General considerations
For our study we used several diagnostic approaches. However, before applying these, we had to realize whether it would be allowed to make a diagnosis without having Van Gogh interviewed and examined in person. In fact, the medical code of ethics is generally very cautious about this point (2). Nevertheless, in this case we think that we can not only exclude several of the previously suggested diagnoses with certainty, but also be more or less sure about other parts of the diagnostic process. This is based on the fact that we have access to his extensive correspondence containing 902 letters, of which 820 were written by him to his brother Theo and other relatives. In these letters he described what he was experiencing in his life, including his mental problems, although it must also be realized that Van Gogh did not write his letters for his doctors, but for his brother Theo and other relatives, to inform, or to reassure them.
Diagnostic assessments
In a first step we profited from the knowledge of three art historians very familiar with Van Gogh as a person, from his correspondence as well as from several other sources. To ‘use this knowledge’ we interviewed them with three diagnostic assessments. The first was the ‘Structured Clinical Interview for DSM-IV’ (SCID-IV) applied by one of the authors (WAN) (3). The SCID scoring system was slightly modified: any possible symptom ever reported in his life in the sources was scored as ‘certainly not’, ‘possibly’, ‘probably’ or ‘certainly’ present or as ‘unclear’. In a next step we searched the whole correspondence for citations that could confirm the responses of the art historians to the SCID-IV. We present the most clear citations in the historical overview of Van Gogh’s mental problems.
The same art historians were interviewed by another author (EVM) using four questionnaires on personality disorders (the ‘Self Test Viersprong’ (4) ; the ‘McLean Screening Instrument for Borderline Personality Disorder’ (MSI-BPD) (5); the ‘General Assessment of Personality Disorders’ (GAPD) (6); and the ‘Personality Inventory for DSM-5’ (PID 5)) (7) about the existence of possible personality pathology while focussing on his life before the ear incident. The answers to these questionnaires were then scored by two independent experienced diagnosticians (T. Ingenhoven, psychiatrist and H. Berghuis, clinical psychologist), who were unfamiliar with the origins of the investigation and the identity of the ‘patient’, i.e. Van Gogh.
Finally, the same art historians were questioned by another author (PV) for a neuropsychiatric examination to evaluate whether the symptoms might be explained by a medical condition, i e. epilepsy.
Historical Overview Of The Mental Problems Of Van Gogh
Already from his early adulthood Van Gogh experiences mental problems. His father writes “he always has the inclination to melancholy” [102; note 53]. At about 20 years old (1873–1875, living in London) he is often gloomy, withdraws himself from other people, is focused on religious issues, and - partly because of these behaviours - he loses his job as an art dealer. In the years 1875–1877 (Paris), he shows a strict ascetic attitude, combined with an unhealthy lifestyle. In 1877–1878 (Amsterdam) he writes “My head is sometimes numb and is often burning hot, and my thoughts are confused” [117] and he mentions “indescribably strong feeling of fear” [141]. He also injures himself “Last night I used the cudgel again" (8). In 1880 (Borinage) he describes himself as “a man of passions, capable of and liable to do rather foolish things for which I sometimes feel rather sorry. I do often find myself speaking or acting somewhat too quickly when it would be better to wait more patiently” [155]. He behaves so strange that his father suggests him to go the psychiatric asylum of Geel which Van Gogh refuses [185, 186]. Shortly thereafter he regains his artistic activities. Late 1881 (Etten) he writes several letters which in comparison with the rest of his correspondence, are remarkably long and also rather incoherent [180–190].
In 1882–1883 (The Hague) he feels “as though one is bound hand and foot, lying in a deep, dark pit, powerless to do anything” [203] and reports fear and sorrow which “cannot but make one agitated and nervous in speech and manner” [221]. Moreover, he mentions that he doesn’t enjoy company, and that dealing with people, talking to them, is often painful and difficult [244]. Nevertheless, he remains active with drawing and painting.
Late 1883 (Drenthe) he “is overcome by a feeling of great anxiety, dejection and even despair, too much to express”. Next (Nuenen) he senses a “procrastination and hesitancy in everything, which paralyzes my own passion and energy like a leaden atmosphere” [410]. A few months later (1884) he is working “from early till late” and being “absorbed in the moment”, in a letter also containing 10 poems [430]. He remains very active for several months, but finally he writes “I’ve worked really hard recently; I believe, in conjunction with other agitation, even overworked. At least I’m in a sad mood, and all these things have affected me to such an extent that I have many days when I’m relatively powerless. I can’t eat and I can’t sleep, that’s to say not enough, and that makes one weak”. [463] In this period he leaves the church and becomes engaged in inappropriate love affairs which also leads to a further disturbed relationship with his parents.
In 1885 Van Gogh moves to Antwerp and after a few months to Paris (1886–1887), where he goes to live with Theo, which means that he temporarily stops writing letters. In Paris, he has “the most impossible and highly unsuitable love affairs from which, as a rule, I emerge only with shame and disgrace” [574] combined with (probably) substantial alcohol use and heavy smoking [603].
In 1888 Van Gogh moves to Arles where initially he is very active “in a fury of work” [592] and experiences a “rage to paint orchards [which] won’t last forever” [594]. However, a month later he reports “ It’s not in black that I see the future, but I see it bristling with many difficulties, and at times I wonder if these won’t be stronger than I am”, and “I was so worn out and ill that I didn’t feel I had the strength to go and live on my own” [602, 608]. He continues drinking and smoking “the only thing that comforts and distracts – in my case – as in others, is to stun oneself by taking a stiff drink or smoking very heavily” [635]; also to find relief “If the storm within roars too loudly, I drink a glass too many to stun myself. It’s being crazy, compared with what one ought to be” [645]. He has days being active with painting, but also days feeling “thoroughly discouraged” and “My life is restless and anxious” [672]. Furthermore, he reports a changed sleeping pattern: “For 3 nights I stayed up to paint, going to bed during the day. It often seems to me that the night is much more alive and richly coloured than the day” [676]. Additionally, he realizes the alternating pattern of his mental problems: “I have a terrible clarity of mind at times, when nature is so lovely these days, and then I’m no longer aware of myself and the painting comes to me as if in a dream. I am indeed somewhat fearful that that will have its reaction in melancholy when the bad season comes” [687].
In October 1888 Gauguin joins Van Gogh in Arles. Initially, their collaboration is fruitful, but soon tensions arise. Already after six weeks Gauguin expresses the idea to leave as he “can absolutely not live side by side without trouble, as a result of incompatibility of temperament, and both he and I need tranquillity for our work” [724, note 1]. In the night of December 22 Gauguin decides to leave. This leads to a crisis in which Van Gogh directs the aggression towards himself. On the evening of December 23, he cuts off his left ear and gives it away to a woman in a brothel.
Alarmed police finds him the next morning at home suffering from blood loss, and he is admitted to the local hospital. Two days later (December 26) he becomes so confused that he is put in isolation: ”My thoughts sailed over many seas. I even dreamed of the Dutch ghost ship and the Horla, and it seems that I sang then” [739]. Afterwards he has only vague memories. He also has vivid visual images: ”I again saw each room in the house at Zundert, each path, each plant in the garden, the views round about, the fields, the neighbours, the cemetery, the church, our kitchen garden behind – right up to the magpies’ nest in a tall acacia in the cemetery” [741] and also “unbearable hallucinations”, anxiety and nightmares [743]. Another seven days later (January 2, 1889), he is recovered and discharged from the hospital on January 7. At that time, he thinks not much is wrong, but afterwards he has the feeling that he has been ill: “What can you say, I have moments when I’m twisted by enthusiasm or madness or prophecy like a Greek oracle on her tripod” [745]. He resumes his activities but within a month it goes wrong again.
On February 7, he is re-admitted with apparently similar symptoms and again placed in isolation. In a report, on request of the Chief of Police, doctor Albert Delon writes “I found this man in a state of extreme excitement suffering from a true delirium, only momentarily recognizing the people around him”, and he hears hallucinations [747, note 1]. It is unclear whether he was drinking alcohol again between his first and second admission. Again his hospital stay is short, and on February 17 he goes back to work. However, there are complaints from a group of 30 residents about nuisance and inappropriate behaviour, e.g. touching women and making obscene remarks (9). This results in the third and this time involuntary admission on February 27. Whether he is confused or just angry by the complaints about his behaviour and that he is placed in isolation, remains unclear [750]. Afterwards, he also mentions “terrible fits of anxiety sometimes without any apparent cause” [764].
Mid-March he has almost recovered and goes back to home although he continues to eat and sleep in the hospital while feeling uncertain about the future: “It will, I hope, suffice to say that I feel decidedly incapable of starting to take a new studio again and living there alone”. In addition, he expresses concerns about his alcohol use [760]. Looking back to what happened in the previous months, he mentions four (?) “big crises in which I hadn’t the slightest idea of what I said, wanted, did”, while he can’t precisely describe what it is like: “there are terrible fits of anxiety sometimes – without any apparent cause – or then again a feeling of emptiness and fatigue in the mind. I consider the whole rather as a simple accident, no doubt a large part of it is my fault, and from time to time I have fits of melancholy and terrible feelings of guilt” [764]. He agrees with the suggestion of his doctor and Theo to agree to a voluntary admission in the asylum in Saint-Rémy on May 8, 1889 where he will stay for a year, experiencing four episodes/crises. The first episode lasts longer (from mid-July to late August 1889) than the previous three crises in Arles. He complains about a “disturbed mind” and is “absolutely distraught, as in Arles, just as much if not worse”. [797] He also shows bizarre behaviour: “It appears that I grab dirt from the ground and eat it, although my memories of these bad moments are vague” [797]. When looking back to this period he writes: “I feel cowardly in the face of anguish and suffering – more cowardly than is justified”, recognizing that the crises “tend to take an absurd religious turn” and mentioning “I reproach myself for my cowardice” [801]. He also he paints himself in a recently to Van Gogh attributed self-portrait (Fig. 1) (10).
Late December 1889 follows a short crisis lasting one week with “great discouragement” [836] while his guard Poulet observes that he swallows paint what is interpreted by his doctor Peyron as an attempt to poison himself [833, note 2]. On January 21, 1890, two days after a visit to Arles, he is again seized by an attack lasting about a week. According to his doctor Peyron “He is incapable at present of any kind of work, and only responds with incoherent words when asked questions” [846, note 2]. A few days after having received a letter from Theo announcing that he has become a father, Van Gogh congratulates him: “It does me more good and gives me more pleasure” and it “contributes a great deal to making me forget these last few days when I was ill, then I no longer know where I am and my mind wanders” [850].
However, a prolonged and severe episode again follows from February to April 1890, where he is “totally dazed”. [857], “not able to read or write” and “ill at its worst” "[864]. Disappointed that he has not recovered in Saint-Rémy he then takes the decision to leave for the North [863, 865]. In May 1890 he moves to the rural Auvers-sur-Oise near Paris. However, he again doesn’t fully recover and finally he shoots himself in the breast on July 27 1890, ending his life two days later (11).