity? Dracoulides 1r. says that "... psychic suffering stimulates artistic creation." He adds, however, that people who "... are afflicted with neuroses or psychoses but who lack artistic talent, don't become artistic." He points out that, collectively, "art flourishes among the least happy peoples; to find joy in art is to compensate for its lack in real life." In his view, the neuroses act as a stimulant to creativity and productivity, whereas the psychoses hinder the creative process. The conflict that has arisen over this question is, if a creative person who is neurotic is treated for his neurosis, will his creativity decrease? If he is made into a well-adjusted person, is society robbed of the benefits of his illness and his creativity? Dracoulides replies affirmatively, saying that psychoanalysis removes the artist's complexes, but at the same time denies his talent and exhausts his artistic creativity. He says analysis is contraindicated for creative artists unless they suffer serious emotional disorders. In all other cases, psychotherapy and drugs represent the treatment of choice for neurotic difficulties. Here, then, is a clear indication that taking away a mental illness may be removing a benefit from society. Some creative artists seek psychotherapy because they wish to overcome inhibitions that interfere with the free exercise of their talents. Nydes,16 in considering this, states that many, if not all, artists have neurotic problems. He says that the neurotic conflict is not associated with creativity in all persons, but it may be one of the factors that in some way contributes to creativity. Nydes refers to Kubie 17 where he points out that psychic conflict is inevitable in view of the enormous complexities of the maturation process in man. He contends that in some, the conflict manifests itself in neurotic symptoms and in others it is resolved in the creative process. Case records of the Silver Hill Foundation substantiate the thesis that creativity and manicdepressive illness are interrelated. One patient was a professional writer, a 53 year old male last admitted in mid· December, 1968. At that time, he was SI~verely depressed, but responded to three E.S.T.'s and moved into a hypomanic phase. On admis· sion he describ{'d himSl'lf as a "mood swinger, but now on dead center." The patient was horn in New York City of successful pan'nts. He said his father suffered recurrent depressions. As a student at a prominent college, he was an All· September·October, 1970
American Tackle. The coach described his as "The emotional tackle" because he became so depressed when the team lost a game. He was married in 1939. During World War II, he joined the U. S. Army. He exper· ienced his first severe depression in Italy, where he had been sent as a commissioned officer. He emerged from this depression without treatment. After the war, the young man began a career of creative writing. Since 1946 he has authored twelve books, numerous newspaper and magazine articles. and many radio and television shows. However, his life has swung from periods of hyperactivity and great productiv. ity to abject depression, with total withdrawal and in· activity. He has a history of one attempt at suicide, but his depressions have responded repeatedly and promptly to E.S.T. A second hyperactive patient was a 57·year·old male with a history of three admissions for depressive reaction, the last of which was in April, 1968. He was horn in New York City to a family of modest financial circumstances, and worked his way through a local college. He began work on Wall Street, but soon demonstrated and developed marked theatrical talents. He has since en· joyed great success as a writer, actor, director, and producer in radio, television, and the theater. He has had psychotherapy since 1946, when he recog· nized his first depression. In recent years, his recurrent depressions have responded fairly well to antidepressants. Six years ago, he directed a smashing Broadway success. Two and a half years ago, while in the midst of directing another show, he became depressed; the show never opened. Currently, however, he has another tremendously successful hit on Broadway. A third patient was also born in New York City. Hi, family's circumstances could be described as "middle class." He was graduated cum laude from an ivy league college and was immediately employed by an electronics firm which has since grown into a very large company. At the time of his death in 1966, at the age of 62, he had eighty patents for various inventions, which included some of the very early developments of radar. This man was considered by most of his friends and associates as a moody individual, but be· cause of his brilliance and his periods of exceptional creativity, his personality problems and his difficulties in interpersonal relationships were tolerated at his place of employment. Preceding his first admission, in early 1963, he had become increasingly agitated and depressed, and finally had plunged a kitchen knife into his abdomen. Following surgery and convalescence, he responded to E.S.T. In early 1965, the patient returned in a clearly manic phase. This time, he responded to psychopharmaceuticals and was discharged after two months. He was admitted again in early 1966 after he had become depressed and taken an overdose of barbiturates. Again he responded to somatic therapies. His employers at that time chose to retire him. Later that year he committed suicide by jumping from a sixth story window. 407
PSYCHOSOMATICS
In all three cases, great creativity was always associated with a manic or high phase, in sharp contrast to the lack of productivity in depressed or low periods. The cases cited in the literature and in practice suggest a more than chance association between extreme creativity and the manic swing. The effect of the lithium ion should reveal evidence that creativity is a substantial result of the mental illness. One major problem in attempting to study the relationship of the creative process to mood and to the effect that a drug like lithium might have, is the paucity of instmments available for subjective or objective ratings of the creative process. A scale is being designed that will be used in testing patients before and after lithium treatment, to validate the hypothesis that lithium alters creativity. A person experiencing a bout of creativity tends, like the hypomanic, to resist all effort'i of being cornered or restrained, or relating his personal ideas and schemes to a doctor or friend, before the creative act or project is completed. Approximately 80% of hypomanics will sleep better and be less euphoric and less hyperkinetic on maintenance lithium therapy.1H Uncontrolled observations have been made on six nationally recognized artists and businessmen on maintenance lithium therapy. These observations suggest that in creative people who also experience manias and/or depressions that result in referral to psychiatrists, the overall productivity of the individual is more uniform and of a sounder quality on lithium. This applies so far to five of the six patients who have been on lithium for a mean period of two years. A sixth patient elected to discontinue lithium after being brought out of a mild hypomania, stating that he felt more creative when hypomanic and preferred yearly swings of hypomanic productiveness and depression, to the effect while on lithium. Investigations to date, then, indicate rather strongly that the manic phase inspires a surge of
408
creative output in creative persons with manic depressive illness. Refinement of a creativity measurement and more intense study of patients should further substantiate the thesis. ACKNOWLEDGEMENT We wish to acknowledge the assistance of Barbara C. Marshall, M.A. in preparation of this paper.
BIBLIOGRAPHY 1. Marshall, M. H. et aI.: Seminar, The "Benefits 0/ Mental Illness, Annual Meeting APA, Bal Harbour, Fla. 1969. 2. Cade, J. F. 1.: Lithium Salts in the Treatment of Psychotic Excitement, Med. J. Aust. 2: 349·352, 1949. 3. Gershon, S., and Yuwiler, A.: Lithium Ion: A Specific Psychopharmacological Approach to the Treatment of Mania, J. Neuropsychial. 1:229-241, 1960. 4. Schlagenhauf, G., Tupin, J., and White, R. B.: The Use of Lithium Carbonate in the Treatment of Manic Psychoses, Amer. J. Psychiat. 123:201-206, 1966. 5. Schou, M., Juel.Nielsen, N., Stromgren, E., and Voldby, H.: The Treatment of Manic Psychoses by the Administration of Lithium Salts, J. Neurol. Neu· rosurg. Psycmat. 17:250-260, 1954. 6. Wharton, R. N., and Fieve, R. R.: The Use of Lith. ium in the Affective Psychoses, Amer. J. Psychiat. 123:706-712,1966. 7. Arieti, S.: The Karen Horney Lecture 1969, The New York Academy of Medicine. 8. Eschenfelder, A. E.: Creating an Environment for Creativity, Research Management, XI (I968), 231· 240. 9. Feinberg, M. R.: Fourteen Suggestions for Man· airing Scientific Creativity: Research Management, XI (I968), 83·92. 10. Offer and Sabshin: Normality. New York: Basic Books, Inc., 1966. 11. Szasz, S.: The Myth of Mental Illness. The American Psychologist, XV (I960), 113. 12. Lindsley, O. R.: Can Deficiency Produce Specific Superiority-The Challenlre of the Idiot Savant, Exceptional Children, XXXI (I96S), 225-232. 13. Kuiper, Die Psychoanalytische Biol!Taphic der Schopferischen Personlichkeit, Psyche, XX (I966), 104-127. 14. Benn. G. Das Genieproblem, Therapie der Gegenwart, CV (} 966), 863-871. IS. Dracoulides, N. N.: Creativite de L'Artiste Psy· chanalyse. Acta Psychother, XII (I%4), 391·401. 16. Nydes, J.: Creativity and Psychotherapy, Psychoanal and Psychoanalyt Rev., XL (I962) , 29-33. 17. Kubie, L. S.: Neurotic Distortion 0/ the Creative Process, Lawrence: University of Kansas Press, 1950. 18. Fieve, R. R.: Unpublished data.
c.:
Volume XI
H.
MARSHALL,
M.D.,
CHARLES
P.
NEUMANN, M.D.,
A definite relationship links lithium, creativity, and manic-depressive iIIness. t It is the nature of the connection that demands attention. A simple cause and effect explanation is insufficient, since, though we can see the manic-depressive state and creativity co-existing. we cannot determine that either caused the other. We do have proof that lithium can be instrumental in countering the manic or hypomanic phase.2-6 Current investigation using lithium in the treatment of manicdepressive patients who are creative in their fields will uncover the actual association. Lithium, working selectively, probably alleviates only the manic phase of the illness. By detennining the qualitative level of creativity in manic-depressives and then administering lithium, we will have controlled data that can show the relationship between creativity and the manic phase of this illness. Varying periods of increased productivity and creativity are associated with the mood swings of severe cyclothymic illness. The relationship of this extreme creativity to manic depressive illness has been noted, for example, by Arieti: 7 " • • • in creative work there is a fusion of primary and secondary processes with the inner world providing motivation." He calls this the principle of "active concretization to give a tertiary proc·ess. One sees the hidden order of the tertiary process in creativitv."
The tie between creativity and psychiatric illness has been discussed for many years. In the present decade, the conceptualization has been that creativity not only may be associated with particular personality diagnoses, but that creativity may be managed in a particular way so as to produce more of it at a lower economic cost. 8-9 This has led to a cult of creativity management prevalent in American industry. Industrial management is being alerted to the "problems" in managing and motivating creativity especially in cases where persons who are creative may also be considered "odd". This is visualized as quite a Dr. Marshall is Consultant in Resl'arch, the Silver Hill Foundation and in private praclice in Wt'stl'rn New York. Dr. Nt'umann is Medical Dirl'clor. The Silvl'r Hill Foun,lation. N.·w Canaan. Conn. Dr. Robinson wbo preSl'ntl't1 this paper is Hl'ad of the Division of Psychialry. Nial!ara Falls Memorial Medical Centl'r, Niagara Falls, N. Y.
406
and
MILTON ROBINSON, M.D.
challenge. It has become fertile ground for social scientist~ to sell their expertise on the management of creativity by enumerating to administrative personnel the characteristics of creative persons, some of which sound quite abnormal to the psychiatrist. Much thought is given to the stimulation of creative scientist~; this is considered to be a rather well-defined area. Such articles as "Sure Steps to Foster Creativity" advise administrators that many creative people have "odd personalities", but add that "... the creative process really arises from the conflict and coalition of personalities." Industry, then, has recognized that creativity may come at the expense of a more "nonnal personality adjustment." Industry may differ from psychiatry in the definition of concepts. Offer and Sabshin,IO in their scholarly book Normality, have shown how difficult it is to define an idea such as nonnality and how various diSciplines explain it in their own tenns. This is no doubt being done with the concept of "mental illness". Even within the profession, individual psychiatrists take varying stands: Thomas Szasz l l branches off from the basic definition of mental illness in his concept of the "myth of mental illness"; the present paper offers a variant in suggesting that mental illness might confer a benefit in creativity. Lindsley t2 raised the point that deficiency might produce specific superiority. Here is the suggestion that because of a serious definable illness, one may have an over-competence to do particular tasks. There are many instances in which a high level of creativity is found in manic depressive persons. In the Gennan literature, KUiper,13 in writing about the psychoanalytic histories of creative personalities, reviews Eissler's biography of Goethe. He is struck by the personalities of creative people, finding in them traits frequently associated with mental illness. The French literature is slanted toward the artist and the writer as examples of creative, productive persons. Benn 14 suggests that mental illness must be contrasted with genius. In his article, "genius" is loosely defined as equivalent to creative, and previous findings of mental illness in very creative individuals are enumerated. Benn's point is that madness is not equivalent to genius, but that the environment often creates the Volume XI
LITHIUM AND CREATIVITY
genius from a mentally unbalanced, gifted individual. \Vhat in the environment contributes to creativity? Dracoulides 1r. says that "... psychic suffering stimulates artistic creation." He adds, however, that people who "... are afflicted with neuroses or psychoses but who lack artistic talent, don't become artistic." He points out that, collectively, "art flourishes among the least happy peoples; to find joy in art is to compensate for its lack in real life." In his view, the neuroses act as a stimulant to creativity and productivity, whereas the psychoses hinder the creative process. The conflict that has arisen over this question is, if a creative person who is neurotic is treated for his neurosis, will his creativity decrease? If he is made into a well-adjusted person, is society robbed of the benefits of his illness and his creativity? Dracoulides replies affirmatively, saying that psychoanalysis removes the artist's complexes, but at the same time denies his talent and exhausts his artistic creativity. He says analysis is contraindicated for creative artists unless they suffer serious emotional disorders. In all other cases, psychotherapy and drugs represent the treatment of choice for neurotic difficulties. Here, then, is a clear indication that taking away a mental illness may be removing a benefit from society. Some creative artists seek psychotherapy because they wish to overcome inhibitions that interfere with the free exercise of their talents. Nydes,16 in considering this, states that many, if not all, artists have neurotic problems. He says that the neurotic conflict is not associated with creativity in all persons, but it may be one of the factors that in some way contributes to creativity. Nydes refers to Kubie 17 where he points out that psychic conflict is inevitable in view of the enormous complexities of the maturation process in man. He contends that in some, the conflict manifests itself in neurotic symptoms and in others it is resolved in the creative process. Case records of the Silver Hill Foundation substantiate the thesis that creativity and manicdepressive illness are interrelated. One patient was a professional writer, a 53 year old male last admitted in mid· December, 1968. At that time, he was SI~verely depressed, but responded to three E.S.T.'s and moved into a hypomanic phase. On admis· sion he describ{'d himSl'lf as a "mood swinger, but now on dead center." The patient was horn in New York City of successful pan'nts. He said his father suffered recurrent depressions. As a student at a prominent college, he was an All· September·October, 1970
American Tackle. The coach described his as "The emotional tackle" because he became so depressed when the team lost a game. He was married in 1939. During World War II, he joined the U. S. Army. He exper· ienced his first severe depression in Italy, where he had been sent as a commissioned officer. He emerged from this depression without treatment. After the war, the young man began a career of creative writing. Since 1946 he has authored twelve books, numerous newspaper and magazine articles. and many radio and television shows. However, his life has swung from periods of hyperactivity and great productiv. ity to abject depression, with total withdrawal and in· activity. He has a history of one attempt at suicide, but his depressions have responded repeatedly and promptly to E.S.T. A second hyperactive patient was a 57·year·old male with a history of three admissions for depressive reaction, the last of which was in April, 1968. He was horn in New York City to a family of modest financial circumstances, and worked his way through a local college. He began work on Wall Street, but soon demonstrated and developed marked theatrical talents. He has since en· joyed great success as a writer, actor, director, and producer in radio, television, and the theater. He has had psychotherapy since 1946, when he recog· nized his first depression. In recent years, his recurrent depressions have responded fairly well to antidepressants. Six years ago, he directed a smashing Broadway success. Two and a half years ago, while in the midst of directing another show, he became depressed; the show never opened. Currently, however, he has another tremendously successful hit on Broadway. A third patient was also born in New York City. Hi, family's circumstances could be described as "middle class." He was graduated cum laude from an ivy league college and was immediately employed by an electronics firm which has since grown into a very large company. At the time of his death in 1966, at the age of 62, he had eighty patents for various inventions, which included some of the very early developments of radar. This man was considered by most of his friends and associates as a moody individual, but be· cause of his brilliance and his periods of exceptional creativity, his personality problems and his difficulties in interpersonal relationships were tolerated at his place of employment. Preceding his first admission, in early 1963, he had become increasingly agitated and depressed, and finally had plunged a kitchen knife into his abdomen. Following surgery and convalescence, he responded to E.S.T. In early 1965, the patient returned in a clearly manic phase. This time, he responded to psychopharmaceuticals and was discharged after two months. He was admitted again in early 1966 after he had become depressed and taken an overdose of barbiturates. Again he responded to somatic therapies. His employers at that time chose to retire him. Later that year he committed suicide by jumping from a sixth story window. 407
PSYCHOSOMATICS
In all three cases, great creativity was always associated with a manic or high phase, in sharp contrast to the lack of productivity in depressed or low periods. The cases cited in the literature and in practice suggest a more than chance association between extreme creativity and the manic swing. The effect of the lithium ion should reveal evidence that creativity is a substantial result of the mental illness. One major problem in attempting to study the relationship of the creative process to mood and to the effect that a drug like lithium might have, is the paucity of instmments available for subjective or objective ratings of the creative process. A scale is being designed that will be used in testing patients before and after lithium treatment, to validate the hypothesis that lithium alters creativity. A person experiencing a bout of creativity tends, like the hypomanic, to resist all effort'i of being cornered or restrained, or relating his personal ideas and schemes to a doctor or friend, before the creative act or project is completed. Approximately 80% of hypomanics will sleep better and be less euphoric and less hyperkinetic on maintenance lithium therapy.1H Uncontrolled observations have been made on six nationally recognized artists and businessmen on maintenance lithium therapy. These observations suggest that in creative people who also experience manias and/or depressions that result in referral to psychiatrists, the overall productivity of the individual is more uniform and of a sounder quality on lithium. This applies so far to five of the six patients who have been on lithium for a mean period of two years. A sixth patient elected to discontinue lithium after being brought out of a mild hypomania, stating that he felt more creative when hypomanic and preferred yearly swings of hypomanic productiveness and depression, to the effect while on lithium. Investigations to date, then, indicate rather strongly that the manic phase inspires a surge of
408
creative output in creative persons with manic depressive illness. Refinement of a creativity measurement and more intense study of patients should further substantiate the thesis. ACKNOWLEDGEMENT We wish to acknowledge the assistance of Barbara C. Marshall, M.A. in preparation of this paper.
BIBLIOGRAPHY 1. Marshall, M. H. et aI.: Seminar, The "Benefits 0/ Mental Illness, Annual Meeting APA, Bal Harbour, Fla. 1969. 2. Cade, J. F. 1.: Lithium Salts in the Treatment of Psychotic Excitement, Med. J. Aust. 2: 349·352, 1949. 3. Gershon, S., and Yuwiler, A.: Lithium Ion: A Specific Psychopharmacological Approach to the Treatment of Mania, J. Neuropsychial. 1:229-241, 1960. 4. Schlagenhauf, G., Tupin, J., and White, R. B.: The Use of Lithium Carbonate in the Treatment of Manic Psychoses, Amer. J. Psychiat. 123:201-206, 1966. 5. Schou, M., Juel.Nielsen, N., Stromgren, E., and Voldby, H.: The Treatment of Manic Psychoses by the Administration of Lithium Salts, J. Neurol. Neu· rosurg. Psycmat. 17:250-260, 1954. 6. Wharton, R. N., and Fieve, R. R.: The Use of Lith. ium in the Affective Psychoses, Amer. J. Psychiat. 123:706-712,1966. 7. Arieti, S.: The Karen Horney Lecture 1969, The New York Academy of Medicine. 8. Eschenfelder, A. E.: Creating an Environment for Creativity, Research Management, XI (I968), 231· 240. 9. Feinberg, M. R.: Fourteen Suggestions for Man· airing Scientific Creativity: Research Management, XI (I968), 83·92. 10. Offer and Sabshin: Normality. New York: Basic Books, Inc., 1966. 11. Szasz, S.: The Myth of Mental Illness. The American Psychologist, XV (I960), 113. 12. Lindsley, O. R.: Can Deficiency Produce Specific Superiority-The Challenlre of the Idiot Savant, Exceptional Children, XXXI (I96S), 225-232. 13. Kuiper, Die Psychoanalytische Biol!Taphic der Schopferischen Personlichkeit, Psyche, XX (I966), 104-127. 14. Benn. G. Das Genieproblem, Therapie der Gegenwart, CV (} 966), 863-871. IS. Dracoulides, N. N.: Creativite de L'Artiste Psy· chanalyse. Acta Psychother, XII (I%4), 391·401. 16. Nydes, J.: Creativity and Psychotherapy, Psychoanal and Psychoanalyt Rev., XL (I962) , 29-33. 17. Kubie, L. S.: Neurotic Distortion 0/ the Creative Process, Lawrence: University of Kansas Press, 1950. 18. Fieve, R. R.: Unpublished data.
c.:
Volume XI