The link between Creativity and Bipolar Disorder: A Systematic Review Silvia Zarraluqui L贸pez
MSc: Mental Health. Psychological Therapies Barts and the London Institute of Psychiatry Queen Mary University London August 2012 (10035 words)
2
AKNOWLEDGEMENT ...................................................................... 3 ABSTRACT ........................................................................................... 4 INTRODUCTION ................................................................................ 6 RESEARCH QUESTIONS: AIMS, OBJETIVES: ......................... 18 METHODOLOGY ............................................................................. 20 QUALITY ASSESSMENT ................................................................ 30 RESULTS ............................................................................................ 35 MAIN FINDINGS ............................................................................... 53 DISCUSSION ...................................................................................... 61 BIBLIOGRAPHY ............................................................................... 68
3 Â AKNOWLEDGEMENT I wish to acknowledge my tutor Nassir Warfa for guide me through the world of the systematics reviews, with patience and professionalism. I would like to thanks also the professor Gella Richards for motivating and encouraging me to do a systematic review about creativity, and finally to my family for their patience and support.
4 Â ABSTRACT There is a common consensus about the existence of a link between creativity and madness, and this unanimity is empirically supported. During the last 30 years a high number of studies have investigated the nature of the relationship between bipolar disorder and creativity. One of the main questions that are creating disagreements in the scientific community is the definition of creativity. The aim of this study is to provide a detailed synthesis of the mayor findings obtained in this field and present a converging summary of the mechanisms that underline the relation between creativity and bipolar disorder. Thirteen papers were selected using electronic databases like MEDLINE, CENTRAL (Cochrane Central Register of Controlled Trials), PsycINFO, ELSEVIER SD, SCIVERSE science direct and APA PSYCnet. Case-control studies were used due to the nature of the variables. Only participants suffering some kind of mood disorder were included, excluding those ones that had any kind of psychotic disorder or schizophrenia. The age inclusion criterion comprehends children on the range between nine and eighteen years old, and adults in between eighteen and sixty four years old. The results suggested that bipolar disease in linked with creativity, and that this relationship is related to a hyperthymic
5 affective pattern. Bipolar descendants have higher creativity than healthy control offspring. Some temperamental variables as neuroticism, cyclothymia, dysthymia, openness and intuition were significantly positive correlated with creativity. The overlap between bipolar disorder subject’s results and creative control subject’s results on the measure tools of creativity suggest that there could be some neurobiological commonalities. There were some limitations, like the restriction of sources used, the use of case –control studies, the risk of “over-matching” and the sample selection. Clearly future studies are needed to clarify the correlation between mania and creativity in Bipolar Disorder. Keywords : Creativity. Bipolar Disorder. Temperament.
6  Introduction  If we analyzed almost all the human history, creativity was assumed to be a privilege of supreme existences. A lot of religions are based on mythologies in which Gods molded the firmament and the earth. It was only very recently that the situation overturned: Men and women started being the creators and
the
Gods
the
inventions
of
their
imagination.
(Csikszentmihalyi, M.1996). Although we cannot predict the ultimate results of creativity, at least we can try to understand this potency and how it works. Creativity is a product of the interaction of a structure constituted of three components: A culture that contains figurative guidelines, an individual who brings innovation into the symbolic area, and a group of specialists who identify and authenticate the invention. (Csikszentmihalyi,
M.
1996)
Creativity
is
the
cultural
corresponding of the process of genetic changes that generates consequences in genetic evolution. On creativity there are not procedures equivalent to the ones that follow the DNAs since a idea or discovery is not automatically delivered to the next generation, the analogy is that creative ideas are elements of evidence that we must study if we want culture to continue. These components of knowledge are the ones that a creative person
7 Â modifies, and if sufficient persons understand the alteration as one advance, it will start being part on our culture background. (Csikszentmihalyi, M.1996). Creative discoveries are unthinkable without having a previous comprehension of what is happening in the field, without the academically networks that inspires to meditate and think, and without the social institutions that accepted and spread the novelties. (Csikszentmihalyi, M. 1996) A creative person if wants to create anything, they must first started to dedicate their attention to the material that has to be studied, and attention is a limited ability, since a great amount of our limited forces are focused on surviving day by day. There are some considerable effects that appeared if we followed these ideas: to be a creative person in an existing domain; this person must
have
extra
capacity
of
attention
available.
(Csikszentmihalyi, M. 1996) .As cultures progress, it becomes progressively more and more difficult to control more than one area of knowledge; therefore creative subjects with specialized knowledge in one field will have more opportunities of creating new ideas over people with generalized knowledge. An important consequence that appears when they limited their attention is that creative individuals could be viewed as egotistical, self-centered, and cold, but in fact creative people are just focused and
8 Â dedicated.
(Csikszentmihalyi,
M.1996).
Considering
these
temperamental differences the idea about a connection between creativity and a mental disease is been considered during hundreds of years, but until the last century questions about the nature of this association have not been considered in the scientific world. Nowadays there is a common consensus about the existence of a link between creativity and madness, and this unanimity is empirically supported. The unresolved questions are about what exactly type of mental illness, psychosis, schizophrenia or affective disorder, is related with the creative behavior. One of the main questions that are creating disagreements in the scientific community is the definition of creativity. Creativity is conceptualized in many different ways, as a single construct, as a continuum and in different forms. Each way to describe the creativity it is also influenced by the implication creativeness with some mental pathologies. Creative genius conceptualizes creativity as a performance that involves effortless and the unconscious, it appears in moments where the cognitive functions were disinherited and not guided by a goal. (Martindale 2007) Other authors like (Amabile, 2010), described creativity as a characteristically human ability to generate new ideas, new
9 attitudes and new explanations”. However, other approaches consider that the current concept of creativity is poor and inappropriate, because it only takes into account the operational level of the activity: creation. Kaufmann (2003) distinguishes between six types of novelty: The one, which comes from the stimulus, the one that comes from the response, proactive, reactive, “Big C” or eminent creativity and “mini C”. Kaufmann gave us a new dimension to explore, the “eminent or “Big C” creativity”, following this line Nora Madjar (2011) published an article proposing that creativity is based on ideas that conform a continuum. This continuum goes from radical ideas that create revolutions to routine performance, considering the existence in between of other options like incremental creativity, radical ideas… being all this concepts potentially positive. She created the new term of “radical or divergent” creativity, being that activity, which generates ideas, that are substantially different from the existing ones, and did not fit into the current organizations and practices. These ideas form new frames and processes. Nora Madjar (2011) showed that inclination to take risks and have resources and dedication are related to radical creativity. According to this position, when individuals are challenged with a new situation, they tried to understand and
10 handle it by creating their own explanation and significance of it. This behavior provides new aims and incentives for the next accomplishment (Nora Madjar, 2011).
She underlined as
especially
making
important
is
the
“sense
theoretical
framework”, which is based on Ford’s (1996) interpretation of creativity. This theoretical framework believes that creative activities are the opposing behavior that appears when the options available are restricted or does not answer our requirements. (Nora Madjar, 2011). Individuals use the creativity to negotiate between conflicting structures of reference assumed by the different groups they are subordinate with. This model suggest that when a creative person made the choice to be involved in a creative task, apart on the personal and circumstantial issues, involves complex cognitive processes. Following this approach, “the sense making” assessment of creativity, offers a valuable structure to understand the causes of how individuals understand and perceive a setting and how and how they perceive the to create something new. Furthermore, this perspective contributes to prevailing models of creativity by recognizing the role of the person´s interpretation of the context. (Nora Madjar, 2011). However those are only some theoretical approaches, creativity is not an isolated concept, is strongly correlated to the
11 environmental forces. Hennessey and Amabile in 2010 represented these forces in concentric circles (figure 1) in which “creativity forces perform”.
Figure 1 (Hennessey, Amabile, 2010) As Csikszentmihalyi, (1996) said, creativity does not happen exclusively inside people´s mind, but in the interaction between a person´s opinions and feelings and a socio-cultural environment. It is a general rather than an individual phenomenon. Adding to that creative expressions are universal phenomenon that appears in all cultures. Rudowicz (2003) argued that the relationship between creativity and culture is complex and historically, socially and individually biased. As we could see there is multitude of approaches to assess the definition of creativity. The majority of then generally have restrained correlations. Because the multiple forms to define the
12 Â paradigm, researches have also considered the abilities that conform the creativity as paradigms. Jonshon in 2012 published a small sample of the different test that was made to measure the abilities linked with creativity. Many of them are founded on conceptual models. For example the Remote Associates Task (RAT), (Mednick, 1967), measure the creativity trough the study of the ability to generate associations, therefore considering creativity as the capacity of produce a broad series
of
associations. Other tests provide measures of originality, fluency and flexibility like the Unusual Uses Task (Guilford, 1967), in this test creativity is conceptualized as the ability to propose no redundant uses for things, the capacity of generate new categories inhibiting
the
prior
responses.
Jonshon
(2012)
finally
distinguished two kinds of processes that we use to solve the creativity difficulties: The logical, systematic, conscious way and the insight, unaware process. This last one refers to the state were the person is not consciously aware of the process that he or she is using to solve a problem, doing new combinations, relating distant concepts. In sum, the literature about creativity is broad and full of different paradigms trying to reach the definition of the concept. This is one of the mayor troubles of the field.
13  It was only recently centuries Bipolarity and Creativity have been linked. In general it is considered that many artists suffered mood disorders, and their creativity increased especially during the manic periods. During the last 30 years a high number of studies have investigated the nature of this relationship. Some of them have considered that creativity is a risk factor to developing a bipolar disorder; others cite creativity as a consequence of the mood disturbance. Bipolarity is an illness that encompasses a wide variety of manic and suppressive symptoms with different severity and variations. The main symptoms are: “vivaciousness and touchiness, reduced need for rest, speeding thoughts, extreme self-assurance, augmented vigor, psychomotor tension, and inclination to engage in reward-oriented comportments without respect of possible negative costs (American Psychiatric Association, 2000). Generally the illness is classified into three subtypes: Bipolar Disorder I, Bipolar Disorder II and Cyclothymic disorder. The RDC (Spitzer et al.1978) divided the Mood disorders into Maniac disorders characterized by elevated, expansive or irritable mood. Hypomanic disorder categorizes the nonpsychotic manic-like states that do not have enough intensity or impairment to meet manic criteria. Bipolar Depression with Mania (Bipolar I) is a
14 category that refers to the subjects who met the standards of a manic syndrome and depressive syndrome, which could be major, insignificant or sporadic depressive disorder. Bipolar Depression with Hypomania (Bipolar II) is diagnosed when any patient has congregated the conditions for hypomanic and depressive disorder together, but has never suffered a full manic disorder. This variation is included because some evidence indicates that the people suffering Bipolar II disorder has a nearer relationship to Bipolar I than to a Unipolar Depressive Disorder. Akiskal and Pinto (1999) said that Bipolar Disorder I and Cyclotimyc disorder meet all the criteria in the “bipolar spectrum”, while patients with Bipolar II Disorder sometimes have “only” one manic episode. Patients with Bipolar Disorder II usually present also less severe hypomanic episodes. Finally, Cyclothymic Disorder draws situations of chronic changes between low and high mood states that are not strong enough to be classified as manic or depressive episodes. There is a long history of investigation into the relationship between creativity and bipolarity. Initially a scientist called Nancy Andreasen undertook what we used to consider the “the landmark” study in 1987;subsequently Kay Jamison published a very influential work in 1989, after in 1993 wrote “Touched With
15 Fire: Manic Depression and the Artistic Temperament”(Jamison, 993), which is one of the most important works ever published in this field. Later in 1995 Arnold Ludwig write “The Price of Greatness: Resolving the Creativity and Madness Controversy”, another important piece of research. As an example of studies that support the correlation between mood disorders and creativity, some Vellante et al. (2011) founded that in a sample of non-clinical professional artist, creative people had higher scores comparing to the control group, on the “CAQ and on the cyclothymic, hyperthymic and irritable sub-scales of the TEMPSA, however not on the GHQ”. They had found as well that those people on the risk for bipolar spectrum (Vellante et al. (2011) specially trough the cyclothymic aspects. Creativity is mainly related to mania episodes as described by the tools to measure the sub-syndromal manic symptoms like as the General Behavior Inventory
(GBI), ( Depue, Krauss, Spoont et al. 1989), and
measured by the Hypomanic Personality Scale (HPS);( Eckblad, Chapman, 1986). For instance Ma (2009) or Ludwig (1992) demonstrate a high level of prevalence of this disorder on a creative population, specially linked with the mania episodes. (Goodwin, Jamison 2007; Rothenbergm 2001). Carlson and Goodwin defined the stages of mania in 1973 as: Stage 1:A Slight
16 distressed speech, divergent, hyperactive, and joyful. Stage 2: Paranoid, hyper-religious, hyper verbal, patrolling and feelings of grandiosity. Stage 3:Hyper verbal, delusional, terrified, labile, suspicious, sexually preoccupied, disoriented and angry. Stage 2: Still paranoid but more cooperative, agitated, hypersexual, manipulative and angry. Stage1: Calmer, more organized, over conversational, seductive, and depressed. In the following graphic we could see how Jonshon in 2012, represented the relationship between Bipolar Disorder and Creativity, being the “Risk of Mania” one of the fourth main factors that contributes to reinforce this correlation.
Bipolar Disorder
Creativity
Diagnosis
Risk for Mania
Family History
Related Related traits traits
Figure 2. (Jonshon et al. 2012)
Eminence achievem ent
Activity Preferenc e
Divergent thinking
17 Â However there are some limitations on the studies that have been done about creativity and bipolar disorder. First most of the researchers were concentrate in one part of the field, being sometimes unaware about the advances in other disciplines related to the psychology of creativity. (B.A. Hennessey. M. Amabile (2010)). Others have used small sample size, becoming their findings insignificants, for instance Vellante et al. 2011) founded that a significant number of studies that show a connection between Bipolarity and creativity were founded on insignificant,
non-randomly
selected
samples,
considered
retroactive explanations on psychopathology. Finally there are some researches that have founded these results inconsistent. For instance De Dreu et al. (2008), or Friedman et al. (2007) showed that how affect the bipolar disorder the creativity is not yet settled. Chavez-Eakle and colleagues (2001) discovered trough a sample of highly creative population that they punctuated low scores on bipolarity, concluding that mood disorders are more related with personality instead of creativity.
18 Â
RESEARCH QUESTIONS: AIMS, OBJETIVES: As explained in the introduction, theories of a relationship between creativity and bipolar disorder date back fifty years. Even recent work exposed a strong association between bipolarity and creativity. However, questions still remain regarding what mechanisms underline such associations, and how an illness that potentially threatens and constrains life could be advantageous to becoming an artist. The research undertaken juggled with different reasons that could explain this link; it involves affective and cognitive components, talent, motivation, neurobiological, and environmental factors. Since explanations of the mechanism that underline such relation are beginning to emerge and more investigation is needed, this study is going to conduct an exhaustive review of the most representative literature relevant to our research question: How is creativity related to bipolarity? The aim of this study is to provide a detailed synthesis of the major findings obtained in this field, selecting a small but representative division of studies, and presenting a converging summary of the mechanisms that underline the relationship between creativity and bipolar disorder.
19 The objectives are to investigate
•
Whether bipolar disease is linked to creativity.
•
The genetic basis of the relationship between bipolarity and creativity through familial studies.
•
How
some
temperamental
features
influence
the
development of creativity.
•
The neurobiological link between creative behavior and bipolar disease
•
Gaps in current research that need to be investigated
•
Provide useful recommendations for future research
20 Â METHODOLOGY The Systematic review is a valuable and an extremely useful scientific
tool,
considering
that
researchers
and
health
professionals are generally overwhelmed with a large amount of information. There is a necessity to integrate all this information in order to identify the most significant data for policymaking. A good systematic review presents the most consistent findings that could be generalized across population and the methodology used instills confidence in professionals about the accuracy of the results obtained. (Mulrow, 1994).The first reason for the necessity of this tool is the vast amount of articles published every year, making it impossible for the investigator to read all of them and be up-to-date in the field. (Mulrow, 1994). The second reason that justifies the use of this instrument is the necessity of providing a summary of the most important and critical results obtained to the analysts that create health policies. This assists in the formulation of new strategies and legislation concerning diagnosis and treatment approaches. The third reason is that it aids researchers in avoiding possible setbacks or difficulties and refines their objectives and research questions. (Mulrow, 1994) A systematic review prevents any deviations or new research in previously explored fields, and enables a faster implementation of
21 Â the diagnostic/treatment strategies. This tool is also one of the search strategies that allow more generalization of the results, since it reviewed very diverse studies. It also provided a more realistic context of the field, sometimes not available in any randomized controlled trials, quasi-experimental studies or observational designs. (Mulrow, 1994) Finally, linked with the capacity of generalization that the systematic reviews gave us, another strength of this methodology is the information regarding the consistency of the relationships between variables, and vice versa the systematic reviews explain data deviation and disparity, and whether findings are effective. Search Strategy Following PICOS strategy the data extracted for this review is in this summary: Population
Patients
suffering
any
mood
disorder
(BD,
MDD,
Cyclothymia ) Intervention
Measure their creativity through different tools.
Comparator
Creative and Healthy people without any mood disorder
Outcome
Creativity performance
Study design
Randomized controlled trials and quasi-experimental studies
22 Â The databases used for this research were the ones linked with the catalogues of Queen Mary Library, the British Library and The Senate House Library. The electronic databases were MEDLINE,
CENTRAL
(Cochrane
Central
Register
of
Controlled Trials), PsycINFO, ELSEVIER SD, SCIVERSE science direct and APA PSYCnet. Another important way of obtaining the articles was searching through the Journal of affective Disorders. The terms used during the research were: Independent Variable
dependent variable
Bipolar Disorder
Creativity
Mood Disorder
Art
Bipolarity
Artist
Mania
Genius
The process of data extraction ended with a large number of potentially interesting papers, but only a few of these studies were selected. A designed protocol was followed in order to minimize mistakes and bias that could appear during the selection process. The first selection was made based on titles and abstracts. The majority of the papers were rejected because the paper was not focused on the research question, for instance papers where the
23 concept of creativity was linked to other mental health problems such as schizophrenia. Other papers were excluded due to the methodological approach; for example, some papers were observational case- studies that specified a large amount of research about individuals like the composer Schuman or the writer Virginia Woolf. In the second stage papers where the full text was unavailable were excluded, as were duplicate papers. In the third and final stage some papers were removed due to their unsuitability with the exclusion criteria. For instance, in this stage papers such as “The Link Between Bipolar Disorders and Creativity: Evidence from Personality and Temperament Studies” (Srivastava,
Ketter
2010),
and
“Art,
alpha-1-atitrypsin
polymorphisms and intense creative energy: Blessing or curse?”(Everett, 2007) were excluded. The former due to the methodological approach, and the latter paper because the biological content was not suitable to compare to other papers.
24
25 Â
Each paper of this review has been selected following clear criteria regarding the study strategy. Certain study designs are methodologically stronger than others, while other designs are comprised of more detailed information even they are less robust, (for example the observational studies). In this area of study an assortment of study strategies is needed in order to adopt diverse variables in the same review. Inclusion and exclusion criteria Study characteristics Only studies whose aims were to find a relationship between creativity and mood disorders were incorporated. Also considered were those who studied the nature of the association. Prospective cohort studies were excluded since the purpose of the review is to find a correlation between the variables at the present time. To study the consequences of the link between creativity and bipolarity across time is an objective excluded and postponed for future investigations. Case-control studies were included due to the nature of the variables, it being necessary to compare groups from the same population (creative people, members of the same
26 family) with and without a mental disorder, therefore the risk of “over-matching” has been considered when the groups were made to make them comparable for possible confounding features. One cross sectional study is included (Soeiro de Souza et al. 2011), because of the nature of the study and the useful information it provides. Participants Only participants suffering some kind of mood disorder were included, excluding those that had any kind of psychotic disorder or schizophrenia. This criterion involved subjects that suffered from Bipolar Disorder I or II, Cyclothymia and Major Depressive Disorder. Patients with a comorbid illness were also included especially the bipolar progenies see (Simeonova et al. 2005), pg. 626. For example, Oppositional Defiant Disorder (ODD), Conduct Disorder (CD) and other anxiety disorders like a general anxiety
disorder,
separation
anxiety
disorder,
obsessive-
compulsive disorder, social phobia, and post-traumatic stress disorder. In the case of the control group, healthy creative participants have been included. The age inclusion criterion consists of children between the ages of nine and eighteen, and adults between eighteen and sixty four years old. College students have also been included; even though
27 Â the age was not specified. Finally, the Forgeard (2008) study does not indicate the overall age of the participants, but it has been included as an exception in this case due to the nature of the study
Intervention and setting All the settings where the intervention was delivered were enclosed. Considering the nature of the study, it is consider that where the test administration was applied did not influence the outcomes. (This sentence is confused) Studies where the data measuring and preparation to assess the relationship between creative behavior and mood disorders was applied in different settings such as hospitals or universities were included. Only the researchers that included a pharmacological or therapeutically cointervention were excluded. Outcomes Only psychometric tools were considered to measure the correlation, but excluding those ones without methodological internal consistency. Meaning that all of the tools used had to have been previously approved and tested. For example, the text analysis software program “Linguistic Inquiry and Word Count� used by Forgeard (2008), has been continuously positively tested by Pennebaker et al. (1998).
28 Â The definition of creativity used for each study is not an exclusion criteria, since this paper underlines in the introduction that there is not a general consensus about the definition of this paradigm. Finally, regarding the results, only studies with significant positive or negative correlations between the independent and the dependent variable were included.
29 Â
INCLUSION
EXCLUSION
Link between creativity and Mood Disorders.
Links between creativity and other mental illness .
Case-Control studies Crossectional studies. Bipolar Disorder II, Cyclothymia and Major Depressive Disorder patients or I. Comorbid illness (ODD, CDD, Anxiety Disorders) All ages included All settings included Intervention focused on assess the relationship between creative behavior and mood disorders
Prospective cohort-studies.
Study Characteristics
Participants
Intervention Setting
Measurement: Psychometric tools Outcomes
All definitions about the concept of creativity Significant correlations on the results between the variables
Psychotic disorder or schizophrenia patients. X X Pharmacological or therapeutically co-intervention Non methodologically tested tools Non consider to define the concept of creativity Non significant correlations on the results
30
Quality assessment There were two types of studies used in this systematic review to assess the correlation between creativity and bipolar. Twelve casecontrols and one cross-sectional study, all of them are observational studies, for this reason it is particularly important to consider the individual aspects of the designs in order to avoid possible bias. The Centre for Reviews and Dissemination of the University of York, described in the publication “Systematic Reviews” (2009), a bias as a “systematic deviation from the true underlying effect brought about by poor study design or conduct in the collection, analysis, interpretation, publication or review of data”. Therefore, assessing the quality of these studies was difficult due to the varied range of data provided per analysis. A procedural research has been carried out trying to recognize the characteristics of each paper most connected with predispositions or prejudices. One of the main problems was that the participants were not blinded. (They knew they were being tested because they were creative or bipolar). The control groups, especially the ones formed by creative controls were another source of difficulty because they could be “contaminated” by the stereotypes of “creative genius”. Armstrong
31 Â et al. (2007) provided a checklist that compiles the criteria for assessing quality on qualitative studies. This study followed those guidelines: 1. Method applicable to research inquiry 2. An clear link to the model 3. Distinctly specified aims and objectives 4. A well-defined explanation of setting 5. A clear description of sample 6. A clear description of research methods 7. Validation of the data analyzed 8. Inclusion of enough data to funding the explanations
32
33 Â
All the studies followed an appropriate methodology to measure the variables with the exception of Soeiro de Souza et al. (2011) who used a cross-sectional methodology to measure the correlations, losing the prospect of having a control group that provides a deeper point of view. Forgeard et al. (2008) does not include information regarding the diagnosis methodology that it used to assess whether the subjects suffered from bipolar or unipolar disorder. The main weakness of this review appears on the description of the context used and the sample characteristics because ten of the thirteen studies used population non-randomly selected from the same environment. Is worth noting that six of the studies samples were collected at the Stanford Clinic (USA), and the other three studies used college students. However, Richars et al. (1988),Kyaga et al.(2011) and Soeiro de Souza et al .(2012) used a less uniform sample. Finally, it is important to underline the descriptive nature of these studies since they are measuring a subjective construct such as creativity, and almost all of them manage to choose the correct methodology to measure the creative behavior. The exceptions being Kiaga et al.(2011) and Nowakowska et al.(2005) that have some limitations, and
34 Â Fodor,Laird(2004) and Forgeard (2008) that were focused on creative writing and probably did not have access to more sources of data measurement.
35 RESULTS
36
37 Â
These thirteen papers were written following generally the same purpose: To find a relationship between Mood Disorders and creativity. However, all of them followed different inclusion and exclusion criteria in order to select the sample and the methodology. independent
Specifically, variable;
two
others
included added
family
as
neurological
an and
pharmacological variables, whilst another two papers purpose was to study the non-eminent creativity excluding other types of creativity. Finally, two researches focused their hypothesis solely on the creativity related to the writing process. Richard et al. (1988) centered their research on the possibility of a familial compensatory advantage to bipolar illness involving creativity, and Simeonova et al. (2005) attempted to find if children with a bipolar parent would display higher creativity scores than healthy control children. Kyaga et al. (2011) also includes the family variable, however, this study gave more importance to another systemic variable: The professional occupations of the participants. The aim of this study was to find the occurrence of creative occupations among individuals with schizophrenia, unipolar depression, bipolar disorder, and their families. Soeiro de Souza et al. (2011) assessed conceivable
38 differences in creativity marks among manic, mixed, and depressive episodes of bipolar disorder, the impact of the executive function, and the effect on medication-free bipolar I Patients, they therefore included the use of medication and how the neurocognitive functioning of their patients, giving another perspective into the problem. Following the neurocognitive approach Soeiro de Souza et al. (2012) investigated whether there was a neurocognitive relationship between the BDNF genotype (Brain-derived neurotropic factor) and creativity. BDNF is the one of the most extensive and practiced neurotropic and it is related to the pathophysiology of Bipolar Disorder. Santosa et al. (2007) investigated the non-eminent creativity in bipolar disorder patients compared to healthy controlled group patients. With noneminent or “everyday creativity” these authors confined their research to a more specific concept. This concept was also used in the study of Shapiro, Weisberg (1999) when they tried to determine if the association between bipolar disorder and creativity would generalize to creative individuals “beyond the circle of eminence”. The Srivastava et al. (2010) paper focused the research on creativity related to intuitive thinking in order to find if Bipolar Disorder is not just linked with negative and changeable feelings but also positive skills. Rybakowski,
39 Â Klonowska (2011) restricted their research to the effects of an acute affective episode (depressed or manic) and the descriptions of how an schizotipy state influences the measurements of creativity. Strong et al. (2007) goal was to investigate the temperament-creativity
relationships,
understanding
those
temperamental behaviors most strongly related to creativity. Nowakowska et al.
(2005), purpose was to examine
consistencies and variances between euthymic mood disorder subjects, creative or healthy controls. Finally, Fodor, Laird (2004) and Forgeard excluded in there research the creativity unrelated to the writing process. They tried to demonstrate that persons with a bipolar inclination would achieve the highest creativity ratings in their writing style than healthy control group participants.
40
41 Â Twelve of the articles in the review used a control group, only the Soeiro de Souza et al. (2011) research did not employ this tool, testing 67 individuals with Bipolar Disorder I. Regarding the size of the sample, it is remarkable the study of Kyaga et al. (2011), 54042 patients with Schizophrenia, 29644 patients with Bipolar Disorder and 217771 patients with Unipolar depression were tested. The information concerning the number of siblings tested in the control group is not provided in the research; nonetheless the sample size is one of the strongest points of this research. Conversely, Simeonova et al. (2005) had the smallest sample size with who belonged to families where at least one member had bipolar disorder, and 18 healthy control subjects. Another interesting methodology tool is the use of Creative Controls in the sample. This offers the perspective of seeing if merely being creative makes you more susceptible to having a mood disorder. Santosa et al. (2007) evaluated 49 bipolar disorder, 25 manic-depressive disorder and 32 creative controls comparing them to 47 healthy control subjects. Srivastava et al. (2010) tested 32 bipolar disorder patients, 21 with a major depressive disorder, 22 creative controls and 42 healthy controls. Strong et al (2007) also utilized a group of 32 creative control subjects, comparing them with 49 bipolar, 25 major depressives
42 Â and 47 healthy controls. Finally Nowakowska el al. (2005) utilized as well a sample of 32 creative controls, relating them with 49 bipolar disorder patients, 25 with major depression, and 47 healthy controls. Finally, another interesting characteristic of the sample is the selection criteria. Forgeard (2008) selected 30 deceased writers, 10 Unipolar, 10 Bipolar and 10 healthy. However, Fodor, Laird (2004) randomly chose 22 living writers with an inclination towards bipolar disorder. Therefore, both studies, despite the fact they were focused on the same field, had completely different sample characteristics.
43
44 Â
All of the studies employed different psychometric tools to diagnose the euthymic disorders in the sample. Two of the studies concerned have accessed patient data. This is interesting considering that each doctor would have to follow different criteria due to their varying psychological approaches. The weakness is that it is difficult to control that variable and we could deal with different concepts of bipolarity, on the other hand this diagnosis data follow test results, and referees- doctor opinion as well, so the profile is much more complete. The study developed by Richards et al. (1988) utilized the clinical records gathered together by Wender et al. (1986), also adding the Centralized Danish registers, always following the DSM IV diagnosis group criteria. Kiaga et al. (2011) employed the Swedish Hospital Discharge Register (National Board of Heath and Welfare), but there was no clarification as to which Diagnosis Criteria System the register follows. The other two pieces of research found the patients through recognized psychometric tools, the positive point is that the result would be more homogeneous and the variables more controlled, however, this meant they lost the opportunity to have a biopsicosocial view of the person, which is how the illness functions in a family, and
45 how it affects society and also the biological system of the individual. Soeiro de Souza et al. (2011) utilized the LICAVAL Clinical trial, the Structured clinical interview (SCID-I/P), The Young Mania Rating Scale, the Montgomery-Asberg Depression Rating scale and the Clinical Global Impression. The SCID: Structured-semi-structured clinical interview is one of the tools more widely used, namely by Soeiro de Souza et al. (2012), Santosa et al. (2007),Simeonova el al.(2005) and Nowakowska et al.(2005). The SCID is a semi-structured interview to assess the major Axis I DSM-III-R diagnoses. It contains a preliminary overview followed by nine modules, seven of which represent the major axis I. Using a “decision tree approach” Ref Inc. (Spitzer el al.1992). The SCID helps the clinician examining diagnostic theories during the dialog. The output of the SCID is a register of the incidence of each of the disorders being considered currently and during a period of time. The Beck Depression Inventory is also frequently utilized. Santosa et al. (2007), Srivastava et al. (2010), Strong et al. (2007) and Nowakowska et al. (2005) applied it so as to determine the appearance of a mood disorder on the subjects of the sample. As by Ref Inc. Beck in 1961, The Beck Depression Inventory (BDI) is a scale that measures 21 feelings or thoughts: sadness,
46 pessimism about the future, feelings of failure, lack of satisfaction feeling of guilt, grief, hatred of self, reproachful towards himself; suicidal Ideation; fits of tears, irritability, social interest, indecision, body image work, sleep disturbances, fatigue, appetite, weight loss, attention towards their health and libido. Each category describes a specific behavioral manifestation of depression and consists of a series of 4 to 5 states. The proposals were ranked by degree of severity ranging from 'no symptoms' to extremely severe. Beck (1961) in his original report on the BDI states that the internal consistency using the split-half method shows high reliability: the Pearson correlation between odd and even categories reached r = 0.86. Correction with the SpearmanBrown coefficient of 0.93 is even reached. An agreement exists with the findings by psychiatrists in 97% of cases, with a point of difference for the four-point scale. Finally, is important to underline the fact that the Forgeard (2008) paper that classified eminent deceased writers by their mood disorder, followed the “Diagnosis of mental illness by Jamison (1993). This was necessary due to the retrospective nature of the study. Forgeard et al. (2008) justified this decision by explaining that the Jamison classification was based on “documentation from different sources.”
47
48 Each study measured the creativity term in different ways. Subsequently, in the data analysis, Richards et al. (1988) and Kyaga et al. (2011) did not apply an elongated battery of tests. Kyaga et al. (2011) (researchers) employed an uncommon methodology to investigate creative subjects. They referred to the Nordic Classification of Occupations for Creative professions so they determine the creativity of the subjects only under productivity or professionally characteristics, disregarding the “unproductive” and creative behavior, (unproductive as in engaged in an unpaid activity or an amateur). Another problem is that there could be creative people, especially bipolar patients that did not feature on that list, as they perhaps lived in an inpatient clinic and they not registered as having a particular occupation. Richards et al. (1988) also utilized the interview as a tool to distinguish creative people, the question is what kind of interview, questions, and measures they have employed. Alternatively, they use the Lifetime Creativity Scales, which is validated, and helps to assess “everyday creativity”. Soeiro de Souza et al. (2011) and Santosa et al. (2007) based their investigation on a long battery of tests. Firstly, they employed the BWAS, the Neurocognitive: WCST, the WCST-CONC, the WCST-PR, the WCST-FMS, the WCST-CC, the WCST-E, the
49  WCST-NP, the WCST-P and the Intelligence Scale: WASI. Santosa et al. (2007) also utilized the Barron-Welsh Art Scale (BWAS) , annexing the Adjective Check list Creative Personality Scale (ACL-CPS), and the Torrance Test of Creative Thinking on Figural (TTCT-F) and verbal versions (TTCT-V). It is important to underline The Barron-Welsh Art Scale (BWAS) utilization, owing to the fact that it is used in several studies of this systematic review with the exception of the two named above. Srivastava et al (2010), Soeiro de Souza et al. (2012), Strong et al. (2007), and the Simeonova et al. (2005) papers also employed this method. Santosa et al. (2007) described the Barron –Welsh Art Scale (BWAS) as an empirically derived metric created by Barron in 1963, formed by 86 black or white images that the subject could rate as like or dislike. Higher scores are given for the subjects that show preference for asymmetrical and complex images. Generally creative people choose those figures more frequently. BWAS involves not only visual processing of the images, it also involves an affective process that appears when the subject expresses there like or dislike of the images. The second most frequently employed instrument is the ACLCPS scale. It is utilized in Srivastava et al. (2010),Santosa et al.(2007),Strong et al.(2007), and finally the Shapiro and
50  Weissberg (1999) papers. Santosa et al. (2007) described it as a derivation of the Adjective Checklist created by Gough in 1979. This scale reflects any supposed personality constituent of creativeness. The participants have to designate adjectives recognized by experimental studies to distinct groups of creative and non-creative individuals. Some of the adjectives like ingenious, hilarious, inventive, and original, are frequently ascribed to creative people, while others like conservative, commonplace, honest, or submissive are rarely linked with creative people. Rybakowski and Klonowska (2011) used two uncommon tests, the Revised Art Scale (RAS) and the Berlin Intelligence Structured Test (BIS). The first one measures creativity from a psychoanalytic perspective, and it assumes, similar to the BWAS scale that creative people have preferences for irregular and complex figures. The BIS however, define creativity as a subcomponent of intelligence. Finally, is important to point out that the Fodor, Laird (2004) and Forgeard (2008) papers utilized completely different measures for their studies. The reason being that they focused their papers solely on the creativity linked with the activity of writing. Fodor and Laird (2004) used Play Therapy to interpret Children´s Stories and compose Haiku Style poems. The use of Haikus is an interesting
51 Â tactic since Blasko and Merski in 2010 stated that the unity of simplicity of form and profundity of connotation makes the haiku a perfect subject for the interdisciplinary analysis of creativeness.
52
53
Main findings This review will analyze outputs following a criteria based on an independent variable, which means that firstly the results concerning to correlations between creativity and a mood disorder (including the creative controls) will be analyzed and secondly, the correlations between creativity and temperament features. Finally, a more in-depth analysis of the correlation between creativity and the bipolar stages: manic or depressive. Only the positive or negative correlations represented by a significant statistic result will be considered. There is a strong positive correlation between having a Bipolar Disorder and being creative. Santosa et al. (2007) found that Bipolar patients, had a 45% higher mean BWAS-Total score than the healthy control group, but no more than the creative people control group and similar to scores previously observed in architects (29.4 ± 10.6) and creative writers (32.9 ± 11.1) It is realistic that temperamental/
character
variances
could
contribute
to
heightened creativity in Bipolar disorder, with medication, and a history of drug misuse also influencing it. Santosa et al. (2007) encouraged further investigation concerning this point and
54 Â stressed the necessity for more studies regarding age differences. Srivastava et al. (2010) presented BWAS- total scores significantly higher compared to HC patients in BP and in CC patients. The same happened with the BWAS-dislike scores. TEMPS-A-Ciclothymia/NEO-Neuroticism
scores
were
significantly upper in BP, MDD and CC. Myers-Brigg Type Inventory: MBTI-Intuition: Had significantly upper scores with the BD group compared to MDD, CC and HC. The authors suggested that Affective (NEO-Neuroticism and TEMPS-ACyclothymia) and cognitive (NEO-Openness and MBTIIntuition) factors contributed to components of the creativity measured
by
the
BWAS-Dislike
and
the
BWAS-Like.
Rybakowski and Knlonowska in 2011 discovered that in the BIS: Berlin Intelligence Structure Test scores, BP subjects had significantly better results compared to HC on the total creativity BIS scale, and especially in the section related to verbal creativity. Simeonova et al. (2005) in their paper concerning the sample size of patients with bipolar disorder, showed that 100% had a comorbid illness such a ADHD, Oppositant defiant disorder, and Conduct Disorder‌Regarding the results in creativity, parents on the BWAS Dislike subscale scores graded significantly higher than the control group. Children related to
55  patients with mood disorders, that also suffered BD or ADHD themselves, had high punctuations particularly on the BWAS Dislike subscales compared to the control group. Elevated/great punctuations on the BWAS Dislike subscale indicate that patients dislike simple and symmetrical figures). This shows that bipolar descendants with psychopathology may have more eminent creativity than healthy control children. Limitations to this study included the small simple size, and the use of BWAS as the only assessment test, where only one aspect of creativity is measured. Furthermore, it is still not validated on children so some of the results may not be reliable. Finally, bipolar descendants might be more creative due to the family environment, being influenced by their parents’ projects and views. Nowakowska et al. (2005) presented that patients with mood disorders and creative controls punctuated higher on Cyclothymic, Irritability and Dysthymia than the healthy control subjects on the TEMPS-A Scores: Measure of Cyclothymia /Irritability/Dysthymia/ Hyperthymia. Surprisingly on irritability, Creative Controls did not grade significantly higher than bipolar and depressive disorder patients. The most significant percentage is the one that showed that Bipolar Disorder patients had significantly more cyclothymic symptoms than the others (Major depressive disorder, creative
56 and healthy controls). Neuroticism had a similarly high grade in BP,
MDD,
and
CC
compared
to
HC.
In
contrast,
conscientiousness was decreased for MDD, BD and CC again compared
to
HC
on
the
NEO-PI-R:
Neuroticism/Conscientiousness/openness. Finally, openness had significantly elevated scores for BD than for CC, and CC obtained significantly higher scores than HC and MDD. On the TCI there was significant group differences for harm avoidance, self-directedness,
novelty
seeking
and
self-transcendence.
Particularly BP, MDD and CC scored much higher than the HC group on harm avoidance and novelty seeking punctuations. These three groups a significantly lower grade that was almost identical on self-directedness compared to HC. Only for selftranscendence did BP score higher than the other groups. Fodor and Laird (2004) showed participants with a bipolar inclination who received exposure to the play therapy procedure were the group who subsequently exhibited the highest levels of literary creativity. DB patients achieved higher creativity scores in their writing of haiku –style poems than CC, and they also achieved insignificantly higher scores interpreting children’s stories. Manic patients produced highly creative poems. Finally, only Forgeard (2008) did not support a positive correlation between creativity
57 Â and mood disorders, in his first study 30 works were analysed using Pennebakes et al. (2011) Linguistic Inquiry and Word Count, 74 lexical groups referring to sensitive, intellectual, bodily, and societal processes were considered. Comparing bipolar, unipolar and control writers, non-significant differences between unipolar, bipolar and healthy writers uses of words connected to emotions during creative process were found. In his second study again employing Pennebaker et al. Linguistic Inquiry and Word Count (2001), he showed that the kind of mood disorder (unipolar or bipolar) that a writer suffers is related with some linguistic characteristics. Writers with unipolar depression explicit more interest in others intellectual processes, while writers with bipolar disorder use more lyrics related to mortality. However, those results were not directly related to creativity. In Kiaga et al. (2011) research indicated the number of individuals with bipolar disorder significantly increased in creative professions, especially in visual artistic professions. The difference is well defined if compared with the control group. The first-degree relatives were also revealed as having more creative occupations, for example, scientific or creative professions.
58 Â Regarding temperament features related to creativity, Soeiro de Souza et al. (2011) research results were divided between three groups formed by twenty patients experiencing manic episodes, twenty-one mixed states and twenty-six depressive episodes. Concerning neurocognitive functions and executive function scores, as rated by the WCST; the manic group had higher scores than the mixed group in the neurocognitive tests. The final scores on the BWAS test were more elevated in the mania group than in the mixed or depression episode groups, however, IQ scores did not differ between them. Kiaga et al. (2011) found that IQ (only in males) was commonly superior in people with creative occupations, but lower in those persons with bipolar disorder and respective siblings, always comparing them with people without any diagnosis. Mood changes and cognitive functions only affect the BWAS scores of the mania group. Richards et al. (1988) found the highest correlation among creativity and Bipolar Disorder on cyclothymic patients than in manic-depressives and their relatives. Indeed, the level of creativity was higher in manicdepressives, cyclothymic, and normal first-degree relatives combined, but cyclothymiacs had a stronger correspondence. Richard et al. (1988) added information about vocational peak creativity (arts, sciences, humanities and social sciences),
59 showing that cyclothymic people punctuated significantly higher creativity than the other two index groups. Rybakowski and Klonowska (2011) study results presented non-relevant effects of a manic episode on creativity, however, depression had a detrimental effect on the creativity measured by the BIS scale. (Depression-creative block) Schizotipy symptoms correlated with RAS-like, RAS-dislike, and RAS-total. Shapiro and Weisberg (1999) results were about the “continuous affective patterns”, Creativity scores measured by the ACL-CPS, are higher when hypomania-plus-biphasic scores are high and depression scores low. With regards to the “criteria affective patterns” individuals displaying a hyperthymic pattern measured significantly higher on ACL-CPS creativity scores than those at risk for either cyclothymic or depression. In conclusion, Shapiro and Weisberg (1999) study gave insignificantly different ACL-CPS creativity scores for individuals meeting GBI criteria for hyperthimic from those least symptomatic, or euthymic individuals. (Those results differ from the results obtained by Richards (1988). Finally, Strong et al. (2007) measuring the temperament –creativity relationship
found
that
BWAS-Total
scores
correlated
significantly with the Neuroticism / Cyclothymia /Dysthymia Factor. BWAS-Dislike scores also correlated significantly with
60 Â the Neuroticism /Cyclothymia /Dysthymia Factor. Specifically correlated
with
NEO-PI-R-Neuroticism
and
TEMPS-A
Cyclothymia. Finally, openness correlated significantly with BWAS-like and ACL-CPS.
61  DISCUSSION This review found answers for the objectives previously fixed. The results suggested that bipolar disease is linked to creativity, and that this relationship is related to a hyperthymic affective pattern. (Shapiro, Weisberg1999). This means that there is a peak of creative behavior in bipolar patients compared to healthy control participants. However, this positive correlation is almost the same for creative control participants. (Santosa et al.2007). This relationship is especially strong in the inventiveness part of the test, particularly in the verbal domain. (Rybakowski, Klonowska 2011). For instance, Fodor, Laird (2004), found that Barnes´s (1996) play therapy technique could intensify literacy creativity in bipolar patients, therefore a person with a bipolar predisposition who had a significantly enhanced temperament practicing play therapy, wrote more creative poems. However, not all the papers reached the same conclusion; creativity is stronger in subjects that have sub-clinical expressions of bipolarity (for instance, cyclothymes), compared to the subjects suffering more severe manifestations of the illness like manicdepressives. (Richards et al.1988). Other results showed a significant
impairment
of
creativity
performance
during
depressive states, the degree of this impairment directly
62 correlated to the severity of the depression, especially those “active” aspects of creativity that were the ones more affected by a “creative block” (Rybakowski, Klonowska 2011). Conversely, one paper´s results revealed no differences between unipolar and bipolar writers when using emotional words, consequently, there may not be any differences in emotional states between writers with a mood disorder and healthy writers during the creative process. (Forgeard 2008). So, even though the relationship between creativity and bipolar disorder appeared clearly, there are still some gaps in our knowledge that remain unresolved. There is clearly a necessity to investigate exactly which phases of the disorder increase creative behavior, and which impairs it. Regarding the genetic bases of this relationship, this review showed that bipolar descendants have higher creativity than healthy control offspring. (See Simeonova et al. 2005). That relationship also affects the tendencies of choosing a creative occupation, bipolar disorder patients and their relatives used to choose more creative occupations than subjects from the healthy control group and their relatives. On the contrary, individuals with a major depressive disorder and their relatives did not show any consistent pattern of association with creative occupations. (Kyaga et al. 2011)
63 Â Studying the relationship between bipolar disorder and creativity in depth we can see there are some temperamental features that specifically influenced the development of creativity. Once again there is a difference between bipolarity and other mood disorders, (Santosa et al. 2007) underlined that those personality differences are constrained to the bipolar disorder, and do not appear in a major depressive disorder. Concretely the personality differences that this review has found were temperamental-affective variances such as neuroticism, cyclothymia and dysthymia, and temperamental- cognitive variances for example, openness and intuition.
This
means
that
these
components
contribute
significantly in increasing the features of creativity. (Srivastava et al 2010), (Strong et al. (2007). The first mentioned (neuroticism, cyclothymia and dysthymia) could provide access to the changeability of the affects, and the others (openness and intuition) to flexibility. Differences among different mood bipolar states were also reported; manic patients were found to have greater creativity results on the psychometric tools, especially on the task related to executive functions (Soeiro de Souza et al. (2011). Another important link found between creative behavior and bipolar disease is the neurological one. The overlap between
64 Â bipolar disorder subject results and creative control subject results on the measure of tools of creativity suggest that there could be some neurobiological commonalities between people suffering bipolarity and individuals that exhibited creative behavior. (Nowakowska et al. (2005). Furthermore, this review showed that the proBDNF (Met-) monoaminergic is linked with a better performance on creative task in individuals suffering bipolar disorder, but only during the manic phase. (Soeiro de Souza et al. (2012) There are clearly some limitations of this review. Firstly, we can see there are a multitude of approaches to assess the definition of creativity, and the majority of them generally have restrained correlations. The general use of artistic and scientific occupations, or specific behaviors defined by the test, as a representation for creativity is clearly a limitation. Secondly, the databases used for this research were restricted to the ones linked to the catalogues of the Queen Mary Library, the British Library and the Senate House Library, being necessary for future research add other sources, and also include studies written in other languages since due to the personal characteristics of the investigator this study in limited to English written papers. Thirdly, only case-control studies were included it being
65 necessary to compare groups from the same population (creative people, members of the same family) with and without a mental disorder, therefore there was a risk of “over-matching” when the groups were made to make them comparable for possible cofounding features, therefore, further research including randomized controlled trials is necessary. Fourthly, the sample characteristics created very important limitations. For instance some of the participants were college students, and they have been included even the age was not specified, and due to their characteristics the investigation was restricted to a highlyeducated sample. Other studies included a mixture of unmedicated and medicated patients in the same sample, which created some uncontrolled bias. Ten of the thirteen studies used population non-randomly selected from the same environment. Another of the sample problems was the difficulty presented by the fact that the participants were not blinded. (They knew they were tested because they were creative or bipolar). The control groups, especially the ones formed by creative control participants were another source of difficulty because they could be “contaminated” by the stereotypes of “creative genius”, this means that the idea of a “genius” has created an image about how a creative person should be, and during the test many participants
66 could exaggerate their behaviour patterns according to that idea. Steve Allen called that “the Bohemian excuse” (Allen, 1998). In The Mad Genius Controversy, the sociologist George Becker (1978) notes that: “The aura of madness served the function of differentiating genius from the mean, the mediocre, or the bourgeois . . . the man of genius could claim some of the powers and privileges granted the ‘fool’ and the ‘possessed’ prophet”. Finally, the majority of the papers used the BWAS, as an assessment tool to measure creativity and this is a restraint since the kind of exact creativity notions underlying the BWAS remains to be recognized. Due to the instruments nonverbal measures and its perceptual tendency, it could be viewed as a measure that assesses only one aspect of creativity. Considering that a systematic review should help researchers to avoid possible drawbacks or difficulties and refine their objectives and research questions, there are some important future recommendations that would allow the generalization to have a more realistic context. (Mulrow, 1994). Clearly future studies are needed to clarify the correlation between mania and creativity in Bipolar Disorder; exploratory analysis using multiple tests replicating these results was necessary. Further studies are needed to determine what increases creativity and how these
67 Â mechanisms are related to temperament, mood, and medication status. It would also be important to distinguish genotypeenvironment exchanges that stimulate creativity, the descendants and relatives of subjects suffering any mood disorder, could be influenced by family atmosphere, parents aesthetic opinions and artistic endeavours. (Simeonova et al. 2005). Finally, more longitudinal studies should be conducted to observe if creativity would continue in the participants who attended therapy for a sustained period of time.
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