An Authentic Portrait of a Manic Episode From the Artistic Perspective of a Patient With Bipolar Disorder

Painting is a piece of visual art, which can be defined as an attempt to express any kind of real or surreal content on a two-dimensional plane using the visual elements; for example, colors or shapes. Whereas the contemplation and manner of painting varied according to alternating art movements throughout history, the “human touch” of illustrated design has always been appraisable regardless of the dominating trend. By daily flourishing the intersection of art and science, painting has started to gain another perspective; a promising scientific material regarding human things; specifically the mind and the mood. Mood, as an ongoing emotional state, is a key part of the human mental condition. Since art is inherently tied to human emotions, it cannot be separated from mood. Recent studies highlight the growing focus on scientific interpretations of artists' moods through their work. For instance, color scales are increasingly used as tools to analyze an artist's mood by way of theoretical and mathematical models [1, 2]. Additionally, contemporary research explores tracking mood changes through painting cues, emphasizing features beyond colors and advocating for more evidence-based approaches [1, 2]. In this case, we present an exposition of a patient's mood alterations. The patient suffers from bipolar disorder (BD), with the representations of her own scratches during the period of her manic episode. A 20-year-old woman (referred to as Patient E for anonymity), a visual and graphic design student, was referred to our center due to her acute agitation at her dormitory, where she resided during her undergraduate studies. According to the consultation notes, Patient E was diagnosed with bipolar disorder (BD) 2 years ago and had been treated with valproate until she recently refused to take her medication. It was reported that she had been experiencing difficulties due to a hostile attitude shown toward her dormmates, absenteeism from classes, and frequent, irrelevant chattering over the past few days. In our mental status examination, Patient E's mood was euphoric with an irritable, vigilant affect. Her responses were easily distractible, and her thought content displayed grandiosity and mild persecution, such as claiming to be a polyglot, a wealthy CEO, and being targeted by organized gangs for her secrets. Her speech was rapid and loud. After obtaining written informed consent, she was hospitalized with a preliminary diagnosis of a manic episode of BD. She declined valproate due to its teratogenic risk, despite not planning a pregnancy. Instead, lithium and olanzapine were prescribed to manage the manic episode. In our psychiatric wards, fully oriented patients can participate in occupational activities, with drawing and painting being the most popular. These allow clinicians to assess their patients' thought content, cognitive function, and treatment response. Patient E shared her artwork daily until discharge. With her written consent, key pieces were collected to illustrate her changing mental state artistically. During Patient E's clinical course, her artwork was roughly categorized into three phases. In the first week of hospitalization, she exhibited manic symptoms, including a flight of ideas, pressured speech, and hypervigilance, making sustained communication nearly impossible. She filled every available paper with numerous figures, often sharing them during daily visits. However, these works were dominated by repetitive scribbles, incoherent symbols, and irrelevant ideological themes, making consistent interpretation challenging. The sheer volume of her drawings was overwhelming, allowing only the most demonstrative pieces to be displayed. By the second week of treatment, Patient E showed considerable improvement in her thought processes, with more understandable speech, though it remained excessive in tone and amount. She continued to have grandiose and persecutory delusions related to art, politics, and religion. Her artworks featured fewer scribbles, more stressed straight lines, and a selective choice of materials. Notable recurring themes included interwoven fish, religious symbols like mosques and Arabic letters (interpreted as Islamic signs, as she identified as Muslim but did not know Arabic), a fire-breathing dragon (similar to that in reference [3]), and half-stained female silhouettes. After a couple of weeks, Patient E's mood stabilized further. The figures she chose from daily life were seen as a reflection of her transition from a manic and a euphoric state to reality. The delusional content and pressured speech diminished. The colors, lines, and compositions in her artwork became more distinctive, with notable changes such as multi-dimensional drawings demonstrating depth perception. Close to discharge, Patient E only drew when requested by clinicians or peers. She expressed satisfaction with her work and herself. Feeling ready for discharge, she and the clinician agreed on her status. At her follow-up, she provided written consent to use her materials for scientific publication. Bipolar disorder exhibits a high clinical heterogeneity in its manifestation and course, requiring patient-specific approaches. Exploring each patient's strengths and weaknesses helps tailor treatment and monitor progress closely. In this case, Patient E's interest in the visual arts allowed daily observation of her mental state and treatment response. The authors aim to discuss “the creativity” in interpreting her artwork. Although associated with novelty and authenticity, “creativity” lacks a universally accepted definition and operationalization. Among various paradigms, divergent thinking tasks provide valuable insight into originality, fluency, and flexibility of creation [4]. While quantifying creativity enriches the literature, individuals like Anne Sexton, Vincent van Gogh, and Robert Schumann transcended scientific limits with their artwork. Notably, these individuals shared a common trait: highly fluctuating moods. This raises the question, “Could mood fluctuations contribute specifically to their creativity?” Biographical studies have suggested that the aforementioned artists may have suffered from BD, which is believed to have contributed to their creativity. These examples brought the scientists closer to the ‘Mad Genius’ concept and forced them to understand, in turn to explain, the linkage between psychopathology and creativity [4, 5]. Recent studies on this issue confirm that creativity in (hypo-)manic episodes of BD is extremely common [5]. As Forthmann et al. [4] clarify, an inverted U-shaped model seems valid between creativity and BD. This means that a divergent thinking performance is anticipated to reach its highest point at a mild, subclinical level of BD, while both individuals with no symptoms of BD and those with severe symptoms are expected to perform at lower levels [4]. Therefore, as mentioned earlier, the clinical heterogeneity of BD hampers analyzing creativity by quantitative methodologies. In this case, Patient E gave a chance to us to follow her mood and cognitive functionality through her creative artworks. As well as the colors, the amount, and the content she preferred while depicting, the technical drawing and depth perception she added into her artwork might be an observable clue indicating a recovery in cognition during her clinical progression. In this regard, the chronological set-up of Patient E's artistic output is presenting a poetry in motion, regarded as how a manic episode transforms within several weeks (Figure 1). The data that support the findings of this study are available from the corresponding author upon reasonable request.