The Tangled Links Between Psychiatric Disorders and Creativity

The potential association of creativity with mental illness has generated both scientific interest and controversy since such a relationship was first posited by the ancient Greeks.

The two might interact in a variety of ways. Both might share similar predisposing factors, yet not be causally related to each other. Or the creative effort might be psychologically taxing to the point of causing psychopathology. Or psychopathologic symptoms (such as bizarre associations, hallucinations, or feelings of grandiosity and boundless energy) might promote creativity.

And it may be that any of these relationships can be true in some people and not in others. Not every possible relationship has been addressed by every study, so that the findings of one study may not address questions raised by another.

As with any scientific question, the most important first step is to establish the validity of the observation: Is there a greater-than-expected level of mental illness among creative people? But even this question is more complex than it might first seem. What do we mean by "creative people"? Creativity is not a unique skill possessed solely by the fortunate few, but a general mode of human thought characterized by motivation, perception, mental imagery, strategic formulation, dexterous execution, temperament, and social context. These principles are the same whether we are trying to avoid a traffic jam, diagnose a patient, or write a poem. We are all, in this way, creative people, but studies addressing this question generally focus on those in more traditionally regarded creative occupations, such as art and music.

In the United States in 2001-2003, 30% of the population experienced some form of mental illness (N. Engl. J. Med. 2005;352:2515-23). Evidence of higher prevalence rates among the more creative comes from biographical and survey studies (typically of eminent people), family studies (via relatives of psychiatric patients), psychiatric patients themselves, correlations among the general public of scores on tests for psychopathology and tests of creativity, and the psychometric assessment of individuals in creative pursuits (J. Res. Person. 2005 Oct. 270 [doi:10.1016/j.jrp.2005.09.004]).

Absolutes rates differ among studies, but many have shown an elevated prevalence of depression among writers (Am. J. Psychiatry 1987;144:1288-92; Br. J. Psychiatry 1994;165:22-34). In Arnold Ludwig’s biographical study of 1,005 individuals whose biographies were published in the New York Times Book Review over a 30-year period, depression, suicide attempts, psychosis, and forced hospitalization were prevalent in more than 60%, 20%, 17%, and 11.3%, respectively, of poets older than age 40 (Am. J. Psychother. 1992;46:330-56).

Other groups fared a bit better, although suicide rates were also relatively high in members of the theatre and in musical performers. Overall, alcoholism and depression were the most common problems among the creative professions. Compared with the nonartistic professions (such as politics or physical science), artists (including writers, painters, musicians, and actors) had higher rates of all forms of psychopathology and psychiatric interventions. Total lifetime depression and anxiety scores correlated with overall level of creative achievement in all professions, but the relationship was weak (R² = 0.04).

Although depression and substance abuse are more prevalent among those in the artistic professions (and writers in particular), it is less clear that this represents a causal relationship. Hypomania may enhance self-confidence and the formation of associations, and may focus goal-directed activity, all of which can foster creativity, but full-blown manic psychosis (or psychosis for any other reason) disrupts rational thought and is not conducive to creativity. Depression saps motivation and thus inhibits creativity.

Patients who are actively psychotic are unable to be creatively productive, but schizophrenic patients who are between psychotic episodes share some creativity-associated traits (such as divergent thinking) with their first-degree relatives and those in the artistically creative professions. This has led some to argue that schizophrenia itself may promote creativity, hence its prevalence and persistence in the human gene pool.

There is indirect neurobiological evidence that supports this claim. Normally, the default network (which includes medial prefrontal, posterior cingulate, and lateral parietal cortices) is active at rest. It is also active during daydreaming and internally generated, task-independent mentation – that is, mental states that foster creative ideas. External sensory stimuli to which we attend result in suppression of the default system activity, and greater suppression is associated with better performance on attention-demanding tasks. In schizophrenic patients, there is reduced suppression of the medial prefrontal component of the default system, which reflects their poor attentional skills. There is also increased connectivity between default regions and the rest of the brain, and this is also thought to promote creativity by facilitating unusual associations and even synesthesia. Among healthy people, reduced suppression is associated with mind wandering, a mental state that predisposes to "aha" moments that characterize some creative activity. These neurophysiological alterations correlate with personality variations, not only in schizophrenic patients but also in their first-degree relatives and "creative controls" (Proc. Natl. Acad. Sci. U.S.A. 2009;106:1279-84).

Is there a creative personality type? Creative and bipolar individuals share the personality traits of high neuroticism and openness to experience (based on the revised NEO Personality Inventory). Schizotypy (a form of personality disorder) is characterized by four factors: unusual experiences, cognitive disorganization, introvertive anhedonia, and impulsive nonconformity. Poets and visual artists score high on unusual experiences and low on introvertive anhedonia, similar to bipolar patients, whereas mathematicians score low on unusual experiences and high on introvertive anhedonia. A high level of both positive schizotypy (unusual experiences) and negative schizotypy (introvertive anhedonia) predisposes to mental illness, whereas a high level of positive schizotypy with a low level of negative schizotypy may promote creativity (J. Res. Person. 2006;40:876-90).

Dopaminergic agonists, which are typically used in the setting of Parkinson’s disease, can sometimes enhance reward-driven behavior to the point of pathological gambling and sexual activity, but is not specifically associated with more successful creative efforts. Dopamine antagonists reduce psychosis and agitation, and with such normalization other behaviors may be restored, although dopaminergic blockade itself is associated with reduced motivation and spontaneity and so is also not conducive to creative behavior (Can. J. Psychiatry 2011;56:132-43). Just as some personality traits appear to overlap creativity and psychopathology, one possible way of explaining the relationship between the two is that of a shared vulnerability model (Can. J. Psychiatry 2011;56:144-53). Reduced latent inhibition (LI), which is the ability to screen out previous experiences from current awareness as irrelevant, as well as novelty seeking and neural hyperconnectivity, all promote creative thought and are all associated with mental illness. (LI and hyperconnectivity are associated with schizophrenia; novelty seeking is associated with substance abuse as well as mania.) High levels of intelligence, working memory, and cognitive flexibility all promote creativity and protect against mental illness, and allow such individuals to better cope with the higher-risk traits. This might explain the observation that families of geniuses also contain mentally ill members at a higher-than-normal rate consistent with the hypothesis that there may be common substrates shared by the two (J. Psychiatr. Res. 2005;39:623-31).

In a recent interview with Bruce Springsteen in which the artist discussed his challenges with depression, David Remnick, editor-in-chief of the New Yorker, wrote, "As Springsteen sees it, the creative talent has always been nurtured by the darker currents of his psyche" (New Yorker 2012 July 30). Quoting Springsteen, he wrote that "you cannot underestimate the fine power of self-loathing in all of this. You think, I don’t like anything I’m seeing, I don’t like anything I’m doing, but I need to change myself, I need to transform myself. I do not know a single artist who does not run on that fuel. ... That’s a motivation, that element of ‘I need to remake myself, my town, my audience’ – the desire for renewal." Clearly, the psychic pain of mental illness can be a source of inspiration that promotes creative efforts, and it may be that this, too, is a reflection of the shared vulnerability model.

But there are two motivational poles: a positive pole (appetite, reward, approach) and a negative one (aversion, fear, avoidance). Either pole can and does serve to drive us towards creative goals. The driving force for creativity – the motivational voltage that derives from the difference in perceived reward value between what is and what should be – means that, in a way, we must be in a constant state of dissatisfaction. Maximum reward value means exceeding our expectations, which by definition cannot happen frequently. Perhaps our creative wiring comes with the cost of predisposing us to depression (resulting from dissatisfaction with the status quo) and schizophrenia (envisioning what does not yet exist to the point of perceptual hallucinatory phenomena).

This raises another intriguing question: Are the greatest creative works driven primarily by this darker side (the need to alleviate an inner pain), or is the positive pole (appetite, reward, approach) just as likely as the negative pole to end in great achievement? The Rolling Stones, for example, produced their most memorable work – expressing their inner demons and finding resolution – early in their career, once they mastered the technical and procedural details of their trade. (Compare, for example their earlier songs, "Sympathy for the Devil" or "You Can’t Always get What You Want" vs. a popular song from their last album, "Rough Justice.") However, once they achieved popular acclaim and wealth, they learned that modeling themselves can be rewarding and they seem (to this fan at least) to be less driven now by alleviating an inner pain than by pursuing financial gain.

Another layer of risk is that which arises from the group dynamic. Few major creative achievements happen as solo efforts. Bruce Springsteen’s E Street Band – guided by his creative mind (and motivated at times by his darker side) – as well as the Rolling Stones and many other bands created a great deal of wonderful music as groups. But group creativity does not always result in positive outcomes. Although creative individuals may function normally by themselves, the dynamics of a group may lead to dysfunctional results and blur the line between normality and mental (or social) illness. Next month, therefore, we will consider disorders of group creativity.

Dr. Richard J. Caselli is medical editor of Clinical Neurology News and is a professor of neurology at the Mayo Clinic in Scottsdale, Ariz.

The potential association of creativity with mental illness has generated both scientific interest and controversy since such a relationship was first posited by the ancient Greeks.

The two might interact in a variety of ways. Both might share similar predisposing factors, yet not be causally related to each other. Or the creative effort might be psychologically taxing to the point of causing psychopathology. Or psychopathologic symptoms (such as bizarre associations, hallucinations, or feelings of grandiosity and boundless energy) might promote creativity.

And it may be that any of these relationships can be true in some people and not in others. Not every possible relationship has been addressed by every study, so that the findings of one study may not address questions raised by another.

As with any scientific question, the most important first step is to establish the validity of the observation: Is there a greater-than-expected level of mental illness among creative people? But even this question is more complex than it might first seem. What do we mean by "creative people"? Creativity is not a unique skill possessed solely by the fortunate few, but a general mode of human thought characterized by motivation, perception, mental imagery, strategic formulation, dexterous execution, temperament, and social context. These principles are the same whether we are trying to avoid a traffic jam, diagnose a patient, or write a poem. We are all, in this way, creative people, but studies addressing this question generally focus on those in more traditionally regarded creative occupations, such as art and music.

In the United States in 2001-2003, 30% of the population experienced some form of mental illness (N. Engl. J. Med. 2005;352:2515-23). Evidence of higher prevalence rates among the more creative comes from biographical and survey studies (typically of eminent people), family studies (via relatives of psychiatric patients), psychiatric patients themselves, correlations among the general public of scores on tests for psychopathology and tests of creativity, and the psychometric assessment of individuals in creative pursuits (J. Res. Person. 2005 Oct. 270 [doi:10.1016/j.jrp.2005.09.004]).

Absolutes rates differ among studies, but many have shown an elevated prevalence of depression among writers (Am. J. Psychiatry 1987;144:1288-92; Br. J. Psychiatry 1994;165:22-34). In Arnold Ludwig’s biographical study of 1,005 individuals whose biographies were published in the New York Times Book Review over a 30-year period, depression, suicide attempts, psychosis, and forced hospitalization were prevalent in more than 60%, 20%, 17%, and 11.3%, respectively, of poets older than age 40 (Am. J. Psychother. 1992;46:330-56).

Other groups fared a bit better, although suicide rates were also relatively high in members of the theatre and in musical performers. Overall, alcoholism and depression were the most common problems among the creative professions. Compared with the nonartistic professions (such as politics or physical science), artists (including writers, painters, musicians, and actors) had higher rates of all forms of psychopathology and psychiatric interventions. Total lifetime depression and anxiety scores correlated with overall level of creative achievement in all professions, but the relationship was weak (R² = 0.04).

Although depression and substance abuse are more prevalent among those in the artistic professions (and writers in particular), it is less clear that this represents a causal relationship. Hypomania may enhance self-confidence and the formation of associations, and may focus goal-directed activity, all of which can foster creativity, but full-blown manic psychosis (or psychosis for any other reason) disrupts rational thought and is not conducive to creativity. Depression saps motivation and thus inhibits creativity.

Patients who are actively psychotic are unable to be creatively productive, but schizophrenic patients who are between psychotic episodes share some creativity-associated traits (such as divergent thinking) with their first-degree relatives and those in the artistically creative professions. This has led some to argue that schizophrenia itself may promote creativity, hence its prevalence and persistence in the human gene pool.

There is indirect neurobiological evidence that supports this claim. Normally, the default network (which includes medial prefrontal, posterior cingulate, and lateral parietal cortices) is active at rest. It is also active during daydreaming and internally generated, task-independent mentation – that is, mental states that foster creative ideas. External sensory stimuli to which we attend result in suppression of the default system activity, and greater suppression is associated with better performance on attention-demanding tasks. In schizophrenic patients, there is reduced suppression of the medial prefrontal component of the default system, which reflects their poor attentional skills. There is also increased connectivity between default regions and the rest of the brain, and this is also thought to promote creativity by facilitating unusual associations and even synesthesia. Among healthy people, reduced suppression is associated with mind wandering, a mental state that predisposes to "aha" moments that characterize some creative activity. These neurophysiological alterations correlate with personality variations, not only in schizophrenic patients but also in their first-degree relatives and "creative controls" (Proc. Natl. Acad. Sci. U.S.A. 2009;106:1279-84).

Is there a creative personality type? Creative and bipolar individuals share the personality traits of high neuroticism and openness to experience (based on the revised NEO Personality Inventory). Schizotypy (a form of personality disorder) is characterized by four factors: unusual experiences, cognitive disorganization, introvertive anhedonia, and impulsive nonconformity. Poets and visual artists score high on unusual experiences and low on introvertive anhedonia, similar to bipolar patients, whereas mathematicians score low on unusual experiences and high on introvertive anhedonia. A high level of both positive schizotypy (unusual experiences) and negative schizotypy (introvertive anhedonia) predisposes to mental illness, whereas a high level of positive schizotypy with a low level of negative schizotypy may promote creativity (J. Res. Person. 2006;40:876-90).

Dopaminergic agonists, which are typically used in the setting of Parkinson’s disease, can sometimes enhance reward-driven behavior to the point of pathological gambling and sexual activity, but is not specifically associated with more successful creative efforts. Dopamine antagonists reduce psychosis and agitation, and with such normalization other behaviors may be restored, although dopaminergic blockade itself is associated with reduced motivation and spontaneity and so is also not conducive to creative behavior (Can. J. Psychiatry 2011;56:132-43). Just as some personality traits appear to overlap creativity and psychopathology, one possible way of explaining the relationship between the two is that of a shared vulnerability model (Can. J. Psychiatry 2011;56:144-53). Reduced latent inhibition (LI), which is the ability to screen out previous experiences from current awareness as irrelevant, as well as novelty seeking and neural hyperconnectivity, all promote creative thought and are all associated with mental illness. (LI and hyperconnectivity are associated with schizophrenia; novelty seeking is associated with substance abuse as well as mania.) High levels of intelligence, working memory, and cognitive flexibility all promote creativity and protect against mental illness, and allow such individuals to better cope with the higher-risk traits. This might explain the observation that families of geniuses also contain mentally ill members at a higher-than-normal rate consistent with the hypothesis that there may be common substrates shared by the two (J. Psychiatr. Res. 2005;39:623-31).

In a recent interview with Bruce Springsteen in which the artist discussed his challenges with depression, David Remnick, editor-in-chief of the New Yorker, wrote, "As Springsteen sees it, the creative talent has always been nurtured by the darker currents of his psyche" (New Yorker 2012 July 30). Quoting Springsteen, he wrote that "you cannot underestimate the fine power of self-loathing in all of this. You think, I don’t like anything I’m seeing, I don’t like anything I’m doing, but I need to change myself, I need to transform myself. I do not know a single artist who does not run on that fuel. ... That’s a motivation, that element of ‘I need to remake myself, my town, my audience’ – the desire for renewal." Clearly, the psychic pain of mental illness can be a source of inspiration that promotes creative efforts, and it may be that this, too, is a reflection of the shared vulnerability model.

But there are two motivational poles: a positive pole (appetite, reward, approach) and a negative one (aversion, fear, avoidance). Either pole can and does serve to drive us towards creative goals. The driving force for creativity – the motivational voltage that derives from the difference in perceived reward value between what is and what should be – means that, in a way, we must be in a constant state of dissatisfaction. Maximum reward value means exceeding our expectations, which by definition cannot happen frequently. Perhaps our creative wiring comes with the cost of predisposing us to depression (resulting from dissatisfaction with the status quo) and schizophrenia (envisioning what does not yet exist to the point of perceptual hallucinatory phenomena).

This raises another intriguing question: Are the greatest creative works driven primarily by this darker side (the need to alleviate an inner pain), or is the positive pole (appetite, reward, approach) just as likely as the negative pole to end in great achievement? The Rolling Stones, for example, produced their most memorable work – expressing their inner demons and finding resolution – early in their career, once they mastered the technical and procedural details of their trade. (Compare, for example their earlier songs, "Sympathy for the Devil" or "You Can’t Always get What You Want" vs. a popular song from their last album, "Rough Justice.") However, once they achieved popular acclaim and wealth, they learned that modeling themselves can be rewarding and they seem (to this fan at least) to be less driven now by alleviating an inner pain than by pursuing financial gain.

Another layer of risk is that which arises from the group dynamic. Few major creative achievements happen as solo efforts. Bruce Springsteen’s E Street Band – guided by his creative mind (and motivated at times by his darker side) – as well as the Rolling Stones and many other bands created a great deal of wonderful music as groups. But group creativity does not always result in positive outcomes. Although creative individuals may function normally by themselves, the dynamics of a group may lead to dysfunctional results and blur the line between normality and mental (or social) illness. Next month, therefore, we will consider disorders of group creativity.

Dr. Richard J. Caselli is medical editor of Clinical Neurology News and is a professor of neurology at the Mayo Clinic in Scottsdale, Ariz.

The potential association of creativity with mental illness has generated both scientific interest and controversy since such a relationship was first posited by the ancient Greeks.

The two might interact in a variety of ways. Both might share similar predisposing factors, yet not be causally related to each other. Or the creative effort might be psychologically taxing to the point of causing psychopathology. Or psychopathologic symptoms (such as bizarre associations, hallucinations, or feelings of grandiosity and boundless energy) might promote creativity.

And it may be that any of these relationships can be true in some people and not in others. Not every possible relationship has been addressed by every study, so that the findings of one study may not address questions raised by another.

As with any scientific question, the most important first step is to establish the validity of the observation: Is there a greater-than-expected level of mental illness among creative people? But even this question is more complex than it might first seem. What do we mean by "creative people"? Creativity is not a unique skill possessed solely by the fortunate few, but a general mode of human thought characterized by motivation, perception, mental imagery, strategic formulation, dexterous execution, temperament, and social context. These principles are the same whether we are trying to avoid a traffic jam, diagnose a patient, or write a poem. We are all, in this way, creative people, but studies addressing this question generally focus on those in more traditionally regarded creative occupations, such as art and music.

In the United States in 2001-2003, 30% of the population experienced some form of mental illness (N. Engl. J. Med. 2005;352:2515-23). Evidence of higher prevalence rates among the more creative comes from biographical and survey studies (typically of eminent people), family studies (via relatives of psychiatric patients), psychiatric patients themselves, correlations among the general public of scores on tests for psychopathology and tests of creativity, and the psychometric assessment of individuals in creative pursuits (J. Res. Person. 2005 Oct. 270 [doi:10.1016/j.jrp.2005.09.004]).

Absolutes rates differ among studies, but many have shown an elevated prevalence of depression among writers (Am. J. Psychiatry 1987;144:1288-92; Br. J. Psychiatry 1994;165:22-34). In Arnold Ludwig’s biographical study of 1,005 individuals whose biographies were published in the New York Times Book Review over a 30-year period, depression, suicide attempts, psychosis, and forced hospitalization were prevalent in more than 60%, 20%, 17%, and 11.3%, respectively, of poets older than age 40 (Am. J. Psychother. 1992;46:330-56).

Other groups fared a bit better, although suicide rates were also relatively high in members of the theatre and in musical performers. Overall, alcoholism and depression were the most common problems among the creative professions. Compared with the nonartistic professions (such as politics or physical science), artists (including writers, painters, musicians, and actors) had higher rates of all forms of psychopathology and psychiatric interventions. Total lifetime depression and anxiety scores correlated with overall level of creative achievement in all professions, but the relationship was weak (R² = 0.04).

Although depression and substance abuse are more prevalent among those in the artistic professions (and writers in particular), it is less clear that this represents a causal relationship. Hypomania may enhance self-confidence and the formation of associations, and may focus goal-directed activity, all of which can foster creativity, but full-blown manic psychosis (or psychosis for any other reason) disrupts rational thought and is not conducive to creativity. Depression saps motivation and thus inhibits creativity.

Patients who are actively psychotic are unable to be creatively productive, but schizophrenic patients who are between psychotic episodes share some creativity-associated traits (such as divergent thinking) with their first-degree relatives and those in the artistically creative professions. This has led some to argue that schizophrenia itself may promote creativity, hence its prevalence and persistence in the human gene pool.

There is indirect neurobiological evidence that supports this claim. Normally, the default network (which includes medial prefrontal, posterior cingulate, and lateral parietal cortices) is active at rest. It is also active during daydreaming and internally generated, task-independent mentation – that is, mental states that foster creative ideas. External sensory stimuli to which we attend result in suppression of the default system activity, and greater suppression is associated with better performance on attention-demanding tasks. In schizophrenic patients, there is reduced suppression of the medial prefrontal component of the default system, which reflects their poor attentional skills. There is also increased connectivity between default regions and the rest of the brain, and this is also thought to promote creativity by facilitating unusual associations and even synesthesia. Among healthy people, reduced suppression is associated with mind wandering, a mental state that predisposes to "aha" moments that characterize some creative activity. These neurophysiological alterations correlate with personality variations, not only in schizophrenic patients but also in their first-degree relatives and "creative controls" (Proc. Natl. Acad. Sci. U.S.A. 2009;106:1279-84).

Is there a creative personality type? Creative and bipolar individuals share the personality traits of high neuroticism and openness to experience (based on the revised NEO Personality Inventory). Schizotypy (a form of personality disorder) is characterized by four factors: unusual experiences, cognitive disorganization, introvertive anhedonia, and impulsive nonconformity. Poets and visual artists score high on unusual experiences and low on introvertive anhedonia, similar to bipolar patients, whereas mathematicians score low on unusual experiences and high on introvertive anhedonia. A high level of both positive schizotypy (unusual experiences) and negative schizotypy (introvertive anhedonia) predisposes to mental illness, whereas a high level of positive schizotypy with a low level of negative schizotypy may promote creativity (J. Res. Person. 2006;40:876-90).

Dopaminergic agonists, which are typically used in the setting of Parkinson’s disease, can sometimes enhance reward-driven behavior to the point of pathological gambling and sexual activity, but is not specifically associated with more successful creative efforts. Dopamine antagonists reduce psychosis and agitation, and with such normalization other behaviors may be restored, although dopaminergic blockade itself is associated with reduced motivation and spontaneity and so is also not conducive to creative behavior (Can. J. Psychiatry 2011;56:132-43). Just as some personality traits appear to overlap creativity and psychopathology, one possible way of explaining the relationship between the two is that of a shared vulnerability model (Can. J. Psychiatry 2011;56:144-53). Reduced latent inhibition (LI), which is the ability to screen out previous experiences from current awareness as irrelevant, as well as novelty seeking and neural hyperconnectivity, all promote creative thought and are all associated with mental illness. (LI and hyperconnectivity are associated with schizophrenia; novelty seeking is associated with substance abuse as well as mania.) High levels of intelligence, working memory, and cognitive flexibility all promote creativity and protect against mental illness, and allow such individuals to better cope with the higher-risk traits. This might explain the observation that families of geniuses also contain mentally ill members at a higher-than-normal rate consistent with the hypothesis that there may be common substrates shared by the two (J. Psychiatr. Res. 2005;39:623-31).

In a recent interview with Bruce Springsteen in which the artist discussed his challenges with depression, David Remnick, editor-in-chief of the New Yorker, wrote, "As Springsteen sees it, the creative talent has always been nurtured by the darker currents of his psyche" (New Yorker 2012 July 30). Quoting Springsteen, he wrote that "you cannot underestimate the fine power of self-loathing in all of this. You think, I don’t like anything I’m seeing, I don’t like anything I’m doing, but I need to change myself, I need to transform myself. I do not know a single artist who does not run on that fuel. ... That’s a motivation, that element of ‘I need to remake myself, my town, my audience’ – the desire for renewal." Clearly, the psychic pain of mental illness can be a source of inspiration that promotes creative efforts, and it may be that this, too, is a reflection of the shared vulnerability model.

But there are two motivational poles: a positive pole (appetite, reward, approach) and a negative one (aversion, fear, avoidance). Either pole can and does serve to drive us towards creative goals. The driving force for creativity – the motivational voltage that derives from the difference in perceived reward value between what is and what should be – means that, in a way, we must be in a constant state of dissatisfaction. Maximum reward value means exceeding our expectations, which by definition cannot happen frequently. Perhaps our creative wiring comes with the cost of predisposing us to depression (resulting from dissatisfaction with the status quo) and schizophrenia (envisioning what does not yet exist to the point of perceptual hallucinatory phenomena).

This raises another intriguing question: Are the greatest creative works driven primarily by this darker side (the need to alleviate an inner pain), or is the positive pole (appetite, reward, approach) just as likely as the negative pole to end in great achievement? The Rolling Stones, for example, produced their most memorable work – expressing their inner demons and finding resolution – early in their career, once they mastered the technical and procedural details of their trade. (Compare, for example their earlier songs, "Sympathy for the Devil" or "You Can’t Always get What You Want" vs. a popular song from their last album, "Rough Justice.") However, once they achieved popular acclaim and wealth, they learned that modeling themselves can be rewarding and they seem (to this fan at least) to be less driven now by alleviating an inner pain than by pursuing financial gain.

Another layer of risk is that which arises from the group dynamic. Few major creative achievements happen as solo efforts. Bruce Springsteen’s E Street Band – guided by his creative mind (and motivated at times by his darker side) – as well as the Rolling Stones and many other bands created a great deal of wonderful music as groups. But group creativity does not always result in positive outcomes. Although creative individuals may function normally by themselves, the dynamics of a group may lead to dysfunctional results and blur the line between normality and mental (or social) illness. Next month, therefore, we will consider disorders of group creativity.

Dr. Richard J. Caselli is medical editor of Clinical Neurology News and is a professor of neurology at the Mayo Clinic in Scottsdale, Ariz.