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A reappraisal of the possible seizures of Vincent van Gogh
Epilepsy & Behavior 6 (2005) 504–510 www.elsevier.com/locate/yebeh
Review
A reappraisal of the possible seizures of Vincent van Gogh John R. Hughes * Department of Neurology, University of Illinois at Chicago, Chicago, IL 60612, USA Received 24 February 2005; revised 24 February 2005; accepted 24 February 2005 Available online 6 April 2005
Abstract The tragic life of Vincent van Gogh is summarized, emphasizing his early departure from formal education, failure as a successful salesman in the art world, attempt at religious studies, difficulty with female and family relationships, return to the art world, and tendencies toward extremes of poor nutrition or near self-starvation and excessive drinking and smoking. In Paris he joined the Impressionists, but drank very heavily both absinthe and cognac. Southward he went to Arles and was joined by Paul Gauguin, with whom he had major personality problems, causing van Gogh to cut off part of his left ear. He experienced paranoid ideation and confinement in mental institutions in Arles, and then returned to Paris and onto Auvers-sur-Oise, where he committed suicide at age 37. Possible physical diagnoses include glaucoma, Me´nie`reÕs disease, acute intermittent porphyria, and chronic lead poisoning, but these diagnoses seem unlikely. Possible psychiatric diagnoses include borderline personality disorder, anxiety–depressive disorder with episodes of depression and hypomania, and also paranoid schizophrenia. Van Gogh did not have spontaneous seizures and, therefore, did not have epilepsy. Before he began to drink heavily, when he was near starvation, he had ‘‘fainting fits,’’ and after drinking, especially absinthe, a convulsant drug, he continued to have similar attacks. His episodes of unconsciousness can be well explained by chronic malnutrition and alcohol abuse, only possibly exacerbated by drinking large quantities of absinthe. Although van Gogh is an excellent example of the Geschwind syndrome, at times associated with temporal lobe epilepsy, this fact does not establish such an epilepsy. Thus, the syndrome is an orphan without the parent condition. Ó 2005 Elsevier Inc. All rights reserved. Keywords: Epilepsy; Seizure; Fit; Absinthe; Starvation; Alcohol; Borderline personality disorder; Depression; Hypomania; Fainting; Fits
1. Summary of Vincent van GoghÕs life Vincent van Gogh was born on March 30, 1853, exactly 1 year from the day his mother had given birth to her first child, also named Vincent, who died at a few weeks of age. This coincidence led to speculation that the second Vincent may have been later troubled by being the ‘‘replacement child.’’ His father was Theodorus, pastor of the Dutch Reformed Church, and his mother was Anna Cornelia Carbentus. Vincent attended a boarding school for 2 years and then a secondary * Present address: Department of Neurology, University of Illinois Medical Center (M/C 796), 912 South Wood Street, Room 862N, Chicago, IL 60612, USA. Fax: +1 312 996 4169. E-mail address: [email protected].
1525-5050/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2005.02.014
school for 2 more, leaving his studies at age 15, never to return to formal education. As uncles Vincent and Cornelis were art dealers, he went to work for the art dealer firm of Goupil in The Hague (The Netherlands), remaining there for 7 years. He was transferred to the London branch, where he stayed for 2 years, and then to the Paris branch of that same firm. He was not a successful salesman, at times insulting the customers by telling them their purchases were poorly chosen. At 23 years of age, unsuccessful as a salesman, he decided to leave the art world and return to England and taught at a religious school; during that summer he experienced a deep religious transformation of his own. He visited his family in The Netherlands over Christmas that year and decided to remain there, working only briefly in a bookshop. In May of the next year
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he tried to prepare himself for the examination for admission to the local university to study theology, but abandoned his preparatory studies after 15 months. Later, he failed to qualify for a mission school and then decided on a trial period of preaching in a poor coal mining district in Belgium. Vincent sympathized with the dreadful working conditions of the miners, giving away most of his food and clothing to these povertystricken miners. The Church disapproved of van GoghÕs asceticism and dismissed him from his post after 6 months. After all of his many positions, hopes, and dreams were unfulfilled, van Gogh began to behave oddly. For example, he decided to visit a French painter (Breton) he admired. As he had only 10 francs, it took him 3 days to walk the entire 70 km to see the man, and, when he finally arrived, he was too timid to knock on the door and returned utterly discouraged. He remained in this poverty-stricken area for more than a year, living as a pauper. His mother said, ‘‘I am so afraid that wherever he goes and whatever he does, he will spoil everything by his peculiar behavior and queer ideas [1].’’ Van Gogh then decided to return to his art studies. He applied for study in a school in Brussels but never was accepted. Back living with his parents at age 28, he fell in love with a cousin (Kee) and was devastated when she rejected his advances. In another example of his strange behavior, he held his hand directly over the flame of a candle, warning that he would not remove it until he was allowed to see Kee. Her father simply blew out the flame, leaving Vincent humiliated. The next woman he met was Clasina Maria Hoornik (‘‘Sien’’), a prostitute already pregnant with her second child, with a face marked from smallpox, a grating voice, and a very bad temper. She gave van Gogh gonorrhea, requiring his hospitalization in 1886 for 25 days. Neurosyphilis has also been considered by some biographers [1–4], but no clear evidence exists to support that diagnosis. The year 1883 was another period of transition in VincentÕs personal and professional life. When his relationship with ‘‘Sien’’ deteriorated, he felt he had failed again—even a prostitute could not stand him. He began to experiment with oil paints, and returned home in the latter part of that year. Once more disaster occurred when he found out that a woman (Margot Begemann) living next door to his parents had been in love with him. This led to emotional upheaval in their relationship and her suicidal attempt. Van Gogh continued to paint and, in 1885, finished his first masterpiece, ‘‘The Potato Eaters.’’ He enrolled in an art academy in Antwerp the next year, but left after a month. He then tried to find something positive in his life in Paris; he moved in with his brother Theo. Paris was where most of the Impressionists lived, and they had some influence on Vincent: he began to move away from darker colors to more vibrant hues. Although Theo had financially and emotion-
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ally supported Vincent throughout his life, a great deal of tension developed when they were living together; for 2 years Vincent ate poorly and drank and smoked to excess. He left Paris in 1888 and headed south toward a warmer climate in Arles, France. He rented his wellknown ‘‘Yellow House,’’ hoping that this would be the ‘‘studio of the south’’ and that artists like Paul Gauguin would join him. Gauguin did join Vincent in October of that year (1888), but their relationship deteriorated throughout December, and Gauguin announced he was leaving on the 23rd. Vincent threw a glass of absinthe at his face, and was brought home and put to bed by his companion. The next day, when Gauguin left the house, van Gogh approached him with an open razor and Gauguin fled. Van Gogh went home, looked in a mirror, hacked off the bottom part of his left ear, tied a scarf around his head, placed a fur cap over it, wrapped the ear in paper, placed it in an envelope, and walked out of the house to a brothel. He gave the envelope to his favorite, Rachel, who then fainted. With blood running down his cheek he was put to bed by his friend, Roulin, in his Yellow House. Having stayed in a hotel that night, Gauguin came the next day, and found Vincent unconscious. Gauguin stated, ‘‘He tried to kill me [2]’’ and he left immediately for Paris. As biographers have stated [2], ‘‘In a deranged or drunken moment he forever marked his place in history as the mad artist who cut off his ear.’’ The police came and took van Gogh to the Hoˆtel-Dieu Hospital in Arles, where he came under the care of a young intern in training, Dr. Felix Rey. Although he had suffered a great blood loss and continued to suffer serious attacks of madness, he did seem to temporarily recover, and returned to his Yellow House. He felt particularly depressed when postmaster Joseph Roulin, the only good friend he ever had, decided to move to Marseilles in early 1889. On February 7 of that year he suffered another attack; he imagined that he was being poisoned and returned to the same hospital for 10 days, returning later to his Yellow House. By this time the citizens of Arles were so alarmed by VincentÕs behavior that 81 of them signed a petition of complaint to the mayor, so van Gogh was readmitted and remained in the hospital for the next 6 weeks. He left Arles on May 8 to be confined voluntarily in an asylum for epilepsy and mental disorders in SaintRe´my-de-Provence. He was under the care of Dr. The´ophile Peyron, an oculist in semiretirement, who thought that Vincent was suffering from some type of epilepsy, likely because that asylum was especially for patients with seizures. Also, the doctorÕs definition of epilepsy was so extended that he stated that van GoghÕs last attack lasted 2 months. Vincent became incapacitated by another attack in mid-July, trying to ingest his own paints, but remained fairly stable for the rest of 1889. On December 23, 1889, a year to the day after the ear
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slashing incident, he had another serious attack, and more of them occurred in the early months of 1890. Brother Theo convinced Vincent he should return to Paris, and on May 16, 1890, he came under the care of Dr. Paul Gachet, a psychiatrist, in Auvers-sur-Oise, near Paris. During the next month he received word that TheoÕs son was seriously ill and worried that his brother would be concentrating on his own son, rather than on him, the brother. During the early summer Vincent seemed absorbed in the fields and plains around Auvers, but on Sunday, July 27, 1890, he went into the fields with his painting materials, took out a revolver, and shot himself in the lower chest. He staggered back to an inn and collapsed on a bed. Dr. Gachet decided not to remove the bullet. Theo was summoned and arrived the next day just before Vincent died from an infection from the bullet wound. He expired at 1:30 AM on July 29, 1890, at the age of 37. In his 37 years Vincent lived in 15 different places, exemplifying his tragic life that required him to leave one position after another. Born in the southern part of The Netherlands in 1852, he went to The Hague (1869), Paris (1875), England (1876), back to The Netherlands (1877), Brussels (1878), Etten, The Netherlands (1881), The Hague (1882), Drenthe, The Netherlands (1883), Nuenen, The Netherlands (1883), Antwerp (1885), Paris (1886), Arles (1888), St. Re´my (1889), and, finally, Auvers-sur-Oise (1890).
2. Possible physical diagnoses Chronic solar injury, glaucoma, and cataracts have been considered [5], mainly because in the last few years of his life, his paintings were characterized by the color yellow. Also, he lived in the Yellow House, but the house was yellow before he moved in, and he was excited by the lighter colors (of the south) since earlier, he had painted mostly with darker colors (of the north). Digitalis intoxication had also been mentioned, with its side effect of xanthopsia, only because he painted one of his doctors (Peyron) holding a foxglove plant, then used for the treatment of various mental disorders. However, no clear evidence exists that Vincent was actually ever given digitalis. He rented his famous Yellow House in May 1888 and had no contact with Dr. Peyron and his digitalis plant for an entire year until May 1889. Thus, these latter diagnoses seem unlikely. Me´nie`reÕs disease has also been considered, especially by Arenberg et al. [6,7]. From 796 personal letters to his family and friends [8,9] attacks of vertigo (using the word vertige) were often mentioned by Vincent. His symptoms, according to Arenberg et al., included episodic vertigo and dizziness, physical imbalance, tinnitus, and auditory complaints. In a discussion of BakerÕs paper [10] Arenberg and colleagues noted that VincentÕs
loss of consciousness could be synchronized with violent attacks of vertigo, and therefore, the diagnosis of epilepsy was incorrect, even though periods of unconsciousness did occur. However, loss of consciousness is not usually associated with Me´nie`reÕs disease. The attacks of dizziness were discussed by Freedman in BakerÕs paper [10], who referred to VincentÕs letter W4: ‘‘I always had fits of dizziness in a horrible nightmare, which has left me since, but which came back regularly then.’’ On the other hand, no evidence of disequilibrium, nausea, or vomiting appeared in VincentÕs letters. Also, Feldman, in a discussion of Baker [10], pointed out that (letter B592 in May 25, 1889) only once did van Gogh refer to an auditory sensation and there were no complaints of ear noises. In summary, this famous painter may well have had some, but not all, of the usual symptoms of Me´nie`reÕs disease, but his vertige can also be associated with other disorders that are discussed later. One consideration is the ‘‘Tumarkin falls,’’ which are sudden drop attacks that occur in a subset of patients with Me´nie`reÕs disease [11]. It is questionable that van Gogh had Me´nie`reÕs disease; the latter drop attacks are not usually associated with the losses of consciousness experienced by this artist. Another physical illness under consideration is porphyria [12]. Kienen [13] has suggested that the symptoms of abdominal pain, anorexia, anxiety, hallucinations, and mania would be explained by porphyria, triggered by fasting and alcohol abuse, which did play a major role in van GoghÕs life. Also, stating that as many 101 specific diagnoses have been made for this artist, Arnold [14], concluded that an inherited metabolic disease, acute intermittent porphyria, would account for almost all of van GoghÕs signs and symptoms. There are a few problems with this diagnosis: there is no obvious family history, although Arnold has provided speculation on family members, and it is twice as common in females. The most common clinical feature is an acute attack with severe abdominal pain, often associated with vomiting and constipation or with diarrhea [15]. Furthermore, peripheral neuropathy, mainly motor, occurs in about one-half of these patients following an attack. This neuropathy can progress to complete paralysis over several weeks. The skin is photosensitive and blistering, often after excessive sun exposure. None of the latter symptoms, as well as dark or red urine, was evident in the letters written by van Gogh [8,9]. Ho et al. [16] have agreed that porphyria is an unlikely diagnosis. Chronic lead poisoning has also been considered [17]. His loss of teeth, progressive character changes, and periods of delirium would fit this diagnosis, but the major question is the possible means of exposure of this metal in his paints. In only one instance, at the asylum in St.-Re´my, during his worst attack, shouting and screaming at another patient, did he attempt to kill himself by trying to swallow paint [1], but he was ‘‘quickly
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restrained by an attendant’’ [2]. The evidence indicates only attempts to swallow the paint, rather than chronic exposure, so chronic lead poisoning seems unlikely. On the other hand, Ho et al. [16] stated that he frequently tasted his paint, but this fact is not evident in his best known biographies [1–4].
3. Possible psychiatric diagnoses Borderline personality disorder (301.83) has been proposed by Mehlum [18], who pointed out that, consistent with this diagnosis, van GoghÕs difficulties of attachment to and separation from his parents continued throughout his life, along with his emotional instability, intensity, and lowered tolerance to frustration. In DSM-IV [19], eight criteria are listed. The first is that the patient makes frantic efforts to avoid real or imagined abandonment. Although van Gogh had great difficulty establishing a pleasant relationship with anyone, he was terrified of being alone, and when Gauguin said he was returning to Paris and leaving him, he panicked. The second criterion is a pattern of unstable and intense relationships. This criterion defines VincentÕs whole personal life, whether with his brother Theo, parents, women, or men. The third is a markedly and persistently unstable self-image or sense of self. Van Gogh always seemed to be searching for his place in the art world and did not have a clear sense of self. The fourth criterion is an impulsivity that is potentially self-damaging. Two excellent examples are his cutting off half of his left ear and his holding his hand over a flame until he could see his cousin Kee. Fifth is recurrent suicidal behavior, gestures or threats, or self-mutilation. Vincent is an example par excellence of this criterion, and his attempts to drink a quart of turpentine and to consume his paints add further evidence. The sixth is an affective instability due to a marked reactivity of mood, lasting hours and, at times, a few days. This famous artistÕs behavior meets this criterion well, as his entire adult existence was characterized by changes from exaltation to deep depression. The seventh criterion is chronic feelings of emptiness, often expressed in letters to his brother Theo [8,9]. The last criterion is inappropriate intense anger and difficulty controlling anger. Could there be a better example of intense anger than when Vincent felt Gauguin was going to leave him and, unable to control this anger, he cut off his own ear? Thus, the evidence seems clear that one psychiatric diagnosis that should be seriously considered is borderline personality disorder. Strik [20] has proposed the diagnosis of cycloid psychosis, consisting of anxiety–elation psychosis. DSMIV [19] refers to the similar cyclothymic disorders (301.13), a chronic fluctuating mood disturbance involving numerous periods of hypomania and also periods of depressive symptoms. Van GoghÕs behavior meets the
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first criterion just mentioned. The second criterion, however, is that the symptom-free intervals should last no longer than 2 months. The latter requirement would be difficult to apply to van Gogh as the timing of his symptoms was so variable. The third requirement is that the initial 2-year period of cyclothymic symptoms be free of major depressive or manic episodes. This requirement would not likely apply. Nor would the fourth criterion that the mood swings not be better accounted for by schizophreniform or delusional disorders. The presence of delusions was especially evident when van Gogh was in Arles. The last requirement is that the mood disturbances must not be due to drugs of abuse. This criterion could not be easily met because of the prominence of absinthe, cognac, and huge quantities of coffee. In summary, van Gogh does not easily present himself as having a cyclothymic disorder. One other possibility would be a mixed anxiety–depressive disorder, as both depression and anxiety were important features of van GoghÕs behavior. The criteria applying to van Gogh include recurrent dysphoric moods, including irritability, hypervigilance, hopelessness, and low self-esteem. An example of the latter two characteristics is found in his letter to his mother [8,9]: ‘‘Success is the worst thing that can happen in a painterÕs life.’’ The latter symptoms caused clinically significant distress or impairment in social functioning, as indicated by his evolving poor relationship with Gauguin. Blumer [21] has elegantly combined two symptoms, depression and hypomania, stating that Vincent ‘‘experienced prolonged episodes of depression’’. . . and also ‘‘experienced sustained periods of hypomania or mania.’’ This type of bipolar history, Blumer claimed, is often not identified, but is ‘‘not uncommon among writers and artists.’’ Blumer stated that a tentative diagnosis of schizophrenia has also been considered by several authors, but believes this diagnosis improbable. Although lateonset schizophrenia was diagnosed in one of van GoghÕs sisters (Wilhemina), and another (Cornelia) attempted suicide, their complete recovery from psychotic episodes helped to make this diagnosis improbable, according to Blumer. However, on July 27, 1890, he went to the wheat fields, took out a revolver, and shot himself in the lower chest–stomach area, and died from the infection from the unremoved bullet. Although this may have been ‘‘an act of considered despair [2]’’, ‘‘complete recovery’’ from this mental illness would appear unlikely. The paranoid type of schizophrenia (295.30) in DSM-IV [19] requires the presence of prominent delusions or auditory hallucinations. His hallucinations were so prominent that when Dr. Rey gave him potassium bromide, they dwindled into nightmares [1]. Van Gogh thought that everyone was in a conspiracy to poison him, and he would accuse the locals in Arles; this behavior landed him in the hospital. After returning to his
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home, he would open windows and scream at people, while hearing voices and seeing figures. This behavior was so extreme that the townspeople appealed to the mayor, who ordered him back to the hospital [1]. In St.-Re´my he and one of the epileptic patients shouted at each other so long and so loud that VincentÕs throat swelled, and he tried to swallow his paint to kill himself. Once he tried to drink a quart of turpentine (1889), which resulted in his return to the asylum. Finally, the director of the hospital at St.-Re´my wrote on his admission sheet that Vincent suffered from ‘‘acute mania with hallucinations of sight and hearing which have caused him to mutilate himself by cutting off his ear [22].’’ The latter author, Hulsker [22], stated that the lack of recall of the ear cutting episode was ‘‘because drinking had caused him to black out.’’ Paranoid ideation was clearly prominent in the later years of his life.
4. Possible epilepsy None of the available records suggests that Van Gogh ever had a generalized tonic–clonic attack, primary or secondarily generalized, or had any automatisms that would qualify as a complex partial attack. In fact, he never had any episodic symptoms reflecting a seizure, until he began to eat less (and later drink more). As epilepsy is a diagnosis that requires spontaneous attacks, rather than reactions to a drug or to withdrawal from a drug, van Gogh did not have epilepsy. The remaining question concerns the nature of the blackouts or episodes of unconsciousness he experienced and whether they can be viewed as reactive seizures. As early as 1882–1983 in his relationship with the prostitute ‘‘Sien,’’ he ‘‘ate less to save money, became sick and faint’’ [1]. In his first 6 weeks with her, he ate only three hot meals, using coffee, bread, and smoking to ‘‘dull the ache.’’ When he sat down to a square meal, he could not digest it, felt sick and faint [1]. Eating less than ever, he was approaching collapse, and by February 1886 his ‘‘fainting fits’’ had increased. During the same year at the academy at Antwerp he often was lightheaded and could not keep food down. Only later during the next year (1887) when he went to Paris did he begin ‘‘to drink more than was good for him [1].’’ Thus, before his heavy drinking had begun in Paris, he had already had many ‘‘fainting fits,’’ likely from hypoglycemia or lack of nourishment. On this basis, we cannot propose that epileptic seizures account for these attacks. When van Gogh went to Paris in 1887 and associated with other Impressionists, he engaged in heavy drinking, especially absinthe and cognac, carousing at times all night in the Montmartre district. In the summer of 1887 ‘‘he drank more and more heavily, grew thinner and thinner, always on the edge of starvation’’ [1]. Vincent wrote to his brother Theo that when he left Paris
for Arles he was ‘‘practically a drunkard’’ [1]. The heavy drinking, heavy smoking, and cup after cup of black coffee created an illusion of vitality. In Arles he sometimes lived on 23 cups of coffee a day and bread [8,9]. His one and only friend, Roulin, kept reminding him that fellow artist Monticelli had died of alcoholism and was an absinthe drunkard. In Arles, as an example of drunkenness, Vincent once threw a glass of absinthe at Gauguin, but missed him. Gauguin managed to get van Gogh home but found that he was in a kind of coma [2]. The next morning, van Gogh apologized and claimed not to know what he had done [1]. Dr. Rey in Arles told him that ‘‘his attacks were due to years of undernourishment and too much drink’’ [1]. In 1888 Vincent went an entire week without any food at all, but drank excessively, claiming, ‘‘If the tempest in my brain gets too violent, I take a glass too much’’ [1]. He also said, ‘‘The only thing to bring ease and distraction is to sedate oneself by smoking and drinking heavily’’ [2]. In summary, the excessive drinking did not seem to have resulted in alcohol withdrawal seizures, but he did drink to a stuporous or unconscious state. The common drink among the Impressionists, especially Henri de Toulouse-Lautrec and van Gogh, was absinthe, the ‘‘Green Fairy’’ [23], so-named because it was made by steeping dried wormwood in 85% ethanol and then filtering the green liqueur containing 74% alcohol. Absinthe was banned in nearly all developed countries in the early 1900s; however, this drink is still legal in Great Britain, Spain, Portugal, and the Czech Republic. Today, the active ingredient, thuzone from wormwood, is present at concentrations <30 ppm; the old Parisian liquor contained about 260 ppm [24]! Thuzone can cause hallucinations, and some maintain that it elicits artistic creativity [25]. For our discussion, it is important to emphasize that it can cause seizures. Schachter [26] was one of the first to discuss absinthe and its tendency to produce hallucinations and also exacerbate seizures [27]. As Schachter mentioned, in the late 19th century, H. Jackson classified absinthe as a ‘‘convulsant poison’’ [28]; it was classified similarly in the 20th century [29] and known to produce an increase in porphyrins [30]. Convulsions have been observed in animals and humans at high doses of absinthe [31], but such attacks were never described in Vincent. In addition, absinthism has been associated with auditory and visual hallucinations, an increased risk of psychiatric illness, and suicide [32]. Thus, this drug likely played some role in van GoghÕs life in his last few years, but never elicited convulsions. The exact mechanism by which thuzone acts as a convulsant drug was studied by Hold et al. [33], who found that a-thuzone is the toxic agent in this drug and modulates the GABA-gated chloride channel. Later, the same authors [34] identified 7-hydroxy-a-thuzone as the major metabolite and 4-hydroxy-a- and -b-thuzones
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as minor metabolites, detoxified by the well-known P450 (3A4) enzyme system. In particular, GABA-induced peak currents (rat) are suppressed by a-thuzone. Thus, absinthe acts as a convulsant by inhibiting GABA(A) chloride currents. In humans, the combination of a high concentration of absinthe and alcohol has a negative effect on attention, resulting in the neglect of peripheral signals, increased reaction times, and increased ‘‘false alarm’’ reactions [35]. However, in subjects given only alcohol or both alcohol and a low concentration of thuzone, the latter effects are not observed. Assessment of mood state indicated that the anxiolytic effect of alcohol is temporarily counteracted by a high thuzone concentration [35]. Thus, there is an antagonistic effect between alcohol and thuzone on the GABA receptor. When van Gogh drank both absinthe and cognac together, as he regularly did, the effects of absinthe were probably minimized by the alcohol. The major question is whether Vincent van Gogh had epileptic seizures or not. Before he began drinking absinthe, he had many ‘‘fainting fits,’’ likely because he was often near starvation; he would eat very little food, going without food for even an entire week. His loss-ofconsciousness episodes after he started to drink heavily were not described any differently than his ‘‘fainting fits’’ before his heavy drinking; he often starved himself during periods of excessive drinking. His episodes of unconsciousness were likely, at times, the result of a high alcohol level, as were the typical amnestic episodes that followed. Thus, it appears that his episodes of unconsciousness were the result of drunkenness or chronic lack of food, or both. Although the thuzone in the absinthe can be considered a convulsant drug, alcohol is mainly a depressant drug and would counteract the hyperexciting effects of the thuzone. As the relative concentrations of these drugs would determine the final effect, it cannot be ruled out that the absinthe produced a seizure state, as suggested by a number of authors [21,24,36]. In Paris in the spring of 1889, during a period of heavy drinking, biographers Ozanne and de Jode [3] described his episodes as ‘‘frequent fainting spells that made him tired and rendered him temporarily amnesic.’’ It is not necessary to assume that absinthe caused these episodes as similar ‘‘blackouts’’ had occurred before he started to drink the absinthe. The suggestion that Vincent van Gogh had psychomotor epilepsy came from an early article written nearly one-half century ago by the well-known epileptologist Henri Gastaut [37], who thought that absinthe precipitated these seizures in the last 2 years of his life. During the middle of the 20th century, epileptologists were discovering the many different ways that complex partial attacks or psychomotor seizures could manifest; and the definition of epilepsy was often expanded to include many different psychiatric or psychological states that do not fit the stricter definition of complex partial
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seizures, as defined today. As Dr. Peter Fenwick [38] has stated, ‘‘It is likely that the earlier accounts of temporal lobe epilepsy and temporal lobe pathology and the relationship to mystic and religious states owe more to the enthusiasm of their authors than to the true scientific understanding of the nature of temporal lobe functioning.’’ Epilepsy in van Gogh has also been considered by other authors [21,27,39–43], but the proof of spontaneous seizures is lacking and the episodes of unconsciousness were never more than losses of consciousness, likely explained by near starvation and very heavy alcohol intake, possibly made worse by absinthe. It is improbable that absinthe played a role in inducing some type of seizure activity [44], as generalized tonic– clonic or tonic seizures were elicited in humans by these essential oils, and van Gogh did not experience these types of episodes. Norman Geschwind [45,46] has become well known for his conclusion that patients with temporal lobe epilepsy tend to demonstrate specific personality characteristics, now called the Geschwind syndrome. A more thorough presentation of this syndrome has been provided by David Bear [47], who listed the characteristics of emotionality, manic tendencies, depression, altered sexuality, anger, hostility, aggression, religiosity, paranoia, guilt, viscosity, and hypergraphia. Van Gogh would seem to be a near-perfect example of this syndrome because he either loved or hated everybody, alternated between manic and depressed states, became impotent and lost interest in sexual behavior, was angry or hostile much of the time, attempted to become a religious minister, believed at times that people were trying to kill him, and wrote letters to his brother amounting to 1700 pages [8,9]. Benson and Hermann [48] have spelled out the majority opinion of epileptologists today that there are only ‘‘a subset of patients with epilepsy in general and temporal lobe epilepsy in particular who present with features of the Geschwind syndrome.’’ I think that Vincent van Gogh is likely the best example of the Geschwind syndrome that can be found. However, the syndrome has been described as a part of temporal lobe epilepsy, and if there is no clear temporal lobe epilepsy, then the syndrome is an orphan without a parent condition. Although van Gogh fits the syndrome well, this fact does not establish a temporal lobe epilepsy, but likely indicates that some neurophysiological disturbance exists within the temporal lobes, as it may with temporal lobe epilepsy, but also as it may with nonepileptic disturbances. In conclusion, Vincent van Gogh had a tragic life in and out of mental institutions, had a number of psychiatric diagnoses, including borderline personality disorder, but with manic and depressive periods, and also paranoid ideation. His near self-starvation likely explains his ‘‘fainting fits,’’ and the absinthe and cognac that he used in great quantities resulted in blackouts
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and amnestic episodes, but there is no clear evidence of epilepsy or a seizure disorder.
References [1] Hanson L, Hanson E. Passionate pilgrim. New York: Random House; 1955. [2] Greenberg J, Jordan S. Vincent van Gogh. New York: Delacorte Press; 2001. [3] Ozanne M, de Jode F. Theo, the other van Gogh. New York: Magawan Press; 1990. [4] Collins B. Van Gogh and Gauguin. Cambridge, MA: Westview Press; 2001. [5] Lee TC. Van GoghÕs vision. Digitalis intoxication. JAMA 1981;245:727–9. [6] Arenberg IK, Countryman LF, Bernstein LH, Shambaugh Jr GE. Van Gogh had Me´nie`reÕs disease and not epilepsy. JAMA 1990;264:491–3. [7] Arenberg IK, Countryman LF, Bernstein LH, Shambaugh Jr GE. VincentÕs violent vertigo: an analysis of the original diagnosis of epilepsy vs. the current diagnosis of Me´nie`reÕs disease. Acta Otolaryngol Suppl 1991;485:84–103. [8] Van Gogh-Bongers JG. Vincent van GoghÕs Briefe an seinen Bruder. Frankfort-am-Main: Insel Verlag; 1988. [9] Van Gogh-Bongers JG. The complete letters of Vincent van Gogh. Greenwich CT: NY Graphic Soc.; 1969. [10] Baker HS. Van Gogh: Me´nie`reÕs disease? Epilepsy? Psychosis. JAMA 1991;265:722–4. [11] Ishiyama G, Ishiyama A, Baloh RW. Drop attacks and vertigo secondary to a non- Me´nie`reÕs cause. Arch Neurol 2003;60:71–5. [12] Loftus LS, Arnold WN. Vincent van GoghÕs illness: acute intermittent porphyria. Br Med J 1991;303:1589–91. [13] Kienin RA. Discussion of van Gogh: Me´nie`reÕs disease? Epilepsy? Psychosis? JAMA 1991;265:722–4. [14] Arnold WN. The illness of Vincent van Gogh. J Hist Neurosci 2004;13:22–43. [15] Evans OB, Bock H-GO, Parker C, Hansen RR. Inborn errors of metabolism of the nervous system. In: Bradley WG, Daroff RB, Fenichel GM, Marsden CD, editors. Neurology in clinical practice, vol. II. Boston: Butterworth–Heinemann; 1991. p. 1269–322. [16] Ho NC, Park SS, Maragh KD, Gutter EM. Famous people and genetic disorders: from monarchs to geniuses—a portrait of their genetic illnesses. Am J Med Genet A 2003;118:187–96. [17] Gonzalez Luque FJ, Montejo Gongalez AL. Implication of lead poisoning in psycho-pathology of Vincent van Gogh. Actas Luso Esp Neurol Psiquiatr Cienc Afines 1997;25:309–26. [18] Mehlum L. Suicidal process and suicidal motives: suicide illustrated by the art, life and illness of Vincent van Gogh. Tidssker Nor Laegeforen 1996;116:1095–101. [19] Diagnostic and statistical manual of mental disorders. DSM-IVTR. Washington, DC: Am. Psychiatric Assoc.; 2000. [20] Strik WK. The psychiatric diagnosis of Vincent van Gogh. Nervenarzt 1997;68:401–9. [21] Blumer D. The illness of Vincent van Gogh. Am J Psychiatry 2002;159:519–26. [22] Hulsker J. Vincent and Theo van Gogh: a dual biography. Ann Arbor, MI: Fuller; 1990.
[23] Holstege CP, Baylor MR, Rusyniak DE. Absinthe: return to the Green Fairy. Semin Neurol 2002;22:89–93. [24] Fox D. Absinthe. In search of the Green Fairy. Internet; 2004. [25] Rekano T, Sulg I. Absinthe and the artistic creativeness. Tidsskr Nor Laegeforen 2003;123:70–3. [26] Schachter SC. Epilepsy and art. Med J Aust 1996;164:245–6. [27] Malcolm SV. Epilepsy and art. Med J Aust 1996;165:64. [28] Temkin W. The falling sickness: a history of epilepsy from the Greeks to the beginning of modern neurology. 2nd ed.. Baltimore: Johns Hopkins Press; 1995. [29] del Castillo J, Anderson M, Rubottom GM. Marijuana, absinthe and the central nervous system. Nature 1975;253:365–6. [30] Bonkovsky HC, Cable EE, Cable JW, et al. Porphyrogenic properties of the terpenes camphor, pinene and thuzone (with a note on historic implications for absinthe and the illness of Vincent van Gogh). Biochem Pharmacol 1992;43:2359–68. [31] Magnan V. Epilepsie alcoolique: action spe´ciale de lÕ absinthe: e´pilepsie absinthique. CR Seanc Mem Soc Biol (Paris) 1869;5:156–61. [32] Amory R. Experiments and observations on absinthe and absinthism. Boston Med Surg J 1868;8:83–5. [33] Hold KM, Sirisoma NS, Ikeda T, et al. Proc Natl Acad Sci USA 2000;97:3826–31. [34] Hold KM, Sirisoma NS, Casida JE. Detoxification of alpha- and beta-thuzones (the active ingredients of absinthe): site specificity and species differences in cytochrome P450 oxidation in vitro and in vivo. Chem Res Toxicol 2001;14:589–95. [35] Dettling A, Grass H, Schuff A, et al. Absinthe: attention performance and mood under the influence of thuzone. J Stud Alcohol 2004;65:573–81. [36] Berggren L. Drugs and poisons in the life of Vincent van Gogh. Sven Med Tidskr 1997;1:125–34. [37] Gastaut H. Vincent van GoghÕs disease seen in the light of new concepts of psychomotor epilepsy. Ann Med Psychol (Paris) 1956;114:196–238. [38] Fenwick P. Temporal lobe epilepsy. Internet; 2004. [39] Steiner U. Was van Gogh an epileptic? (A contribution to schizophrenic symptoms in organic twilight states). Psychiatr Neurol Med Psychol (Leipz) 1959;11:170–9. [40] Morrant JC. The wing of madness: the illness of Vincent van Gogh. Can J Psychiatry 1993;38:480–4. [41] Meissner WW. The artist in the hospital: the van Gogh case. Bull Menninger Clin 1994;58:283–306. [42] Voskuil PH. Vincent van GoghÕs malady: a test case for the relationship between temporal lobe dysfunction and epilepsy? J Hist Neurosci 1992;1:155–62. [43] Lambert C. Van GoghÕs malady. Harv Mag Jan–Feb 1999. [44] Burkhard PR, Burkhard K, Haenggeli CA, Landis T. Plantinduced seizures: reappearance of an old problem. J Neurol 1999;246:667–70. [45] Waxman SA, Geschwind N. The interictal behavioral syndrome of temporal lobe epilepsy. Arch Gen Psychiatry 1975;32: 1580–1586. [46] Geschwind N. Behavioral changes in temporal lobe epilepsy. Psychol Med 1979;9:217–9. [47] Bear DM. Temporal lobe epilepsy: a syndrome of sensory limbic hyperconnection. Cortex 1979;15:357–84. [48] Benson DF, Hermann BP. Personality disorders. In: Engel Jr J, Pedley TA, editors. Epilepsy: a comprehensive textbook, vol. II. Philadelphia: Lippincott–Raven; 1998. p. 2065–70.
Review
A reappraisal of the possible seizures of Vincent van Gogh John R. Hughes * Department of Neurology, University of Illinois at Chicago, Chicago, IL 60612, USA Received 24 February 2005; revised 24 February 2005; accepted 24 February 2005 Available online 6 April 2005
Abstract The tragic life of Vincent van Gogh is summarized, emphasizing his early departure from formal education, failure as a successful salesman in the art world, attempt at religious studies, difficulty with female and family relationships, return to the art world, and tendencies toward extremes of poor nutrition or near self-starvation and excessive drinking and smoking. In Paris he joined the Impressionists, but drank very heavily both absinthe and cognac. Southward he went to Arles and was joined by Paul Gauguin, with whom he had major personality problems, causing van Gogh to cut off part of his left ear. He experienced paranoid ideation and confinement in mental institutions in Arles, and then returned to Paris and onto Auvers-sur-Oise, where he committed suicide at age 37. Possible physical diagnoses include glaucoma, Me´nie`reÕs disease, acute intermittent porphyria, and chronic lead poisoning, but these diagnoses seem unlikely. Possible psychiatric diagnoses include borderline personality disorder, anxiety–depressive disorder with episodes of depression and hypomania, and also paranoid schizophrenia. Van Gogh did not have spontaneous seizures and, therefore, did not have epilepsy. Before he began to drink heavily, when he was near starvation, he had ‘‘fainting fits,’’ and after drinking, especially absinthe, a convulsant drug, he continued to have similar attacks. His episodes of unconsciousness can be well explained by chronic malnutrition and alcohol abuse, only possibly exacerbated by drinking large quantities of absinthe. Although van Gogh is an excellent example of the Geschwind syndrome, at times associated with temporal lobe epilepsy, this fact does not establish such an epilepsy. Thus, the syndrome is an orphan without the parent condition. Ó 2005 Elsevier Inc. All rights reserved. Keywords: Epilepsy; Seizure; Fit; Absinthe; Starvation; Alcohol; Borderline personality disorder; Depression; Hypomania; Fainting; Fits
1. Summary of Vincent van GoghÕs life Vincent van Gogh was born on March 30, 1853, exactly 1 year from the day his mother had given birth to her first child, also named Vincent, who died at a few weeks of age. This coincidence led to speculation that the second Vincent may have been later troubled by being the ‘‘replacement child.’’ His father was Theodorus, pastor of the Dutch Reformed Church, and his mother was Anna Cornelia Carbentus. Vincent attended a boarding school for 2 years and then a secondary * Present address: Department of Neurology, University of Illinois Medical Center (M/C 796), 912 South Wood Street, Room 862N, Chicago, IL 60612, USA. Fax: +1 312 996 4169. E-mail address: [email protected].
1525-5050/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.yebeh.2005.02.014
school for 2 more, leaving his studies at age 15, never to return to formal education. As uncles Vincent and Cornelis were art dealers, he went to work for the art dealer firm of Goupil in The Hague (The Netherlands), remaining there for 7 years. He was transferred to the London branch, where he stayed for 2 years, and then to the Paris branch of that same firm. He was not a successful salesman, at times insulting the customers by telling them their purchases were poorly chosen. At 23 years of age, unsuccessful as a salesman, he decided to leave the art world and return to England and taught at a religious school; during that summer he experienced a deep religious transformation of his own. He visited his family in The Netherlands over Christmas that year and decided to remain there, working only briefly in a bookshop. In May of the next year
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he tried to prepare himself for the examination for admission to the local university to study theology, but abandoned his preparatory studies after 15 months. Later, he failed to qualify for a mission school and then decided on a trial period of preaching in a poor coal mining district in Belgium. Vincent sympathized with the dreadful working conditions of the miners, giving away most of his food and clothing to these povertystricken miners. The Church disapproved of van GoghÕs asceticism and dismissed him from his post after 6 months. After all of his many positions, hopes, and dreams were unfulfilled, van Gogh began to behave oddly. For example, he decided to visit a French painter (Breton) he admired. As he had only 10 francs, it took him 3 days to walk the entire 70 km to see the man, and, when he finally arrived, he was too timid to knock on the door and returned utterly discouraged. He remained in this poverty-stricken area for more than a year, living as a pauper. His mother said, ‘‘I am so afraid that wherever he goes and whatever he does, he will spoil everything by his peculiar behavior and queer ideas [1].’’ Van Gogh then decided to return to his art studies. He applied for study in a school in Brussels but never was accepted. Back living with his parents at age 28, he fell in love with a cousin (Kee) and was devastated when she rejected his advances. In another example of his strange behavior, he held his hand directly over the flame of a candle, warning that he would not remove it until he was allowed to see Kee. Her father simply blew out the flame, leaving Vincent humiliated. The next woman he met was Clasina Maria Hoornik (‘‘Sien’’), a prostitute already pregnant with her second child, with a face marked from smallpox, a grating voice, and a very bad temper. She gave van Gogh gonorrhea, requiring his hospitalization in 1886 for 25 days. Neurosyphilis has also been considered by some biographers [1–4], but no clear evidence exists to support that diagnosis. The year 1883 was another period of transition in VincentÕs personal and professional life. When his relationship with ‘‘Sien’’ deteriorated, he felt he had failed again—even a prostitute could not stand him. He began to experiment with oil paints, and returned home in the latter part of that year. Once more disaster occurred when he found out that a woman (Margot Begemann) living next door to his parents had been in love with him. This led to emotional upheaval in their relationship and her suicidal attempt. Van Gogh continued to paint and, in 1885, finished his first masterpiece, ‘‘The Potato Eaters.’’ He enrolled in an art academy in Antwerp the next year, but left after a month. He then tried to find something positive in his life in Paris; he moved in with his brother Theo. Paris was where most of the Impressionists lived, and they had some influence on Vincent: he began to move away from darker colors to more vibrant hues. Although Theo had financially and emotion-
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ally supported Vincent throughout his life, a great deal of tension developed when they were living together; for 2 years Vincent ate poorly and drank and smoked to excess. He left Paris in 1888 and headed south toward a warmer climate in Arles, France. He rented his wellknown ‘‘Yellow House,’’ hoping that this would be the ‘‘studio of the south’’ and that artists like Paul Gauguin would join him. Gauguin did join Vincent in October of that year (1888), but their relationship deteriorated throughout December, and Gauguin announced he was leaving on the 23rd. Vincent threw a glass of absinthe at his face, and was brought home and put to bed by his companion. The next day, when Gauguin left the house, van Gogh approached him with an open razor and Gauguin fled. Van Gogh went home, looked in a mirror, hacked off the bottom part of his left ear, tied a scarf around his head, placed a fur cap over it, wrapped the ear in paper, placed it in an envelope, and walked out of the house to a brothel. He gave the envelope to his favorite, Rachel, who then fainted. With blood running down his cheek he was put to bed by his friend, Roulin, in his Yellow House. Having stayed in a hotel that night, Gauguin came the next day, and found Vincent unconscious. Gauguin stated, ‘‘He tried to kill me [2]’’ and he left immediately for Paris. As biographers have stated [2], ‘‘In a deranged or drunken moment he forever marked his place in history as the mad artist who cut off his ear.’’ The police came and took van Gogh to the Hoˆtel-Dieu Hospital in Arles, where he came under the care of a young intern in training, Dr. Felix Rey. Although he had suffered a great blood loss and continued to suffer serious attacks of madness, he did seem to temporarily recover, and returned to his Yellow House. He felt particularly depressed when postmaster Joseph Roulin, the only good friend he ever had, decided to move to Marseilles in early 1889. On February 7 of that year he suffered another attack; he imagined that he was being poisoned and returned to the same hospital for 10 days, returning later to his Yellow House. By this time the citizens of Arles were so alarmed by VincentÕs behavior that 81 of them signed a petition of complaint to the mayor, so van Gogh was readmitted and remained in the hospital for the next 6 weeks. He left Arles on May 8 to be confined voluntarily in an asylum for epilepsy and mental disorders in SaintRe´my-de-Provence. He was under the care of Dr. The´ophile Peyron, an oculist in semiretirement, who thought that Vincent was suffering from some type of epilepsy, likely because that asylum was especially for patients with seizures. Also, the doctorÕs definition of epilepsy was so extended that he stated that van GoghÕs last attack lasted 2 months. Vincent became incapacitated by another attack in mid-July, trying to ingest his own paints, but remained fairly stable for the rest of 1889. On December 23, 1889, a year to the day after the ear
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slashing incident, he had another serious attack, and more of them occurred in the early months of 1890. Brother Theo convinced Vincent he should return to Paris, and on May 16, 1890, he came under the care of Dr. Paul Gachet, a psychiatrist, in Auvers-sur-Oise, near Paris. During the next month he received word that TheoÕs son was seriously ill and worried that his brother would be concentrating on his own son, rather than on him, the brother. During the early summer Vincent seemed absorbed in the fields and plains around Auvers, but on Sunday, July 27, 1890, he went into the fields with his painting materials, took out a revolver, and shot himself in the lower chest. He staggered back to an inn and collapsed on a bed. Dr. Gachet decided not to remove the bullet. Theo was summoned and arrived the next day just before Vincent died from an infection from the bullet wound. He expired at 1:30 AM on July 29, 1890, at the age of 37. In his 37 years Vincent lived in 15 different places, exemplifying his tragic life that required him to leave one position after another. Born in the southern part of The Netherlands in 1852, he went to The Hague (1869), Paris (1875), England (1876), back to The Netherlands (1877), Brussels (1878), Etten, The Netherlands (1881), The Hague (1882), Drenthe, The Netherlands (1883), Nuenen, The Netherlands (1883), Antwerp (1885), Paris (1886), Arles (1888), St. Re´my (1889), and, finally, Auvers-sur-Oise (1890).
2. Possible physical diagnoses Chronic solar injury, glaucoma, and cataracts have been considered [5], mainly because in the last few years of his life, his paintings were characterized by the color yellow. Also, he lived in the Yellow House, but the house was yellow before he moved in, and he was excited by the lighter colors (of the south) since earlier, he had painted mostly with darker colors (of the north). Digitalis intoxication had also been mentioned, with its side effect of xanthopsia, only because he painted one of his doctors (Peyron) holding a foxglove plant, then used for the treatment of various mental disorders. However, no clear evidence exists that Vincent was actually ever given digitalis. He rented his famous Yellow House in May 1888 and had no contact with Dr. Peyron and his digitalis plant for an entire year until May 1889. Thus, these latter diagnoses seem unlikely. Me´nie`reÕs disease has also been considered, especially by Arenberg et al. [6,7]. From 796 personal letters to his family and friends [8,9] attacks of vertigo (using the word vertige) were often mentioned by Vincent. His symptoms, according to Arenberg et al., included episodic vertigo and dizziness, physical imbalance, tinnitus, and auditory complaints. In a discussion of BakerÕs paper [10] Arenberg and colleagues noted that VincentÕs
loss of consciousness could be synchronized with violent attacks of vertigo, and therefore, the diagnosis of epilepsy was incorrect, even though periods of unconsciousness did occur. However, loss of consciousness is not usually associated with Me´nie`reÕs disease. The attacks of dizziness were discussed by Freedman in BakerÕs paper [10], who referred to VincentÕs letter W4: ‘‘I always had fits of dizziness in a horrible nightmare, which has left me since, but which came back regularly then.’’ On the other hand, no evidence of disequilibrium, nausea, or vomiting appeared in VincentÕs letters. Also, Feldman, in a discussion of Baker [10], pointed out that (letter B592 in May 25, 1889) only once did van Gogh refer to an auditory sensation and there were no complaints of ear noises. In summary, this famous painter may well have had some, but not all, of the usual symptoms of Me´nie`reÕs disease, but his vertige can also be associated with other disorders that are discussed later. One consideration is the ‘‘Tumarkin falls,’’ which are sudden drop attacks that occur in a subset of patients with Me´nie`reÕs disease [11]. It is questionable that van Gogh had Me´nie`reÕs disease; the latter drop attacks are not usually associated with the losses of consciousness experienced by this artist. Another physical illness under consideration is porphyria [12]. Kienen [13] has suggested that the symptoms of abdominal pain, anorexia, anxiety, hallucinations, and mania would be explained by porphyria, triggered by fasting and alcohol abuse, which did play a major role in van GoghÕs life. Also, stating that as many 101 specific diagnoses have been made for this artist, Arnold [14], concluded that an inherited metabolic disease, acute intermittent porphyria, would account for almost all of van GoghÕs signs and symptoms. There are a few problems with this diagnosis: there is no obvious family history, although Arnold has provided speculation on family members, and it is twice as common in females. The most common clinical feature is an acute attack with severe abdominal pain, often associated with vomiting and constipation or with diarrhea [15]. Furthermore, peripheral neuropathy, mainly motor, occurs in about one-half of these patients following an attack. This neuropathy can progress to complete paralysis over several weeks. The skin is photosensitive and blistering, often after excessive sun exposure. None of the latter symptoms, as well as dark or red urine, was evident in the letters written by van Gogh [8,9]. Ho et al. [16] have agreed that porphyria is an unlikely diagnosis. Chronic lead poisoning has also been considered [17]. His loss of teeth, progressive character changes, and periods of delirium would fit this diagnosis, but the major question is the possible means of exposure of this metal in his paints. In only one instance, at the asylum in St.-Re´my, during his worst attack, shouting and screaming at another patient, did he attempt to kill himself by trying to swallow paint [1], but he was ‘‘quickly
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restrained by an attendant’’ [2]. The evidence indicates only attempts to swallow the paint, rather than chronic exposure, so chronic lead poisoning seems unlikely. On the other hand, Ho et al. [16] stated that he frequently tasted his paint, but this fact is not evident in his best known biographies [1–4].
3. Possible psychiatric diagnoses Borderline personality disorder (301.83) has been proposed by Mehlum [18], who pointed out that, consistent with this diagnosis, van GoghÕs difficulties of attachment to and separation from his parents continued throughout his life, along with his emotional instability, intensity, and lowered tolerance to frustration. In DSM-IV [19], eight criteria are listed. The first is that the patient makes frantic efforts to avoid real or imagined abandonment. Although van Gogh had great difficulty establishing a pleasant relationship with anyone, he was terrified of being alone, and when Gauguin said he was returning to Paris and leaving him, he panicked. The second criterion is a pattern of unstable and intense relationships. This criterion defines VincentÕs whole personal life, whether with his brother Theo, parents, women, or men. The third is a markedly and persistently unstable self-image or sense of self. Van Gogh always seemed to be searching for his place in the art world and did not have a clear sense of self. The fourth criterion is an impulsivity that is potentially self-damaging. Two excellent examples are his cutting off half of his left ear and his holding his hand over a flame until he could see his cousin Kee. Fifth is recurrent suicidal behavior, gestures or threats, or self-mutilation. Vincent is an example par excellence of this criterion, and his attempts to drink a quart of turpentine and to consume his paints add further evidence. The sixth is an affective instability due to a marked reactivity of mood, lasting hours and, at times, a few days. This famous artistÕs behavior meets this criterion well, as his entire adult existence was characterized by changes from exaltation to deep depression. The seventh criterion is chronic feelings of emptiness, often expressed in letters to his brother Theo [8,9]. The last criterion is inappropriate intense anger and difficulty controlling anger. Could there be a better example of intense anger than when Vincent felt Gauguin was going to leave him and, unable to control this anger, he cut off his own ear? Thus, the evidence seems clear that one psychiatric diagnosis that should be seriously considered is borderline personality disorder. Strik [20] has proposed the diagnosis of cycloid psychosis, consisting of anxiety–elation psychosis. DSMIV [19] refers to the similar cyclothymic disorders (301.13), a chronic fluctuating mood disturbance involving numerous periods of hypomania and also periods of depressive symptoms. Van GoghÕs behavior meets the
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first criterion just mentioned. The second criterion, however, is that the symptom-free intervals should last no longer than 2 months. The latter requirement would be difficult to apply to van Gogh as the timing of his symptoms was so variable. The third requirement is that the initial 2-year period of cyclothymic symptoms be free of major depressive or manic episodes. This requirement would not likely apply. Nor would the fourth criterion that the mood swings not be better accounted for by schizophreniform or delusional disorders. The presence of delusions was especially evident when van Gogh was in Arles. The last requirement is that the mood disturbances must not be due to drugs of abuse. This criterion could not be easily met because of the prominence of absinthe, cognac, and huge quantities of coffee. In summary, van Gogh does not easily present himself as having a cyclothymic disorder. One other possibility would be a mixed anxiety–depressive disorder, as both depression and anxiety were important features of van GoghÕs behavior. The criteria applying to van Gogh include recurrent dysphoric moods, including irritability, hypervigilance, hopelessness, and low self-esteem. An example of the latter two characteristics is found in his letter to his mother [8,9]: ‘‘Success is the worst thing that can happen in a painterÕs life.’’ The latter symptoms caused clinically significant distress or impairment in social functioning, as indicated by his evolving poor relationship with Gauguin. Blumer [21] has elegantly combined two symptoms, depression and hypomania, stating that Vincent ‘‘experienced prolonged episodes of depression’’. . . and also ‘‘experienced sustained periods of hypomania or mania.’’ This type of bipolar history, Blumer claimed, is often not identified, but is ‘‘not uncommon among writers and artists.’’ Blumer stated that a tentative diagnosis of schizophrenia has also been considered by several authors, but believes this diagnosis improbable. Although lateonset schizophrenia was diagnosed in one of van GoghÕs sisters (Wilhemina), and another (Cornelia) attempted suicide, their complete recovery from psychotic episodes helped to make this diagnosis improbable, according to Blumer. However, on July 27, 1890, he went to the wheat fields, took out a revolver, and shot himself in the lower chest–stomach area, and died from the infection from the unremoved bullet. Although this may have been ‘‘an act of considered despair [2]’’, ‘‘complete recovery’’ from this mental illness would appear unlikely. The paranoid type of schizophrenia (295.30) in DSM-IV [19] requires the presence of prominent delusions or auditory hallucinations. His hallucinations were so prominent that when Dr. Rey gave him potassium bromide, they dwindled into nightmares [1]. Van Gogh thought that everyone was in a conspiracy to poison him, and he would accuse the locals in Arles; this behavior landed him in the hospital. After returning to his
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home, he would open windows and scream at people, while hearing voices and seeing figures. This behavior was so extreme that the townspeople appealed to the mayor, who ordered him back to the hospital [1]. In St.-Re´my he and one of the epileptic patients shouted at each other so long and so loud that VincentÕs throat swelled, and he tried to swallow his paint to kill himself. Once he tried to drink a quart of turpentine (1889), which resulted in his return to the asylum. Finally, the director of the hospital at St.-Re´my wrote on his admission sheet that Vincent suffered from ‘‘acute mania with hallucinations of sight and hearing which have caused him to mutilate himself by cutting off his ear [22].’’ The latter author, Hulsker [22], stated that the lack of recall of the ear cutting episode was ‘‘because drinking had caused him to black out.’’ Paranoid ideation was clearly prominent in the later years of his life.
4. Possible epilepsy None of the available records suggests that Van Gogh ever had a generalized tonic–clonic attack, primary or secondarily generalized, or had any automatisms that would qualify as a complex partial attack. In fact, he never had any episodic symptoms reflecting a seizure, until he began to eat less (and later drink more). As epilepsy is a diagnosis that requires spontaneous attacks, rather than reactions to a drug or to withdrawal from a drug, van Gogh did not have epilepsy. The remaining question concerns the nature of the blackouts or episodes of unconsciousness he experienced and whether they can be viewed as reactive seizures. As early as 1882–1983 in his relationship with the prostitute ‘‘Sien,’’ he ‘‘ate less to save money, became sick and faint’’ [1]. In his first 6 weeks with her, he ate only three hot meals, using coffee, bread, and smoking to ‘‘dull the ache.’’ When he sat down to a square meal, he could not digest it, felt sick and faint [1]. Eating less than ever, he was approaching collapse, and by February 1886 his ‘‘fainting fits’’ had increased. During the same year at the academy at Antwerp he often was lightheaded and could not keep food down. Only later during the next year (1887) when he went to Paris did he begin ‘‘to drink more than was good for him [1].’’ Thus, before his heavy drinking had begun in Paris, he had already had many ‘‘fainting fits,’’ likely from hypoglycemia or lack of nourishment. On this basis, we cannot propose that epileptic seizures account for these attacks. When van Gogh went to Paris in 1887 and associated with other Impressionists, he engaged in heavy drinking, especially absinthe and cognac, carousing at times all night in the Montmartre district. In the summer of 1887 ‘‘he drank more and more heavily, grew thinner and thinner, always on the edge of starvation’’ [1]. Vincent wrote to his brother Theo that when he left Paris
for Arles he was ‘‘practically a drunkard’’ [1]. The heavy drinking, heavy smoking, and cup after cup of black coffee created an illusion of vitality. In Arles he sometimes lived on 23 cups of coffee a day and bread [8,9]. His one and only friend, Roulin, kept reminding him that fellow artist Monticelli had died of alcoholism and was an absinthe drunkard. In Arles, as an example of drunkenness, Vincent once threw a glass of absinthe at Gauguin, but missed him. Gauguin managed to get van Gogh home but found that he was in a kind of coma [2]. The next morning, van Gogh apologized and claimed not to know what he had done [1]. Dr. Rey in Arles told him that ‘‘his attacks were due to years of undernourishment and too much drink’’ [1]. In 1888 Vincent went an entire week without any food at all, but drank excessively, claiming, ‘‘If the tempest in my brain gets too violent, I take a glass too much’’ [1]. He also said, ‘‘The only thing to bring ease and distraction is to sedate oneself by smoking and drinking heavily’’ [2]. In summary, the excessive drinking did not seem to have resulted in alcohol withdrawal seizures, but he did drink to a stuporous or unconscious state. The common drink among the Impressionists, especially Henri de Toulouse-Lautrec and van Gogh, was absinthe, the ‘‘Green Fairy’’ [23], so-named because it was made by steeping dried wormwood in 85% ethanol and then filtering the green liqueur containing 74% alcohol. Absinthe was banned in nearly all developed countries in the early 1900s; however, this drink is still legal in Great Britain, Spain, Portugal, and the Czech Republic. Today, the active ingredient, thuzone from wormwood, is present at concentrations <30 ppm; the old Parisian liquor contained about 260 ppm [24]! Thuzone can cause hallucinations, and some maintain that it elicits artistic creativity [25]. For our discussion, it is important to emphasize that it can cause seizures. Schachter [26] was one of the first to discuss absinthe and its tendency to produce hallucinations and also exacerbate seizures [27]. As Schachter mentioned, in the late 19th century, H. Jackson classified absinthe as a ‘‘convulsant poison’’ [28]; it was classified similarly in the 20th century [29] and known to produce an increase in porphyrins [30]. Convulsions have been observed in animals and humans at high doses of absinthe [31], but such attacks were never described in Vincent. In addition, absinthism has been associated with auditory and visual hallucinations, an increased risk of psychiatric illness, and suicide [32]. Thus, this drug likely played some role in van GoghÕs life in his last few years, but never elicited convulsions. The exact mechanism by which thuzone acts as a convulsant drug was studied by Hold et al. [33], who found that a-thuzone is the toxic agent in this drug and modulates the GABA-gated chloride channel. Later, the same authors [34] identified 7-hydroxy-a-thuzone as the major metabolite and 4-hydroxy-a- and -b-thuzones
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as minor metabolites, detoxified by the well-known P450 (3A4) enzyme system. In particular, GABA-induced peak currents (rat) are suppressed by a-thuzone. Thus, absinthe acts as a convulsant by inhibiting GABA(A) chloride currents. In humans, the combination of a high concentration of absinthe and alcohol has a negative effect on attention, resulting in the neglect of peripheral signals, increased reaction times, and increased ‘‘false alarm’’ reactions [35]. However, in subjects given only alcohol or both alcohol and a low concentration of thuzone, the latter effects are not observed. Assessment of mood state indicated that the anxiolytic effect of alcohol is temporarily counteracted by a high thuzone concentration [35]. Thus, there is an antagonistic effect between alcohol and thuzone on the GABA receptor. When van Gogh drank both absinthe and cognac together, as he regularly did, the effects of absinthe were probably minimized by the alcohol. The major question is whether Vincent van Gogh had epileptic seizures or not. Before he began drinking absinthe, he had many ‘‘fainting fits,’’ likely because he was often near starvation; he would eat very little food, going without food for even an entire week. His loss-ofconsciousness episodes after he started to drink heavily were not described any differently than his ‘‘fainting fits’’ before his heavy drinking; he often starved himself during periods of excessive drinking. His episodes of unconsciousness were likely, at times, the result of a high alcohol level, as were the typical amnestic episodes that followed. Thus, it appears that his episodes of unconsciousness were the result of drunkenness or chronic lack of food, or both. Although the thuzone in the absinthe can be considered a convulsant drug, alcohol is mainly a depressant drug and would counteract the hyperexciting effects of the thuzone. As the relative concentrations of these drugs would determine the final effect, it cannot be ruled out that the absinthe produced a seizure state, as suggested by a number of authors [21,24,36]. In Paris in the spring of 1889, during a period of heavy drinking, biographers Ozanne and de Jode [3] described his episodes as ‘‘frequent fainting spells that made him tired and rendered him temporarily amnesic.’’ It is not necessary to assume that absinthe caused these episodes as similar ‘‘blackouts’’ had occurred before he started to drink the absinthe. The suggestion that Vincent van Gogh had psychomotor epilepsy came from an early article written nearly one-half century ago by the well-known epileptologist Henri Gastaut [37], who thought that absinthe precipitated these seizures in the last 2 years of his life. During the middle of the 20th century, epileptologists were discovering the many different ways that complex partial attacks or psychomotor seizures could manifest; and the definition of epilepsy was often expanded to include many different psychiatric or psychological states that do not fit the stricter definition of complex partial
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seizures, as defined today. As Dr. Peter Fenwick [38] has stated, ‘‘It is likely that the earlier accounts of temporal lobe epilepsy and temporal lobe pathology and the relationship to mystic and religious states owe more to the enthusiasm of their authors than to the true scientific understanding of the nature of temporal lobe functioning.’’ Epilepsy in van Gogh has also been considered by other authors [21,27,39–43], but the proof of spontaneous seizures is lacking and the episodes of unconsciousness were never more than losses of consciousness, likely explained by near starvation and very heavy alcohol intake, possibly made worse by absinthe. It is improbable that absinthe played a role in inducing some type of seizure activity [44], as generalized tonic– clonic or tonic seizures were elicited in humans by these essential oils, and van Gogh did not experience these types of episodes. Norman Geschwind [45,46] has become well known for his conclusion that patients with temporal lobe epilepsy tend to demonstrate specific personality characteristics, now called the Geschwind syndrome. A more thorough presentation of this syndrome has been provided by David Bear [47], who listed the characteristics of emotionality, manic tendencies, depression, altered sexuality, anger, hostility, aggression, religiosity, paranoia, guilt, viscosity, and hypergraphia. Van Gogh would seem to be a near-perfect example of this syndrome because he either loved or hated everybody, alternated between manic and depressed states, became impotent and lost interest in sexual behavior, was angry or hostile much of the time, attempted to become a religious minister, believed at times that people were trying to kill him, and wrote letters to his brother amounting to 1700 pages [8,9]. Benson and Hermann [48] have spelled out the majority opinion of epileptologists today that there are only ‘‘a subset of patients with epilepsy in general and temporal lobe epilepsy in particular who present with features of the Geschwind syndrome.’’ I think that Vincent van Gogh is likely the best example of the Geschwind syndrome that can be found. However, the syndrome has been described as a part of temporal lobe epilepsy, and if there is no clear temporal lobe epilepsy, then the syndrome is an orphan without a parent condition. Although van Gogh fits the syndrome well, this fact does not establish a temporal lobe epilepsy, but likely indicates that some neurophysiological disturbance exists within the temporal lobes, as it may with temporal lobe epilepsy, but also as it may with nonepileptic disturbances. In conclusion, Vincent van Gogh had a tragic life in and out of mental institutions, had a number of psychiatric diagnoses, including borderline personality disorder, but with manic and depressive periods, and also paranoid ideation. His near self-starvation likely explains his ‘‘fainting fits,’’ and the absinthe and cognac that he used in great quantities resulted in blackouts
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and amnestic episodes, but there is no clear evidence of epilepsy or a seizure disorder.
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