| The Neurobiology of the Arts |
The Incurable Disease of Writing As a neurologist at Massachusetts General Hospital, Flaherty was able to diagnose herself—and to put her symptoms to good use. Within a year she had completed her first book, The Massachusetts General Hospital Handbook of Neurology, which has since been translated into three languages. And in The Midnight Disease: The Drive to Write, Writer’s Block, and the Creative Brain (Houghton Mifflin, 2004), Flaherty explores both hypergraphia and its seeming antithesis, writer’s block. We asked her about her personal and professional views on literary creativity. Byron: How did your first bout with hypergraphia begin? Flaherty: One morning, exactly ten days after my babies died, I woke up feeling as if a switch had been thrown and a thousand volts were flowing through me. It was like in Hamlet, when “the sheeted dead / Did squeak and gibber in the Roman streets.” I was filled with an overwhelming compulsion to write. That’s all I was conscious of—I had important ideas that I needed to write down because otherwise I would forget them. Everyone kept saying, “It’s a grief reaction,” or “She’s depressed.” But I liked my sorrow. I was wallowing in it—I think that would be the So I wrote all the time. In the middle of the night, I’d write on a PalmPilot or on tiny Post-it notes. I would stick the Post-its on the wall, collect them the next morning, then type my scribbles into the computer. My husband, Andy, who was incredibly supportive through all this, told me, “That’s when I knew you were sick. The smallest Post-its—why not even the medium-sized ones?” I don’t know why—it just had to be the tiny ones. About some of my behavior, I’d think, well, doesn’t everybody do that? Many people write on their hands; I just extended that up my arm while driving across the Longfellow Bridge. And everyone will suddenly jot something down—but maybe not on toilet paper in the public bathroom, and not for half an hour. Byron: And didn’t you write on napkins in the cafeteria at Mass General? Flaherty: Lots of people write on napkins—that’s normal! Physicists do it all the time. Go to MIT. They’re all in the cafeterias writing on napkins. Except when they attend fancy dinners—then they write on the damask tablecloths. Byron: What were you scribbling on all those Post-its and napkins? Flaherty: It was largely autobiographical. Some of it was just phrases, ideas that I can’t decipher now but at the time led me on all sorts of tangents. It was a mentally ill flight of ideas, and yet those scribbles were where most of the ideas for my book on writing came from. As it is, the book is largely memoir disguised as neurology. But if I were hypergraphic all the time, I could never be a writer. First of all, I’d die of exhaustion. And the writing would be much too personal and disorganized, its associations too loose. Editing is best done when you’re normal or a whiff depressed, willing to toss out the trash. Then, after four months of mad scribbling, another switch was thrown, and I became completely torpid, with no impulse to write—or even to move. It was peaceful, unless I tried to write or speak. Then I felt as though my lungs were full of water. That lasted about six weeks. The following year, by a strange symmetry, I gave birth to premature—but healthy—twin girls, my wonderful daughters Katerina and Elizabeth. Again, I experienced four months of hypergraphia followed by a short period of semi-catatonia. Whatever brain-hormonal interactions caused hypergraphia in me might have caused more traditional postpartum psychosis in someone with a different premorbid personality. The truth is that, even before the pregnancies, I’d always been inclined to write a bit more than normal. When my attention wandered during medical school lectures, for example, I would furiously write whatever thoughts came into my head. Then my classmates would get mad because they assumed I had taken great notes that I just wasn’t willing to share. And this past summer I tried hard not to start a new book—the result was an oratorio libretto about Jacob wrestling with the angel, a 165-page biographical sketch, and a children’s book on the adventures of a picky eater and the Loch Ness monster. In general, hypergraphia doesn’t guarantee great writing, just lots of it. Hypergraphics tend to be internally driven; they write for their own pleasure or to deal with their own demons. Being paid a dollar a word can make you prolific, but it’s not the same as being hypergraphic. Sometimes hypergraphia can take the form of copying the same poem over and over. I’ve done that, because of the blackness of the letters on the page and the way the vowels rang like bells in my head. Or hypergraphics make useless lists of everything, like lists of their favorite songs. And to a more pathological extreme—I can’t think of a tactful word— Byron: Like Jack Nicholson in The Shining? Flaherty: Yes, typing reams of “All work and no play makes Jack a dull boy.” Byron: Which famous authors have been hypergraphic? Flaherty: Isaac Asimov, who wrote nearly 500 books, is a classic example. He would sit down and compose 90 words a minute on his typewriter and reportedly never suffered a blocked moment. Everyone thinks of Proust as hypergraphic because he wrote such a long novel over such an extended time. Other writers often described as hypergraphic include Stephen King, Charles Dickens, Honoré de Balzac, Agatha Christie, Anthony Trollope, John Updike, Herman Melville, and Joyce Carol Oates. Byron: You mention in your book that Joyce Carol Oates objects to people calling her writing compulsive. Flaherty: Yes, and I can understand that, since most people consider “compulsive” an insult. But doctors get blasé about using medical terms. We medicalize everything. When conferences get dull, we entertain ourselves by diagnosing each other—congenital toe walking, swan-neck deformity, frontal release signs. People don’t realize that not all aspects of mental illnesses are terrible, although most mental illnesses, of course, cause great suffering. Some of my patients have told me that, for them, a single episode of depression was far worse than living through World War II or cancer. But an obsessive-compulsive personality can be useful if you’re an engineer checking the Challenger for flaws. That’s going to be my next book: Make Your Mental Illness Work for You. If you have narcissistic personality disorder, become a dictator. I think one reason Joyce Carol Oates gets irritated about being called compulsive is that she derives pleasure from her writing. That’s important to remember. Some people write because they’re unhappy, but when they’re writing, they’re often filled with joy. People who didn’t know me when I was hypergraphic ask why I call it a disease, especially since I also consider it a blessing. I call it a disease, in part, because of the way my writing sucked me away from everything else. And because of how strange it felt to be suddenly propelled into a creative state by what were probably postpartum biochemical changes. I hated to think that writing—one of the most refined, even transcendent talents—should be so influenced by biology. On the other hand, as a neuroscientist, I realized that if we can get a handle on fluctuations in creativity, we might be able to find ways to enhance it. Byron: What causes hypergraphia? Flaherty: Certain brain conditions can trigger it, and they all seem to involve the temporal lobes. It was Norman Geschwind [’51] and colleagues who first showed an association between temporal lobe epilepsy and hypergraphia. Fyodor Dostoevsky’s temporal lobe epilepsy almost certainly caused his prolific writing. Just before his seizures, he would enter a state of religious ecstasy in which his world was flooded with meaning. Between seizures, he wrote hypergraphically, often about his struggle with the fact that the periods in which he seemed to experience the highest truths were also the product of a disease. Like Dostoevsky, some people with temporal lobe epilepsy display a group of personality traits—collectively called the Geschwind syndrome—that include hypergraphia, strong religious or philosophical interests, and wild mood swings. But about 50 years before Geschwind did his work, the German psychiatrist Emil Kraepelin described hypergraphia in people with bipolar depression. Although at first glance temporal lobe epilepsy and bipolar disorder seem quite different—one a neurological disease with seizures, the other a psychiatric disorder with mood swings—on closer examination, the symptoms and the treatment overlap a great deal. Clinicians often have trouble deciding whether to diagnose temporal lobe epilepsy or bipolar depression in patients today, so imagine how difficult it is to identify the afflictions of people long dead. Biographers have diagnosed Edgar Allan Poe and Lord Byron both ways as they have tried to account for Poe’s and Byron’s prolific writing and mercurial temperaments. Schizophrenia also can cause hypergraphia. With his copious manifestos and journals, Theodore Kacyznski, the Unabomber, is a classic example of a high-functioning schizophrenic who became hypergraphic. Drugs sometimes induce hypergraphia as well. One of my patients was referred to me because a neuroleptic her doctor had prescribed suddenly made her start writing in her pocketbook and on her clothes. She even wrote ten-page letters to her parents while sitting in the same room with them. And Robert Louis Stevenson churned out all 60,000 words of The Strange Case of Dr. Jekyll and Mr. Hyde during a six-day cocaine high. Byron: Don’t a high proportion of writers have bipolar disorder? Flaherty: Yes, or depression with bipolar features. The work of psychologist Kay Redfield Jamison and others has shown that writers are ten times more likely to be bipolar than the rest of the population, and poets are a remarkable forty times more likely. Bipolar disorder is strongly genetic. You can see this in writing families like the Jameses, in which the mildly affected members are more productive than both their relatives with a more severe form of the disease and the general population. Henry James had unipolar depression and his famous siblings William [Class of 1869] and Alice were mildly bipolar, but their brother Robert’s writing career was crippled by his severe bipolar disorder. Danielle Steel, whose late son also had severe bipolar disease, likely has enough of the bipolar gene cluster to make her hypergraphic—she’s published more than 60 books—but not enough to be impaired. Severe mental illness leaves little room for creativity. Sylvia Plath, who was bipolar, once said, “When I was ill, that’s all I was.” Byron: In your book, you state, “Hypergraphia is neither painful (except sometimes to the reader) nor common. Writer’s block is both.” Flaherty: Yes—all blocked writers share two traits: they don’t write despite being intellectually capable of doing so, and they suffer because they’re not writing. One of my favorite descriptions of block was by a nineteenth-century English poet, John Clare: “They have cut off my head, and picked out all the letters of the alphabet—all the vowels and consonants—and brought them out through my ears; and then they want me to write poetry! I can’t do it.” The list of famous writers with block is long—Franz Kafka, Virginia Woolf, Saul Bellow, William Styron, Sylvia Plath, Norman Mailer, Ralph Ellison, Katharine Mansfield. Gustave Flaubert, who had temporal lobe epilepsy and wrote hypergraphically, crossed out nearly as many words as he wrote. Of course, these writers managed to be productive enough to become famous. One of the tragedies of block is that it also afflicts unknown people—talented individuals who just disappear from their fields because they stop being able to produce. That’s why treating block as a disease isn’t frivolous. Byron: Is writer’s block the true opposite of hypergraphia? Flaherty: No. Originally I thought it was, but you can suffer from both almost simultaneously, whether they alternate at different times of year—as in people with seasonal patterns of productivity—or whether you’re blocked in one genre but not in another. Samuel Taylor Coleridge is a classic example of this: he used to churn out metaphysical treatises at the same time that he was paralyzed in his attempts to write poetry, which is what really mattered to him. So, from that phenomenological point of view, hypergraphia and block seem too closely related to be considered true opposites, just as mania and depression are difficult to present as complete opposites. Everyone from Freud on has argued that mania is, in many ways, closer to depression than it is to the normal emotional state. And that’s true on a number of axes, including treatment. Treating the mania often treats the depression. There seems to be a frontal/temporal lobe interaction that is important for writing—and probably other creative endeavors—and if this interaction becomes imbalanced, problems arise. In people with injuries to the temporal lobe, you see disinhibitions and loquacious speech, as opposed to the laconic kind of speech typical of frontal lobe injuries. Wernicke’s aphasia, where you talk gibberish, and Broca’s aphasia, where you struggle to speak, are the classic examples. And there is evidence, although preliminary, that when your frontal judgment mechanism gets out of control, you can end up with creative block. The frontal/temporal lobe axis turns the received view of creativity 90 degrees, because until recently, the only theories about the creative brain were ones that speculated that the right hemisphere is the seat of creativity and the left hemisphere just helps you do your taxes. I’m oversimplifying, but the picture is still much more complicated than even the best of those theories suggest—not only because of the way the temporal lobes on both sides may drive creative work, but also because of the role the frontal lobe may play in judging or editing the often over-exuberant products of temporal lobe changes. Byron: How can writing disorders be treated? Flaherty: For many hypergraphics, the question should be, do they want to be treated? And what exactly is it that you’re treating? Is it bad hypergraphia, in that they write poorly? Or are you treating hypergraphia in which the quality of writing is relatively good, but they’re so obsessed with writing that they’re alienating family and friends? For hypergraphics who want help, redirecting some of their energy to the editing phase can help. And mood stabilizers are both anticonvulsants and antimanics, so they get at the two most common neurological causes of hypergraphia, temporal lobe epilepsy and mania. As for block, writers have a long history of self-medicating, usually unsuccessfully, with everything from alcohol to coffee to amphetamines. These days, people who complain to a psychiatrist of writer’s block tend to be treated for depression or anxiety. Also, some blocked writers struggle with critical inner voices. The writer Anne Lamott personified one of these critics as, “the vinegar-lipped Reader Lady, who says primly, ‘Well that’s not very interesting, is it?’” Low doses of atypical dopamine antagonists may quieten those inner voices. Byron: You mention in your book that different parts of the brain control the drive to write and the ability to write. Can you elaborate on that? Flaherty: Roughly, the limbic system primarily controls emotion and drive and the cerebral cortex is more concerned with cognition. Yet the neurology of emotion and cognition are tightly intertwined. The cortical area that is the most connected to the limbic system is probably the temporal lobe. And the reason the temporal lobe can trigger hypergraphia is probably because the limbic system produces our strong biologic drive to communicate, which in turn drives the speech area of the temporal lobe. In psychological terms, it seems that drive is more important than talent in producing creative work. The psychologist Dean Simonton has argued, for example, that the composers who produced the greatest music were simply the ones who wrote the most. Mozart and Beethoven composed all the time, whether walking down a street or attending a dinner party. Byron: What can writing disorders teach us about creativity? Flaherty: Temporal lobe changes can increase creative drive in fields besides writing; for instance, one kind of temporal lobe dementia causes people to begin painting or composing even though other aspects of their lives are degenerating. Vincent van Gogh—who almost certainly had temporal lobe epilepsy—painted with an amazing fury, sometimes producing a fresh canvas every 36 hours. At the same time, he wrote several long letters a day to his brother, Theo. Robert Schumann, who had bipolar disorder, wrote feverishly at the same time that he was composing music feverishly. The rate of mental illness is about 70 percent for musical performers, poets, prose writers, painters, and composers, but only 25 percent for doctors, scientists, politicians, and businesspeople. Does that mean that doctors’ creativity stems from a different source? Or that they are less creative? I’d guess it’s that doctors have more social pressure to hide psychiatric illness. After all, physicians have higher-than-average suicide rates. Clearly, though, you don’t have to be sick to be creative. It may be that engaging in creative work not only is a sign of health, but also makes you healthy. The relationship between illness and creativity doesn’t mean we should foster disease. Perhaps we should think of creativity as an adaptive response to difficult situations such as illness. Many plants won’t bother to flower unless they’re stressed just a little; people are like cyclamen. Focusing on the relationship between illness and creativity is also useful because mental illnesses are often exaggerations of normal brain states that allow us to see more clearly how a mechanism works, even in healthy people. It would be tragic to go from there to pathologizing creativity, though. It makes more sense to go in the opposite direction and notice that everyone shares traits with the mentally ill. Unfortunately, doctors are trained to see all facets of illness as bad, and we tend to dismiss patients who complain of “soft” medication side effects, such as decreased creativity, as simply being noncompliant. Byron: Why are so many doctors also writers? Flaherty: Just the other night, I was sitting next to a department chairman at a stuffy dinner party. He was asking questions about my book, and I began to suspect that his interest was more than casual. So I asked him pointblank, “You write, don’t you?” “How did you know?” he replied, sounding defensive. I pursued it: “What are you working on?” He hemmed and hawed, and I finally interrupted, “You’re writing a thriller, aren’t you?” Of course he was—they all write thrillers. I could name you ten Harvard doctors who are writing thrillers. At least the young ones are; when they get older, they write memoirs. Doctors who write have a rich experience to mine because they’re constantly confronted with issues of life-and-death importance. It’s that limbic tug—the ache and blood of medicine. The flip side of that, though, is that doctors are trained to write scientific papers and case workups in a prose style that is not only bad writing, but also often actively neurotoxic to creativity. I’d bet if you did volumetric MRIs of residents exposed to the typical progress note, with its passive voice and its refusal to describe the patient as a human being rather than as a collection of prostheses and malfunctioning organs, you’d find that after four years the language areas of the residents’ brains had shriveled up to the size of walnuts. Just a suspicion. Byron: You seem to be focusing your own research more and more on issues of creativity. What are you working on now? Flaherty: I’m interested in biological interventions that affect creativity. For instance, my colleague Shelley Carson and I are studying the effect of lightboxes on undergraduates, because even people without seasonal affective disorder seem to experience winter dips in productivity that could benefit from phototherapy. As for drugs, I’m primarily interested in those that affect dopamine. Many creative people with mood disorders hesitate to take dopamine antagonists—the neuroleptics—because they feel that the drugs flatten their creativity. If we could show that the newer neuroleptics don’t dampen creativity, compliance might improve. That would be incredibly beneficial, especially for people at high risk for suicide. Another study will focus on stimulants like Dexedrine, because a fair number of studies suggest that stimulants can actually boost creativity. But they need to be used only intermittently and in low doses—sometimes a difficult proposition, given their addictive potential. Much of my research has been on the basal ganglia’s role in initiating movement, and I have been intrigued with their role in sparking ideas as well. Some patients who have deep-brain stimulators for movement disorders like Parkinson’s disease experience profound changes in mood and idea generation. One of my patients, who has Tourette’s syndrome, is a remarkable example of this. Although her tics have nearly disabled her—she has broken her limbs and blinded one eye, she works successfully as a medical editor, is happily married, and is so bright and persuasive that two of my colleagues at Mass General—Emad Eskandar and Rees Cosgrove—agreed to her request for experimental surgery to preserve her remaining vision. The stimulator has helped calm her tics—I no longer hear her chirps and cusses down the hall. To our surprise, though, it also controls her moods and her creativity. When her stimulator releases current deep under her frontal cortex, she Less invasive technologies, such as transcranial magnetic stimulation, may offer some of the same effect temporarily. One case report even described a subject in whom TMS had induced the sensation of being visited by the Muse. It may seem ludicrous to imagine sitting under a contraption resembling an old-fashioned hair dryer to stimulate your creativity, like something out a 1950s sci-fi flick. But it’s not just a question of ridding writers of their block because of publish-or-perish pressures. There are worldwide problems urgently in need of creative solutions. Just imagine if you were trying to develop a vaccine for a lethal new virus and a wand waved over your temporal lobe could help you. To the extent that insights into the writing process may carry over into broader problem-solving realms, they have the potential to benefit many people in profound ways. Paula Byron is the editor of the Harvard Medical Alumni Bulletin. This article appeared in the Autumn 2003 issue of the Harvard Medical Alumni Bulletin. Photo: Graham Gordon Ramsay; Illustration: Richard Tuschman |
appropriate clinical term. Depressed people don’t enjoy being depressed; I vaguely remembered that from medical school. I was full of grief, but I was euphoric too, and I had no intention of getting better, even though there were days that I felt that my brain was going to explode, or that I was like a balloon attached to the earth by a single frayed thread. 
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