Autism Added to Behavioral Profile of Vincent van Gogh

Vincent Van Gogh and Autism Spectrum Disorder (ASD) Added to His Differential Diagnosis

From early childhood, Vincent van Gogh was solitary, lonely, highly agitated, disruptive, and unsuccessful in obtaining acceptance from most of his family. He manifested many characteristics and problems, as well as savant characteristics. While a multitude of medical and psychiatric diagnoses have been ascribed to him, the DSM-5 diagnosis of Autism Spectrum Disorder (ASD) should also be considered in his extensive differential diagnosis.

There are many clinically pertinent findings consistent with ASD that were evident from earliest childhood, through adolescence, and into his early adulthood years. The addition of ASD to Vincent’s extensive differential diagnoses may provide further clarity and perspective to his well-known, yet incompletely understood, and atypical presentation he manifested throughout all periods of his shortened life. The ASD diagnosis may provide some explanation as to why those who had only brief contact and interactions with him considered him to be so peculiar and socially awkward, if not crazy.

There appears to be several misconceptions about Vincent van Gogh’s medical, psychological, and anti-social presentations. It has been noted that he was misdiagnosed with epilepsy [1] and his problem with inner ear vertigo was not recognized. While the popular narrative regarding the famous painter is that he was simply mad (“fou”), there is reason to argue that many of his social and behavioral difficulties can at least be partially ascribed to the diagnosis of ASD.

The diagnosis of ASD does not account for all of Vincent’s problems. It is very common for individuals with ASD to have other co-occurring psychiatric, medical, and neurological conditions, sometimes presenting confusing diagnostic and treatment challenges. In addition to his Meniere’s disease and probable ASD, Vincent appeared to have intermittent episodes of severe depression and mania, consistent with bipolar disorder [2]. Hundreds of articles, books, and film productions have offered explanations about Vincent’s clinical presentation with many psychiatric problems. During the past 130 years since his death, Blumer noted that van Gogh has been analyzed by over 150 physicians, including medical and mental health professionals, with as many as 30 different medical, psychological, and psychiatric diagnoses [2]. The diagnosis of ASD has never been considered.

Clinical History

At the age of twenty-seven, Vincent’s father, Theordorus, attempted to have him committed to the open-air-asylum in Gheel. Vincent refused to cooperate, as he did not agree with the assessment by Professor Johannes Nicolaas Ramaer in The Hague to obtain the “certification of insanity”. Vincent said: “I resisted with all my might”.

His adult medical history included his treatments for venereal disease in 1882 at a hospital in The Hague. He again was treated for this condition in 1885 by Dr. Amadeus Cavenaille at the Stuyvenberg hospital in Antwerp. He subsequently was treated by Dr. Felix Rey at Hotel Dieu Hospital in Arles in 1888-89 after the ear mutilation episode. Dr. Theophile Peyron at St Paul-de-Mausole Asylum for Lunatics and Epileptics in Saint-Remy-de-Provence diagnosed Vincent with epilepsy in 1889, as being the source of his attacks and hallucinations. He also presumed that epilepsy contributed to his mental illness. The misdiagnosis persisted to 1990, when the attacks were accepted to be Meniere’s disease [1].

Vincent sought connection with men his age and with similar interests. The pattern unfortunately was always the same: initial high excitement and enthusiasm, subsequently becoming predictably volatile, argumentative, and alienated. He would attempt to reconcile but the damage usually was irreparable. Well known examples of these types of relationships were with Anthon van Rappard, Anton Mauve, H.G. Tersteeg, Emile Bernard, and Paul Gauguin. The several communities in which Vincent lived, Nuenen, Auvers, and Arles, all viewed him as quite strange. People avoided contact with him, and he frequently was taunted by young boys. Given his inability to emotionally engage and authentically connect with people, Vincent resorted to prostitutes as his primary form of consolation.

Vincent possessed savant qualities and was a  brilliant and creative person; many consider him in a class of genius on par with Albert Einstein, Pablo Picasso, or Leonardo da Vinci. He also was obsessively focused on specific interests. Traits that raise the likelihood of ASD include his ongoing difficulties with social niceties, intense focus on one thing at a time, restricted interests in specific topics, for which he had a great memory.

Vincent spoke incessantly about his view of art, life, and society in a very controlling and often manipulative manner. He could be argumentative to the point of exhaustion, fighting until the other person accepted his point of view or just acquiesced. This type of behavior routinely and negatively affected his interactions with other people, with most of his relationships ending poorly. Consideration of ASD offers possible explanations for his problems with social skills and general lack of meaningful relationships.

Vincent’s problems frequently were attributed to depression. The presence of clinical depression does not preclude the diagnosis of ASD. People with ASD are at significantly higher risk for other behavioral or psychiatric problems, including anxiety, irritability, depression, and suicide [3]. Vincent’s time in the asylum may not have resolved his ongoing social issues or his recurrent depression completely, although he did become calmer by comparison to his prior persona in Arles. The year of self-isolation, abstaining from liquor, taking the baths, and painting as much as he could, allowed him time to rethink his life and future.  The most effective treatment appeared to be the four self-portraits he produced during this period. Looking deeply into a mirror for hours, presumably allowed deep introspection and meditation to capture his inner self. This activity allowed Vincent the opportunity to reset his inner self and rid himself of his many personal demons. The year in the asylum resulted in a renewed and calmer man compared to the turbulent and wild Vincent of Arles. He was notably more “normal,” more comfortable with himself and others, and more open and capable of enjoying and pursuing his new life. When he was in Auvers he experienced greater comforts, productivity, and calmness than previously, bringing into question whether he truly was suicidal at the time of his death. The long-standing accepted suicide theory has recently been challenged with an extensive modern forensic analysis of the mortal wound he suffered, concluding it was not probable for Vincent to self-inflict his mortal wound [4].

Asperger Disorder was first described in the 1940s by Viennese pediatrician Hans Asperger [5] and would not have been a diagnosis Vincent’s doctors made. However, Vincent’s presentation, as extensively described by Naifeh and White Smith [6], may be consistent with prior DSM-4 diagnostic category for Asperger Disorder (American Psychological Association (APA)) [7]. Vincent did not have significant language delays, appears to have had difficulties with pragmatic use of language, and was unaware of some of the nuances of social communication. While Vincent certainly wrote many eloquent letters and had mastery of multiple languages, he could not understand why something he was doing or saying was inappropriate.  His challenges with understanding social rules and boundaries, were recurring themes throughout Vincent’s troubled life.

Could the Diagnosis of Autism Spectrum Disorder Provide Better Insight into Vincent’s Presenting Social and Behavioral Difficulties?

DSM-4 [7] had a section for Pervasive Developmental Disorders, which included Autistic Disorder; Pervasive Developmental Disorder, Not Otherwise Specified (PDD, NOS); Asperger Disorder; Rett Disorder; and Childhood Disintegrative Disorder, with the first three categories reflecting the autism spectrum disorders. In 2013, significant changes were made to this group of conditions with the publication of DSM-5 [8]. The diagnosis of Autistic Disorder, PDD, NOS, and Asperger Disorder were combined into one diagnostic category: Autism Spectrum Disorder.  While there was much controversy regarding that change, it was influenced by the general agreement among experts if an individual was on the autism spectrum, while notably less agreement about where on the spectrum an individual belonged.

According to the Diagnostic and Statistical Manual of Mental Disorder- 5th edition -diagnostic criteria for ASD include the following

Selected examples provided for each category. DSM-5 299.00A Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history:

299.00 A1: Deficits in social-emotional reciprocity, ranging, for example, from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions, or affect; to failure to initiate or respond to social interactions.

Vincent was socially inept, lacking social graces and empathy. People noted it was unpleasant to be with him. He lacked social normative behavior and understanding of personal boundaries.

Vincent was unable to clearly notice and accept someone’s romantic disinterest, and he was unable to maintain long-term friendships. His relationships with others often devolved into arguments and verbal fights, reflective of his difficulties in understanding others’ points of view.

Vincent ceaselessly struggled with his painful loneliness. His efforts to find love and marriage were tragic failures. If Vincent found someone attractive, he unilaterally determined that this woman was the one for him without consideration of the woman’s own feelings and desires. This type of behavior possibly occurred with Eugenie Loyer in Brixton, England and most famously in Amsterdam with his cousin Kee Vos- Stricker, who responded to Vincent’s marriage proposal with an unequivocal “Never, No, Never.” Vincent initiated three unwelcomed and near violent confrontations with Kee’s father and brother. He relented although could never accept her rejection of him.

299.00 A2: Deficits in nonverbal communicative behaviors used for social interaction, ranging, for example, from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and use of gestures; to a total lack of facial expressions and nonverbal communication.

Vincent did not appear to pick up social cues, often testing others’ patience. He engaged in inspirational readings to the boarders living in the same residence as him, as he was being scorned and mocked. As Vincent moved from adolescence into adulthood, he could not meet his employer’s expectations and lacked discretion in relating to customers, for example, labeling certain art terrible and not worth purchasing.

In Vincent’s ongoing and frustrating efforts to master figure drawing, he always had a problem obtaining models, primarily due to his disturbing physical appearance and unappealing persona. Madame Ginoux agreed to be a model for Vincent only because Gauguin was present. Adeline Ravoux refused to model a second time. While a patient at Saint-Remy-de-Mausole Asylum, Vincent made trips to Arles to connect with Madame Ginoux, his idealized L’Arlesienne, who eventually avoided contact with him. In line with this desperate need for models, he would accost people in public asking them to pose for him, who generally rejected these impositions, reinforcing his image as the “mad artist.” Vincent’s reputation for eccentric and offensive behaviors, resulted in dissonant relationships with community members. People in Nuenen, Drenthe, and Arles were disturbed by his presence in their communities. In Arles, a “community petition” was signed by thirty people demanding his removal, leading to Vincent’s voluntary admission to the asylum in Saint-Remy. Despite this community reaction, Vincent still had plans to return to Arles.

299.00 A3: Deficits in developing, maintaining, and understanding relationships, ranging, for example, from difficulties adjusting behavior to suit various social contexts, to difficulties in sharing imaginative play or in making friends; to absence of interest in peers.

Vincent had no friends for decades of his life and often engaged in solitary activities. On a visit with relatives, he stood in a corner reading while others played cards. Vincent’s conflict with his “artist friends,” and with his brother Theo, resulted from his obstinate insistence that his view of art was the only correct one. Vincent clung to his delusional vision of a “fraternal brotherhood” living in a rural community, mutually supporting one another, even financially. In Auvers, he added to this fantasy of “fraternal brotherhood,” the vision of a “family house” so that his brother, Theo, his wife, and son would join him, ignoring or denying that this idea was totally unrealistic and rejected by his brother.

DSM-5 299.00 B Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history: 299.00 B1: Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypes, lining up toys or flipping objects, echolalia, idiosyncratic phrases). Examples in the category are limited. However, Vincent generally was considered a “strange boy.” Peasants observed Vincent rubbing his hands together repeatedly…and considered him “mad.” Vincent had a frantic need for forward motion. He used pencil and paper obsessively, long before he even knew the meaning of his markings, which Vincent called his “little scratches.” 299.00 B2: Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., extreme distress at small changes, difficulties with transitions, rigid thinking patterns, greeting rituals, need to take the same route or eat the same food every day). Family recollections of Vincent referred to him as obstinate, unruly, self-willed, hard to deal with, a queer one, having strange manners, and a difficult temper… the least pleasant of the children. His mother, Anna, said: “I was never busier than when we only had Vincent.” Not knowing how to manage Vincent, Anna and Dorus enrolled Vincent, at age 13, into private schools in Zevenbergen for two years and then another two years in Tilburg [6].

Vincent had a dramatic and unrelenting need to finish a painting that he started. He became very upset, frustrated, and acted out when an attack of “le vertige” [1] occurred amid painting, making it impossible for him to continue. He displayed prolific output and needed to quickly complete a painting. He feared his “attacks” would ruin his ability to paint while in Auvers. He needed to follow his routine, with an unremitting need to finish a painting the same day, sometimes producing two, three or more paintings in a single day.

299.00 B3: Highly restricted, fixated interests that are abnormal in intensity or focus (e.g., strong attachment to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).

During Vincent’s early childhood, he became an obsessive collector, primarily wildflowers, bird eggs and beetles. He recorded where the rarest of wildflowers grew, examined the differences between the nests of thrushes, blackbirds, finches, and wrens and made little boxes to display his beetle collection, labelling each one with their proper Latin names. As an adult, he became zealous in his interest in religion. As a catechist, the children referred to him as “fou” (crazy). Being a poor public speaker led him to be dismissed from his desired career as a missionary, but the real reason was his unyielding personality.

Likewise, he was obsessed with painting, which he did in extreme weather and adverse conditions, making unusual modifications to allow him to do so. His need to paint superseded any concerns about his need to alter his life to address his financial problems. Vincent read with incredible speed and quantity, while committing volumes to memory, especially poetry. He had an obsession about collecting prints and categorized admired painters, as he had done with scripture. In his letter writing, especially to his brother, Theo, he wrote drafts of letters and then sent long winded missives of his daily activities. He might send multiple letters in a single day or a string of letters in a week depending on his mood.

299.00 B4: Hyper- or hypo- reactivity to sensory input or unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature, adverse response to specific sounds or textures, excessive smelling or touching of objects, visual fascination with lights or movement). Vincent took walks in all types of weather without adequate clothing, including being shoeless in the winter. These excursions were extreme and repetitive whether in the Belgian Borinage, the south of England, or southern France. He admitted after one such long walk in the Borinage that he thought he would die. Vincent would not attend concerts as the rustle of the audience upset him. He stated that he left Paris after visiting Theo and his family in May 1890 because of the city “noise”.

Vincent had an intense emotional sense of color. He was a passionate advocate of The Law of Simultaneous Contrast [9]. Vincent was indeed an “expressionist.” He always sought to translate his intense subjective experience of nature onto his canvases with likewise vivid colors and vigorous brush strokes. “I want to paint what I feel and feel what I paint.”

Conclusion

Vincent has confounded the many medical and psychiatric professionals trying to reconcile the diverse and unusual aspects of his emotional and mental persona, all wrapped neatly into just one bundle. We contend that the diagnosis of ASD, in its variable manifestations, could provide some diagnostic clarity. In Vincent’s time, the diagnosis of ASD did not exist. Even today, patients with ASD often present with complex developmental and psychiatric profiles. Consideration of the diagnosis of ASD for Vincent, appears to provide further understanding to his life, art, intense use of color, and artistic output.