Music and the Brain: Depression and Creativity Symposium

from the Library of Congress in Washington DC good evening I'm KJ misen I'm from the department of psychiatry at Johns Hopkins and I'm delighted to be here this evening to chair a symposium the symposium on depression and creativity which is jointly sponsored by the Library of Congress and the Dana foundation this evening marks the bicentennial of the birth of the German composer Felix Mendelssohn who died after a depression a very severe depression following the death of his sister dr. Y brow is going to be talking a little bit about Mendelssohn in his talk there are rare Mendelssohn related items from the archives of the Library of Congress which will be on display during the commemorative series of programs presented by the Library of Congress the National Academy of Sciences the National Gallery of Art and the Smithsonian Institution this evening my colleagues and I will be discussing the relationship between depressive illnesses particularly bipolar disorder partly because bipolar disorder has by far the most connection to creativity and also all three of us actually specialize in the treatment and study of bipolar disorder we're going to be talking about the link between the depressive illnesses in general and creativity I will be presenting an overview and history of the relationship as well of us as a summary of the findings from the studies that have been conducted to date and then I want to briefly discuss some of the reasons why there might be a connection between mood disorders and creativity why why is it that you could have such devastating illnesses be in any way connected to something as marvelous as human imagination and then talk a little bit about some of the implications of this connection dr. Terrence Kenner who's professor of psychiatry at Stanford University and chief of the Stanford University bipolar disorders clinic will then discuss clinical and neuroimaging studies of creativity and this will be followed by dr. Peter Y brow who's director of the simul Institute for Neuroscience and human behavior at UCLA as well as chairman of psychiatry at UCLA professor Y Braille will talk about the creative cycle biological and psychological elements of creativity a possible link between madness and extreme moods and genius is one of the oldest and most persistent of cultural notions it is also one of the most controversial this evening we would like to discuss several aspects of this link between mood disorders and artistic creativity we're going to be talking about studies of dead people who are highly creative and also had problems with their moods and we're going to be talking about living studies of living artists and writers and talking about some of the what we know about the biological and psychological and cognitive links between extreme mood States cognitive states and creativity clearly most artists and writers do not have any kind of mental illness the argument is not that the argument is that artists and writers and especially poets suffer disproportionately from depressive illnesses the clinical and ethical implications of this association are important but poorly understood many treatment strategies pay insufficient attention to the occasional fleeting benefits that bipolar illness in particular can bestow upon some individuals it's important to know what the side effects of drugs are that might be treated and the and the dangers of not treating these illnesses we know for example the left untreated bipolar illness usually worsens over time and clearly no one is creative when severely depressed psychotic in four-point restraints or dead in addition patients with mood disorders frequently use other mood altering drugs such as alcohol or cocaine which cause serious medical and psychiatric complication the real task as any clinician will understand of imaginative compassionate and effective treatment is to give to all patients more meaningful choices than they are now afforded and I think that the research is going in the direction of allowing this scientists and I think you will hear this from both doctor why brow and from doctor Keter are gaining a real understanding into what's going on in the brain when people are creating as well as when they are depressed and when they are manic so I would like to start now with just and an overview as I said about what we know about the relationship I wanted to start with a caveat this is Robert Lowell arguably one of the great poets American poets of the 20th century who had suffered from at least 20 major breakdowns in his life had bipolar illness and he described one of his manic episodes as a magical orange grove in a nightmare what we're going to be talking about this evening focuses a little bit on the magical orange grove side of things but it's very important to keep in mind the devastating aspects of these illnesses particularly suicide 1 million people a year die by their own hands across the world most of those are related to mood disorders so it's important not to in any way romanticize bad illnesses but also understand that there are some aspects of these illnesses that are particularly interesting when there you can really look at the relationship between mood disorders and creativity and depressive illnesses by looking at people biographical studies of people who have died and as I say studies of living people I'm going to be focusing in first part of my talk on people biographical studies of people who have died and basically there are a lot of things that we know about mood disorders we know about the family history we noted that their genetic illnesses that they run in families we know that there's a natural course there's a progression to the illness we know a lot of things and say we want to bring that to whatever it is when we're looking at someone's life whether we're looking at Felix Mendelssohn or Robert Schumann or Virginia Woolf I'm not going to get into just discussion of the diagnosis of mood disorders partly it's one of those have to say probably intrinsically not wildly interesting topics in its own right but it's also complicated it's just to say that we again we know a lot about the diagnosis and treatment of these illnesses and that when you study anyone whether they're in your office or whether you're looking at their papers and medical records you you look at certain aspects of symptoms how the symptoms present how they present together because it's never just one symptom alone it's a patterning of symptoms it's a severity of symptoms and it's a patterning of symptoms over a period of time so you want to start by talking a little bit about the course of the illness one of the things that you can look at if you're looking at the life for example of Robert Schumann or Vincent van Gogh you can look at how does the illness manifest itself over time if the person had problems with moods when did it first occur we know for example the average age of onset for bipolar illness is about 18 and so if somebody started at first getting ill like van Gogh did in his late teens it's just one piece of evidence it's like a very complicated crossword puzzle but you're putting together pieces of evidence we know that it's an episodic illness that comes and goes that people by and large at least in the early stages of their illness tend to go back to normal functioning between episodes we know a lot about the duration of episodes we're not talking about somebody who's just sort of moody broody who's depressed for a few days we're talking about the average length of an untreated episode of bipolar depression is 9 to 12 months of untreated manic mania is about 1 to 3 months so we're not talking about short periods of time we're talking about people who have very severe illnesses for prolonged periods of time though both doctor Y Brown and I think dr. Kenner and particularly talking about the far less severe forms I'm going to be focusing on people who are seriously illed dr. Kenner is going to be focusing on the temperaments that are associated with these disorders and we also know again as I said earlier that these illnesses tend to progress over time get worse if they're not treated and depression is a not uncommon outcome that's the pro side of me we know that again that the average age of onset is early on these are most of the psychiatric illnesses or illnesses of youth and you can see here that most people who get bipolar illness will get it before the age of 25 so if you look at looking at another German composer who was actually a colleague and friend of Felix Mendelssohn and Robert Schumann one of the things that you can look at is the patterning of productivity over time so if you see someone who has very episodic productivity and it's seasonal and it's accompanied by other symptoms that are associated with hypomania or depression then that gives you some sense that that person may be more likely to have a mood disorder and the productivity follows so Slater and Myer in England quite some time ago now plotted out the number of works by Robert Schumann as a function of the years that he was hypomanic and depressed and you can see that in those years in which he was very depressed he produced very little and in those years in which he was hypomanic or mildly manic he was indeed very very productive and and in the last two years in two and a half years of his life he was in insane asylum and produced next to nothing Vincent van Gogh you couldn't see again that the if you're looking at the progression of an illness that he started first getting melancholic when he was in his teens but then as time went on you could see the increasing number of episodes the worsening of his illness and then by the last few years of his life increased number of psychotic episodes and then of course killed himself at the end Edgar Allen Poe who perhaps one could say was never a wildly happy man but you can see this is reading it different the years in a different direction here but you can see again the same pattern that early on in his life he certainly had periods of melancholia but as he got older these progressed and then in the year before he died he attempted suicide and in fact that photograph before was taken not long after he after he attempted to kill himself but one of the things that's most important piece of evidence is in particularly bipolar illness is bipolar illness is a very genetic very heritable illness and so if you look at the family histories of the individual artists and writers and musicians you can see whether or not these illnesses tend to go down the family tree this is Lord Tennyson and this is the first of two slides and you can track his family history back to the late middle of 1600s and you can see that it's one-point the Clayton family and the Tennyson family intermarried and there was insanity and severe depression on both sides of family and violence and you can see this as time goes by a tendency the Tennyson's grandfather there George and had full-blown disorder bipolar disorder and both of his aunts and uncle were affected and then what you see is it's really quite astonishing group brothers and sisters his father Tennyson's father had psychotic episodes and died quite ill but you can see also almost all the tennis and children were affected one way or another by mood disorders and again these aren't mild forms of illnesses Tennyson was treated went to doctors at different times in his life for depression had a brother who was an insane asylum for mania from for decades all three of the eldest of brothers had significant problems with their moods and they also walked off with all the major writing Awards when they're at Cambridge this is George Gordon Lord Byron this is his wife they had one of the most miserable marriages on record and Byron was kind enough to document it with great wit but lady Byron who seems to have had no sense of humor whatsoever said the day after my marriage he said you were determined not to marry a man and whose family there was insanity you have done very well indeed or some ironical expression to that effect followed by the information that his maternal grandfather committed suicide and a cousin had been mad and set fire to a house well actually she was she and he were very much understating it and in fact you couldn't trace the bipolar illness back to a very particular point in the Byron family trees the fourth Lord Byron married into the Berkeley family which had constitutional insanity in it his father had a breakdown and was reputed to have slit his throat his grandfather repeated to have a breakdown as well and his mother long line of suicide and violence Byron himself suffered from very severe mood disorder and his daughter who was quite a famous mathematician had delusions both manic and depressive delusions Byron as I say if you have to read a set of letters in English language recommend Byron's and he said I should many a good day I've blown my brains out but for the recollection that it would have been a pleasure to my mother-in-law and even and then if I could have been certain to haunt her Ernest Hemingway of course himself committed suicide his father was a physician who also had bipolar illness committed suicide his brother and sister committed suicide and his granddaughter committed suicide his sons one of them was treated with ECT with electroshock therapy and another one had severe psychiatric problems Virginia Woolf again just go this briefly just say that a very extensive family history of mania depression cyclothymia G yourself of course died of suicide and this is vanko's family tree and his brother Thao died psychotic his younger brother is suspected having killed himself Wilhemina his sister was in an asylum for decades and he himself of course killed himself this is just a very quick summary of the studies that have been done some of the studies that have been done looking at bipolar 1 which is the severe form of bipolar illness and bipolar 2 which is the form with milder manias and depressive illnesses in blue there and looking at the population rate which you would expect in and seeing the comparison with the all the studies of artists and writers and all the studies essentially show a very much elevated rate particularly bipolar illness but of depressive illness in general likewise the studies that have looked at suicide rates in artists and writers find a very much elevated rate of suicides so why should it be so why why would this illness why would these this constellation of illnesses really be correlated and and if they say doctor why Brown and dr. Keller are going to be discussing this in much more detail but you can imagine that be certain changes in mood and certain changes in thinking that occur when people are manic and when people are depressed they also sense the world in a very different way they have hyper accuses very often when people are mildly manic they feel an experience the world very differently they have very different patterns of energy and sleep high energy during mania and then there might be long-term correlations with personality and temperament that a particular kind of person may be more likely to have bipolar illness and that particular kind of temperament might be more linked to the creative process this is a very very very old slide and I just use it as really metaphorical not because of its accuracy per se but just just to say that the brain is a very complicated sort of thing that is acting very differently in mania and depression and again dr. Keller is going to be going into this this is a study that was done in the very early stages in very early studies of imaging and it shows a woman's brain who was a rapid cycler who had 24 hours of mild manias than 24 hours of depression and you can see the brain when she was hypomanic and that center row showing a much more activated state and this as I say very simplified is really more metaphorical than not it's just to say the brain is doing very different things when people are manic and depressed no there's a lot of history behind this this is not a new idea the notion of a connection between creativity and madness goes back to pre Grecian myths and and history and likewise the old writers going back to the ancient physicians this is something they observed the philosophers Aristotle Plato the relationship between highly elevated mood states in particular and I just want to touch on temperament because dr. Keller will this has actually taken from my nephews art class and is quite wonderful because there are a lot of things that go into creativity other than just creativity itself I mean it's one thing to have an idea it's another thing to act on an idea and acting on an idea has some aspects of grandiosity and expansiveness and driven us but also there's a resilience and a tendency to persevere but anybody who is doing anything that's at all different it's going to get very criticized and the question is not whether or not you get criticized the question is what once you're criticized whether you bound back or not and not to speak highly of depression because I don't think anyone who's been depressed would but there are certain aspects of depression that lend itself to reflection and introspection and puts into perspective things that might have been generated in a more volatile or fevered manic state people tend to get very obsessive and critical when they're depressed and if they have written something or composed something when they were feeling expansive they might then when they're depressed get highly critical of it and at the end of the day make it into a much better object there's a tendency for many people who have experienced depression to feel that they have increased sensitivity and compassion as a result of that and therefore some perhaps increased awareness of the human condition and a tendency to for anyone who's been depressed to have less denial there's a kind of classic study that shows that people who are depressed actually have a much more accurate view of a depressing world than people who are not depressed which is depressing in its own right okay I just want to finish up now by talking about a few of the implications this is the question comes up and very legitimately of what are what are the implications you know if if you have these illnesses that are on the one hand highly destructive and potentially lethal and on the other hand bring a highly imaginative quality to some people the minority of people who have these illnesses but and therefore add something to society as well quite what happens if you then treat them and I think that there are in treating anyone there are a series of issues that you have you always have an obligation to tell people what the risks of treatment are what the side effects are of any medication what the long-term effects are of any medication or psychotherapy for that matter not just medication but you also have an obligation to say what are the risk of no treatment and if somebody who spent a great deal of my psychotherapy life treating artists and writers I can tell you that artists and writers tend to focus on the risks of treatment and not on the risks of no treatment and I think as a result clinicians have a real obligation to to emphasize what happens if you don't get treated and that they're not either/or sorts of things in this day and age fortunately we have medications that are less devastating and I'll get that to that in a minute there are certainly risks to treatment these are drugs most of the drugs that are used to treat mood disorders act obviously by acting on the brain you can't have it both ways you can't say that you have a medication that works on the brain that doesn't work on the brain it does it works on energy works on mood it works on cognition the question is always to try and get people to take the minimal amount of any medication the best kind of psychotherapy and get people involved in their treatment so that they they can minimize the side-effects and maximize their imaginations but there are very real risks of treatment and no treatment and those include suicide first and foremost and always because these are potentially very lethal disorders that there are very destructive aspects of having repeated manic episodes and repeated depressive episodes and I'm sure dr. Keller will probably be talking about this these are toxic conditions these have a real effect on the brain it's not and these the medications that work well for example lithium actually has it turns out it has a very neuro protective neuro generative quality so these are things to really keep in mind again the illness tends to progress and the effects of medications I'm always struck by artists and writers somehow feeling that drugs like alcohol and cocaine or somehow have fewer side effects and if you're a long term adverse effects than prescribed medications this is just a it's a sexually study of a long time ago I actually meant to replace it but it's essentially the same data there the medications that we have now really do save lives and since suicide is such a major risk we know they're probably 3035 studies now showing a lowered risk of suicide in people who have been treated with lithium and another thing in terms of mitigating factors is that two-thirds of patients for example who are on lithium in fact report no significant changes in intellectual functioning of any kind and the two studies that have looked at artists and writers and said do you feel as productive more productive less productive on medication than you did before medication for your mood disorder three-quarters of them of the artisan writers say that they are as productive or more productive on medication and that's again because these are such totally debilitating illnesses and I just want to end before introducing dr. Kenner by getting back to Robert Lowell and Robert Lowell was just got treated really on the cusp of when when lithium was first introduced and once he was put on lithium he stopped having his manic episodes he stopped needing to be in the hospital and his publisher said about him and his editor of all our conversations I remember most vividly vividly Lowell's words about the new drug lithium carbonate which had had such good results and gave him reason to believe he was cured it's terrible Bob to think that all I've suffered and all the suffering I've caused might have been arisen from the lack of a little salt in my brain thank you now it's my pleasure to introduce dr. Terrence Keter who's professor of psychiatry at the Stanford University School of Medicine and chief of the Stanford bipolar disorders clinic he's one of the world's leading authorities on brain imaging techniques and study of mood disorders particularly bipolar disorder as well as a physician scientist who has conducted important research and a pharmacological treatments of mood disorders dr. keller is the editor of the text advances in the treatment of bipolar disorders and he and his colleagues at Stanford have undertaken pioneering studies into the relationship between temperament and creativity he'll be talking this evening about clinical and neuroimaging studies of creativity Carrie thanks Kay thank you Kay it's pleasure to be here with you today and to be able to share some of these findings with you that's about halfway through it yeah okay there we are okay so for this what I tried to do is to try to put this in the language English instead of a lot of jargon okay so I the the title is feelings and thinking mechanisms of creativity in bipolar disorder okay so as as dr. Jamison Illustrated there appears to be a linkage between bipolar disorder and creativity and if that is the case then how does that happen I got interested in this because I'm running a clinic and you can't help but notice in your clinic that there are individuals that are highly creative and they have concerns about medications and perhaps need to share some of those concerns in order to get the best treatment and the clinical samples that I'm describing today all have a level mood there between episodes about a third of them are not taking medications and about two thirds we're taking medicines and actually in a separate analysis I won't present today it didn't make any difference and really I think having a level mood is is a key aspect of this so I want to do three things today I want to show you some data from our group showing that creativity is enhanced in patients with bipolar disorder these are patients in our clinic and I also want to look at some preliminary steps towards figuring out how that works so what contributes to this and I'll present some data that suggests that negative or changeable feelings okay so emotions have a piece and also that intuitive and open-minded thinking has a piece so there's a feelings piece and a thinking piece and then I'll show share with you very little bit of our neuroimaging data that we have that we've applied to to these sort of these sort of issues ok so Ken can we put the whole talk in to six words on one slide and and this is it okay so the mechanisms creativity in bipolar disorder and what I want to try to convince you after I've shown you that that it's enhanced in our group is that negative and changeable feelings have a piece an intuitive and open-minded thinking has a piece okay so two different aspects now you might think that feelings are inherently related to mood disorder so that that perhaps is not quite as novel as the notion that the kind of thought process or the the way people think the way they do mental operations which is not as obviously directly related to mood has a piece in this I've done my best to protect you from this sort of stuff which is jargon so that's basically the same slide using the kind of jargon that we that we get we in the in the field expose ourselves to and so that negative feelings are termed the by the unfortunate term neuroticism which is highly pejorative you could in fact say people who lot lack this have passion deficit disorder if you wanted to label a group so it's unfortunate the name some of these things have cyclothymia is is a descriptive term for very changeable feelings at a moody temperament if you like over on the other side the jargon translates a little better intuition and openness to experience rather than open-mindedness so what I'll be describing today is some work that's going to be presented at the American Psychiatric Association in San Francisco this spring and so there's thirty two bipolar patients forty two healthy controls twenty-one unipolar patients and twenty-two creative controls so the real comparison is the bipolar and the healthy controls the unipolar patients are there to see if there's anything special about bipolar versus unipolar and the creative controls are there as a kind of check on some of the creativity metrics and some of the temperament metrics okay and so there are a battery of tests that we have focused on and I'm this is very selective presentation just sort of giving you the essence of what it is and so as a creativity test I'll show you something called the Barron Walsh art scale and then for looking at personality and thinking there's something called the five factor model of personality that we'll look at there's another thing called the myers-briggs type inventory this is used very much by occupational psychologists not so much by psychiatrists and finally Hogg abacus Cal has a temperament scale that is developed by a psychiatrist so one of the problems with looking at so-called everyday creativity where you're looking at samples clinical sample is that you have to have some kind of a metric of creativity and there are lots and lots of these metrics and some of them have good face validity but they're very difficult to do others may not have the greatest face validity they don't look so as obviously valid as as some of the other ones but this one was developed by Frank Barron and George Welsh and over at the University of California at Berkeley there was a creativity group that was very interested in developing a wide range of creativity measures and this is but one of them so this is just a representative measure and this one is interesting because it was derived empirically from hundreds of line drawings and looking at creative and uncreate of groups and just skimming off the 86 that best separated those two groups okay so it's an empirically derived measure it is a measure that has a theoretical basis as well it wasn't completely random but the instructions are decide whether you like or don't like each of the following drawings mark each with an L for like and D for dislike if you can't decide guess don't skip any drawings try to work as fast as you can okay so this is a forced choice okay and buried inside this I think is actually an effective task okay because there's like and dislike and I have seen few metrics in which the people who start score the highest on the metric are the most pissed off by the test and think it's the least valid but this is one of them okay so this is an intriguing little test and one of the things is that there isn't a whole lot of language besides the besides the instructions this is this was developed and then validated and interestingly perhaps is not surprising the visual artists and such can score very well on this but creative writers will score well on this so it's it's not confined to the visual realm anyway the way it works out is that you get points for liking complex asymmetric images and you get points for not liking simple symmetric images and actually you can get more points by not liking things than liking things okay so could it be that if you had access to negative emotion you'd be able to not like things and then pick on that stuff on the right could it be if you were open-minded and sort of intuitive you could like the stuff on the left and say like that and could it be if you had changeable mood you can flip back and forth between those two and do the test well let's see well what else are we so what are we measuring and just give you a little bit of the background here so these negative feelings are so-called neuroticism and open-mindedness these come from something called the five factor model of personality development in Baltimore of all places National Institute of Aging landmark studies they're done some people thinking this is really the benchmark for personality research there are five factors two of them are of importance to us one of them is this so-called neuroticism if you have a look worrying temperamental self pitying self-conscious emotional vulnerable this this instrument has a hard edge and even openness I mean its imaginative creative original prefer variety curious and liberal that sounds alright okay but if you're not open then your uncreate of conventional prefer routine I'm curious and conservative okay so it it has been it has been criticized as perhaps having too hard of an edge and myers-briggs type inventory has taken a completely different approach to personality saying well people are different they're not good or bad they're different and so this is where neuroticism and openness has its origin the myers-briggs type inventory doesn't have neuroticism okay and it has it has four factors basically and these roughly correspond to the non neuroticism factors of the five factor model and in fact custom McCrae did this we we actually did the correlations in our group they were almost identical to those Acosta and McCrae and so there's no neuroticism there so nobody has to be sick with this and in fact the people who develop the myers-briggs type inventory very interested in leadership and occupational medicine and don't want anything to do with somebody running a bipolar clinic and so what you see there though is something called intuition that correlates with openness to experience okay and if you look in the creativity literature the thinking constructs that perhaps are the most widely cited as being related to creativity they are these two intuition and openness to experience just to give you an idea of how warm and fuzzy the myers-briggs is you can see the intuitive types on the right there all kinds of things that are a little bit like openness to experience but then the sensing types on the left rather than being on open or closed as in the Ennio is sensing types they're trying to find something nice to say about everybody okay and this may be a little too warm and fuzzy but I the sensing type there are values in having people in our society you have these skills and certainly the people who work with the myers-briggs see it as an instrument that doesn't pathologize personality okay and so it's important to have something in that because if you're really trying to step back and look at the creative process in general and get free of this notion of psychopathology it would be nice to have something and perhaps this cognition approach of myers-briggs is worth integrating so anyways this is the sample for that God all of those assessments and so you can see there's there's a slight majority of women we did not feel we did not find any creativity difference between men and women and the in pretty well everything and in the myers-briggs they does fit one cultural stare stereotype women are more feeling and men or more thinking but we didn't find any any other finding with respect to junior gender of significance the age of this group k mentioned that these be that folks who have bipolar disorder have an onset in late teens and many studies of bipolar disorder you'll see an average age in mid 30s to 40 with an average duration of about 20 years ours is no exception education uh this you know the generalizability of this cohort is a little bit of a problem because we're from suburban San Francisco sort of Silicon Valley and so these people all have insurance that Stanford takes okay so the generalizability of this to a community mental health clinic is limited this population has plenty of education slightly more education in the creative controls creative controls have slightly more education because every single one of them is a graduate student in product design fine arts are writing at Stanford okay so it's a little bit of a bias you can correct for all these things and then down along the bottom is Beck Depression Inventory scale and in clinical trials too if you've got depression you want to get into clinical trial you need about a twenty on this and if it's less than ten you're doing pretty okay and you can see that in general these people are not clinically depressed and know the more hypomanic at the time creative controls about half of them had a history of either depression or drug or alcohol use but not bipolar and half didn't basically their creativity scores in those two groups who are very similar so it's a these are the results so that funny line drawing test it's that's the barren Wells total and then you can look at the dislike scale and like scale and what you see there's about a 50% advantage over the healthy controls in the bipolar and creative controls 50% higher scores in the total and most of its coming out of the dislikes subscale there in the middle okay and there it's like 80 90 percent taller and even the inner you know Polar's get in the act on that now the unipolar group was able to they're pretty good at disliking things but they've actually had a deficit at liking things they're below alright so you know it's that maybe that's why then maybe that's why they didn't make it on the total okay and there is some if you look at if you look at some of the mechanisms that that kind of fits as well so I was trying to say that negative feelings changeable feelings intuitive thinking open-minded thinking we're over represented in the bipolar patients so let's have a look here so these are the negative feelings this is the so-called neuroticism you'll notice that this is this pretty substantial difference but it's dwarfed by this ten times bigger difference on change ability of emotion okay and the reason is that that change ability of emotion is is a scale made by a psychiatrist going after differences between unipolar and bipolar and in fact you see this this difference here but basically the mood disorders negative emotion lacks any kind of valence with respect to unipolar bipolar and that's dr. Kissel's big problem with that construct okay and by bringing cyclothymia change ability you get something that distinguishes the bipolar does this take it across the goal line on creativity I don't think it does in fact I think what what ends up taking it across the goal line are the differences in thought processes and so if we go over here to thinking and you'll notice this now has a different scale okay these are smaller differences they're still significant but not as highly significant and the reason that is that these are things that are not specifically designed for mood disorders applied to a mood disorders issue but you can see that scores for intuition in the bipolar and the creative control are elevated significantly we like to just like remember in school the teacher give you a star when you did something good you get a star if you're clinically statistically significant okay so that's what the stars are for and so we see an increase in intuition kind of similar between the bipolars and creative controls and also an increase in open-mindedness okay so basically these constructs intuition and open-mindedness that have associated with creativity are enhanced in the bipolars and the creative controls and the healthy and the healthy controls the norms we looked at normative data our healthy controls are within a percent or two of the population norms so there's nothing odd about that and then the the unipolar group is something just a little bit different and doesn't quite make it there's a little bit of it there but doesn't quite make it to statistical significance so we can build this kind of a model so what we can do to say okay creativity's increased and negative feelings changeable feelings intuitive thoughts open-minded thoughts are increased what's like those relate to each other and the answer is yes so these are correlations and they do something by squaring the correlation coefficient to give you a number that explains the contribution okay so you see with respect to feelings negative feelings contributed about 15% of that total score of the barren Welsh and changeable about 14 so pretty I thinking intuitive thinking and open-mindedness not quite as much a little bit less all of those were significant though now looking at these kind of percentages if I saw something that that accounted for like 80 percent of creativity one one item I'd really wonder what was up because this is multifaceted okay and I think things that are things that are in the neighborhood 10 to 20 percent are of clinical interest it's very interesting we a lot of a lot of the the work that we do with medications if a medication has a 10% advantage over placebo that is usually enough to get it fda-approved okay so those are the kind of margins that we're working at and so so 10 percent so but if we drill down on this a little bit we can see something okay the negative feelings in changeable mood were basically working on the dislike subscale okay remember saying that those would that certainly the negative feelings you maybe you would be able to dislike things better and in contrast which is kind of enlightening intuitive thought process and open-mindedness actually correlated with the like subscale now like as the junior partner and the whole enterprise okay but negative feelings and changeable feelings did not correlate with like and in fact intuitive feelings and open-minded feeling thoughts and intuitive thoughts did not correlate with this like although intuition got close so you've got it you got a potential mechanism there that in fact the creative advantage we see in the bipolars comes from not all not only the mood itself but perhaps as as suggests by the right-hand side of the screen the way thinking occurs and just to show you that this this notion about using thought processes is not totally irrelevant to to the enterprise of understanding creativity we did something called the edge 2 checklist create a personality scale and there you see open-mindedness really start to shine because it really is the poor cousin it's kind of it's the least a month amongst the four but it did quite well on that and as did intuition there have been multiple studies showing that in the past so that's where kind of focusing on that and the feelings didn't really have that much to do with that scale now one of the things is suppose we we know how this works and there's the thinking brain and the feeling brain how can we relate these kind of things to what's going on inside the brain Hustler's definition creativity is meaningful rule transcendent production and you can actually parcel out parts of the brain that will give effective meaning to different stimuli or remember things or create associations or actually implement plans so there's brain areas that can do these kind of things and just as one example these are some correlations of brain images and these are correlations with that art scale okay and this is brain structure actually this is just a picture of the structures of the brain even you can do this with functional MRI and say have them do the bear and Welsh in the scanner and things like that but this is even at the level of structure and then Kay was mentioning that some of these medications could be neuro trophic but what we found basically the in 25 healthy volunteers who had MRI scans we did something that they call voxel-based morphometry where you basically look at the entire brain and look for differences or correlations and the measure that came out positive was gray matter density and one of the problems with brain imaging is that we're we can we we are able to measure things before we fully understand what they mean okay and bring him a gray matter density is probably one of those measures but in any case we got positive correlations in regions associated with feelings and associative thought okay so the feelings it could have something to do with those negative feelings or changeable feelings associative thought could have something to do with intuition could have something to do with open-mindedness and then we got negative correlations in regions associated with analytic thought okay more more kind of operational rote thinking okay so these are some interesting interesting preliminary data that we're still working on so in conclusion we have data from a clinical sample that shows creativity is enhanced in our patients with bipolar disorders to a level similar to that to grad graduate students in creative disciplines and we've got at least some preliminary evidence of how this happens and it may be mediated through negative changeable feelings so having emotional component as well as intuitive open-minded thought processes and there are emerging data trying to explore exactly where this lives in the brain and with this as well as for the clinical studies hopefully we can better understand how to treat our patients with bipolar disorder thank you very much thank you dr. cater I should have said earlier that we're just holding questions till the end we decided we wanted to have as much time as possible for questions at the end so we kept our talks relatively short so after dr. Y brow spoken we'll be answering as best we can anyway Dutch Peter why brow as I said earlier is the director of the Semel Institute for Neuroscience and human behavior as well as chairman of the department of psychiatry at UCLA he was before that chairman of psychiatry at Dartmouth Medical School and before and then at the University of Pennsylvania he is an internationally acknowledged scientist who has been fundamental and contributing to our understanding of the role of the thyroid hormone on the brain especially its critical role not only in the pathophysiology of bipolar disorder but also in his treatment particularly in the treatment of people who have very rapid cycling forms of the disorder which is particularly terrible form of the disease doctor why brow is as well as superb and widely published author most recently of American mania and earlier a wonderful thoughtful and beautifully written book called a mind apart it's a remarkable book on the philosophical and clinical and humanistic aspects of depression and mania and if you don't have it I recommend it dr. Y Brown this gentleman whose birthday it is today was a prodigy he was born of a wealthy family in Hamburg and moved very rapidly to Berlin he then started to play the piano under the tutelage of his mother about the age of six the family was very musical and they would have Suarez in their house in Berlin his father was a banker his grandfather Moses Mendelssohn was a famous philosopher in Germany and by the age of nine he was giving concerts by the age of 13 he had written a quartet at the age of 15 he had orchestrated a full symphony and of course then you will know the Midsummer Night's Dream music that he wrote which is the wedding march which he did when he was about 17 by the time he's 20 and he went to England he was a celebrity he fell in love with England in fact wrote a fine Scottish Symphony and Hebrides and Fingal's cave and all those pieces that are their associated then at 26 he was the head of the Devon house Orchestra in Leipzig 34 he founded the Leipzig Conservatory for music at 38 he was dead so this man as extraordinary most of us at the age of 38 are wondering what to do with our lives so we have to ask ourselves and what was it that drove this man why is he so different well a few years ago now five probably I met a man in Los Angeles whose name is Michael Tannenbaum he is something of an entrepreneur himself and a very successful businessman and he challenged me and the Institute to look at what is the biology of creativity we really know very little about creativity creativity at the moment is at about the same place as memory was in our understanding scientifically twenty years ago and so he said to me I want you to study this I said well nobody knows how to begin he said well that's the challenge I'm going to give you an endowment and you have to figure that out so fortunately we have many wonderful neuroscientists at the Institute and at UCLA and I started off by just asking people to submit ideas that they thought might be relevant to creativity and we got all sorts of ideas from across the university ranging from frontotemporal dementia which is an odd deterioration of the frontal lobes that sometimes reveals artistry in the individual who's suffering and the use of drugs schizophrenia and manic depressive illness all sorts of things came in and from that we began to distill what it might be that underlies this extraordinary creativity as one might see it in a man like Mendelssohn and as you can see from this slide we came to the conclusion that at the core was emotion of course because emotion is the system in the brain that connects us to the to the world around us the ATS you can imagine it as vision emotion can go wrong in many different ways but actually its function every day is to integrate what we have within ourselves and what we perceive in the world and create an opportunity for performance based upon those things but around that if you think about creativity what is it that you need and we came down to the conclusion that first of all you need some sort of novelty generator which you see here in the purple and of course in order to manipulate ideas of any size or number you must have memory a prodigious memory and then the other thing which is very important we decided as we went through the proposals that we had was what the psychologist calls response inhibition in other words you have to break up habit you know most of us if you think about it are creatures of habit we drive to work through the same streets we sit in the same chair it's quite uncanny you know at the Institute if we have meetings and we have regular meetings people always come into the into the room and they sit in the same chair we're very much creatures of habit and in order to be creative one must break that up so these three elements around the core of emotion seem to us to be important and so we set forth trying to figure out how we might study that and we're now in the middle of this series of studies but on the following through with the colors you can see that in terms of novelty generation memory and cognition we have set up some studies which start at the basic science level usually with animal models and then go through to a human investigation and we have been collecting 300 very brilliant young children from the Los Angeles area and we are beginning to study them in terms of what makes them different with the hope that we might be able to associate some of our basic science studies with what we find in the young human being so I'm good I'm going to do I'm not going to talk about all this tonight because there isn't time but I'm going to talk briefly about the novelty generation particularly as it pertains to some work we've been doing in songbirds and then also a little bit about memory and an enhanced memory mouse that has been made and then I will talk a little bit about the cognitive control side of things and bring that back to the discussion of music etc so songbirds are very interesting because this is the zebra finch for obvious reasons it has a little zebra coat and these creatures teach each other how to sing this is actually a pupil with his tutor usually his father and they learn the standard song but the young finches which are particularly good managed to extrapolate upon that basic song and they actually are the ones who get the the female birds they're the ones who the ladies flock to so it's a courtship behavior among other things and of course there is some overlap in one sense with what we do you see we're all very creative let's just think about it every time you open your mouth and create a sentence you have made something novel because that sentence probably will never be repeated again and you do this in an interactive way with others and there is some evidence that in fact as you can see from poets and from Serrano and others that the courtship behavior is embedded in that the poet always gets the woman you know so in music - so in fact there's an interesting association between verbal facility and the ability to actually generate not only the first song which of course is the first art in music but also perhaps with music itself well about 20 years ago in England a family was discovered who for about three generations that had particular difficulty with language in fact you couldn't really understand what they said in some of the members of the family even though they tried extremely hard they could not maintain the intonation which most of us automatically are able to do as we grow and it was discovered that this family had a particular gene on chromosome 7 which is now called the fox p2 gene because it is actually has got a forked it's called Fox because it's a forked head and also a box gene which is a particular genetic generic form of genetics which these are these are actually genes which don't do very much themselves but they turn on a great deal of other genes in the brain and it was discovered that this particular gene was damaged in these individuals who could not develop proper language and this was a fraction of you can see it those of you are at the front the little red line that goes across that was a mutation in this family that completely disrupted the function of the gene and from there it was found that in fact this gene is extremely old and it is conserved as the geneticists say throughout evolution a mouse for example who is we diverged from the mice about 70 million years ago has this same gene and so do chimpanzees and all the other Apes the interesting thing is that the mouse and the ape have only one mutation different in their fox p2 gene that same gene is in the zebra finch as well now we the human species Homo sapiens have two mutant differences from the great apes and the other primates and there's some speculation that in fact those mutations have occurred in the last hundred to two hundred thousand years which may suggest why it is that we can articulate sounds in a much more precise way so that with that articulation we're able to communicate much more precisely than the songbird can or the other primates can so there may be an interesting correlation here with language with this particular gene so Stephanie white who is one of the scientists at the Institute who works in this project has been able to show that when you actually damage this gene in the finch you don't actually remove it completely but you downgrade it so that it doesn't work quite as effectively the songbird actually doesn't produce the the the tune in quite the same way as the father is teaching it and similarly you find that when the the songbird the young songbird that the the one being taught is particularly adept that there is a great advance in the activity of this particular gene so we're not saying here that in fact this gene explains the activity of language or music but what we are saying is that it relates to a cascade of genes which actually are very important and of course all of us are all slightly different as you can see everybody's face is the same but it's also unique and so is our chemistry so you can imagine that there would be minor changes that might lead to somebody having a much greater facility for example my father who is a musician had perfect pitch and he never quite understood why I couldn't play the violin like he did because I do not have perfect pitch there was a scrambling of our genes and he I did not get what he had so almost asks then in this particular instance in this first area of how does novelty get generated what happens when somebody is speaking or when one somebody is reading or when somebody is playing or or reading music and in this particular slide I hope you can see it from the back these are all individuals who are actually patients of ours at the Institute and this is work of Susan book Homer one of my other colleagues and this man who is a fantastic sight reader of music has a tumor in his brain where you can see it with thee where the yellow arrow is is focused and it's in his parietal region the way you look at this is if I took off my head okay and held it up like this you're looking at it underneath so in fact the the way you are looking at it is that this side of the head is the left side and this man is right-handed so he has a tumor in the dominant hemisphere and of course when you go to operate on such a chimney you want to be sure that you take out only the pieces that you must and you try to preserve the speech areas and other areas that are important so what dr. book Homer does is she does these fMRI scans similar to what you were seeing earlier which then help us understand exactly where that tumor is and what we should be careful of when taking it out and as you can see in this particular instance when the individual is is reading or playing music there is a much more active area in the parietal visual area of the cortex which is in that circle that you see on the far right there your far right compared to when they are speaking words so let's look at another person who is a composer now this person is in the scanner and is asked to think of a story compose a story in his in his mind and also then to compose a piece of music he's not playing the piece of music but he's thinking about the piece of music so first of all note where the tumor is the tumor in this case is in fact very close to what is called Broca's area which is where the production of language occurs and so we were very concerned that when taking this particular tumor out we would destroy his speech center and so these studies were done extensively and as you can see again when he's generating language there are far few orange and yellow pieces on that particular slide just to emphasize that let's look at the next one excuse me we've gone too far let's look at this one and you can see that in fact in that Square that yellow Square and the top of the top there which is when he is thinking of melodies there is a whole area of brain which is being used in fact what this man is doing is he's using his acoustic part of the cortex as well as the parietal cortex so his he is listening if you will to himself generating the music without making a sound so what we can conclude is that composers Mendelssohn for example probably listen to all that musing in his head when he was composing and he was able to do that at a very early age just as Schumann was for example or who I will talk about briefly in a minute so in order to be able to do that not only do you have this cascade of very unusual generating machine which that was the novelty generator but have to have a prodigious memory and so we go back to our diagram and let's think about what is working memory in this particular instance so in order to be able to substantiate this hypothesis it should be possible should it not to be able to improve memory and in fact that's exactly what one of our scientists has done Alcee know silver is a molecular biologist and a behaviorist and what he's been able to do is build something which he calls the Mighty Mouse now this work started from neurofibromatosis some of you may know of that illness that so you individuals have the prominent nerve fibers in their body develop little nodules and they also have cafe au lait patches on their skin but very often people who have this illness they have intellectual deficits and so it was in studying this that that al sino discovered that in fact this again this transcription gene Russ H Ross which you see at the top of the of the green slide here was actually something that generated the the e RK which is the extracellular receptor kinase and this particular kinase is very important in going to a next stage of the metabolic cascade which is the synapse in one which in turn creates a lot of these vesicles which are where the communicating packages of neurotransmitters sit in the in the neuron and so what we see here is that there is a change in one of the neurons the pre-synaptic neuron which becomes much more active and in becoming much more active it generates much more signal a much more information that goes across the synaptic left how do we know that this animal is smarter well interestingly enough in a swim test where you put the little mice in a bowl of water and they can swim around they can't see the bottom they find a platform on which they can stand and then you take the platform away and you put them in again and the Mighty Mouse swims immediately over to where the platform was and starts looking for it these this the regular Mouse and the Mighty Mouse have had the same amount of number of trials and it's it's obvious that the Mighty Mouse learns much faster in these circumstances the regular Mouse can be trained but he needs much more in the way of training probably three times as many tests before he gets it right so here's another example of how various changes in genetics can probably enhance memory so we can enhance the novelty seeker than a novelty generator we can enhance the memory and we begin to think that this is perhaps some of the elements that we have to see in creativity now let's talk about this man who was as Kay said a contemporary of Mendelssohn he was actually born a year later lived a little longer here he his with his love of his life Clara Schumann who had actually was the daughter of his piano teacher and there's a some of you may know that story of how they their great love affair was was actually frustrated by the father Wieck who was the fellow who was training Clara to be one of the preeminent female pianists of her time and also was teaching Schumann but he didn't like Schumann too much who'd been a bit of a wild fellow when he was younger but Schumann actually started to compose music when he was 7 very similar to Mendelssohn but he also wrote his father was a publisher and a writer and by the time that Schumann was 16 he'd written a novel he started in fact a litter a book of literary criticism and magazine of literary criticism an of music criticism which you can still buy today he was in fact another prodigy and this man was as I said frustrated in the interest of time I won't go into the many details frustrated in his courtship of Clara but eventually he was able to marry her and then that was about 1839 and the year later he wrote something like a hundred and thirty-eight songs some were in adoration of his wife but in general they were wonderful songs and this was then called the Lydia the year of this song and in fact as you saw this slide earlier this is what has generated that he in fact had had a hypomanic episode in fact his roustabout behavior when he was younger which so upset his piano teacher because Clara was nine years younger than he was and the father did not think that having this fellow around with his young teenage daughter was a good idea but when they finally did get married he was in his late twenties and Clara had just turned 21 you can see that he went into a hypomanic episode he'd had similar episodes or they were not so severe when he was younger when he was reading law which he didn't like and turn to music and as Kaye also said he ended with a severe depression which was untreated and basically he starved himself to death but the important point here is that in fact we are now back to the third piece of our cycle which is the response inhibition and as you were seeing earlier in what Kay was talking about and Terry was talking about the interesting thing about severe illness and it is not just mental illness but mental illness is perhaps the one that particularly engages us is that it generates a whole new vision of the world in fact it breaks up old habits so in fact what you see is that the element here of cognitive control is lost because of the illness which then gives insights which without the illness the individual would not have and that's particularly true of bipolar illness but it also occurs in other disturbances as well so in this case Schumann's hypomania which led to his extraordinary creativity was a contributing factor but it wouldn't have been the only thing which have generated his creativity as Kay said at the very beginning mental illness is not equivalent with creativity the individual has to have many other things but but nonetheless the mental illness can sometimes change the nature of the creativity and that's an example here for in the case of Van Gogh who we also touched upon earlier now this man is extraordinarily fascinating because during his lifetime he only sold one picture all the others were kept and were in fact curated by his his sister-in-law Joanna who because his brother died only six months after he did and probably of syphilis but in this particular instance we also have some 800 letters which were written by Vincent and you put the two together and you have an excellent ability to actually investigate his life his artistry and his thinking at the same time you'll notice that he's smoking a pipe here one of the things that van Gogh also recognized in addition to his ability to change his behavior under the stress of his illness was that he could change his moods by using tobacco and also by using alcohol now in those days absinthe was a particularly favorite drink because it has in it herbs which will give you a heightened perception and so many of the artists in that time drank this stuff and you can see that he spent a lot of time in Arles towards the end of his life when he was trying to court Dogen to come down and be with him and as you can see from this life chart which he's made up from his letters and so on most of his productivity most of Vincent's productivity was in the last few years of his life the last three years is what we associate before that there was a whole different of but in fact by the time he got down to Arles and he was in a mixed state of sort of irritability and mania and hypomania and if you read his if you read his letters of that summer he's busily talking about how he wants to create a whole new school that gogo and he will put together in in the south what the other most important thing here apropos of our third element of this cycle is that you see how his his creativity changes with the illness now he was a very solid painter by this time he had been training himself for many years and he was a great draftsman and in the spring he painted this particular picture in the year before he two years before he died and you can see those of you who are at the front that this is a complicated picture it draws your eye into the middle but in fact there's very little to define the picture other than some construct which you can't really tell but in you look if you x-ray this picture you see that he planned it very carefully and he's got the center organized very carefully with this grid which was a commonplace thing that people would do in those days so he this picture is very planned and he did the same after he got into the mental hospital this is after he's cut off the lobe of his ear and he's feeling better and you can see this is again a planned picture but look what happens in the fall and in fact many of the pictures that you see of Vincent van Gogh in the museum's if you get close to them you will see that it's layered the paint is layered one on top of the other and in fact he was painting by this time of his life more fluently but particularly during his hypomanic episodes it seems as if he just painted directly onto the canvas he didn't plan anything in fact he was painting several canvases at once and there are descriptions of him with the paint using down his arms in his hypomanic State so you see again this interesting shift in the nature of his art based upon the expression of his illness so here we come once again then back to the cycle and if you think of the way in which we need novel ideas we need working memory and we need this disruption of cognitive control which actually was something that dr. Kato was also referencing in terms of his studies so you might ask well what happened to Paul Mendelssohn who actually was pretty healthy he had a healthy childhood he grew up most of his life here wasn't much evidence of mental illness but then towards the end of his life his sister Fanny to whom he was extraordinarily attached and in fact she was a brilliant pianist and and wrote some music of her own and the family very often thought that she was the person who was the musician but in fact because she was a woman in those days that was out of the question but well after she died it was only a year or so later that in his depression although he wrote still some fine music that he too died and one has to ask whether in fact that wasn't something that disrupted his his creativity but also led to his death in the way that we have been discussing it with manic-depressive disease he would have had a unipolar illness following the grief of his the death of his sister so on this occasion of his birthday let's remember him and let's also remember the complexity of these creative processes thank you so if any of you all have questions yes those of us and DVS a for those of you who do devote your careers to research in the area of bipolar disorder not only for the benefits we see we receive in the area of treatment but for programs like this the help to people to learn maybe perhaps people who have only heard bipolar disorder referred to when someone with bipolar disorder commits a crime it's off I think it's a very positive thing in many respects that you are putting on a performance excuse me performing a program like this tonight so thank you all very much well thank you Julie yes I have a question about the phrase flight of ideas that I see in a lot of the literature when I'm reading about manic depressive / bipolar illness and in many cases it's depicted as a negative in the literature and from what I'm hearing tonight I can see a lot of positives connected to that in particular to this last idea of the generation of non-habit-forming thinking's I just would love to hear what you all think about that phrase the flight of ideas well I think in general actually when you read in the historic literature the psychiatric literature flight of ideas really doesn't have either positive or negative associated with it is it's a descriptive term that really is talking about a kind of a leap frogging effect of going from one concept to another concept to another so tangentially related usually generated during a what's known as classic mania are you fork mania and the F the mood state is generally up I think that one of the things that's consistent and the creativity literature is that in fact you see that kind of flight of ideas if you if you take the kind of test of creativity a standard measure of creativity is a word association test and so if you ask people to associate to the word tulip and you can measure them in say two minutes you give them two minutes to do it you can measure the number of responses and you can respect measure the number of original responses by national norms a form of kind of a small form of flight of ideas is exactly that kind of leapfrogging off into ideas and that is certainly related to both creative thought and to people who are mildly manic to people who have if you put people in the situation and you elevate their mood artificially by music you get an increased number of word associations but I'd be curious to know what you all think agree with that I think I think it is it breaks up the habits so when your mind is moving very rapidly especially in hypo Romania there's no doubt that as Kay has written about very beautifully that there is a whole new expansion of the world which is real which is very real and that's why many hypomanic people especially if the if there they have what's called bipolar 2 and their hypomania is somewhat sustained and they don't move into the psychotic disruption of severe mania they actually become very attractive to other people they they they are seen as people who have vision who have some sort of clairvoyance which the rest of us don't have so I think that's it's very much a in that sense a the ability to break up the usual cognitive habits which contain us so just to add to some of the cautions the Kay raises though what you can see in hypomania is as Peter described a mild increase in in rate of thinking could be a positive thing could be engaging could be charismatic but left untreated about two-thirds with no additional intervention two-thirds of people with bipolar one disorder who are hypomanic within a month will become mania manic and it literally is too much of a good thing and it gets to a rate which is uninterpretable not only to the individual but to others and the thinking is no longer a benefit and so there are a lot of in medicine there are a lot of instances of a little bit being helpful and a lot not so helpful if you get a single gene for sickle-cell you have resistance to malaria if you've got to get a life-threatening illness and so a little bit of mood elevation may have advantages a lot has definite disadvantages and there is something at least for folks with bipolar one disorder that is is unstable about being just a little bit elevated it needs to go one way or the other generally if that happens so we have to take all of these potential silver linings that that cake as mentioned with with a grain of salt if you like by that that any of these things if they get unleashed and they can get unleashed in some forms of the illness particularly bipolar one disorder if these things get loose they are going to wreak havoc on one's life yes up there at the back yeah and secondly if you could address so the implications of that on education I'm sorry was that not could you not hear me just in case they're recording it can you repeat the question certainly a special education teacher I'm really conscious of these things but I feel relatively uninformed probably in this crowd wonder if you could speak to the level of undiagnosed cases of a bipolar disorder manic depression among particularly youth and any implications that that would have on education or anything any thoughts in that in that regard my first fellow was Kiki Chang and his first project was to look at the kids of the patients in our clinic and do structured interviews of them and half of them had something or other and the most common thing was a disruptive behavioral disorder like attention deficit disorder occupation oppositional defiant disorder or conduct disorder and the genetics that Kay was talking about they're very robust we may see something called age-dependent presentations where the prodrome of a bipolar illness in the offspring of somebody with bipolar may present in a pre-pubertal child as a disruptive behavioral disorder may also present with depression kay was talking about age of onset Barbra Keller showed that if you got a pre-pubertal kid who gets depressed even if they don't have a Bible or parent half of them in ten years have bipolar diagnosis young adults who get hospitalized 18 to 25 to get hospitalized for depression 40% of them in 10 years will have bipolar diagnosis so the age of onset that Kay was talking about is an important one and so a lot of the undiagnosed pediatric bipolar disorder may be because the presentations are unusual these disruptive behavioral disorders perhaps and one of the most important things is that if an individual has a bipolar parent and has that kind of problem they not just go to a the attrition rates a ritalin script right away because this in fact can destabilize mood or if they depress go to pediatrician who thankfully will hesitate a little bit these days now with antidepressants but that the offspring of people with bipolar disorder HAP's who have these kind of presentations need a careful evaluation in a lot of caution before giving any medicine hello you know just to emphasize that the problem is that they don't usually present with mania they present with depression and so there I think the when I a few years ago I conducted a study for the national depressive and manic depressive Association as it was called then and the results were quite startling some people it took up I think it was about twenty or thirty percent of people they went ten years before the right diagnosis was made and might have met six or seven doctors before the diagnosis was actually confirmed hello I have a question just a housekeeping one if you could tell us at the end of your speech whether or not we can get copies of the things that you put up by going to your websites we'd like to know that but I am more interested in a person who is may get depressed as well but who is basically okay normal but the ingestion of drugs particularly nodos and drugs that are taken to help people feel better and feel more positive when they're trying to lose weight the effect of those drugs on the brain a what happens because I did take notice when I was in school and it was like my brain was on fire and I was so productive and I was working till I crash and burn but what happens in the brain and does it have a permanent effect I think it'd be safe to say nobody knows whether it has a really permanent effect because it'd be hard to sort out what was what's going on I think it's also safe to say that drugs like note I haven't even heard no doze and quite a while but these drugs are not great I mean most I think where you really see a lot of complications with bipolar illness in particular mood disorders is that there's a comorbidity in other words sixty percent of people who have bipolar illness for example have a history of alcohol and/or drug abuse and usually the mood disorder comes first and then the drug drug abuse comes later these drugs are just can be really dangerous not only to precipitating an acute episode of mania or depression but in making worse the course of the illness and the nature of the symptoms so the people when dr. wibro is describing sort of a mixed state where you've got elements symptoms of both depression and mania that is far and away the most dangerous state and bipolar illness for example in terms of suicide and risk and impulsiveness and so forth those can really be easily set off by all sorts of medications and prescribed medications and over-the-counter medication so it's potentially really dangerous most of these drugs also particularly nodos by definition have a profound effect on sleep and once you start the biology is sleep in depression and in bipolar illness is particularly I mean it's like paramount it's central to the nature of the illness so once you start mucking about with sleep you're really playing with fire too but if you all right sleep and sleep and hearing but when students take no doze and other things you know to keep awake that's actually almost a diagnostic probe for people who have bipolar I remember when I was at the University of Pennsylvania we did a study on what time did the average undergraduate go to sleep what time do you think it was 2:30 in the morning to 32 to be precise but the fact is that that that that that type of sleep deprivation coupled with caffeine no doze any alcohol and any other a monadic stimulant drug will drive you into mania if you happen to have the predisposing family history and so some people don't even need the nodos dr. Dement one of us are very very esteemed lectures and in sleep mentioned to the stent one of his classes that if they had if individuals had sleep deprivation they could get psychotic and one of those people got to meet me with no no doze just the sleep deprivation and one of the routes to psychotic mania is the the sleep deprivation accelerating the disease the episodes can cause brain damage okay if you've had one depression in your life your your risk of another is 50% to 70% three ninety percent there's something going on so about your question I could the drugs cause something irreversible well that are they could and that irreversible thing could be an episode I asked dr. kiddo in your presentation of that test something breaks test of the like and dislike of the of the diagrams once I the creative art scale okay whatever and I would just little bit dismayed at how simplistic the definition of creativity is right on one side you see squares or maybe circles then and it takes that lines well Plato wouldn't like that right he advocated the circle and if you go into then the simpler the better or even Noguchi or jut the whole modern 20th century art attest to the violation of that and how could that continue on the meaning just define those people who dislike those simply simple geometric figures are more creative and vice-versa I am just supported I dislike that let me put it that way you aren't the only person who doesn't like that test I mean when we we did a whole battery including the torrents tests of creative thinking where people draw imaginative drawings and these things and these all had sort of correlations with the more cognitive constructs but the one that drilled down on the effect of side was this annoying test it gets to people and there are people who try to solve the test or guess the test any study of non eminent creativity is going to have some trouble with the measure okay and so we've studied four or five different measures the the alternative is the kind of thing the case talking about where you have an absolutely rock-solid measure of creativity okay there's no doubt about somebody like Mendelssohn but then you don't have control over other things like getting research quality diagnosis knowing about medicines knowing about the way their thought processes worked this is not using you using the Baron Walsh that was the one that popped up separating the groups for effect I am I'm just as skeptical as that of that test that test is it's as creativity tests go though it has it has performed as well as other tests that have much better face validity than it so what you presented today was looking at the correlates of pathology and creativity and I I'm curious what the research shows about the converse which is creativity and wellness and thinking about it in two terms one is what extent does artistic activity maybe serve as a coping mechanism to control this and then the flip side is I'm fascinated that they're just some fantastically productive artists that are just so darn normal I mean you think about the the the music of Hyden and you know and how hide and treated his musicians and his lifelong steady growth and creativity it's a very different story than Mozart for instance I think a couple things first of all again the argument would not be that anyone who's creative has a mood disorder I I mean that's clearly not the case as I wouldn't no one that I know who's studying this would begin to say something like that it is rather that there is a way disproportionate rate of that and I think it's just important to keep that in mind there are a lot of people who have addressed the question that you asked is there something about doing art as it were that is a binding that is helpful that that keeps people together in a way that they would not otherwise be and many many artists and writers have addressed that Anthony store the late English psychiatrist and psychoanalyst talked a lot about that aspect in his book on the psychodynamics of creativity but Robert Lowell Virginia Woolf I mean you name it individual artists have said if I didn't have my art I would be even madder than I am that it it binds it contains Tennyson wrote about it beautifully and many many people have written about that but I I think you know one of the things you have to keep in mind is Kay has said repeatedly is that creativity is not just the province of the artist it we're all creative as I mentioned every time you make a sentence you're being creative and I think that we have tended to narrow the definition of creativity to people like Mendelssohn who are obviously several standard deviations from from the from the mean and if we're ever going to understand what it is that creates this potential deviation we have to begin looking at people who are closer to them which is basically what we're trying to do in the Tannenbaum program and to dissect it out and because the disruption as I was trying to show on the series of slides that I put up the disruption of the habit is really you can get there from many different routes and so it could be that in fact solitude will allow you to disrupt habit just by just by in fact when I write myself I've discovered that I need if I want to go to sleep I let myself go to sleep and then I will wake up and a few minutes later I might have the solution to the paragraph that I couldn't write before I went to sleep so in fact I think creativity is is is something that is within all of us and we probably will learn more about it by coming closer to the norm than we will by trying to study only people who are extraordinarily gifted such as Mendelssohn and so on final word is that of course is not just in the arts as as Kay has pointed out scientists are creative even administrators are creative sometimes it's even people the Library of Congress are created yeah and I think we've just seen how creative accountants can become as well just just to to echo this this idea that Peter talked about that there being many pathways to creativity and there are many creativity instruments okay and the kind of thing the barren Welsh measures is not the kind of creativity you find in a Zen master it's the kind of creativity to find an irritable person who was in a garret you know i the the creative personality scale is more like that some of the things with the myers-briggs are like that the myers-briggs type inventory and intuition it's trying to bring it into business and basically that their their book developing leadership it's in the business school library at Stanford so I mean in the whole bay area there there's a lot of lot of notions about collegial creativity the the class that we hold in creativity each year we have 12 students and four are from the arts and four from psychology and four from neuroscience the idea of bringing disparate groups of people together for a creative collegial process so this is this is a lot bigger than one little figure test or or pathology this is something that in fact can be one of the engines of our economy even if we find ways to generalize it into healthy human activity so your point is very well taken yes the term seasonality was on the screen is this distinct from seasonal affective disorder does either of these play a role in either diagnosing illnesses or sparking them would you address this place sure seasonality is certainly related to seasonal affective disorder seasonal affective disorder refers to generally depression not always people often having a fall depression and then lightening up or becoming hypomanic in the spring although there are all sorts of variations on that particular theme and it is a particular diagnostic category and what anyway developed mainly by dr. Norman Rosenthal and his colleagues at the National Institute of Mental Health but it's really based on the fact that we've known for we are basically mammals first and foremost and mammals are enormous ly responsive to light and we know that moods and energy are tremendously beholden to light and so if you look at patterns of everything of I'm sure dr. Y Brock could talk in great detail about particularly for example thyroid cholesterol serotonin almost anything that goes on that's important in the brain and the body is seasonal has a seasonal pattern to it we know that hospitalization rates for mania are very seasonally driven than the summer in the late fall suicide the over a hundred studies of suicide showing a tremendous peaking spiking of suicide in the late spring and early summer months I mean so we know treatment rates for example for electroshock therapy which is an index of actually severity of depression we know that they're very strong seasonal peaks in that for hospitalizations for depression so these are in fact yes very seasonal yeah I once wrote a book about it actually called hype the hibernation response and Cays absolutely right this is when I was living in northern Ewing northern New England teaching at Dartmouth and we everybody everybody there gets completely miserable in the winter and yes that's right they call it the call it the cabin blues or something and but anyway we studied normal people over a seasonal variation a whole year and the interesting thing was that people normal people sleep longer in the winter when you're in in the in the north and they gain weight so you know one thing out of that is if you ever want to start losing weight don't try November try in March because you'll have a much better success and you'll think you're really doing very well the other thing is that reproduction even in human beings is still seasonal and if you again go to I took the trouble of going and looking at the births that were at the naree Hitchcock Hospital in in Hannover and in fact the conception is greatest in the fall which is exactly the same as the deer herd which I always thought was rather interesting and it's all driven by testosterone basically which is then in turn driven by the light but I've always been grateful that we don't grow antlers like the like the deer because if we did you know just imagine what traveling in the fall would be like on the aeroplane but so now there's human beings are mammals and we definitely have seasonal variation as Kay was saying maybe two more questions what I have a question over here all right I have a friend who's in a nursing home she's a former beauty queen and newspaper columnist she now has a rare form of Parkinson's disease of a Punk Euler something or other which is caused by the lithium she has taken over her lifetime for bipolar disorder and is there any word of Solace you can offer someone like her she she said why couldn't they just medicate me and keep me sedated during my bipolar periods so that I would live through them to see another day and I wouldn't have to go on lithium and have this terrible disease she has a Stephen Hawking situation where she can type with one finger and that's it she can't talk she can't walk nothing what what words would you offer somebody like her is this going to improve into the future she's 63 well I have it I was going to say that first of all you can't be sure that the lithium goes to Parkinson's disease you can look at merck manual factors the fact is that occasionally you will get basal ganglia disruption when the person has been exposed to very high levels of lithium because they did not you know they were not monitored properly but that's a that's very rare I sure that catch is the same I've you know and k2 I've had the first IND in America in northern New England to to actually use lithium back in the early 70s and actually it's an extraordinarily safe drug and although you may see occasional things like this it's highly possible that they are running in parallel the interesting thing about lithium is on the other side of the coin it actually is neuroprotective and the one of the interesting things is you rarely see anybody without Simas disease who's been taking with him so it's I think that story needs to be looked into very carefully in terms of the individual and the tragedy that she faces then there are various things that could be done but I'm not sure that one should blame lithium and then generalize it it's good to say I mean because one of the things about lithium one of the advantages of lithium is it's been used for more than 55 years in hundreds and hundreds of thousands of patients so we have more than any drug in psychiatry really more data on what are the adverse long-term effects and there's next to no literature on that suggesting that that's a problem and and what Peter was suggesting is that there have been recent studies that we know that before lithium existed that people who had bipolar illness had increased rates of all the dimensions Alzheimer's and and other dimensions and if you look at cohorts of populations of people who have bipolar illness who have been treated with lithium that dementia rate goes down to the population rate not below so it's it's a very complicated thing and it's like kidney disease it very often there may be a something else that's that's going along with it there's so many means that people have taken lithium that you know there are very very few case reports of what you're describing it doesn't take away from the personal tragedy but it's just not something that is thought of as an adverse effect of lithium certainly there are there are antipsychotics that have a huge track record for this kind of problem and one of the one of the things that was thought to be so desirable about lithium was that this would be so much less common these neurological problems with lithium as compared to the antipsychotics that actually tracks to the question I was wanting to ask which is I know that in addition to lithium there are other drugs that are being marketed now for bipolar disorder namely lamotrigine and I'm wondering what if there is a consensus among you what the preferred pharmaceutical approach would be in conjunction with psychotherapy is a way of managing bipolar illness but not quashing the creative side of it more than it's necessary and also whether there are sort of alternative medicine approaches like meditation or Eastern European approaches that are sorry Eastern Asian approaches that are being looked at in addition to just eyes psychotherapy with more traditional meds I think if you look at the gold standard of across hundreds and hundreds of studies of medications medications with psychotherapy psychotherapy alone that there would be at least my reading of it would be that there would be a very strong consensus that in an ideal world insurance companies being reasonable agents doctors being good doctors psychotherapists being good psychotherapists that you would have a combination particularly early on in the illness when someone's young of psychotherapy medication and I think the gold standard in bipolar illness remains lithium that that is if you look at the scientific evidence for treatment that doesn't mean that there aren't a lot of other drugs out there that are available not everybody responds the lithium not a baby wants to take lithium but if you actually look at the gold standard for treatment it I think it still would be lithium in terms of alternatives I mean we know that there are certain certainly foods and everything from you know I think it was kind of Kodiak beer of diet which is eating salmon and eating lots of blueberries lots of exercise I mean all these things you know can't help but but help meditation is is good up to a point as long as you're doing it the right right time of day when I was had a practice in Los Angeles a lot of people meditated and it was very helpful to a lot of people as long as they weren't doing it in the middle of the night because one of the things that happens is that they get sleep-deprived and then they would get worse again hypomanic and they're also get worse so it's like everything I think is using common sense and science I would agree with that when at the University of Pennsylvania we ran a clinic for people who had the most malignant form of the illness that is rapid cycling disease and I was told at the beginning that I would should I was a fool to do this because they would constantly be plaguing me these poor persons and they would constantly be in the hospital turned out not to be true and one of the secrets to that is what Kay was talking about what I call essentially mental hygiene in fact if you begin to regulate your life in a way that and as people as people learn about their illness the best person to take care of oneself is oneself after all as one learns about one's illness and one learns what are the triggers staying up too late taking too much caffeine taking any caffeine at all in the case of this particular these particular persons making sure you don't take sudafed when you get a cold these are the sorts of things that once you begin to understand them that they can bring things into order and there's there's absolutely no doubt that exercise meditation certain diets all these things if they're put together in a in a common-sense way as Kay was saying can be an adjunct to the use of wise counsel and medication and I too would start with lithium although in some instances it's particularly helpful for people who have the classic form which is severe mania followed by depression than a free interval but persons who have bipolar - and have other more complex mixed states sometimes the the more recently invented antipsychotics can be helpful I'm sure dr. Katherine is more thorough with the latest on that than I but I think that it's it's a thoughtful approach which includes the participation of the person who suffers and the person who has the medical knowledge and everybody around them the family and so on and so forth which keeps these illnesses stable so you have the wisdom though don't you I do this all day every day yeah and have a book coming out this summer clinical manual bipolar disorders American Psychiatric publishing set you up very well yeah it is great TR yes um and in this actually it does an analysis of there's this movement called evidence-based medicine that everything we do ought to be based on knowledge from randomized controlled trials and every fda-approved treatment beats placebo by at least 10% that's good news bad news is that it's by at most about 30% and so you can calculate something called number needed to treat which ends up is the number of people you have to treat to get one additional good outcome and for most of our interventions it is in single digits okay at least a 10% benefit problem is that often it's four or five and maybe that's why patients need four or five intervention and the kind of interventions you're talking about the the randomized controlled trials of adjunct of psychotherapies the effect sizes were similar to the drugs this is one of the best-kept secrets in bipolar they worked as well as the drugs but they don't work without the drugs it's all yeah so this is this I said adjunctive okay so if you try it without the drugs it seems like the drugs are in some way the foundation but the systematic treatment announcement program largest study the NIH did on the treatment of bipolar disorder had to depression studies one was adding antidepressants to a mood stabilizer and there was no additional benefit the other was adding intensive psychotherapy stew mood stabilizer and it worked with a number needed to treat that was signaled single digits so all of the things you've been talking about lifestyle measures there's that it's probably got an effect size similar to that of adjunct of psychotherapy which has an effect size similar to the first medicine and actually if you add a second medicine it looks like that has a similar sort of addition so it what's necessary these days is to craft the the treatment that best fits the patient and what you want to have is you want to have stable mood without a bunch of side effects including affective blunting that could undermine creativity and whatever it is that takes to do that that's going to be the best patient the starting point traditionally it's been lithium we may see that vary with time but certainly tradition dictates that lithium is the gold standard thank you all very much this has been a presentation of the Library of Congress visit us at loc.gov

Channel: Library of Congress

Views: 100,276

Keywords: library, congress, music, brain, depression, creativity, neurology, psychiatry, composers, musicians

Id: k4UJhPiBE6c

Length: 124min 44sec (7484 seconds)

Published: Thu Jul 30 2009