Madness as creative energy: Self-observations during episodes of unipolar mood elevation

Abstract This self-study is based on first-hand experiences gained from 19 episodes of hypomania and mania that inform on the workings of the mind driven by the creative energy of madness. Diverse sources of data (e.g. diaries written during or around episodes) were used for self-diagnosis. Self-observations reveal no depression of clinical severity, compromised reality testing, or impulse control. Cognitive disturbances did not preclude outpourings of creativity. Moreover, a good many of the symptoms exhibited (e.g. literary-artistic-esthetic sensibilities, capacity to enjoy life) may be viewed as positive. Discussion centers on the atypical features and cultural context of my case, interaction between madness and creativity, and limitations of research on mood disorders based on the deficit model. I argue that it is unsound to accommodate cases such as mine under the rubric of bipolar disorders. Evidence derived from self-observations supports the contention that superefficiency in memory retrieval and ideational associations is a mechanism underlying creativity in euphoric states—probably, however, at the cost of mental fatigue, in line with recent research. More generally, the evidence provides support for viewing madness as creative energy in at least some cases.

ABOUT THE AUTHOR Professor David Y.F. Ho was responsible for having introduced professional clinical psychology into Hong Kong. He has authored numerous scholarly contributions in psychology, psychiatry, sociology, and education. With extensive multicultural experiences, he has held professorial appointments in various counties in Asia as well as North America. He was the first Asian to have served as President of the International Council of Psychologists. Life-changing events occurring late in his career enabled him to gain extraordinary or mystical firsthand experiences during recurrent episodes of mood elevation. They have turned his research focus to interactions among "madness," creativity, and spirituality. By the blessing of circumstance, the present self-study is the work of a qualified author. In separation, being a psychologist, steeped in a bilingual-bicultural background, experiencing mystical glimpses of magnanimity, or having episodes of "madness" may not be that uncommon. But the confluence of all these is rare, if not unique.

PUBLIC INTEREST STATEMENT
The present self-study of, and conducted by, a professor of clinical psychology promises to shed light on some psychiatric issues concerning mood disorders. First, having experienced 19 episodes of mood elevation and none of depression, the professor-cum-patient can hardly be viewed as having suffered from a bipolar disorder. Rather, his case exemplifies unipolar mania (or hypomania). Second, first-hand experiences gained from his episodes reveal a linkage between unipolar mania and creativity: As stated in his own words, "My mind explodes. Creative thoughts and flashes of insight rain down fast." This has prompted the author to argue for viewing madness as creative energy, and not solely in pathological terms. There is growing evidence that unipolar mania may be more prevalent than was previously thought. Hence, greater attention should be paid to the understanding and treatment of unipolar mania, particular in terms of the creative potential that it may bring to humanity.

Introduction
Observing the workings of the mind is tricky business. For, in principle, they cannot be directly observed. We have no idea, for instance, of how we arrive at the answer to a simple arithmetic problem or how we generate our thoughts. All we know is that products of the mind flow as naturally as water out of a tap. Once in a while, however, extraordinary circumstances provide opportunities to come close to observing the workings, the mechanisms and processes, themselves. Those opportunities came when I reached the age of 58. Prior to that age, I had no history of psychiatric disturbance. Then something happened that profoundly changed my life, unexpectedly and inexplicably. From 1997 to 2016, I have had altogether 19 episodes of elevated mood disorder, 17 hypomanic, and 2 arguably severe enough to be considered manic. From these episodes, I have gained invaluable first-hand experiences that inform on the workings of the mind driven by the creative energy of madness.
My first-hand experiences raise significant issues concerning diagnosis, the nature of mood disorders, as well as the failure of mental professionals to recognize the positive aspects of abnormality. In what follows, first I present a self-diagnostic exercise based on diverse sources of information. Next, I discuss diagnostic issues and the place of madness in creativity in cultural context. Atypicality is the most salient feature that emerges from the self-diagnosis. This atypicality is manifest in enhanced health, physical, mental, and spiritual; creativity; and literary-artistic-esthetic sensibilities. I rely on a dialectical conception to discuss the place of madness in creativity: Each transforms, and is transformed by, the other. In a nutshell, the objective of this self-study is to shed light on how and the conditions under which madness may be viewed as creative energy.

A self-diagnosis
The primary data consist of (a) a thorough self-study completed when I was a graduate student in clinical psychology, (b) diaries written during or around episodes, (c) a free association done in the midst of a manic episode, and (d) correspondence with friends and colleagues about perceptions of my behavior during episodes. (A chronicle of 17 unipolar episodes, diaries, and an original transcript of the free association with notes and comments are available to interested readers as supplemental materials. See also Ho, 2014aHo, , 2014bHo, , 2016

Diaries
The following is an excerpt from my diaries written in the midst of a hypomanic episode (with ellipses and added materials in square brackets). I have deliberately kept the reproduction exactly as it was written (excepting spacing between paragraphs) to reflect my thought process. physical fatigue, but tremendous energy, mentally active, auto racing, voice recovered, very alert, but the body needs rest and sleep […] takes 20 minutes to find my underwear, distractible, how annoying […] I have a theory about intelligence the brain is the same but after removal of repression the whole bloody unconscious is available the raw emotions […] no repression = greater intelligence, creativity = intelligence infinite association of ideas all at once […] in just a split of a second, it's gone, can't recall, and lost memory, forever [like] Korsakoff syndrome? Keep trying to reconstruct the past when immediate memory cannot be transferred to long term memory like a funnel, can't hold water use logic, make distinctions, fear, now I know what ob-compulsive is!? (joy and delight) save this file before it's lost, but I dare not!!! No longer able to process thoughts, recollect, obsessive, like the brain is no longer able to function properly […] Stupid, can do only one thing at a time, keep on forgetting what I had been doing a minute ago, start looking the things ("I spend most of my life looking for things", in the past, previously, no, in the past, previously, … compulsive!!!!!) keep on forgetting thoughts I had just a while ago […] not the same ob-compulsive in youth, excitation beyond the ability of the central nervous system to cope with that memory, creative associations nothing to do with forbidden/sexual [thinking Freud doesn't apply] same brain → self-reprocessing → different brain [→] self-creation potential! "It's nonsense, from a science point of view; uninspiring from a literary point of view" These passages, input into my computer as fast as I could, read like an outpouring of a stream of consciousness. They illustrate my intense struggle with brain fatigue, disturbances of memory and executive functioning. Flight of ideas and distractibility, two classic symptoms of mania, were clearly present. The thought that my memory was "like a funnel, can't hold water" was scary. There were also lucid moments of reflectiveness, during which I brought my inflated self-confidence down to size: Of my thinking output, I wrote: "It's nonsense, from a science point of view; uninspiring from a literary point of view." I mused that "I spend most of my life looking for things." Also salient was the obsessivecompulsivity I struggled to rid myself of. I experienced "joy and delight" when I felt freed from its grip. However, obsessive-compulsivity and creativity can "co-exist." I theorized that the obsessive-compulsivity was due to "excitation beyond the ability of the central nervous system to cope … nothing to do with forbidden/sexual (Freud doesn't apply)." I thought of the potential of brain alteration through self-reprocessing: "same brain → self-reprocessing → different brain [→] self-creation potential!" The most interesting idea was that I had "no repression anymore." The consequences must be profound: Truly "no repression = greater intelligence, creativity = … infinite association of ideas all at once." Here is another excerpt from my diary, also written in the midst of a hypomanic episode, about my physical and psychological condition.
My physical condition was one of great imbalance. The body was near exhaustion. The mind remains active, running on fast time. I felt thirsty all the time. I felt hot, where others may feel cold. Aware that my energy reserve might be depleted, I moved around slowly to conserve energy.
Recollections of remembrances may throw fresh insights informative on brain functioning. The positive side was the creativity. Like boundaries between the conscious and the unconscious had vanished. The unconscious became accessible. Retrieval of information was superefficient. In addition, association of ideas was facilitated, fast, but I also felt overwhelmed by these endless associations.
Similarly, I had to try to focus on one thought. While staying focused, a myriad associations. The next moment, the memory of what I had just been thinking about was gone. Attempts to recall were usually futile. I became obsessive about keeping memories from being lost. So I tried to record my thoughts on paper or in a computer file. Thus, brain fatigue may well be the mechanism for obsessive symptoms. I have also experienced this when the air con is turned off. Mild cerebral anoxia. I don't want to say that this applies to all forms of obsessive phenomena. These obsessive phenomena I have described are qualitatively different from the psychoneurotic varieties described in the psychiatric literature.
This diary recapitulates the theme of brain fatigue expressed in the preceding episode. However, the contrast in the quality of writing between the two episodes cannot be more striking. This reflects the fact that dramatic changes in cognitive functioning can occur as a function of fluctuations in energy level.
And here is an abridged version of my diary written around the end of my first manic episode.
Clearly, my manic period was marked by extraordinary creativity, heightened aesthetic sensitivity, depth of feelings, and deep humility. These positive, delightful features are significant: They define the nature of my mania. Definitely, racing thoughts, faster than usual, appeared. Sometimes I was obsessed with losing these thoughts, which I couldn't utter fast enough, let alone put down in writing. Speed was also manifest in an extraordinary sensitivity to cues in social interaction. Watching films or TV shows provided delightful occasions for predicting the next scene, what the actors would say and do. My predictions showed uncanny accuracy, as if I had overtaken the role of the director. That was empathy: I and the director became one. Probably I conducted some of my best psychotherapy sessions or workshops, during which my empathy joined forces with the courage to be myself.
I glimpsed into the mystical-transcendental. But one concern I had was that the combined forces of heightened sensibility and intensified emotionality can be hazardous. I might be too easily fired up by ephemeral ideals and thus act impulsively. Or I might be overly attached to, and hence enslaved by, objects of pleasure or beauty. However, I thought that the Buddhist attitude of nonattachment may keep overattachment at bay: engaged and involved with worldly objects, without being possessive; letting go of fixations. It differs from detachment, which refers to emotional noninvolvement with and disengagement from the world ….
Retrieval of information and association of ideas were superefficient, so much so that I was overwhelmed by my own outpouring of creativity. I became obsessively attached to ideas and objects, including the self. I had no physically aggressive or destructive tendencies, although direct expressions of verbal aggressiveness sometimes exceeded my normal level.
I have not been able to duplicate the feats achieved during my first manic episode, at least not as dramatically: self-healing, the completeness of the no-mind state of emptiness, and the willful visual hallucinations. The depth into which I had gone was proportional to the extent to which my social relations suffered.
Finally, here is a diary written around the time of my latest episode.
I enter into a state of selfless-oblivion, like a trance. I experience disinhibition like I had never experienced before. I become spontaneous, liberated. My mind explodes. Creative thoughts and flashes of insight rain down fast. I see beauty everywhere, in people's faces, in living things, and in the cosmos. Simply, I am enjoying life.
The positive tone is characteristic of the later episodes I have had, which tend to be mild. Increasingly, I welcome them with open arms and, more significantly, feel that I am gaining mastery in control of their place in my life.

Summation
A summary of the psychiatric symptoms, as well as a composite of psychophysical, affective, cognitive, perceptual, and social functioning across all 19 episodes is presented in Table 1. A perusal of this table reveals no depression of clinical severity. Among the plethora of symptoms, some can hardly be characterized as pathological (e.g. enhanced creativity, literary-artistic-esthetic sensibilities, capacity to enjoy life); some pertain to gains in health, physical, mental, and spiritual (e.g. liberation from obsessive-compulsivity and self-condemnation by a punitive superego). This is not to deny that psychiatric symptoms have indeed incurred occupational and social costs. Psychophysical and cognitive-perceptual features figure more prominently than affect features, contrary to the  ) typical pattern described in psychiatric texts. The overall picture is characterized by imbalances: ecstasy intermingling with anguish; maintaining a sense of psychophysical well-being, while suffering from inability to fall asleep, physical exhaustion, and depletion of reserves; hyperactivity coexisting with mental or physical fatigue; alterations between bursts of creative output and cognitive disturbances (e.g. extreme forgetfulness or mental confusion). More so than mood elevation, depth of feelings (in both positive and negative directions), it may be argued, describes my condition accurately.

Discussion: Madness in cultural context
This discussion begins with acknowledging that my account of the workings of the mind during episodes of unipolar mood elevation is based on only one case. However, it is a self-study of an exceptional case by a mental health professional, based on his first-hand experiences. Being a self-study raises questions of objectivity. To address this issue, I rely on a rereading of my diaries, which is replete with cautionary remarks about my inflated self-confidence. I also engage in extensive correspondence with friends and colleagues about my condition, which has helped to guard against bias. By definition, an exceptional case is one that does not fit into regularities in a body of knowledge that researchers have commonly accepted at a given period of time. Precisely for this reason, it is invaluable for providing impetus to challenge prevailing scientific beliefs.
A focus on two themes provides a convenient way to structure the following discussion: (a) diagnostic issues and (b) the place of madness in creativity. Both themes are discussed in cultural context.

Atypicality
The question of whether or not unipolar mania constitutes a distinct disorder remains controversial (Nurnberger, Roose, Dunner, & Fieve, 1979;Perugi, Passino, Toni, Maremmani, & Angst, 2007;Yazici et al., 2002). However, reported prevalence rates of mania without major depression from two largescale epidemiological studies of adolescents and young adults (Beesdo-Baum et al., 2009;Merikangas et al., 2014) fall in the range of 1.7-1.8%. As Angst (2015) has noted, these rates are higher than even those of schizophrenia. Furthermore, recent reviews (Angst & Grobler, 2015; see also Mehta, 2014) reveal considerable evidence (derived from epidemiological, clinical, treatment, cardiovascular, and genetic studies) pointing to the existence of mania as a distinct disorder. Obviously, the phenomenon of unipolar mood disorder with only hypomanic and/or manic episodes refuses to be unheard.
My first-hand experiences counter much of the psychiatric literature on mood disorders. The presumption of a shift in polarity between mania and depression is inherent in the use of the term bipolar. Having had 19 episodes of euphoria and none of depression, I cannot be said to have suffered from a bipolar mood disorder at all. If so, attempts to accommodate cases such as that of mine within a bipolar category would lead only to a linguistic-conceptual conundrum.
There are also other atypical features of diagnostic significance: age of onset; absence of identifiable precipitating factors; salience of psychophysical and cognitive-perceptual features; and enhanced literary-artistic-esthetic sensibilities. Most importantly, there is no impairment serious enough to incapacitate occupational or daily functioning. Self-reflection and self-monitoring, both indicative of metacognitive functioning, play a crucial role in maintaining my capacity to function. Even in the depth of madness, I would frequently ask myself, "Am I mad or enlightened?" This has helped me greatly to deflate my supreme self-confidence, keep in touch with reality, and avoid causing more harm to myself or others. All these clinical features summate to a most atypical case that casts doubt on the deficit model according to which mental disorders are viewed solely or primarily in pathological terms.

Unipolar mania and zouhuorumo
We need to clarify a diagnostic issue in the cultural context of the East. The evidence suggests that pure or unipolar mania is more common in non-Western cultures (Angst & Grobler, 2015). Significantly, the third edition of the Chinese Classification of Mental Disorders (CCMD-3) continues to list, as in the second edition, "recurrent mania" (without depression, bipolar disorders, or cyclothymia) as a subtype of mood disorder.
Given the combined forces of heightened sensibility and intensified emotionality, I was self-enchanted during madness. Fortunately, self-reflectiveness saved me from being captured by the allure of virtual pleasures. My self-enchantment did not result in psychotic-like or bizarre behaviors, a culture-bound syndrome commonly known in China as zouhuorumo, which translates as "catching fire, entering demon." It is listed as a mental disorder "due to qigong" in the Chinese Classification of Mental Disorders (Chinese Society of Psychiatry, 2001) under the category of culture-related disorders. Zouhuorumo is thought of as a transient psychotic state found among qigong practitioners thought to have gone astray due to excessive or improper practice (literally, qigong means "breath work," and may be translated as "vital energy work"). One essential feature is a loss of control and reality testing; the practitioner cannot disengage himself from qigong and return to the non-qigong state. Zouhuorumo shares common features with the physio-kundalini syndrome described by Greyson (2000). It should be distinguished from the demon possession syndrome, in which the patient believes he is "possessed" by an exogenous demonic agent. It may also be interpreted as a type of reactive psychosis or as the precipitation of an underlying mental illness. An estimate from human rights groups of about 600 people, or 0.01% of the 60 million qigong practitioners in China, have received psychiatric treatment (Lee & Kleinman, 2002). Not being an advanced qigong practitioner, I am certain I did not suffer from zouhuorumo. However, it is important to be cognizant that bizarre behaviors manifest in zouhuorumo may also appear in hypomania or mania and confound diagnosis.

Mania as the antithesis of nirvana
In Buddhist thought, the ideal to be attained, nirvana (literally, "blowing out," as of a lamp), is a state of absolute, eternal quiescence, achieved through ridding oneself of passions and desires, including one's attachment to life. It is a state of enlightenment achieved through moral-intellectual perfection only after strenuous personal effort-a transcendent state of supreme equanimity (Ho, 1995). In the language of psychoanalysis, nirvana may be described as an infantile state of precathexis, before libido has been invested in objects. Purposeful ridding of passions and desires may be described as decathexis, which should not be confused with anticathexis, the opposition to cathexis by the ego or superego (Ho, 1995(Ho, , 2014a. Decathexis should be further distinguished from withdrawal, a maladaptive defense mechanism. It is the antithesis of hypercathexis, the profuse and excessive investment of libidinal energy in objects. From this perspective, mania may be conceived as the antithesis of nirvana. In my case, especially during the two manic episodes, I did enter into states of transcendent consciousness devoid of self-reference, such that the subject-object distinction appeared to have vanished. In such a state, cognition was suspended; the self was absent. Furthermore, I experienced self-enchantment: I erotized myself, other people, and the world. The underlying mechanism, I would argue, is hypercathexis.

Mood disorders and creativity
Since ancient times, a common perception is that genius and madness are closely associated. There is good reason for genius to be associated especially with bipolar disorders, among the great variety of mental disorders. Hyperactive mental activity and grandiosity are conducive to creative productivity. Aristotle asks, "Why is it that all men who are outstanding in philosophy, poetry or the arts are melancholic?" The answer, I venture to suggest, is that feelings of anguish, self-rejection, and hopelessness in the depths of depression provide the raw materials for creative production. Melancholia, therefore, bars no creativity. Kierkegäärd writes, "A poet is an unhappy being whose heart is torn by secret sufferings, but whose lips are so strangely formed that when the sighs and cries escape them, they sound like beautiful music" (Thomte, 1948(Thomte, /2009).
There is empirical support for linking creativity to psychopathology, especially mood disorders (Andreasen, 1987(Andreasen, , 2008(Andreasen, , 2011Jamison, 1993;Kyaga et al., 2011). My first-hand experiences lend further support to this linkage. During madness, I was inspired; creative ideas rained down faster than I could cope. I had supreme confidence, with a touch of "megalomania," enabling me to write without inhibition or self-doubt. I could become self-enchanted, captured by the allure of my own runaway thoughts, resulting in a blurring between the virtual and the real, as if I had entered into zouhuorumo. I erotized myself, other people, and the world. I yearned to share my creative insights with others. These were favorable conditions for productions of inspirational creativity (Ho, 2016).

Creativity from a modified psychoanalytic perspective
From a psychoanalytic viewpoint, with repression vanished, the unconscious became accessible; my mind functioned with holistic oneness, interconnected. Superefficiency in memory retrieval and ideational association may then result from undoing or bypassing repression with ease, thus enabling me to gain unhindered, direct access to the unconscious, a condition for creativity as postulated in psychoanalytic theory. Such superefficiency has the effect of enhancing my esthetic, empathic, and cognitive capabilities. This conception may augment or even modify the psychoanalytic theory of creativity. It receives support from a recent study of highly creative individuals by Andreasen (2011): (a) Introspective accounts suggest that unconscious processes play an important role in achieving creative insights and (b) neuroimaging studies indicate that the association cortices are the primary areas activated during the state of "REST" (random episodic silent thought). Of special relevance to the notion of cognitive superefficiency is the finding that highly creative individuals have more intense activity in the association cortices when performing tasks that challenge them to "make associations".
It is important to distinguish between thoughts, words, and deeds in terms of impulse control, particularly when repression vanishes, as in my case, and access to the unconscious is unhindered. Impulses are harmless as long as they remain in the domain of thought. This is a fundamental viewpoint in psychoanalytic theory, in sharp contrast with Confucian ethics. According to Ho (1989): A contrast between the Confucianism and psychoanalysis is most explicit with regard to thought control. Psychoanalysis is predicated on the total eradication of all restrictions on thought: Nothing is unthinkable … Now, to dare to think the unthinkable is the fountainhead of creativity. Thought control suffocates it. (p. 7) And when nothing is unthinkable, there is no boundary to creativity.

Mental fatigue as a cost of cognitive superefficiency
There is, however, a price to be paid for creativity in madness: Mental fatigue is a prominent symptom that often prevents me from doing work requiring concentration for days. An additional observation is that mental fatigue becomes increasingly severe in later episodes. As I age, a decline in cognitive abilities, particularly short-term memory, is unmistakable in my normal daily life. Remarkably, this decline has no effect on superefficiency in memory retrieval or fluency in articulation during abnormal states. Oftentimes, everything seemed to have speeded up, in my thinking, talking, writing, responding to social cues, and so forth.
In the midst of a hypomanic episode, which, incredibly, occurred, while I was in the process of writing the present article, mental fatigue prevented me from serious writing for several weeks. So I indulged myself in playing the game of Weiqi (Go in Japanese, Baduk in Korean), without question the most complex board game ever invented, via an Internet website. Despite dedicated practice, I was never strong enough to attain the status of an advanced player. Though mentally tired, I was able to play Weiqi because the game requires focus on only one thing, namely, how to plan one's moves to win. One night, in a state of near mental exhaustion, I suddenly found myself able to recall what I had studied and seen the strategies of grand masters decades earlier. Then my skill improved by leaps and bounds, enabling me to compete with advanced players. There were many other similar, though less dramatic, experiences in memory recall (e.g. of events long past, what people had said or done but had forgotten themselves). All these constitute a convincing demonstration that superefficient retrieval of past learning and memory may occur during episodes (Ho, 2016).
Thus, mental fatigue and cognitive superefficiency both stand out as prominent features in my case. Cognitive superefficiency may be the mechanism underling a host of my first-hand experiences: physical symptoms such as fatigue and shaking chills; psychiatric symptoms such as talkativeness and flight of ideas (which I experienced as an "infinite association of ideas all at once"); cognitive symptoms such as heightened sensitivities and bursts of creativity.
A reading of Fatigue as a Window to the Brain (DeLuca, 2007) suggests a new avenue for understanding conditions such as those I have experienced. High energy consumption by the brain may result from hyperactive neural activity, involving probably the sympathetic autonomic nervous system. This hyperactivity may lead to superefficiency in memory retrieval and in forming remote semantic or conceptual associations, but at the cost of mental fatigue. My conjecture that mental fatigue may result from increased energy consumption by the brain during manic or hypomanic states has received empirical support: Proton magnetic resonance spectroscopy shows that acute manic patients have elevated glutamate/glutamine levels within the left dorsolateral prefrontal cortex (Michael et al., 2003). Yüksel and Öngür (2010) have reviewed the growing evidence for glutamatergic abnormalities in mood disorders from magnetic resonance spectroscopy studies. More generally, Kaidanovich-Beilin, Cha, and McIntyre (2012) claim that there exists an intimate link between the brain and sugar metabolism. Thus, the connection between metabolic disturbances and neuropsychiatric disorders has been strengthened by recent clinical studies.

Conclusion
The psychiatric literature is replete with studies showing cognitive deficits in patients suffering from mania or hypomania (e.g. Martínez-Arán et al., 2004). My intention is not to dispute the results of these studies, but rather to drawn our attention to the limitations of research based on the deficit model. First, we need to guard against overgeneralization, for there may well be a subset consisting of exceptional or atypical patients who show little or no deficits. More importantly, albeit relatively small in numbers, they are often among the more creative members of humanity. Second, alternative interpretations of findings concerning cognitive deficits should be entertained. A parsimonious interpretation is that the deficits result from the lack of sleep, rather than from mood elevation per se. A more plausible interpretation is that they result from not only sleep disturbance but also mental fatigue due to high energy consumption by the brain associated with hyperactive neural activity. Third, as in my case, the presence of cognitive disturbances does not necessarily preclude outpourings of creativity. My self-observations have provided some evidence in support of the contention that superefficiency in memory retrieval and ideational associations is a mechanism underlying creativity in euphoric states and, more generally, of viewing madness as creative energy.