Detailed and comparative evaluation of markers ofcreativity in the bipolar disorder risk group andpatients with bipolar disorder

Objective:. Existing research suggests the possibility of a connection between Bipolar Disorder (BD) and creativity. Certain personality and temperament traits commonly found in creative individuals are more frequently observed in individuals diagnosed with BD. Limited studies have explored creativity in individuals at risk for BD, primarily focusing on those with familial risk. Assessing creativity in individuals at a clinical high risk for bipolar disorder (CHR-BD) and possibly in the prodromal stage of BD may carry clinical significance and play a role in reducing stigma. However, to date, only a pilot study involving the evaluation of nine individuals has been conducted on this topic. The aims of this study are to compare the levels of creativity in cases with CHR-BD with those of BD, healthy controls, and creative controls. Additionally, the study seeks to reveal the relationship between creativity observed in BD and CHR-BD and personality, temperament, and other variables. Method: The research was conducted at the DEU Faculty of Medicine Psychiatry Early Diagnosis and Intervention Program (EDIP) and the bipolar disorder outpatient clinic. The sample of the study consists of 128 individuals, including 31 with a diagnosis of Bipolar Disorder (BD), 31 with a clinical high risk for BD (CHR-BD), 32 healthy controls, and 34 creative controls. Individuals in the CHR-BD and BD groups were assessed during the euthymic phase. The CHR-BD diagnosis was established using the Bipolar Prodrome Symptom Scale - Prospective (BPSS-P), and the Structured Interview for Psychosis-Risk Syndromes (SIPS) was conducted for prodromal psychotic and negative symptoms in this group. Hypomanic symptoms in the creative control group were screened using the Hypomania Checklist-32, and the BPSS-P was applied to exclude suspected cases based on this scale or clinical history. Cognitive functions were assessed using the Screening Cognitive Impairment in Psychiatry (SCIP) test. Personality and temperament characteristics of the participants were evaluated using the Big Five Personality Test (B5PT-50), TEMPS-A temperament scale, Behavioral Inhibition System/Behavioral Activation System Scale (BIS/BAS), and the What Are You Striving For (WASSUP) test. The Creative Activities and Achievements Inventory (CAAI) were utilized for autobiographical assessment of success and interest in creative pursuits. Objective creativity tests such as the Visual Aesthetic Sensitivity Scale (VAST), Barron-Welsh Art Scale (BWAS), Divergent Thinking Test (DTT), and Remote Associates Test (RAT) were implemented. Differences between groups were examined using ANOVA and chi-square tests. The relationship between creativity and clinical, psychometric, and cognitive variables in BD and CHR-BD groups was explored through Pearson correlation analyses. Multiple regression analyses were employed to determine more detailed predictors of creativity in these groups. Results: There was no significant difference between the groups in terms of age and gender. When cognitive functions (SCIP total) were examined, the performance of the BD group was significantly lower than that of the CHR-BD and control groups. In the evaluation of ambition levels, a significant difference was found between the groups (F=3.50, p=0.02). While the ambition level of the BD group (mean (S.S) =90.5 (26.0)) was significantly higher than that of healthy individuals (mean (S.S) =73.5 (18.3)), CHR-BD and creative control groups were in the middle of these 2 groups. The temperament characteristics examined by TEMPS were that depressive, anxious and cyclothymic temperament characteristics weresignificantly increased in the CHR-BD group. When personality traits were examined, a significantly lower score was found in the dimension of emotional stability in the CHR-BD group. In the extraversion dimension, the creative control group's score was significantly higher, while the BD group got a score between creative control and the other 2 groups. When the objective variables related to creativity were examined, a significant difference was found between the groups for BWAS (F=2.7, p<0.05). BD (mean (S.S) =37.4 (13.2)) and creative control (mean (S.S) =37.2 (10.6)) groups were found to have statistically higher scores than healthy groups (mean (S.S) =29.8 (12.7)). It was determined that the CHR-BD group (mean (S.S) =32.6 (14.4)) scored between the BD/creative control and the healthy group. When the autobiographical variables related to creativity were examined, a significant difference was found between the groups in the evaluation of ICAA-activities (F=2.96, p=0.03). In this evaluation, the performance of the creative control group (mean (S.S): 44.9 (22.0)) was significantly higher than that of the BD group (mean (S.S): 28.6 (24.8)). The score of the CHR- BD group (mean (S.S): 39.3 (24.3)) also tended to be higher than the healthy control and BD group. In correlation analyzes, cognitive functions were positively associated with VAST (r=0.38, p=0.03) in the CR-BB group, while premorbid intelligence was significantly associated with UBT (r=0.42, p=0.02). In the BWAS, creative responses were positively associated with BIS/BAS recreational seeking (r=0.45, p=0.01) and inversely correlated with prodromal negative findings (r=-0.43, p=0.02). Extraversion (r=0.44, p=0.01), openness/intelligence-imagination (r=0.58, p=0.001) and severity of prodromal manic symptoms (r=0.47, p=0.009) were positively associated with personality dimensions of the ICAA-Activity score. The ICAA-Achievement score also showed a positive correlation with the B5PT-50 Openness/Intelligence/Intelligence Imagination score (r=0.39, p=0.03) and the severity of prodromal manic symptoms (r=0.42, p=0.02). In the multiple regression analysis for ICAA-Activities, the model was significant (F=5.98, p=0.002, Adjusted R2=0.41), and severity of prodromal manic symptoms and personality traits openness/intelligence-imagination were found to be significant predictors. In the multiple regression analysis for BWAS, the model was significant (F=3.39, p=0.01, Adjusted R2=0.37), and high BIS/BAS fun seeking, low BIS/BAS reward sensitivity, and low prodromal negative findings were significant predictors of creativity. In the correlation analyzes performed for BWAS, which was high in the BD group, it was found that this variable was positively correlated with the BIS/BAS Behavioral Inhibition score (r=0.49, p=0.006) and negatively correlated with TEMPS hyperthymia (r=-0.42, p=0.02). Conclusion: Findings from our study indicate that individuals diagnosed with Bipolar Disorder (BD) and creative individuals, in contrast to healthy individuals, prefer asymmetrical and complex visual stimuli, demonstrating a similarity in this regard. This pattern is particularly true for individuals with BD who exhibit pronounced behavioral inhibition and are not in a hypomanic state. A similar trend may be applicable to some individuals with a clinical high risk for BD (CHR- BD), especially those without prodromal negative symptoms and with a high novelty-seeking tendency. Importantly, CHR-BD individuals may be inclined to show more interest in creative activities than healthy individuals. This tendency is particularly evident in CHR-BD adolescents who are extroverted and open to experience. A clinically significant point is that the severity of prodromal manic symptoms in CHR-BD is associated with an interest in and success in creative domains. On the one hand, this can be considered among the positive features associated with the risk of bipolar disorder. On the other hand, engagement in creative pursuits and increased creativity in young individuals seeking help and reporting sub-threshold hypomanic symptoms may be associated with the risk of bipolar disorder. Longitudinal studies are needed to examine the relationship between creativity and the long-term course in the CHR-BD group. Keywords: Bipolar disorder, prodrome, creativity,