Journal of Psychiatric Research 153 (2022) 149–158

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Journal of Psychiatric Research

journal homepage: www.elsevier.com/locate/jpsychires

Bipolar spectrum traits and the space between Madness and Genius: The
Muse is in the Dose
Tiffany A. Greenwood a, *, Lauren J. Chow a, Ruben C. Gur b, John R. Kelsoe a, c
a
Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
b
Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
c
Institute for Genomic Medicine, UC San Diego, La Jolla, CA, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Creativity has long been associated with the bipolar spectrum, particularly among unaffected first-degree rela­
Bipolar disorder tives and those with milder expressions of bipolar traits, suggesting that some aspects of the bipolar spectrum
Creativity may confer advantages for creativity. Here we took a multifaceted approach to better define the shared
Mood
vulnerability between creativity and bipolar disorder. We recruited 135 individuals with bipolar disorder, 102
Temperament
Personality
creative controls, and 103 non-creative controls for a total of 340 participants. All participants completed a
Cognition comprehensive assessment battery that included several self-report temperament and personality questionnaires,
a computerized test of cognitive function across multiple domains, and an evaluation of creative performance
and achievement. Significant group differences were observed for the hypothesized shared vulnerability traits of
hypomanic personality, cyclothymic temperament, impulsivity, and positive schizotypy. While both the creative
and bipolar groups demonstrated superior creative ability, the creative group alone revealed enhanced cognitive
performance. Accounting for intercorrelations between traits, a combination of openness, hypomanic person­
ality, divergent thinking, and reasoning ability emerged as the strongest predictors of creativity, collectively
explaining 34% of the variance in creative achievement and correctly classifying 85% of individuals with high
achievement irrespective of diagnosis. These results confirm and extend earlier observations of a shared
vulnerability between creativity and bipolar disorder and suggest that mild to moderate expressions of bipolar
spectrum traits are associated with enhanced cognitive functioning and creative expression. Further investigation
of these traits is needed to clarify the nature of this shared vulnerability and suggest individualized treatment
strategies to improve clinical outcomes in bipolar disorder.

1. Introduction
Bipolar disorder is a lifelong mood disorder characterized by extreme
mood swings between the highs of mania and the lows of depression
(Goodwin and Jamison, 2007). Mania is accompanied by pathological
elevations in energy and mood, grandiosity, racing thoughts, and risk
taking; whereas depression is associated with low energy and motiva­
tion, as well as feelings of sadness and hopelessness. Up to 50% of pa­
tients also experience symptoms of psychosis in the form of
hallucinations and delusions (Goodwin and Jamison, 2007). Bipolar
disorder is common, affecting more than 5.7 million adults in the United
States each year with a lifetime prevalence of 3.9% (Kessler et al., 2005).
In an effort to inform treatment, current diagnostic systems group pa­
tients into discrete categories based on the pattern and severity of mood
symptoms. However, this practice has failed to capture the extensive
phenotypic heterogeneity of bipolar disorder and has yielded a limited
understanding of the underlying pathology. Further insight and progress
toward a precision medicine approach may be gained by viewing the
illness as a dimensional construct existing at the extreme of normal
population variation in mood, personality, and cognition (Burmeister
et al., 2008; Akiskal, 2002).
It has long been observed that certain positive traits or enhanced
abilities exist within the bipolar spectrum, including creativity.
Numerous biographical studies of the eminently creative combined with
large population-based studies of everyday creativity provide strong
support for a connection between creativity and bipolar disorder
(Jamison, 1993; Tremblay et al., 2010; Kyaga et al., 2011). While these
studies have found a ten-fold increase in the rate of bipolar disorder

* Corresponding author. Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, MC 0689, La Jolla, CA, 92093, USA.
E-mail address: tgreenwood@health.ucsd.edu (T.A. Greenwood).

https://doi.org/10.1016/j.jpsychires.2022.07.009
Received 4 October 2021; Received in revised form 18 June 2022; Accepted 1 July 2022
Available online 5 July 2022
0022-3956/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
T.A. Greenwood et al.
among creative individuals, they have also shown that creativity and
professional success are particularly enhanced among unaffected
first-degree relatives and individuals expressing bipolar spectrum traits
(Verdoux and Bourgeois, 1995; Richards et al., 1988; Kyaga et al., 2013;
Coryell et al., 1989; Simeonova et al., 2005; Akiskal and Akiskal, 2007).
These findings suggest that some bipolar spectrum traits may confer
advantages for creativity.
A shared vulnerability model and inverted-U relationship has been
suggested, according to which creativity would increase with genetic
risk for bipolar disorder up to a threshold and then diminish with the
increasing impairment that accompanies a more severe expression of
symptoms (Richards et al., 1988; Greenwood, 2017, 2020; Nettle, 2001;
Carson, 2011). Creativity is typically defined as behaviors or thoughts
that are both novel and useful and represents a complex, multidimen­
sional construct with both cognitive and affective components (Eysenck,
1995; Russ, 1993; Srivastava et al., 2010; Feist, 1998). Traits related to
mood instability (hypomanic traits, cyclothymic temperament), “expe­
riencing” personality types (openness to experience, positive schizotypy,
impulsivity), and conceptual over-inclusiveness are associated with
creativity, bipolar disorder, and creativity in bipolar disorder and may
represent aspects of the shared vulnerability. While mild to moderate
expression of these shared traits may enhance creativity, more extreme
expressions result in symptoms associated with illness, such as mood
cycling, psychosis, risk taking, racing thoughts, and cognitive disorga­
nization. Creative individuals may also possess cognitive protective
traits in the form of high IQ or cognitive flexibility, which help them to
more effectively integrate original ideas into artistic expression and
novel inventions (Carson, 2011). However, it has been suggested that
the eventual success of individuals possessing these cognitive abilities
relies heavily on personality factors, like openness (Jauk et al., 2013).
While previous studies have provided an abundance of data to sup­
port the connection between bipolar disorder and creativity, most
focused on a limited number of phenotypes in a small sample, creativity
in unaffected individuals, or the correlation between diagnosis and
creative occupation in a population-based setting. Here we build on
these earlier investigations with an assessment of multiple dimensions of
affective temperament, personality, and cognition in a cohort comprised
of individuals with bipolar disorder and both creative and non-creative
comparison subjects. We expect the shared traits relating to mood and
personality to follow an intermediate phenotype model, with moderate
expressions among creative individuals and more extreme expressions in
bipolar disorder. Conversely, shared cognitive and creative traits are
expected to follow an inverted-U pattern, with enhanced performance
on such tasks observed for creative individuals. From these observations,
we hope to discover the traits that are most predictive of high creative
achievement, as well as gain additional insight into the nature of the
shared vulnerability.
2. Methods
2.1. Subject ascertainment
Recruitment for this study was achieved through advertisements,
physician referral, and the re-contact of previous research study par­
ticipants. To avoid selection bias, recruitment materials targeting bi­
polar and non-creative comparison participants made no mention of
creativity, whereas recruitment materials targeting creative individuals
made no mention of mental health. Structured clinical interviews were
conducted according to DSM-5 criteria for all participants to confirm
diagnoses of bipolar disorder and to ensure that the comparison par­
ticipants were free of a personal or family history of bipolar disorder,
psychosis, or recurrent major depression (Nurnberger et al., 1994). For
those BP participants meeting criteria for a current manic, depressed or
mixed episode during the clinical interview, study participation was
suspended and resumed, if possible, once active symptoms had abated.
As part of the initial interview, participants were also queried as to their
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Journal of Psychiatric Research 153 (2022) 149–158
current occupation and creative involvement.
The final sample of 316 participants included 111 individuals with
bipolar disorder (BP), of whom 57% were bipolar I and 43% were bi­
polar II. All BP participants were judged to be euthymic at the time of
assessment with only mild symptoms or impairment present over the
past month, as assessed by the clinician-administered Global Assessment
of Functioning, (GAF, range 60–100, mean = 75). Of the 205 compari­
son subjects, 102 reported involvement in a creative profession, whether
full time or freelance (e.g., visual artist, musician, creative writer, etc.)
and were considered creative controls (creCTL), while the remaining
103 reported no significant involvement in creative pursuits and were
considered non-creative controls (nCTL). Approximately 38% of BP
participants also reported engagement in a creative profession.
The age, gender, and education distributions were similar across the
three groups, as shown in Table 1. The racial and ethnic composition of
the sample reflects local demographics with 64% white, 17% Hispanic,
12% Asian, and 6% Black by self-report. Written informed consent was
obtained for all subjects according to the local institutional review
board.
2.2. Temperament and personality assessment
We evaluated multiple aspects of temperament and personality
through self-report questionnaires, all of which have validated in both
healthy and clinical samples. The rationale for these particular ques­
tionnaires is discussed in detail elsewhere and summarized here as a
Supplement (Greenwood, 2017, 2020). The Hypomanic Personality Scale
evaluates aspects of hypomanic traits related to high mood, activation,
grandiosity, and impulsivity and has been shown to predict risk for bi­
polar spectrum disorders (Eckblad and Chapman, 1986; Kwapil et al.,
2000). The Barratt Impulsiveness Scale evaluates impulsivity in terms of
cognitive instability, attention, self-control, cognitive complexity,
motor, and perseverance (Patton et al., 1995). The Temperament Evalu­
ation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire quantifies
lifelong, milder aspects of bipolar symptomatology according to 5
temperament domains: hyperthymic, dysthymic, cyclothymic, irritable,
and anxious (Akiskal et al., 2005; Kawamura et al., 2010). The Schizo­
typal Personality Questionnaire captures aspects of positive schizotypal
traits relating to cognitive disorganization (eccentric behavior and odd
speech) and cognitive-perceptual experiences (ideas of reference,
magical thinking, unusual experiences), as well as negative schizotypal
traits (constricted affect, social anxiety, no close friends, and suspi­
ciousness) (Raine, 1991; Carson et al., 2003; Higier et al., 2014). The
NEO Personality Inventory is the standard questionnaire for the Five
Factor Model, encompassing the personality domains of neuroticism,
extraversion, openness, agreeableness, and conscientiousness, as well as
six facets that define each domain (Costa and McCrae, 1992; Bagby
et al., 1999).
2.3. Cognitive assessment
A customized version of the Penn Computerized Neuropsychological
Battery (CNP) was used to assess specific cognitive abilities that may
relate to creativity, some of which are novel in this regard (Brodzinsky
and Rubien, 1976; Gur et al., 2010; Thorson and Powell, 1993; Furnham
et al., 2008; Kuncel et al., 2004). The Penn Humor Appreciation Test
Table 1
Sample description.
nCTL creCTL BP
N 103 102 111
% Female 65.0% 62.7% 62.2%
Age (years) 41.5 ± 13.2 40.7 ± 14.1 38.1 ± 12.8
Education (years) 15.4 ± 2.1 15.6 ± 1.9 15.0 ± 2.3
All group comparison p-values are non-significant (>0.05).
T.A. Greenwood et al.
presents pairs of verbal (newspaper headline gaffes) and figural (Mor­
dillo cartoons) stimuli, with the original stimulus displayed next to one
with the joke removed (e.g., “Red Tape Holds up New Bridge” versus
“Red Tape Delays New Bridge”), and asks the participant to determine
which one is funny (Bozikas et al., 2007; Kohn et al., 2011). Verbal and
figural scores were averaged for a total humor appreciation score. The
Penn Verbal Reasoning Test consists of verbal analogy problems from the
Educational Testing Service factor-referenced test kit (Gur et al., 1982).
The Penn Matrix Reasoning Test evaluates nonverbal reasoning in a
manner analogous to Raven’s Standard Progressive Matrices, for which
the participant must conceptualize spatial, design, and numerical re­
lations to choose the best option to complete increasingly complex ar­
rays (Bilker et al., 2012). Verbal and nonverbal scores were averaged to
provide a reasoning ability summary score as a measure of fluid intel­
ligence, which is a component of general intellectual ability correlated
with other measures of IQ (Gur et al., 2012). The Penn Line Orientation
Test is a test of spatial processing ability in which participants are shown
a pair of lines with different orientations and asked to rotate one line so
that it is parallel to the other (Moore et al., 2015). The Penn Conditional
Exclusion Test is a measure of mental flexibility that uses a set-shifting
task analogous to the Wisconsin Card Sort Test (Kurtz et al., 2004).
Tasks assessing general cognitive function in terms of working
memory, attention, and memory were also included to provide a point of
comparison. The Letter N-Back is a working memory task presented in
blocks of three conditions: 0-Back, 1-Back, and 2-Back (Ragland et al.,
2002). The Penn Continuous Performance Test provides a measure visual
attention and vigilance through the presentation of vertical and hori­
zonal lines that requires the participant to respond when a complete
number (or letter) is formed (Kurtz et al., 2001). Finally, three declar­
ative memory tasks, reflecting the main visual modalities, were
administered with the scores averaged to produce a summary score (Gur
et al., 1997; Glahn et al., 1997). The Penn Face Memory Test presents 20
target faces that must be memorized and then identified amongst 20
distractors. The Penn Word Memory Test employs a similar paradigm
using words as a test of verbal memory, and the Visual Object Learning
Test uses three-dimensional Euclidean shapes as a test of spatial
memory.
2.4. Creativity assessment
We took a multifaceted approach to assessing creativity, as discussed
elsewhere and included here as a Supplement (Greenwood, 2017, 2020).
The Creative Personality Scale is derived from the Adjective Check List
and consists of 30 self-descriptive items that predict high creativity
across diverse domains (Gough, 1979; Gough and Heilbrun, 1965). The
Barron-Welsh Art Scale evaluates figure preference through a series of
black and white figures that subjects rate as “like” or “dislike”, with
higher scores reflecting a preference for asymmetry and complexity
(Barron, 1963). The Torrance Test of Creative Thinking provides a classic
laboratory measure of divergent thinking ability (Torrance, 1974).
Verbal divergent thinking was assessed using word-based exercises that
required listing unusual uses for a common item, suggesting ideas for
product improvement, and guessing consequences of a hypothetical
situation. These exercises were scored for fluency (quantity of ideas),
flexibility (categories of ideas, shift in focus), and originality (statistical
infrequency and unusualness of ideas). Figural divergent thinking was
assessed through drawing exercises involving picture construction and
completion from marked cues that were similarly scored for fluency and
originality, as well as elaboration (level of imagination and richness of
detail), abstractness of titles (ability to capture the essence of the image
and provide depth), and resistance to premature closure (the ability to
keep open long enough to make the mental leap that facilitates origi­
nality). A total divergent thinking score and summaries of fluency and
originality were computed across the verbal and figural domains.
Finally, the Creative Achievement Questionnaire was administered, as it
provides a real-life measure of involvement and achievement (ranging
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Journal of Psychiatric Research 153 (2022) 149–158
from no talent whatsoever to public acknowledgment of one’s talent)
across 10 domains (visual arts, creative writing, performing arts, humor,
inventions, etc.) and displays good test-retest reliability, internal con­
sistency, and convergent validity with other measures of creativity
(Carson et al., 2005).
2.5. Statistical analyses
Univariate linear regression was used to adjust for the effects of age
and gender, and the resultant standardized residuals were used to
calculate z-scores for each participant relative to the mean and standard
deviation of the nCTL group. The relationships between individual traits
were evaluated through correlational analyses using Pearson’s r. Anal­
ysis of variance (ANOVA) was used to assess global group differences
with Tukey post hoc testing for specific group comparisons.
Stepwise regression analyses were conducted to identify the traits
with the largest independent effects on high creative achievement in
unaffected individuals. All traits that significantly distinguished the
creCTL group were included as potential predictor variables, including
aspects of mood (hypomanic personality and the cyclothymic, hyper­
thymic, irritable, and anxious temperaments), personality and behavior
(openness, positive schizotypy, and impulsivity), and cognitive and
creative performance (humor appreciation, reasoning, spatial process­
ing, memory, divergent thinking). Significant predictors with the
strongest effects were selected through an iterative process to generate a
final model including only predictors with unique contributions to cre­
ative achievement. The standardized residual from the regression model
was then calculated across all individuals, and the area under the
receiver operating characteristic (ROC) curve (AUC) was evaluated to
assess its predictive utility. For these analyses, a standardized creative
achievement score of 3.0, reflecting outlying values ≥ 3 standard de­
viations from the nCTL mean, was used as a threshold for high creativity.
While all bipolar individuals reporting creative involvement met this
threshold, only 65% of self-reported creative individuals qualified for
inclusion in the revised creative group (creCTL_rev). This threshold was
also used to consider creative bipolar (creBP) and non-creative (nBP)
bipolar subgroups in confirmatory analyses of the shared vulnerability
traits.
3. Results
As shown in Table 2, all hypothesized shared vulnerability traits
significantly discriminated among the groups and followed the expected
pattern, with medium to large effects observed for the creCTL group
compared to the nCTL group. The BP group exhibited very large effect
sizes for all shared vulnerability traits except openness, which was in­
termediate between the creCTL and nCTL groups. A graphical repre­
sentation of these patterns is provided in Fig. 1. The anxious and
irritable temperaments followed a similar pattern of medium and very
large effect sizes in the creCTL and BP groups, respectively, whereas
hyperthymic temperament was moderately elevated in the creCTL group
only. Other temperament and personality traits appeared specific to the
BP group, with dysthymic temperament, negative schizotypy, and
neuroticism being significantly higher and extraversion, agreeableness,
and conscientiousness significantly lower. Creative personality, which
reflects an individual’s self-assessment of defining characteristics, was
significantly higher in the creCTL group only, with the most commonly
endorsed items suggesting that creative individuals view themselves as
unconventional, individualistic, original, inventive, and reflective (p <
0.001 vs. nCTL).
A closer look at the trait facets provides additional insight into the
creative temperament and the shared vulnerability (Fig. 2). For
example, the BP group was high across all aspects of impulsivity,
whereas the creCTL group was primarily characterized by cognitive
instability (racing thoughts, changing interests) and motor impulsivity
(spontaneous behavior), with more modest increases seen for attention
T.A. Greenwood et al. Journal of Psychiatric Research 153 (2022) 149–158

Table 2
Group differences in temperament, personality, creativity, and cognitive
function.
creCTL BP ANOVA

Mean Mean F P
± SD ± SD Value

Shared Hypomanic 1.46 ± 2.72 ± 104.56 <0.001

Vulnerability Personality ‡ 1.39** 1.67**
Traits Cyclothymic 1.21 ± 4.47 ± 180.64 <0.001
Temperament ‡ 1.76** 2.30**
Positive Schizotypy 1.37 ± 2.76 ± 64.04 <0.001
‡ 1.69** 2.36**
Openness † 0.99 ± 0.63 ± 24.41 <0.001
0.82** 1.21**
Impulsivity ‡ 0.69 ± 2.03 ± 67.96 <0.001
1.28** 1.56**
Other Irritable 0.52 ± 2.32 ± 79.94 <0.001
Temperament Temperament ‡ 1.13* 1.93**
& Personality Anxious 0.59 ± 2.23 ± 68.39 <0.001
Traits Temperament ‡ 1.35* 1.84**
Hyperthymic 0.44 ± 0.10 ± 6.09 0.002
Temperament † 0.75* 1.04 Fig. 1. Temperament and personality traits that distinguish both the creative
Dysthymic 0.29 ± 1.80 ± 54.20 <0.001 and bipolar groups and may represent a shared vulnerability. Mean standard
Temperament ‡ 1.24 1.75** scores for the creCTL and BP groups represent effect sizes with dashed lines
Negative 0.39 ± 1.71 ± 43.67 <0.001 indicating thresholds for small (±0.2), medium (±0.5) and large (±0.8) effects.
Schizotypy ‡ 1.15 1.87** The value for cyclothymic temperament in BP is truncated for ease of
Neuroticism ‡ 0.34 ± 1.84 ± 81.25 <0.001 presentation.
1.13 1.22**
Extraversion † 0.07 ± − 0.41 5.67 0.004
1.03 ± (restlessness) and the impulsiveness facet of neuroticism (impulsive
1.31* behavior, overindulgence). While the BP group was extreme across all
Agreeableness − 0.05 − 0.33 3.48 0.032 facets of schizotypy, the creCTL group revealed significant elevations
± 0.94 ±
1.00*
across all facets of positive schizotypy with only a small effect for the
Conscientiousness − 0.10 − 1.29 47.80 <0.001 negative schizotypy facet of constricted affect (aloof) and a trend toward
‡ ± 1.06 ± significance for social anxiety (p = 0.057), consistent with the low score
1.16** observed for the gregariousness facet of extraversion (preference for
Cognition Humor 0.40 ± − 0.06 5.80 0.003
solitude). The higher score for the creCTL group with regard to the
Appreciation ‡ 0.95* ± 1.20
Reasoning ‡ 0.45 ± − 0.07 8.83 <0.001 positive emotions facet of extraversion reflects an upbeat mood,
0.78* ± 1.06 consistent with the results for hyperthymic temperament. The BP group
Spatial Processing ‡ 0.43 ± − 0.05 9.16 <0.001 was significantly higher on all facets of neuroticism and lower on all
0.72* ± 0.93 facets of conscientiousness, consistent with the results for temperament
Mental Flexibility 0.16 ± − 0.13 2.65 0.072
0.86 ± 0.91
and impulsivity. The agreeableness domain was mixed, with the BP
Working Memory ‡ 0.22 ± − 0.41 9.46 <0.001 group scoring lower on facets of trust (suspicious) and compliance
0.70 ± (uncooperative) and the creCTL and BP groups scoring similarly low on
1.37* straightforwardness (manipulative) and high on tendermindedness
Attention † − 0.10 − 0.48 5.13 0.006
(sympathetic). Finally, as expected, the creCTL and BP groups scored
± 0.91 ±
1.42* similarly high across the openness facets of fantasy (imagination), aes­
Memory ‡ 0.40 ± − 0.21 11.40 0.000 thetics (appreciation of art and music), feelings (wide range of emotion,
0.79* ± 1.02 empathetic), and values (open-minded, tolerant). The creCTL group also
Creativity Creative 0.79 ± 0.21 ± 14.15 <0.001 scored significantly higher for the ideas facet (intellectual curiosity),
Personality ‡ 0.97** 1.28
Figure Preference 0.00 ± 0.25 ± 2.5 0.089
whereas the BP group was significantly lower for the action facet
0.95 1.04 (preference for routine).
Divergent Thinking 0.70 ± 0.57 ± 10.74 <0.001 As shown in Fig. 3, the creCTL group generally demonstrated
1.08** 1.33** enhanced cognitive and creative performance. In terms of cognitive
Originality 0.65 ± 0.72 ± 12.41 <0.001
ability, the creCTL group performed significantly better on tasks related
1.12** 1.28**
Fluency 0.45 ± 0.41 ± 4.94 0.008 to humor appreciation, reasoning ability (fluid intelligence, problem
1.08* 1.32* solving), spatial processing, and declarative memory compared with the
Achievement ‡ 5.24 ± 2.88 ± 82.71 <0.001 nCTL and BP groups, which did not differ in performance (Fig. 3a).
3.29** 3.63** Deficits in working memory and attention were particular to the BP
Means and standard deviations listed for the creCTL and BP groups are z-scores group, with no differences observed between the creCTL and nCTL
relative to the nCTL group and thus may be considered effect sizes. The nCTL groups. In terms of divergent thinking ability, the creCTL and BP groups
group by default has a mean of 0 and standard deviation of 1 for all traits and is both outperformed the nCTL group (Fig. 3a), demonstrating a greater
not listed. number of independent ideas (fluency) and more originality. The
Significance with respect to nCTL is indicated as * (p < 0.05) or ** (p < 0.001). divergent thinking summaries were primarily driven by the results of the
Group differences between creCTL and BP are indicated as † (p < 0.05) and ‡ (p
verbal tasks, on which both the creCTL and BP groups significantly
< 0.001).
outperformed the nCTL group across all domains (Fig. 3b). While per­
formance on the figural tasks was somewhat less impressive, the creCTL
and BP groups both demonstrated greater originality and abstractness of
titles, and the creCTL group revealed superior elaboration.

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T.A. Greenwood et al. Journal of Psychiatric Research 153 (2022) 149–158

Fig. 2. Association of the personality facets across groups for impulsivity and schizotypy (a) and the NEO (b). Mean standard scores for the creCTL (blue) and BP
(red) groups represent effect sizes with dashed lines indicating thresholds for small (±0.2), medium (±0.5) and large (±0.8) effects. Significance with respect to nCTL
is indicated as * (p < 0.05) or ** (p < 0.001). Group differences between creCTL and BP are indicated as † (p < 0.05) and ‡ (p < 0.001).

We investigated the correlational patterns among all traits that
distinguished creative from non-creative individuals (Table 3). All hy­
pothesized shared vulnerability traits were significantly correlated
among unaffected individuals and predicted higher creative achieve­
ment. A similar correlational pattern was observed for the BP group,
although, notably, there was no appreciable correlation between open­
ness and cyclothymic temperament, and only openness was associated
with higher achievement. Creative personality was strongly correlated
with hypomanic personality, openness, and hyperthymic temperament
among unaffected and affected individuals alike. Openness also pre­
dicted better cognitive and creative performance in both unaffected and
affected individuals, while hypomanic personality and hyperthymic
temperament were only associated with better creative performance in
the BP group. Despite following a similar pattern to the shared vulner­
ability traits, the irritable and anxious temperaments were not associ­
ated with creative achievement.
Given the intercorrelations among traits distinguishing creative from
non-creative individuals (see Table 3), a stepwise regression model was
applied to identify those traits exhibiting the strongest independent ef­
fects on high creative achievement among unaffected individuals.
Openness (b = 0.93, p < 0.001), hypomanic personality (b = 0.79, p <
0.001), divergent thinking (b = 0.50, p = 0.013), and reasoning ability

153
T.A. Greenwood et al.
(b = 0.49, p = 0.043) emerged as the most significant, independent
predictors, collectively explaining 35% of the variance in creative
achievement. The standardized residual from the regression model
correctly classified 84.8% (95% CI [78.9%, 90.8%], p < 0.001) of un­
affected individuals with high creative achievement. Notably, this
model also held for the BP group, correctly classifying 85.4% (95% CI
[78.4%, 92.4%], p < 0.001) of individuals with high creative
achievement.
A re-evaluation of the shared vulnerability traits with regard to high
creative achievement revealed no significant differences for the revised
creCTL group (creCTL_rev) compared with the original (creCTL), sug­
gesting that the patterns previously observed provide an accurate
reflection of creative traits and abilities regardless of the level of
achievement to date. While the creative BP (creBP) and non-creative BP
(nBP) subgroups were indistinguishable across most measures, key dif­
ferences emerged (Table 4). The creBP subgroup scored significantly
higher for hyperthymic temperament, openness, and creative person­
ality and demonstrated superior performance on the divergent thinking
tasks, comparable to the creCTL group. Still, even the nBP subgroup
revealed higher openness scores, better creative performance and higher
creative achievement than the nCTL group, clearly demonstrating that
the initial results for the BP group were not entirely driven by creative
individuals who also happen to have bipolar disorder.
4. Discussion
These results confirm and extend earlier observations of a shared
vulnerability between bipolar disorder and creativity in the most
comprehensive evaluation of such traits to date. The defining
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Journal of Psychiatric Research 153 (2022) 149–158
Fig. 3. Enhanced cognitive and creative performance
among creCTL Mean standard scores for the creCTL
and BP groups represent effect sizes with dashed lines
indicating thresholds for small (±0.2), medium
(±0.5) and large (±0.8) effects. (a) Mean group per­
formance across individual cognitive tasks and sum­
maries of overall divergent thinking. (b) Details of the
verbal and figural divergent thinking performance
with creCTL in blue and BP in red. Significance with
respect to nCTL is indicated as * (p < 0.05) or ** (p <
0.001). Group differences between creCTL and BP are
indicated as † (p < 0.05) and ‡ (p < 0.001).
characteristics of the shared vulnerability that emerged through the
analyses are summarized in Fig. 4. These traits range from those asso­
ciated with mood to aspects of personality and behavior, which may
provide richer experiences, greater emotional range, and perceptual
differences that may combine with enhanced cognitive abilities to foster
creativity. Consistent with the proposed inverted-U relationship, only
the more moderate expressions of hypomanic, cyclothymic, and
cognitive-perceptual schizotypal traits observed for creative individuals
were significantly correlated with creative achievement, whereas more
extreme expressions are maladaptive and associated with illness.
Conversely, openness predicted higher achievement regardless of diag­
nosis, and the creative cohort demonstrated cognitive enhancements
that may additionally foster creativity. Accounting for intercorrelations,
a combination of openness, hypomanic traits, divergent thinking, and
reasoning ability explained 35% of the variance in creative achievement
and correctly classified 85% of individuals with high achievement
irrespective of diagnosis.
It is readily conceivable how the mild to moderate expressions of
hypomania that define the hypomanic personality (high mood and en­
ergy, enhanced flow of ideas, self-confidence, social ease, etc.) could
provide an advantage for creativity and professional success, the “hy­
pomanic edge” (Gartner, 2005). Indeed, hypomanic personality has
previously shown associations with creative performance and achieve­
ment (Furnham et al., 2008; Schuldberg, 2001), and we have replicated
these findings here. Impulsivity is another key feature of bipolar disor­
der that is elevated in unaffected family members and correlated with
both hypomanic traits and creativity (Schuldberg, 2001; Lombardo
et al., 2012; Peluso et al., 2007). While all facets of impulsivity were
significantly elevated among the BP group, more moderate increases
T.A. Greenwood et al. Journal of Psychiatric Research 153 (2022) 149–158

Table 4

Only traits characteristic of creative individuals are shown for comparison among all unaffected individuals (CTL, i.e., nCTL and creCTL combined) and the bipolar group (BP). Correlations of at least small effect (r = 0.20)
0.61**

0.28**
Re-assessment of shared vulnerability traits and creativity in groups defined by

− 0.01
− 0.12
− 0.01
0.03

0.18
high creative achievement.

BP
Hyperthymic creCTL_rev creBP nBP ANOVA

Mean ± SD Mean ± Mean ± F P Value

− 0.12

− 0.04
0.42*

0.20*
0.07

0.00

0.11
CTL
SD SD

Hyperthymic 0.52 ± 0.38 ± − 0.02 ± 5.46 0.001

Correlational patterns between temperament and personality traits and their relationships to measures of creativity and cognition among unaffected individuals and those with bipolar disorder.

Temperament 0.71* 0.91* 1.05

− 0.05

− 0.06

0.17*
Openness 1.17 ± 1.17 ± 0.37 ± 23.99

0.01

0.01

0.03
0.01

0.13
<0.001
BP

0.76** 0.92** 1.25*

Creative 0.99 ± 0.76 ± − 0.05 ± 16.35 <0.001
Personality 0.98** 1.00** 1.33
Anxious

− 0.06
− 0.02 Divergent 0.76 ± 0.96 ± 0.34 ± 9.56

0.17*

0.15*
0.19*
<0.001
0.03

0.13
0.05
CTL

Thinking 1.02** 1.43** 1.22*

Fluency 0.41 ± 0.70 ± 0.23 ± 4.27 0.003
1.01* 1.44** 1.23
Originality 0.67 ± 1.07 ± 0.50 ± 10.02
0.68**

<0.001
− 0.06
0.22*

0.17* 1.11** 1.28** 1.24*

0.08
0.01

0.03
0.01

0.13
BP

Creative 5.90 ± 6.05 ± 0.63 ± 241.59 <0.001

Achievement 2.46** 2.53** 1.15*
Irritable

Means and standard deviations listed are z-scores relative to the nCTL group and
0.55**

0.17*

0.15*
0.16*
0.14

0.09
0.08
0.06
0.01

thus may be considered effect sizes. Key: creCTL_rev = individuals from the
CTL

creCTL group with achievement scores 3 standard deviations above the nCTL
mean; creBP = individuals from the BP group with achievement scores 3 stan­
dard deviations above the nCTL control mean; nBP = non-creative individuals
¡0.34**

¡0.21*
0.36**

− 0.10

− 0.14

− 0.01

from the BP group. Significance is indicated as * (p < 0.05) or ** (p < 0.001).

0.28*
0.15
0.01

0.01
BP

specific to racing thoughts and impulsive behavior were observed for the
Impulsivity

creCTL group, which may provide insight into the role of impulsivity in
0.33**
0.35**

0.20**

0.21*

creative generativity (Murray and Johnson, 2010).

0.03
0.08
0.13
0.10

0.13
0.03
CTL

Openness to experience is characteristic of those who are imagina­

tive, open-minded, intellectually curious, and attentive to their emo­
tions (Costa and McCrae, 1992). High scores reveal a fluid style of
0.33**
0.55**
0.38**
0.35**
0.41**
0.37**

0.36**
− 0.04

0.25*
0.07
0.03

consciousness that fosters novel associations among remotely connected

BP

ideas. Unsurprisingly, openness has shown strong correlates with

Openness

divergent thinking and is viewed as a central feature of creativity (Feist,

0.31**
0.26**

0.51**

0.32**

0.30**
0.26**
0.42**
0.20*

0.20*

1998; Dollinger et al., 2004; Ma, 2009; Parson et al., 1984; McCrae,
0.14*

0.19*
CTL

1987). Consistent with previous studies, we observed higher scores for

nearly all facets of openness in both the creCTL and BP groups (Srivas­
tava et al., 2010; Feist, 1998; Nowakowska et al., 2005; Barnett et al.,
0.39**

0.51**
0.48**
0.25*

0.27*
0.27*
0.19*
0.01
0.07
0.15
0.18
0.10

2011). Higher openness predicted better cognitive and creative perfor­

BP

mance in both unaffected and affected individuals and was one of the
Schizotypy

strongest predictors of creative achievement. This effect was largely

0.43**
0.38**
0.42**
0.36**

0.32**

independent of hypomanic personality, consistent with the suggestion

0.21*

0.18*

0.17*
0.08

0.01

0.13
0.06
CTL

that openness may mediate the link between hypomanic traits and
are shown in bold. Significance is indicated as * (p < 0.05) or ** (p < 0.001).

engagement in daily creativity activities (Furnham et al., 2008).

Much research on creativity has focused on aspects of schizotypy as a
0.52**

0.57**
0.60**
0.56**

− 0.01
− 0.08
− 0.09
− 0.13

subclinical expression of psychosis, and it has been suggested that both

0.09

0.08
0.01

0.18
0.12
BP

may result from reduced cognitive inhibition, which allows more stimuli
Cyclothymic

to filter into conscious awareness and may facilitate originality (Carson

et al., 2003; Green and Williams, 1999). Positive schizotypal traits
0.55**
0.39**
0.46**
0.63**
0.59**

0.24**
0.16*

0.15*
0.17*
0.07

0.05

0.06
0.13

reflecting cognitive disorganization and unusual perceptual experiences

CTL

are consistently elevated among individuals active in the creative arts

(Schuldberg, 2001; Schuldberg et al., 1988; Nelson and Rawlings, 2010;
0.53**
0.52**
0.45**
0.44**
0.51**
0.31**
0.62**
0.46**

0.36**

Sass, 2001; Tsakanikos and Claridge, 2005; Batey and Furnham, 2008;
− 0.06

− 0.07
0.06

0.03

0.12

Barrantes-Vidal, 2004; Burch et al., 2006). We observed similar eleva­

BP

tions in the creCTL group that significantly correlated with creative

Hypomanic

achievement. While the BP group also scored higher on measures of

0.54**
0.46**
0.47**
0.38**
0.43**
0.38**
0.44**
0.38**

0.42**
0.17*

0.17*

positive schizotypy, consistent with prior observations (Rybakowski and

0.10
0.06

0.09
CTL

Klonowska, 2011; Nettle, 2006; Mahon et al., 2013), these elevations

were more extreme and not predictive of creative achievement.
Expectedly, the creCTL group showed significant enhancements
Creative Achievement
Humor Appreciation
Creative Personality
Positive Schizotypy

Divergent Thinking

across multiple cognitive domains, including humor appreciation,

Spatial Processing

reasoning, and spatial processing ability. Humor appreciation has been

Hyperthymic
Cyclothymic

previously linked to creativity (Brodzinsky and Rubien, 1976; Thorson

Impulsivity

Reasoning
Openness

Memory

and Powell, 1993), and reasoning ability is a measure of fluid intelli­

Irritable
Anxious
Table 3

gence and creative problem solving that is highly correlated with

155
T.A. Greenwood et al.
creativity (Furnham et al., 2008; Kuncel et al., 2004; Batey et al., 2009).
Notably, the BP group did not show deficits on these tasks that have been
linked to creativity as has been observed for other cognitive functions in
bipolar disorder here and elsewhere (Bora et al., 2009; Van Rheenen
et al., 2017; Burdick et al., 2014). Contrary to previous studies that have
used figure preference tests to demonstrate increased creativity in bi­
polar disorder, we found only a weak elevation in the BP group that was
driven by the dislike subscale (Simeonova et al., 2005; Srivastava et al.,
2010; Soeiro-de-Souza et al., 2011; Soeiro-de-Souza et al., 2012; Strong
et al., 2007; Fears et al., 2014). However, the creCTL and BP groups
showed similarly superior divergent (“outside the box”) thinking and
originality, revealing large effect sizes comparable to previous reports
(Ma, 2009). It is important to note that educational attainment showed
similar distributions across the three groups and was not predictive of
creative performance or achievement in any group.
A positive mood has been suggested to provide a significant cognitive
advantage in terms of creative performance (Vosburg, 1998). Consistent
with prior reports, we found hyperthymic temperament to be elevated
specifically in the creCTL group and associated with creative achieve­
ment in unaffected individuals (Schuldberg, 2001; Vellante et al., 2011).
While hyperthymic temperament was not characteristic of the BP group
as a whole, higher scores were associated with better creative perfor­
mance and were observed for the creBP subgroup. We also noted higher
cyclothymic, irritable, and anxious temperament scores in both the BP
and creCTL groups, consistent with previous findings (Nowakowska
et al., 2005; Strong et al., 2007; Srivastava and Ketter, 2010). However,
unlike the changeable affect and emotional intensity that characterizes
cyclothymic temperament, the negative affect reflected by the irritable
and anxious temperaments was not associated with creative achieve­
ment. This is consistent with the low signal observed for negative
schizotypal traits and dysthymic temperament in the creCTL group.
Similarly, we did not replicate previous reports of increased neuroticism
among creative individuals (Srivastava et al., 2010; Feist, 1998; Now­
akowska et al., 2005; Strong et al., 2007; Srivastava and Ketter, 2010;
Gelade, 1997). These findings thus confirm and extend our hypotheses
regarding the relationship of positive affect and mood instability to
creative potential (Greenwood, 2017, 2020).
There are possible limitations to this study that should be considered.
First, in order to promote comparison with existing literature, we have
156
Journal of Psychiatric Research 153 (2022) 149–158
Fig. 4. Bipolar disorder, creativity, and the space
between. Traits identified through the analyses are
summarized by type, and the defining characteristics
are listed for each group. Shared traits are shown in
the space between. We note that many of these traits
are more extreme in the context of illness and less so
among creative individuals. These traits range from
those associated with mood or temperament to as­
pects of personality and behavior to cognitive attri­
butes that are associated either with dysfunction or
enhanced ability.
evaluated aspects of ‘everyday’ creativity in groups defined by self-
report of creative occupation, which may represent a poor proxy for
creativity. While we were able to demonstrate the reproducibility of
these results using groups defined by high creative achievement, future
studies could consider more objective indices of creative ability and
performance. Additionally, it has been suggested that the over­
representation of bipolar disorder observed in population-based studies
of creativity may reflect a preference for the unconventional lifestyle
provided by creative occupations, rather than a true association. Indeed,
the personality traits most associated with choosing a creative occupa­
tion are openness and impulsivity (Feist, 1998), which are also associ­
ated with bipolar disorder as discussed above. However, our results
show that the association of these traits is not solely tethered to creative
profession, as even the nBP subgroup scored higher on openness and
demonstrated more originality and higher creative achievement than
the nCTL group. These results thus support the notion that bipolar
spectrum traits offer advantages for creativity and provide motivation
for further research in this area (Greenwood, 2017, 2020).
Bipolar disorder is somewhat unique among common medical ill­
nesses, as many patients view their illness as an inherent part of their
identity that imparts confidence, empathy, self-awareness, social ease,
productivity, and creativity. Yet, it comes at a high cost in terms of
disability and suicide, and delayed treatment seeking and non-
compliance, particularly among those who believe that their creative
abilities are directly related to their mood fluctuations, pose significant
concerns. While creativity is far from a ubiquitous trait in bipolar dis­
order, exploring this relationship may have important clinical and social
implications. A better understanding of this complex illness will facili­
tate personalized treatment strategies and suggest methods to enhance
the positive attributes while limiting mood swings. Investigations of the
shared vulnerability may also shed light on the biological causes of
illness, providing novel treatment targets. Finally, appreciating the
positive traits associated with bipolar disorder will foster the celebration
of neurodiversity and help reduce the stigma.
Contributors
Ms. Chow was responsible for data collection and quality assurance
and assisted with manuscript revision. Drs. Gur and Kelsoe participated
T.A. Greenwood et al.
in study design and manuscript revision. Dr. Greenwood is responsible
for the conception of the study, data collection and analysis, and inter­
pretation of results, as well as drafting and critically revising the
manuscript. All authors approved the final manuscript.
Declaration of competing interest
Ms. Chow and Drs. Greenwood, Gur, and Kelsoe have no competing
financial interests to report.
Acknowledgements
The authors wish to thank all of the participants, without whom this
study would not have been possible. We also offer our sincerest gratitude
to the research volunteers who devoted their time and effort to this
study: Augusta Wong, Frank Qiu, and Tiffany So. This study was sup­
ported by a grant from the National Institute of Mental Health (R21-
MH106917).
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.jpsychires.2022.07.009.
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