'Artistic creativity' and risk of hospitalisation for schizophrenia, bipolar disorder and unipolar depression

"Students of artistic subjects at university are at increased risk of developing schizophrenia, bipolar disorder and unipolar depression in adulthood."

So concluded the findings reported by James MacCabe and colleagues [1] who set about examining whether studying a creative subject at high school or university placed someone at an enhanced risk of later hospitalisation for a mental disorder such as schizophrenia, bipolar disorder or depression. The rationale behind the research was the 'long-standing idea' that "mental disorders are associated with enhanced creativity, intelligence or artistic talent."

To test the hypothesis, researchers employed some of those fabulous Scandinavian population registries (yet again), this time covering the population of Sweden. Based on the "unique registration number carried by all Swedish residents" they were able to look at educational records, results of intelligence tests (via testing during military service) and details of any psychiatric hospitalisations for nearly 4.5 millions people. A creative subject studied at high school or University was defined in both a broad sense - "which included a wider variety of creative or artistic subjects corresponding to ‘Art and Media’... but excluding ‘Science and History of Art, Music, Dance, Film and Theatre’" and also following a narrower definition: "comprising visual arts, music, dance, theatre and drama, film, radio and TV production, and fashion design." As I said, a fabulous population resource.

Results: about 5% of the population studied (~194,000) were deemed to have studied an artistically creative subject by the broad definition, falling to just over 1% (50,000) when the narrow criteria were followed. As per that opening sentence of this post, there did seem to be something in the idea that studying an artistically creative subject was *associated* with hospitalisation for schizophrenia, bipolar disorder and unipolar depression. Authors also noted that: "The associations remain when the analyses are restricted to sibling pairs, indicating that family-level factors alone cannot explain the association."

The possible reasons for this association are also explored by MacCabe et al. The ‘balancing selection’ hypothesis is mentioned whereby "the genetic variants conferring risk for psychosis also carry a biological advantage, such as enhanced intelligence or creativity, and this translates into reproductive advantage in the relatives of those with psychoses; thus maintaining the frequency of risk alleles in the population." Similar to the idea that the genetics of autism are probably not just 'genes for autism' (see here) so the genetics potentially linked to psychiatric disorders such as schizophrenia, probably also affect other areas of functioning (positively and negatively). Authors also entertain more 'psychological theory' (here we go) where, for example: "certain cognitive styles may be associated with artistic creativity and psychosis." Personally, I'd be more inclined to believe the first explanation over the second on the basis that 'cognitive styles' tends to make rather sweeping generalisations (see here for an example) and are rather difficult to confirm/refute from a scientific perspective.

Despite the results obtained by MacCabe, I am not totally convinced of any universally general connection between artistic creativity (or any other kind of creativity) and psychiatric disorder. I say this on the basis of other, independent findings (see here) that have not been so kind to the hypothesis. I'm also a little cautious that making such sweeping generalisations could potentially detract from the often very significant effects that such psychiatric disorders have on a person's life; many of which can lead to issues such as 'hospitalisation' (where hospital records were an important data source for the authors in this study).

Still, these are interesting results and have grabbed some media attention...

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[1] MacCabe JH. et al. Artistic creativity and risk for schizophrenia, bipolar disorder and unipolar depression: a Swedish population-based case–control study and sib-pair analysis. British Journal of Psychiatry. 2018. April 26.

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Sub-threshold autistic traits and creativity

I was intrigued by the results reported by Catherine Best and colleagues [1] recently and the suggestion that yet another sweeping generalisation attributed to autism (or at least autistic traits) might turn out to be not as accurate or universal as we might have all been led to believe.

Based on the analysis of data from over 300 people who completed an on-line questionnaire (anonymously) measuring autistic traits, researchers reported that creative ideas as measured by a divergent thinking task might show some connection to self-reported autistic traits. Further: "autistic traits were associated with high numbers of unusual responses on the divergent thinking tasks." Ergo, thinking outside of the box may show something of a relationship to autistic traits and creativity may not be an alien concept for those on the autism spectrum (a shocker I know).

Bearing in mind headlines such as 'Scientists discover people with autism have 'fewer ideas but are more creative and think outside the box'' that don't really reflect the study design and findings in their entirety (only 75 of the study participants said they had received a diagnosis of autism), I do think that the Best study findings call for quite a bit more research inspection in this area. Previous investigations have for example, suggested that there may be quite a bit more to see when it comes to verbal creativity and [some] autism [2] bearing in mind the small participant numbers included in such trials.

Divergent thinking and it's links to creativity is not necessarily a new concept when it comes to autism despite the increasing recent popularisation of this phenomenon. Viewers in the UK might have already seen the Channel 4 series 'The Autistic Gardener' detailing how a diagnosis of autism may not be a hurdle to good design skills; also over-turning other generalisations about perceived interests and vocations for those on the autism spectrum too (see here).

Caution does need to applied to the Best findings as they stand bearing in mind the study methodology used and the application of their findings to "a non-clinical sample." As per other commentary on the paper, it is still a little unclear as to how listing alternative uses for a brick or paper clip actually translates into a real-world setting. That also aspects of creativity have been previously associated with other labels (see here) and the lack of information on study participants with some of these other aspects in mind (e.g. comorbidity), and one needs to be mindful not to push the findings beyond their original scope however desirable they may be.

Still, the study results do make for some interesting reading and reiterate that all minds potentially have something rich to offer to society. Indeed, playing to strengths is a key theme of other recent research as per the concept of 'attention to detail' and threat detection [3] for example.

Music: Daft Punk - One More Time.

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[1] Best C. et al. The Relationship Between Subthreshold Autistic Traits, Ambiguous Figure Perception and Divergent Thinking. Journal of Autism & Developmental Disorders. 2015. August 14.

[2] Kasirer A. & Mashal N. Verbal creativity in autism: comprehension and generation of metaphoric language in high-functioning autism spectrum disorder and typical development. Front Hum Neurosci. 2014 Aug 11;8:615.

[3] Rusconi E. et al. XRIndex: a brief screening tool for individual differences in security threat detection in x-ray images. Front Hum Neurosci. 2015 Aug 10;9:439.

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Best, C., Arora, S., Porter, F., & Doherty, M. (2015). The Relationship Between Subthreshold Autistic Traits, Ambiguous Figure Perception and Divergent Thinking Journal of Autism and Developmental Disorders DOI: 10.1007/s10803-015-2518-2

"We of the craft are all crazy"

I hope that you don't think I am making light of mental illness with the title of this post which originally comes from Lord Byron but I got from this article by Hankir* on bipolar disorder and poetic genius. The reason for it stems from this paper by Simon Kyaga and colleagues** which, in quite a large population group, asked the eternal question about whether those in the creative professions are more likely to be treated for mental illness compared with the general population.

Nevermore, nevermore @ Wikipedia 

This latest work follows on from a previous study from the same group*** who talked about a "familial cosegregation of both schizophrenia and bipolar disorder with creativity". I had to look it up but cosegregation apparently is a genetics term relating to "the transmission of two or more linked genes on a chromosome to the same daughter cell leading to the inheritance by the offspring of these genes together".

Going back to the most recent work by Kyaga and colleagues, a few important points are worth mentioning:

• A sample size which was positively eye-watering at 1,173,763 participants based on a nested case-control methodology, looked at cases diagnosed with one or more of psychiatric diagnoses and compared them with asymptomatic cases to ascertain the rate of creative (scientific and artistic) occupations. 
• Psychiatric diagnoses included: schizophrenia, bipolar disorder, anxiety disorders, alcohol abuse, drug abuse, autism, ADHD, and completed suicide, to name some.
• The study was not just confined to patient cases but also their non-diagnosed relatives.
• Results: although some of the headlines are a little misleading (see here), outside of bipolar disorder, there was no significant trend towards creative occupations = more psychiatric disorder. Unless that is, you were an author which "was specifically associated with increased likelihood of schizophrenia, bipolar disorder, unipolar depression, anxiety disorders, substance abuse, and suicide".
• A look at the relatives of those diagnosed with a psychiatric disorder however did suggest an association with the creative occupations.

I've perhaps been a little harsh in translating these results which have already received some media attention. The connection between being diagnosed with bipolar disorder and also being in a creative occupation is not to be sniffed at, as per the Hankir paper and some quite high profile cases such as Twitter royalty Stephen Fry. Indeed seemingly everyday now, one or more of the creative geniuses in public life seem to 'come out' and talk about their experiences of bipolar disorder as per the Wikipedia page titled: List of people with bipolar disorder. Obviously I'm going to have to be careful here not to make too much of the link based on comparatively few names set against the hundreds of thousands of people involved in the creative arts who do not seemingly present with the features of bipolar disorder (or at least don't tell the public). Things are never so cut-and-dried. 

Indeed I was also interested in the other links that have been made between diagnoses such as bipolar disorder and cognitive styles. So, this research from Gales and colleagues**** who asked whether bipolar disorder was more commonly present in highly intelligent people. Their conclusion was very possibly but generally seen more in men and without the interference of other comorbidity. Indeed I hope Mr Fry does not mind me using him again as an example, but one would speculate that his IQ score (or should that be QI?) would be 'up there somewhere'. 

Looking at the occupations listed under creative careers, I also noted 'scientific' to be listed. I have to say that I did a bit of double-take at this given that I never really looked at science as sharing the same creativity as say a writer or an artist. Having said that, if we take the literal meaning of creativity to mean invention and originality, I can see how even boring old researchers talking about study design and p-values might have reason for some creative flair at times. One might ask whether the most creative scientists, such as those Nobel Prize winners for example, might also be more prone to mental ill-health like bipolar disorder? The subsequent questions are: which came first (creativity or bipolar disorder) and whether the propensity and/or actuality of bipolar disorder might drive someone to make certain creative career choices.

I cannot leave this post without also making further mention of the author - mental illness link reported by Kyaga et al. Reading between the lines it seems that the notion of a tormented writer - like for example Edgar Allan Poe - might actually have more truth than fiction. Noting for example, that authors were significantly more likely to commit suicide is an important observation and something which could potentially inform strategies to reduce suicide. That being said, suicide is a complicated thing. Based on the wealth of other literature on occupation and suicide, as per the high rates of suicide in medical physicians for example, one has to be cautious at making such correlations set against the bigger picture.

This is an interesting area of research and discussion, not just in terms of cognitive styles and mental health, but also as to how aspects of creativity may very well overlap with the perceptions of mental health and ill-health. I draw back from making too much of such data however (despite the current study sample size) given the multitude of other factors potentially at work and the seemingly increasing tide of labelling the extraordinary with some kind of diagnosis.

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* Hankir A. Review: bipolar disorder and poetic genius. Psychiatr Danub. 2011; 23 Suppl 1: S62-S68.

** Kyaga S. et al. Mental illness, suicide and creativity: 40-Year prospective total population study. J Psychiatr Res. 2012. pii: S0022-3956(12)00280-4.

*** Kyaga S. et al. Creativity and mental disorder: family study of 300,000 people with severe mental disorder. Br J Psychiatry. 2011; 199: 373-379.

**** Gales CR. et al. Is bipolar disorder more common in highly intelligent people? A cohort study of a million men. Mol Psychiatry. April 2012.

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Kyaga S, Landén M, Boman M, Hultman CM, Långström N, & Lichtenstein P (2012). Mental illness, suicide and creativity: 40-Year prospective total population study. Journal of psychiatric research PMID: 23063328