Many analysts, such as American psychiatrist Dietrich Blumer, agree that one of the things Vincent van

Gogh suffered from was bipolar disorder. This mental illness builds up on itself and will grow stronger if
not treated.

here is no consensus on Vincent van Gogh's health. His death in 1890 is generally accepted to have been
a suicide. Many competing hypotheses have been advanced as to possible medical conditions from
which he may have suffered. These include epilepsy, bipolar disorder, borderline personality disorder,
sunstroke, acute intermittent porphyria, lead poisoning, Ménière's disease, schizophrenia,
schizoaffective disorder, substance use disorder, non-suicidal self-injury disorder "self-harm", and a
possible anxiety disorder.

bstract

Vincent van Gogh (1853–1890) had an eccentric personality and unstable moods, suffered from
recurrent psychotic episodes during the last 2 years of his extraordinary life, and committed suicide at
the age of 37. Despite limited evidence, well over 150 physicians have ventured a perplexing variety of
diagnoses of his illness. Henri Gastaut, in a study of the artist’s life and medical history published in
1956, identified van Gogh’s major illness during the last 2 years of his life as temporal lobe epilepsy
precipitated by the use of absinthe in the presence of an early limbic lesion. In essence, Gastaut
confirmed the diagnosis originally made by the French physicians who had treated van Gogh. However,
van Gogh had earlier suffered two distinct episodes of reactive depression, and there are clearly bipolar
aspects to his history. Both episodes of depression were followed by sustained periods of increasingly
high energy and enthusiasm, first as an evangelist and then as an artist. The highlights of van Gogh’s life
and letters are reviewed and discussed in an effort toward better understanding of the complexity of his
illness.

Vincent van Gogh’s life has become a legend. Within the short span of 10 years, he persevered to
overcome many struggles and failures to accomplish, through often feverish but always disciplined
efforts, his goal to create exceptional works of art for the people. This study of the illness of Vincent van
Gogh is based chiefly on Gastaut’s article on the topic (1), monographs about the artist (2–4), and van
Gogh’s own letters (5, 6).

The Life of van Gogh

Origins

Vincent van Gogh’s ancestry includes Dutch preachers, art dealers, and artisans. Both his father and
paternal grandfather were preachers; his paternal great-grandfather was a gold wiredrawer who also
was a catechism teacher. No incidences of mental illness are recorded among van Gogh’s ancestors. His
mother married at the age of 31, had a stillborn first son, and 1 year later gave birth to Vincent. Vincent
was a moody child, self-willed, and often annoying. At the age of 12, he was sent to a boarding school
for the next 4 years. A photograph of Vincent as an adolescent and later self-portraits suggest a
significant craniofacial asymmetry. Gastaut (1) submitted that this physical feature and early
temperamental changes suggest that Vincent had suffered an early brain injury, probably at birth. His
intense emotionality, which was evident early and became frequently unbearable in his adult life, is set
forth in his own statement: “I am a man of passion, capable and prone to undertake more or less foolish
things which I happen to repent more or less” (3).
Vincent had five younger siblings, three sisters and two brothers. The steadfast support of his brother
Theo made Vincent’s work possible; Theo died 6 months after Vincent’s suicide. After a failed marriage,
Cornelis, the youngest sibling, enlisted as a volunteer in the Boer army in South Africa; he may have
committed suicide or been killed in battle. The youngest sister, Wilhelmina, to whom Vincent wrote a
series of letters, was interned in a psychiatric asylum at the age of about 35, a few years after Vincent’s
death; she was said to suffer from schizophrenia and died in the asylum at the age of 79. His mother,
with whom Vincent exchanged occasional letters, lived to the age of 87, surviving not only her husband
but all of her sons. Her three sons all died in their 30s, while the three daughters lived into their 70s.

Failed Careers and Beginnings as an Artist

At the age of 16, Vincent began to work as an apprentice for an art dealer in a firm founded by an uncle.
After 4 years near his family in The Hague, he was transferred to London, where he stayed for 2 years.
During that time, he suffered a severe disappointment in his first amorous infatuation and became
deeply depressed. For months he remained gloomy, renounced any social life, and communicated little
with his family. His thoughts turned increasingly toward religion. As he became more passionately
involved in religion, he lost all interest in his job as an art dealer, the financial aspects of which he
disdained, and was dismissed by his firm. He devoted the next 4 years to his calling as a preacher. He
failed to obtain a formal theology degree and eventually worked as an evangelist in a miserably poor
mining district in Belgium. There, he shared his last belongings with his brethren and soon looked dirt
poor and black faced himself. His extreme charitable behavior was viewed by his superiors as
incompatible with the dignity of an ecclesiastic position. When he refused to moderate his deportment,
van Gogh was dismissed by the church; he again suffered a marked depression. To the great distress of
his parents, he abandoned the religious beliefs that had sustained him and began to adhere to socialist
ideals and agnostic views. “Though I have changed, I am the same,” he wrote in a letter to Theo (6). “My
only anxiety is, how can I be of use in the world?” At the age of 27, he resolved to become an artist with
the passion to produce works of art for the people.

Largely on his own, van Gogh pursued his new career with singular intensity. He was able to persevere in
spite of lack of recognition, thanks to the unfailing financial and moral support from his brother Theo,
who had become an art dealer in Paris. The life of van Gogh is well documented through a steady flow of
letters to Theo (5) and others (6). He experienced his second passionate and ill-fated infatuation with an
ardent and incredibly stubborn pursuit of his recently widowed cousin Kee, who scorned him. He then
alienated most of his family by living with a prostitute and her two children for over a year. Theo warned
Vincent that their father planned to put him in a lunatic asylum. After he returned to live with his
parents for a period, Vincent and his father quarreled frequently and violently. He painted Still Life With
Bible, in which next to an open bible was the novel La Joie de Vivre, written by the socialist and agnostic
Emile Zola. In 1885, his father died suddenly at the door of their home when returning from a walk.
Vincent’s devotion to art remained intense all the while.

Paris: Onset of Illness

After 6 years as an artist in the Netherlands and Belgium, Vincent joined Theo in Paris for 2 years (1886–
1888). There he met many painters who were to become famous, Paul Gauguin among them, and was
strongly influenced by the impressionist movement. While in Paris, he began to suffer from minor
paroxysms consisting of episodes of sudden terror, peculiar epigastric sensations, and lapses of
consciousness. Observers reported occasions of an initial tonic spasm of the hand and a peculiar stare,
followed by a confusional-amnestic phase. His use of absinthe, an alcoholic beverage with convulsant
properties favored by French artists, appears to have played a crucial role in the precipitation of van
Gogh’s illness. He tended to be untidy and quarrelsome; his irascible temper caused many unpleasant
scenes and rendered him an undesirable in a number of places. He lived with his brother and often kept
him up much of the night with endless disputes. Theo remained sympathetic, yet increasingly felt his
brother’s presence a burden. Theo described Vincent in a letter to their younger sister as follows: “It
seems as if he were two persons: one, marvelously gifted, tender and refined, the other, egotistic and
hard hearted. They present themselves in turns, so that one hears him talk first in one way, then in the
other, and always with arguments on both sides. It is a pity that he is his own enemy, for he makes life
hard not only for others but also for himself” (3). All along, Vincent persisted in perfecting his art.

Provence: A Major Illness Unfolds

When van Gogh left for Arles in southern France early in 1888, he was an accomplished artist, although
not recognized and still dependent on regular financial support from Theo, who believed in his genius.
He would now create perhaps the most intense paintings ever produced; yet in Arles his illness evolved
and reached psychotic dimensions for the first time before the end of 1888.

Vincent wrote after his arrival in Arles, “I was surely about to suffer a stroke when I left Paris. It affected
me quite a bit when I had stopped drinking and smoking so much, and as I began to think instead of
knocking the thoughts from my head. Good heavens, what despair and how much fatigue I felt at that
time” (5). Yet he soon resumed his former habits of using absinthe and cognac. He explained in a letter
how he was coping with his state of heightened emotionality: instead of thinking of disastrous
possibilities, he would throw himself completely into his work, and “if the storm within gets too loud, I
take a glass more to stun myself” (5). He became more disturbed. Feverish creative activity alternated
with episodes of listlessness to the point of exhaustion. Unpredictable mood shifts of dysphoria
alternating with euphoria or with “indescribable anguish” became more frequent. Excerpts of letters
written after his first breakdown best document his mental states that before had been present to a
lesser degree. “I am unable to describe exactly what is the matter with me; now and then there are
horrible fits of anxiety, apparently without cause, or otherwise a feeling of emptiness and fatigue in the
head.…and at times I have attacks of melancholy and of atrocious remorse” (6). “There are moments
when I am twisted by enthusiasm or madness or prophecy, like a Greek oracle on the tripod. And then I
have great readiness of speech” (5). He became more prone to violent rages and noticed an increasing
lack of sexual arousal. He frequently complained of feeling faint and of having “poor circulation” and a
“weak stomach.” He continued to write to Theo, often daily, reporting on the creation of his works in
precise detail. And he kept painting. When he announced to Theo his first painting of a starry night, he
wrote, “It is good for me to work hard. But that does not keep me from having a terrible need of—shall I
say the word—yes, of religion. Then I go out at night to paint the stars” (6). Indeed, in a zeal reminiscent
of his selfless efforts as an evangelist, he relentlessly devoted himself to create works of art for the
people.

Vincent felt lonely in Arles and with Theo’s help persuaded Gauguin to join him in the fall of 1888 to
establish together a “Studio of the South.” The relationship of the two artists became increasingly
quarrelsome, and Vincent wrote, “Our dispute is at times excessively animated like with electricity, at
times we end up with tired and empty heads, like an electric battery after discharge” (5). Gauguin’s visit
lasted only 2 months and ended in catastrophe. On Christmas Eve 1888, after Gauguin already had
announced he would leave, van Gogh suddenly threw a glass of absinthe in Gauguin’s face, then was
brought home and put to bed by his companion. A bizarre sequence of events ensued. When Gauguin
left their house, van Gogh followed and approached him with an open razor, was repelled, went home,
and cut off part of his left earlobe, which he then presented to Rachel, his favorite prostitute. The police
were alerted; he was found unconscious at his home and was hospitalized. There he lapsed into an
acute psychotic state with agitation, hallucinations, and delusions that required 3 days of solitary
confinement. He retained no memory of his attacks on Gauguin, the self-mutilation, or the early part of
his stay at the hospital.

His murderous gesture directed against Gauguin was reported by the intended victim in his memoirs.
The scandalous event in the house of prostitution and van Gogh’s subsequent hospitalization were
recorded in the local press. Some plausible explanations later were offered for the strange happenings.
Already psychotic, van Gogh may have carried out the attack on Gauguin driven by hallucinatory
command voices and may have cut off part of his own ear in self-punishment for his offensive voices.
This psychotic logic was perhaps influenced by van Gogh’s knowledge of the bullfight ritual, in which the
matador presents a cut-off ear of the killed bull to a fair lady of his choice.

At the hospital, Felix Rey, the young physician attending van Gogh, diagnosed epilepsy and prescribed
potassium bromide. Within days, van Gogh recovered from the psychotic state. About 3 weeks after
admission, he was able to paint Self-Portrait With Bandaged Ear and Pipe, which shows him in serene
composure. At the time of recovery and during the following weeks, he described his own mental state
in letters to Theo and his sister Wilhelmina: “The intolerable hallucinations have ceased, in fact have
diminished to a simple nightmare, as a result of taking potassium bromide, I believe.” “I am rather well
just now, except for a certain undercurrent of vague sadness difficult to explain.” “While I am absolutely
calm at the present moment, I may easily relapse into a state of overexcitement on account of fresh
mental emotion.” He also noted “three fainting fits without any plausible reason, and without retaining
the slightest remembrance of what I felt” (5, 6).

After 2 weeks in the hospital, van Gogh was still followed by Dr. Rey but evidently was not sufficiently
warned to abstain from absinthe. He suffered another two psychotic episodes with brief
hospitalizations. Following the humiliation of being taunted publicly by juveniles and confined to the
hospital for the fourth time upon the demand of concerned citizens, van Gogh voluntarily entered the
asylum at Saint-Rémy in May 1889. During the full year he remained there, he experienced three
psychotic relapses with prominent amnesia, at least twice upon leaves to Arles with resumption of his
use of absinthe in the company of old friends and Rachel. Dr. Peyron, an old-fashioned physician who
had served in the French navy, was the medical director at Saint-Rémy; he maintained Dr. Rey’s
diagnosis of epilepsy but failed to continue treatment with potassium bromide. The last psychotic
episode was the most protracted, lasting from February to April 1890; van Gogh experienced terrifying
hallucinations and severe agitation. Upon recovery, he complained bitterly of the religious content of his
episodes and wished to get away from the nuns who cared for him. While at Saint-Rémy, he produced
some 300 works of art, among them several copies of religious scenes by older masters and the
transcendental masterpiece Starry Night, which was painted in June 1889.

Auvers: The Suicide

Theo became engaged toward the end of 1888, married 4 months later, and became a father in early
1890. Each event coincided with an exacerbation of van Gogh’s condition; he may have been drinking
more whenever he felt that his unique bond with Theo was threatened. Shortly before entering the
asylum at Saint-Rémy, Vincent had written to his brother, “And without your friendship I would be
driven to suicide without pangs of conscience—and as cowardly as I am, I would finally do it” (6). Theo
had continued to support his brother without fail. Suicidal gestures by Vincent, reported at the time of
his initial hospitalization in Arles and during his stay at the asylum, had consisted of ingesting turpentine,
paint, or lamp oil and were carried out in a confusional state. Such an episode was described by the
painter Signac (who had been permitted to take van Gogh from the hospital in Arles to visit his studio).
Signac described van Gogh as being entirely rational until after suffering a minor attack, at which point
he put a bottle of turpentine to his mouth and had to be brought back to the hospital.

At discharge from the asylum in May 1890, van Gogh was judged cured by his physician. The artist then
moved north of Paris to Auvers-sur-Oise, where he spent the last 10 weeks of his life. Theo had
recommended Auvers, where van Gogh could live near Paul Gachet, a physician and friend of the artists.
He abstained from drinking by now and remained free from seizures and confusional episodes. His art
was beginning to gain recognition, and a painting had been sold. But further financial support became
uncertain as Theo’s health began to fail. There were some bitter words between the brothers, and
Vincent felt himself to be a burden. Still, he worked at a furious pace, completing 70 paintings and 30
drawings during his 70 days at Auvers. The heavenly bodies, so luminous in the past, now were absent
from his skies, except for a single peculiar occasion (The White House at Night With Figures and a Star).
He painted immense fields of wheat under dark and stormy skies, commenting, “It is not difficult to
express here my entire sadness and extreme loneliness” (6). In one of his last paintings, Wheat Field
With Crows, the black birds fly in a starless sky, and three paths lead nowhere. He borrowed a gun from
his innkeeper “to scare the crows away” when he was painting. There still was another episode of fury
directed at Dr. Gachet, who had failed to frame a painting by Guillaumain as van Gogh had demanded.
Vincent gestured toward the gun in his pocket, but he walked away. In his last letter sent to Theo, he
mentioned that he wanted to replenish his stock of paint and asked for help to this end. Three days
later, on a Sunday, Vincent shot himself in the lower chest or upper belly in a field outside Auvers. “I
couldn’t stick it any longer, so I shot myself,” he told a friend (3). He died 2 days later with Theo next to
him. It has been assumed that his Field With Stacks of Wheat, a bright picture of grain harvested and
sheaved, may have been his very last—a symbol of work completed (3).

Theo died 6 months after his brother, reportedly from a kidney disease with uremia and a prolonged
delirious state. His widow made sure the treasure of art Theo had collected from Vincent and kept
mostly unframed in their home was passed on to posterity. Within a few years after his death, Vincent
van Gogh was acknowledged as one of the famous artists of modern times.

Epilogue

An analysis of van Gogh’s illness and emotionality must not obscure the fact that the great artist also
had great strengths (4). Apart from distinct episodes of madness when he used absinthe and had
seizures, he maintained a remarkable degree of lucidity during his stormy life, as is well documented in
his letters.

Vincent remained marvelously creative until his death. He did not paint during his major crises except
during the last prolonged episode at Saint-Rémy. There he painted, before full recovery, a few canvases
from memory, which he referred to as “reminiscences of the North.” Jan Hulsker (3) pointed out that
these paintings are the only works of his entire voluminous oeuvre to show signs of a transient mental
collapse.

Almost invariably, van Gogh drew and painted from nature. The influence of his exceptional emotional
and spiritual intensity on his art is most evident when van Gogh deviated from the depiction of natural
scenes, particularly in the rendering of the sky, in several of his masterpieces. He had confessed to a
“terrible need for religion” when he painted his first picture of a starry night (over the river Rhone) in
September 1888. Starry Night, painted in June 1889 at Saint-Rémy, is undoubtedly van Gogh’s most
mysterious picture. The artist, usually so verbal, never revealed the origin of his scene of a spectacularly
transfigured sky. Tralbaut (2) commented on Starry Night, “The fire that smoldered within him and
broke out in hallucinations of the senses has here been set down on canvas in a most striking fashion.”
With this painting, van Gogh may have immortalized his memory of a particularly haunting and perhaps
recurrent vision of apocalyptic dimension experienced during a twilight state. The vision is set in the
familiar surroundings of the soft hills and flame-shaped cypresses of Provence, and yet the village with
its church spire is reminiscent of van Gogh’s native Brabant. He seems to be telling us, “This is where I
come from, this is where I am now, and here is my universe of overpowering storms.”

Discussion

The illness of van Gogh has perplexed 20th-century physicians, as is evident from the nearly 30 different
diagnoses that have been offered, from lead poisoning or Ménière’s disease to a wide variety of
psychiatric disorders. Many writers have acknowledged the epilepsy but considered the psychiatric
disorder an independent mental illness. Monroe (7, 8) recognized the unique episodicity of van Gogh’s
mental changes, the role of absinthe in his illness, and an underlying epileptoid limbic dysfunction that
was associated with his creativity but also, if overly intense, would render him ill. Earlier, in an
exceptionally well-documented study, Gastaut (1) reasoned that the artist’s psychiatric changes were
based on temporal lobe epilepsy produced by the use of absinthe in the presence of an early limbic
lesion.

Earlier in his life, van Gogh experienced two prolonged episodes of reactive depression. Both episodes
were followed by a prolonged period of hypomanic or even manic behavior: first as evangelist to the
poor miners in Belgium and then as the quarrelsome and overly talkative artist in exciting Paris. The
major illness of his last 2 years developed in the presence of seizures, and its nature has remained
controversial. The known details of his psychiatric illness will be reviewed together with what is known
about the psychopathology of individuals with epilepsy, and differential diagnostic considerations will
follow.

Views of Gastaut and the Earlier French Physicians

Felix Rey, the young physician who attended van Gogh in Arles and diagnosed his epilepsy, was familiar
with the psychiatric aspects of epilepsy as they were taught in France during the second half of the 19th
century. In fact, Aussoleil, a medical school companion of Felix Rey, wrote a dissertation on larvate
epilepsy and worked nearby when van Gogh was admitted to the hospital in Arles (1). In 1860,
Morel (9) listed the symptoms that were to be so prominent in van Gogh’s illness:

Under the term larvate epilepsy I have described a variant of epilepsy which does not reveal itself by the
actual minor or major attacks, but on the contrary by all the other symptoms which accompany or
precede ordinary epilepsy characterized by seizures, that is: periodic alternation of excitement and
depression; manifestations as it were of sudden fury without sufficient grounds and for most trivial
reasons; a usually most irritable disposition; amnesia, as usually occurs in epilepsy, of dangerous acts
carried out during momentary or transient rages. Some epileptics of this type have even experienced
genuine auditory and visual hallucinations.

Morel had already recognized the highly conscientious (hypersocial) disposition of such patients that
contrasted strikingly with their proneness to outbursts of violent anger.

Gastaut (10) pointed out that premodern psychiatrists who had studied institutionalized patients with
epilepsy chiefly had observed individuals with mesial temporal sclerosis, as documented by their
neuropathologic studies. His findings linked premodern psychiatric views of epilepsy to modern
epileptology. Gastaut published his study of van Gogh in 1956, after he had conducted a series of
investigations on carefully selected groups of patients with different forms of epilepsy. He documented
that certain behavioral and emotional changes among patients with epilepsy were specifically related to
mesial (limbic) temporal lobe epilepsy: episodic irritability contrasting with an otherwise hypersocial
disposition, slow-adhesive (viscous) personality traits, and a global hyposexuality (11–13). This temporal
lobe syndrome associated with epilepsy was manifest in van Gogh.

Gastaut pointed out that the three major interictal behavior changes of patients with mesial temporal
lobe epilepsy—heightened emotionality (with enhanced anger, moods, and fear), viscosity
(adhesiveness), and hyposexuality—represent the very opposites of the Klüver-Bucy syndrome observed
after bilateral temporal lobe resections in animal experiments—placidity, flighty attention span, and
hypersexuality (14, 15). He noted that this was not a surprising finding considering that interictally,
because of the effects of the irritative lesion, patients with temporal lobe epilepsy present a state of
excitation of the temporal limbic system as opposed to a state of depression after the ablation
experiment. While viscosity and hyposexuality tend to be relatively persistent, the heightened
emotionality tends to appear in a highly labile or alternating pattern.

Gastaut recognized the crucial role of absinthe in the manifestation of van Gogh’s major psychiatric
symptoms. By his own confession, van Gogh required “a glass too much” to numb his inner storms when
they became too intense. The artist was not known to become intoxicated and may not have been
drinking more than many of his contemporaries, but he was particularly vulnerable to the epileptogenic
properties of absinthe, the favorite drink of the French artists of his time. Oil of wormwood (from the
herb Artemisia absinthium) constitutes the toxic principle of the alcoholic drink absinthe. Wormwood oil
contains the terpene compound thujone, a structural isomer of camphor. Both thujone and camphor
induce convulsions and were used during the 1920s and 1930s in the study of models for epilepsy; von
Meduna considered the use of thujone for the convulsive therapy of schizophrenia before using
camphor (16, 17). In 1873, Magnan (18) described for the first time what he termed épilepsie
absinthique, and later neurologic textbooks of the period referred to the relationship of absinthe and
epilepsy. In the early part of the 20th century, absinthe became outlawed in most countries because of
its psychotoxic effects.

During his stay in Paris, where he was introduced to absinthe, van Gogh developed complex partial
seizures with gradual accentuation of partially preexisting emotional and behavioral changes. In most
patients with temporal lobe epilepsy, psychiatric changes tend to occur only gradually and in a less
violent form. In van Gogh, perhaps because of an early temporal-limbic lesion, these changes became
fully evident soon, characterized by heightened emotionality with the opposite poles of irritability and
hyperethical or hyperreligious trends, by meticulous attention to detail and stubborn persistence in
speech and writing (viscosity), and by hyposexuality (11–13). His seizures and his psychotic episodes
were precipitated by the use of absinthe and stopped once he abstained.

Modern Concepts of the Neuropsychiatric Disorders of Epilepsy

The presence of seizures, the intermittent and pleomorphic symptoms of the interictal phase, the
prolonged amnestic-confusional psychotic episodes at the height of van Gogh’s illness, and, finally, the
profile of his personality traits all suggest a diagnosis of epilepsy-related illness.

While in Arles, van Gogh developed an interictal dysphoric disorder with the near complete range of its
intermittent and pleomorphic (affective-somatoform) symptoms: irritability, depressive and euphoric
moods, anxiety, anergia, insomnia, and pains. The artist probably also had a fear of heights, but phobic
symptoms cannot be considered a well-established symptom of dysphoric disorder. Interictal dysphoric
disorder was well recognized by premodern psychiatrists from the German language area as the most
common psychiatric disorder (Verstimmungszustand) associated with epilepsy (19, 20). The validity and
the importance of this diagnostic concept have been affirmed (21–24). At least three of its seven
symptoms need to be present, each to a troublesome degree, to meet the diagnostic criteria for
interictal dysphoric disorder. In his letters, van Gogh referred to his dysphoric symptoms as “attacks of
melancholy,” “moments of enthusiasm or madness,” “fits of anxiety,” or a transient “feeling of
emptiness and fatigue,” rendering a lucid picture of highly episodic mental states that clearly are more
intermittent and pleomorphic than those experienced by an individual with the more sustained mood
changes of manic-depressive illness. He also reported insomnia and stomach pains but was not
outspoken about his frightening outbursts of rage, which were well documented by Gauguin and many
others. While his stomach pains are of uncertain origin, van Gogh clearly reported six of the seven
cardinal symptoms of interictal dysphoric disorder.

Interictal dysphoric disorder, not recognized in its entirety by Gastaut, represents a refinement of the
description by early French psychiatrists that included only the most striking features of the disorder:
periodic alternation of excitement and depression and episodes of fury (9). The validity of interictal
dysphoric disorder as a diagnostic entity is confirmed by its specific etiology, phenomenology, course,
and its response to specific psychotropic medication (24, 25). The disorder tends to appear interictally
during predominance of seizure-suppressing inhibitory mechanisms. This phenomenon was termed
“forced normalization” by Landolt, who observed that dysphoric moods, as well as psychotic episodes,
tend to be associated with EEG normalization (26, 27). Dysphoric symptoms also tend to be present in
the prodromal and particularly in the postictal phase, when they seem to result from the acute
engagement of inhibitory responses at the time of seizure events. It is assumed that still poorly defined
inhibitory mechanisms exert psychotoxic effects in both the interictal and the peri-ictal phases of
epilepsy (23, 24).

Severe dysphoric disorders may become readily associated with psychotic symptoms (19, 20, 28). At the
height of his illness, van Gogh became hallucinatory, paranoid, and delusional with confusional-amnestic
features, all known to occur in psychosis due to epilepsy. Psychosis due to epilepsy may follow a flurry of
seizures (i.e., postictal psychosis), appearing often but not invariably with amnestic-confusional features.
Alternatively, the psychosis may occur during the interictal phase, in the absence of clouded
consciousness, particularly when seizure activity has become suppressed. In both instances, psychosis,
like the dysphoric symptoms, seems to result from excessive inhibitory activity that has become either
acutely engaged in the postictal phase by the preceding seizure activity or predominant in the interictal
phase. A third type of epilepsy-associated psychosis, termed para-ictal psychosis (29), occurs with
ongoing frequent seizure activity and combines features of both the postictal and the interictal
psychoses; this type of psychosis is now rare because of the advent of effective antiepileptic medication.
The psychotic symptoms seen in van Gogh apparently were precipitated by the epileptogenic absinthe,
but no modern experience with this substance exists. From what is known, his psychotic episodes
neither followed a flurry of seizures nor occurred at times when his seizures had diminished, and his
prolonged psychotic episodes may be best classified as para-ictal. While interictal psychoses require
psychotropic medication, para-ictal psychoses respond to improved antiepileptic medication (28), and
van Gogh was probably correct when he recognized a beneficial effect on his psychosis from Dr. Rey’s
prescription of potassium bromide. Recurrences followed the initial episode, when he relapsed into
using absinthe, and were perhaps more prolonged when he was not treated with potassium bromide
during his year in the asylum.

There has been fair agreement among experts about the personality traits observable among patients
with epilepsy (19, 20, 30–33). Vincent’s viscosity was manifest by his intense clinging to people he loved,
his persevering on details, and a tendency to debate endlessly and to write excessively. Gastaut viewed
viscosity as the characteristic core trait of an individual with temporal lobe epilepsy (11, 13). Gastaut
also pointed out how van Gogh’s hypersocial, spiritual, and even hyperreligious personality contrasted
sharply with his episodes of anger to the point of fury (1), a conflict that other authors have considered
the dynamic core issue in patients with epilepsy and heightened emotionality (34).

Before becoming an artist, van Gogh had been devoted to a religious career for years and had served as
an utterly selfless evangelist; religious motives later reemerged in his artwork. Yet his episodic rages are
well documented, became notorious once he used absinthe, and reached a peak with his acute illness
and the murderous gesture directed at Gauguin. He represents an example of the heightened conflict
between fury and atonement—good and evil forces—that has so often been noted among individuals
afflicted with epilepsy. Paroxysmal episodes of irritability to the point of rage on the one hand and a
(remorseful) highly ethical, selfless, helpful, and often hyperreligious disposition on the other had been
noted by observers before Gastaut, from Morel and Kraepelin to Freud and Szondi.

In his essay “Dostoevsky and Parricide,” Freud (35) rendered a coherent picture of the contradictory
personality of this great author who had epilepsy. Elements seen in Dostoevsky’s life and novels
included experiencing the threat of repeated uncontrollable acts of violence, feeling guilt and the need
for atonement, seeking forgiveness and help from God, attempting to adhere to a strict moral code, and
proving oneself to be the mildest, kindest, most helpful person possible. In Szondi’s genetically based
system of human drives (24, 34, 36), the tendency to accumulate and discharge crude affects (anger,
hate, vengeance, envy, or jealousy) is paired with the opposite tendency to make amends (repentance,
tolerance, kindness, helpfulness, or piety). These two tendencies determine ethical behavior and appear
most pronounced in epilepsy.

Suicidal attempts infrequently may be carried out in a state of acute postictal depression (37, 38). The
artist’s earlier suicide attempts probably had been of this nature and were not consciously planned. In
patients with interictal dysphoric disorder, the moods of euphoria tend to be brief, their depressive
moods more prominent. With the latter comes a suicidal risk that is 4–25-fold higher among patients
with epilepsy over the rate in the general population and is particularly associated with chronic temporal
lobe epilepsy (39). Suicide tends to occur, peculiarly, at a time when a long-standing seizure disorder has
been brought into remission and often comes as a surprise (37, 40).

Supported by his brother Theo, van Gogh had lived for his art. Theo was the one person in his life who
had faith in Vincent’s extraordinary accomplishments and had been, in fact, the lifeline throughout his
career as an artist. With Theo’s support threatened, the storm within became less bearable. When
considering the forward-looking tone of his last letter to Theo, Hulsker had no doubt that the suicidal act
resulted from a momentary impulse (3). For the last few months of his life, van Gogh had abstained
from absinthe and was free from both seizures and psychosis. Depressive moods were more prevalent,
although not persistent. His productivity had been unbroken in Auvers, and his suicide was not
anticipated by those who knew him. It seems to have occurred with a final attack of melancholy,
resulting from a still persistent dysphoric disorder. One needs to remember, however, that van Gogh
had experienced marked depressive episodes before his seizure disorder.

Differential Diagnostic Considerations

Several authors have offered a tentative diagnosis of schizophrenia for van Gogh. In view of both the
absence of any of the fundamental symptoms of the disorder and the presence of psychotic episodes
with amnestic-confusional features and complete recovery, this diagnosis appears improbable, in spite
of the fact that late-onset schizophrenia was diagnosed in one of his sisters.

The diagnosis of neurosyphilis has to be considered in view of van Gogh’s lifestyle (he was treated for
gonorrhea in 1882), the prevalence of the disease at the time, and its diverse symptoms. However, none
of the relatively specific symptoms of the disease was ever noted. Above all, this diagnosis is unlikely,
since he did not show any persistent impairment of mental or somatic functions.

Following two major disappointments (an unrequited early love and a failed career as an evangelist), van
Gogh clearly experienced prolonged episodes of depression; both events preceded major career
changes. He also experienced sustained periods of hypomania or mania. His career as an evangelist
ended when he developed a sort of altruistic religious mania. A bipolar history of prolonged periods of
extremely high levels of energy, enthusiasm, and productivity alternating with episodes of depression is
not uncommon among writers and artists, and the hypomanic phase is often not identified (41). The
artist’s increasingly elevated mood during his exciting stay in Paris probably was a factor in his use of
absinthe, the substance that precipitated his second major illness.

Vincent experienced seizures only after his use of absinthe with its convulsant property. He never
experienced generalized seizures but had only partial seizures, suggesting the presence of a latent
epileptogenic zone, most likely in the mesial-temporal area, that was activated by his use of absinthe. As
postulated by Gastaut, a perinatal brain lesion may have resulted in van Gogh’s severe reaction to
absinthe: the partial seizures, the marked interictal dysphoric disorder, and the psychotic episodes with
prominent amnesia. When he became increasingly ill during the last 2 years of his life, van Gogh did not
experience any of the sustained mood changes characteristic of bipolar disorder. Instead, he
experienced sudden and brief changes of depressive mood, elation, anxiety, or fury, and his intense
artistic efforts were frequently disrupted by episodes of listlessness; these intermittent pleomorphic
changes developed after onset of seizures and are specific for the dysphoric disorder of epilepsy.
While interictal dysphoric disorder and psychosis tend to become manifest after an interval of years
following onset of epilepsy, there are also patients with dysphoric or epileptoid traits in the absence of
overt seizures; these patients often have identifiable subtle brain lesions (24, 42). The existence of an
epileptoid temperament analogous to schizoid or cyclothymic temperaments, before or independent of
the respective major illness, was often debated in the premodern psychiatric literature when epilepsy
was a major topic (20). The early intense emotionality of van Gogh, with the contrasting poles of
explosive irritability on the one hand and goodness and religiosity on the other, may be considered an
expression of this temperament independent from his cyclothymic disposition.

Vincent van Gogh’s suicide may have been an unexpected event, perhaps precipitated by a dysphoric
mood; remission of the seizures may have favored the final depressive event. But when he had
recovered from his severe illness upon discharge from the asylum, the support from his brother, upon
whom he had depended totally for his career as an artist, had become seriously threatened. Although
the artist had been able to remain productive, a depressive mood had become more evident. In the
past, he had reacted to crucial losses with marked depression, and this illness probably was the main
factor in his death.

Received Feb. 16, 2001; revisions received June 4, July 19, and Aug. 30, 2001; accepted Sept. 5, 2001.
From the Department of Psychiatry, University of Tennessee Health Science Center. Address reprint
requests to Dr. Blumer, Department of Psychiatry, University of Tennessee Health Science Center, 135 N.
Pauline St., Suite 633, Memphis, TN 38105. The author thanks David Armbruster, Ph.D., for editorial
assistance.
 VINCENT VAN GOGH'S
BIOGRAPHY: MENTAL HEALTH
Hundreds of physicians and psychiatrists have tried to define Van Gogh's medical conditions over the years.
The following are some of the more probable mental and physical diagnoses.
Temporal Lobe Epilepsy

Van Gogh suffered from seizures which doctors, including Dr. Felix Rey and Dr.
Peyron, believed to be caused by temporal lobe epilepsy. Van Gogh was born
with a brain lesion that many doctors believe was aggravated by his prolonged
use of absinthe causing his epileptic condition. Dr. Gachet, another of Van
Gogh's physicians, was thought to have treated his epilepsy with digitalis. This
prescription drug can cause one to see in yellow or see yellow spots. This may
have been one of the reasons why Van Gogh loved this color.

Bipolar disorder

Due to Van Gogh's extreme enthusiasm and dedication to first religion and then
art coupled with the feverish pace of his art production many believe that mania
was a prominent condition in Van Gogh's life. However, these episodes were
always followed by exhaustion and depression and ultimately suicide. Therefore,
a diagnosis of bipolar disorder or manic depression makes sense with the
accounts of these episodes in Van Gogh's life.

Thujone poisoning

In order to counter act his attacks of epilepsy, anxiety, and depression, Van
Gogh drank absinthe, a toxic alcoholic drink popular with many artists at the
time. Thujone is the toxin in absinthe. Unfortunately, the Thujone worked against
Van Gogh aggravating his epilepsy and manic depression. High doses of thujone
can also cause one to see objects in yellow. Various physicians have differing
opinions on whether or not this is what caused Van Gogh's affinity with yellow.

Lead poisoning

Because Van Gogh used lead based paints there are some who believe he
suffered from lead poisoning from nibbling at paint chips. It was also noted by Dr.
Peyron that during his attacks Van Gogh tried to poison himself by swallowing
paint or drinking kerosene. One of the symptoms of lead poisoning is swelling of
the retinas which can cause one to see light in circles like halos around objects.
This can be seen in paintings like The Starry Night.
Hypergraphia

Hypergraphia is a condition causing one to need to write continuously; this

Sunstroke

Because Van Gogh strived for realism in his paintings he was often painting
outdoors especially during his times in the South of France. Some of his episodes
of hostility and the nausea and "bad stomach" he refers to in his letters may
have been the effects of sunstroke.