Schizophrenia is a serious disorder which affects how a person thinks, feels and

acts. Someone with schizophrenia may have difficulty distinguishing between what
is real and what is imaginary; may be unresponsive or withdrawn; and may have
difficulty expressing normal emotions in social situations.

Contrary to public perception, schizophrenia is not split personality or multiple

personality. The vast majority of people with schizophrenia are not violent and do not
pose a danger to others. Schizophrenia is not caused by childhood experiences,
poor parenting or lack of willpower, nor are the symptoms identical for each person.

What Causes Schizophrenia?

The cause of schizophrenia is still unclear. Some theories about the cause of this
disease include: genetics (heredity), biology (abnormalities in the brains chemistry
or structure); and/or possible viral infections and immune disorders.

Genetics (Heredity)

Scientists recognize that the disorder tends to run in families and that a person
inherits a tendency to develop the disease. Similar to some other genetically-related
illnesses, schizophrenia may appear when the body undergoes hormonal and
physical changes (like those that occur during puberty in the teen and young adult
years) or after dealing with highly stressful situations.

Biology

Chemistry - Scientists believe that people with schizophrenia have an imbalance of

the brain chemicals or neurotransmitters: dopamine, glutamate and serotonin. These
neurotransmitters allow nerve cells in the brain to send messages to each other. The
imbalance of these chemicals affects the way a persons brain reacts to stimuli--
which explains why a person with schizophrenia may be overwhelmed by sensory
information (loud music or bright lights) which other people can easily handle. This
problem in processing different sounds, sights, smells and tastes can also lead to
hallucinations or delusions.
Structure - Some research suggests that problems with the development of
connections and pathways in the brain while in the womb may later lead to
schizophrenia.

Viral Infections and Immune Disorders

Schizophrenia may also be triggered by environmental events, such as viral
infections or immune disorders. For instance, babies whose mothers get the flu
while they are pregnant are at higher risk of developing schizophrenia later in life.
People who are hospitalized for severe infections are also at higher risk.
What are the Early Warning Signs of Schizophrenia?
The signs of schizophrenia are different for everyone. Symptoms may develop
slowly over months or years, or may appear very abruptly. The disease may come
and go in cycles of relapse and remission.
Behaviors that are early warning signs of schizophrenia include:
Hearing or seeing something that isnt there
A constant feeling of being watched
Peculiar or nonsensical way of speaking or writing
Strange body positioning
Feeling indifferent to very important situations
Deterioration of academic or work performance
A change in personal hygiene and appearance
A change in personality
Increasing withdrawal from social situations
Irrational, angry or fearful response to loved ones
Inability to sleep or concentrate
Inappropriate or bizarre behavior
Extreme preoccupation with religion or the occult

Anyone who experiences several of these symptoms for more than two weeks
should seek help immediately.
What are the Symptoms of Schizophrenia?
A medical or mental health professional may use the following terms when
discussing the symptoms of schizophrenia.
Positive symptoms are disturbances that are added to the persons personality.
Delusions false ideas--individuals may believe that someone is spying on him or her, or that
they are someone famous (or a religious figure).
Hallucinations seeing, feeling, tasting, hearing or smelling something that doesnt really exist.
The most common experience is hearing imaginary voices that give commands or comments to the
individual.
Disordered thinking and speech moving from one topic to another, in a nonsensical fashion.
Individuals may also make up their own words or sounds, rhyme in a way that doesn't make sense,
or repeat words and ideas.
Disorganized behavior this can range from having problems with routine behaviors like
hygiene or chosing appropriate clothing for the weather, to unprovoked outbursts, to impulsive and
 uninhibited actions. A person may also have movements that seem anxious, agitated, tense or
constant without any apparent reason.
Negative symptoms are capabilities that are lost from the persons personality.
Social withdrawal
Extreme apathy (lack of interest or enthusiasm)
Lack of drive or initiative
Emotional flatness

How is Schizophrenia Treated?

If you suspect someone you know is experiencing symptoms of schizophrenia,
encourage them to see a medical or mental health professional immediately. Early
treatment--even as early as the first episode--can mean a better long-term outcome.
Recovery and Rehabilitation
While no cure for schizophrenia exists, many people with this illness can lead
productive and fulfilling lives with the proper treatment. Recovery is possible through
a variety of services, including medication and rehabilitation programs.
Rehabilitation can help a person recover the confidence and skills needed to live a
productive and independent life in the community. Types of services that help a
person with schizophrenia include:
Case management helps people access services, financial assistance, treatment and other
resources.
Psychosocial Rehabilitation Programs are programs that help people regain skills such as:
employment, cooking, cleaning, budgeting, shopping, socializing, problem solving, and stress
management.
Self-help groups provide on-going support and information to persons with serious mental
illness by individuals who experience mental illness themselves.
Drop-in centers are places where individuals with mental illness can socialize and/or receive
informal support and services on an as-needed basis.
Housing programs offer a range of support and supervision from 24 hour supervised living to
drop-in support as needed.
Employment programs assist individuals in finding employment and/or gaining the skills
necessary to re-enter the workforce.
Therapy/Counseling includes different forms of talktherapy, both individual and group, that can
help both the patient and family members to better understand the illness and share their concerns.
Crisis Services include 24 hour hotlines, after hours counseling, residential placement and in-
patient hospitalization.
Coordinated Specialty Care (CSC) has been found to be especially effective in
improving outcomes for people after they experience their first episode of psychosis.
Coordinated Specialty Care involves a team of providers who work with the
individual using shared decision making to implement a multi-faceted program
aimed at helping the individual to recover. CSC often includes a combination of case
management, therapy, supported employment and education services, support and
education for the family of the individual, and/or medication. The CSC team also
works closely with the individual's primary care provider. Learn more about CSC
through NIMH's Recovery After an Initial Schizophrenia Episode (RAISE) Project.
Antipsychotic Medication
Medications are often used to help control the symptoms of schizophrenia. They
help to reduce the biochemical imbalances that cause schizophrenia and decrease
the likelihood of relapse. Like all medications, however, anti-psychotic medications
should be taken only under the supervision of a mental health professional. Atypical
(or "New Generation") antipsychotics are less likely to cause some of the severe
side effects associated with typical antipsychotics (i.e. tardive dyskinesia, dystonia,
tremors).
There are two major types of antipsychotic medication:
Typical ("conventional") antipsychotics effectively control the positivesymptoms such as
hallucinations, delusions, and confusion of schizophrenia. Some typical antipsychotics are:
Chlorpromazine (Thorazine)
Haloperidol (Haldol)
Mesoridazine (Serentil)
Perphenazine (Trilafon)
Fluphenazine (Proxlixin)
Thioridazine (Mellaril)
Thiothixene (Navane)
Trifluoperazine (Stelazine)
Atypical ("New Generation") antipsychotics treat both the positive and negative symptoms of
schizophrenia, often with fewer side effects. Some atypical antipsychotics are:
Aripiprazole (Abilify, Aristada)
Asenapine (Saphris)
Brexpiprazole (Rexulti)
Cariprazine (Vraylar)
Clozapine (Clozaril, FazaClo, Versacloz)
Iloperidone (Fanapt)
Lurasidone (Latuda)
Olanzapine (Zyprexa)
Paliperidone (Invega)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
A third, smaller category of drugs used to treat schizophrenia is known as
"miscellaneous antipsychotic agents." Miscellaneous antipsychotic agents function
differently than typical or atypical antipsychotic medications. Loxapine (Adasuve,
Loxitane) is one such miscellaneous antipsychotic and is used to treat agitation in
people with schizophrenia.
Side effects are common with antipsychotic drugs. They range from mild side
effects such as dry mouth, blurred vision, constipation, drowsiness and dizziness
which usually disappear after a few weeks to more serious side effects such as
trouble with muscle control, pacing, tremors and facial ticks. The newer generation
of drugs have fewer side effects. However, it is important to talk with your mental
health professional before making any changes in medication since many side
effects can be controlled.
Schizophrenia is a challenging disorder that makes it difficult to distinguish between what is real
and unreal, think clearly, manage emotions, relate to others, and function normally. But that
doesn't mean there isn't hope. Schizophrenia can be successfully managed. The first step is to
identify the signs and symptoms. The second step is to seek help without delay. With the right
treatment and support, a person with schizophrenia can lead a happy, fulfilling life.

What is schizophrenia?
Schizophrenia is a brain disorder that affects the way a person behaves, thinks, and sees the
world. People with schizophrenia often have an altered perception of reality. They may see or
hear things that dont exist, speak in strange or confusing ways, believe that others are trying to
harm them, or feel like theyre being constantly watched. This can make it difficult to negotiate
the activities of daily life, and people with schizophrenia may withdraw from the outside world
or act out in confusion and fear.
Although schizophrenia is a chronic disorder, there is help available. With support, medication,
and therapy, many people with schizophrenia are able to function independently and live
fulfilling lives.

Early warning signs of schizophrenia

In some people, schizophrenia appears suddenly and without warning. But for most, it
comes on slowly, with subtle warning signs and a gradual decline in functioning long
before the first severe episode. Many friends and family members of people with
schizophrenia report knowing early on that something was wrong with their loved one,
they just didnt know what.

In this early phase, people with schizophrenia often seem eccentric, unmotivated,
emotionless, and reclusive. They isolate themselves, start neglecting their appearance,
say peculiar things, and show a general indifference to life. They may abandon hobbies
and activities, and their performance at work or school deteriorates.
The most common early warning signs include:

1. Depression, social withdrawl

2. Hostility or suspiciousness, extreme reaction to criticism

3. Deterioration of personal hygiene

4. Flat, expressionless gaze

5. Inability to cry or express joy or inappropriate laughter or crying

6. Oversleeping or insomnia; forgetful, unable to concentrate

7. Odd or irrational statements; strange use of words or way of speaking

While these warning signs can result from a number of problemsnot just
schizophreniathey are cause for concern. When out-of-the-ordinary behavior is
causing problems in your life or the life of a loved one, seek medical advice. If
schizophrenia or another mental problem is the cause, treatment will help.

Signs and symptoms

There are five types of symptoms characteristic of schizophrenia: delusions,
hallucinations, disorganized speech, disorganized behavior, and the so-called negative
symptoms. However, the signs and symptoms of schizophrenia vary dramatically from
person to person, both in pattern and severity. Not every person with schizophrenia will
have all symptoms, and the symptoms of schizophrenia may also change over time.

Delusions

A delusion is a firmly-held idea that a person has despite clear and obvious evidence
that it isnt true. Delusions are extremely common in schizophrenia, occurring in more
than 90% of those who have the disorder. Often, these delusions involve illogical or
bizarre ideas or fantasies. Common schizophrenic delusions include:
Delusions of persecution Belief that others, often a vague they, are out to get him
or her. These persecutory delusions often involve bizarre ideas and plots (e.g. Martians
are trying to poison me with radioactive particles delivered through my tap water).

Delusions of reference A neutral environmental event is believed to have a special

and personal meaning. For example, a person with schizophrenia might believe a
billboard or a person on TV is sending a message meant specifically for them.

Delusions of grandeur Belief that one is a famous or important figure, such as Jesus
Christ or Napoleon. Alternately, delusions of grandeur may involve the belief that one
has unusual powers that no one else has (e.g. the ability to fly).

Delusions of control Belief that ones thoughts or actions are being controlled by
outside, alien forces. Common delusions of control include thought broadcasting (My
private thoughts are being transmitted to others), thought insertion (Someone is
planting thoughts in my head), and thought withdrawal (The CIA is robbing me of my
thoughts).

Daniels story

Daniel is 21 years old. Six months ago, he was doing well in college and holding down a
part-time job in the stockroom of a local electronics store. But then he began to change,
becoming increasingly paranoid and acting out in bizarre ways. First, he became
convinced that his professors were out to get him since they didnt appreciate his
confusing, off-topic classroom rants. Then he told his roommate that the other students
were in on the conspiracy. Soon after, he dropped out of school.

From there, things just got worse. Daniel stopped bathing, shaving, and washing his
clothes. At work, he became convinced that his boss was watching him through
surveillance bugs planted in the stores television sets. Then he started hearing voices
telling him to find the bugs and deactivate them. Things came to a head when he acted
on the voices, smashing several TVs and screaming that he wasnt going to put up with
the illegal spying any more. His frightened boss called the police, and Daniel was
hospitalized.

Hallucinations

Hallucinations are sounds or other sensations experienced as real when they exist only
in the person's mind. While hallucinations can involve any of the five senses, auditory
hallucinations (e.g. hearing voices or some other sound) are most common in
schizophrenia. Visual hallucinations are also relatively common. Research suggests that
auditory hallucinations occur when people misinterpret their own inner self-talk as
coming from an outside source.

Schizophrenic hallucinations are usually meaningful to the person experiencing them.

Many times, the voices are those of someone they know. Most commonly, the voices are
critical, vulgar, or abusive. Hallucinations also tend to be worse when the person is
alone.

Disorganized speech

Fragmented thinking is characteristic of schizophrenia. Externally, it can be observed in

the way a person speaks. People with schizophrenia tend to have trouble concentrating
and maintaining a train of thought. They may respond to queries with an unrelated
answer, start sentences with one topic and end somewhere completely different, speak
incoherently, or say illogical things.

Common signs of disorganized speech in schizophrenia include:

Loose associations Rapidly shifting from topic to topic, with no connection between
one thought and the next.

Neologisms Made-up words or phrases that only have meaning to the patient.

Perseveration Repetition of words and statements; saying the same thing over and
over.

Clang Meaningless use of rhyming words (I said the bread and read the shed and
fed Ned at the head").

Disorganized behavior

Schizophrenia disrupts goal-directed activity, causing impairments in a persons ability to

take care of him or herself, work, and interact with others. Disorganized behavior
appears as:

A decline in overall daily functioning

Unpredictable or inappropriate emotional responses
Behaviors that appear bizarre and have no purpose
Lack of inhibition and impulse control

Negative symptoms (absence of normal behaviors)

The so-called negative symptoms of schizophrenia refer to the absence of normal
behaviors found in healthy individuals. Common negative symptoms of schizophrenia
include:

Lack of emotional expression Inexpressive face, including a flat voice, lack of eye
contact, and blank or restricted facial expressions.

Lack of interest or enthusiasm Problems with motivation; lack of self-care.

Seeming lack of interest in the world Apparent unawareness of the environment;

social withdrawal.

Speech difficulties and abnormalities Inability to carry a conversation; short and

sometimes disconnected replies to questions; speaking in monotone.

Causes
The causes of schizophrenia are not fully known. However, it appears that
schizophrenia usually results from a complex interaction between genetic and
environmental factors.

Genetic causes

Schizophrenia has a strong hereditary component. Individuals with a first-degree

relative (parent or sibling) who has schizophrenia have a 10 percent chance of
developing the disorder, as opposed to the one percent chance of the general
population.

But schizophrenia is only influenced by genetics, not determined by it. While

schizophrenia runs in families, about 60% of schizophrenics have no family members
with the disorder. Furthermore, individuals who are genetically predisposed to
schizophrenia dont always develop the disease, which shows that biology is not destiny.

Environmental causes

Twin and adoption studies suggest that inherited genes make a person vulnerable to
schizophrenia and then environmental factors act on this vulnerability to trigger the
disorder.

As for the environmental factors involved, more and more research is pointing to stress,
either during pregnancy or at a later stage of development. High levels of stress are
believed to trigger schizophrenia by increasing the bodys production of the hormone
cortisol.
Research points to several stress-inducing environmental factors that may be involved in
schizophrenia, including:

Prenatal exposure to a viral infection

Low oxygen levels during birth (from prolonged labor or premature birth)
Exposure to a virus during infancy
Early parental loss or separation
Physical or sexual abuse in childhood

Abnormal brain structure

In addition to abnormal brain chemistry, abnormalities in brain structure may also play a
role in schizophrenia. Enlarged brain ventricles are seen in some schizophrenics,
indicating a deficit in the volume of brain tissue. There is also evidence of abnormally
low activity in the frontal lobe, the area of the brain responsible for planning, reasoning,
and decision-making.

Some studies also suggest that abnormalities in the temporal lobes, hippocampus, and
amygdala are connected to schizophrenias positive symptoms. But despite the
evidence of brain abnormalities, it is highly unlikely that schizophrenia is the result of
any one problem in any one region of the brain.

Effects of schizophrenia
When the signs and symptoms of schizophrenia are ignored or improperly treated, the
effects can be devastating, both to the individual with the disorder and those around him
or her. Some of the possible effects of schizophrenia are:

Relationship problems. Relationships suffer because people with schizophrenia often

withdraw and isolate themselves. Paranoia can also cause a person with schizophrenia
to be suspicious of friends and family.

Disruption to normal daily activities. Schizophrenia causes significant disruptions to

daily functioning, both because of social difficulties and because everyday tasks
become hard, if not impossible to do. A schizophrenic persons delusions,
hallucinations, and disorganized thoughts typically prevent him or her from doing normal
things like bathing, eating, or running errands.

Alcohol and drug abuse. People with schizophrenia frequently develop problems
with alcohol or drugs, which are often used in an attempt to self-medicate, or relieve
symptoms. In addition, they may also be heavy smokers, a complicating situation as
cigarette smoke can interfere with the effectiveness of medications prescribed for the
disorder.

Increased suicide risk. People with schizophrenia have a high risk of

attempting suicide. Any suicidal talk, threats, or gestures should be taken very seriously.
People with schizophrenia are especially likely to commit suicide during psychotic
episodes, during periods of depression, and in the first six months after theyve started
treatment.

Diagnosing schizophrenia
A diagnosis of schizophrenia is made based on a full psychiatric evaluation, medical
history, physical exam, and lab tests.

Psychiatric evaluation The doctor or psychiatrist will ask a series of questions about
you or your loved one's symptoms, psychiatric history, and family history of mental
health problems.

Medical history and exam Your doctor will ask about your personal and family health
history. He or she will also perform a complete physical examination to check for
medical issues that could be causing or contributing to the problem.

Laboratory tests While there are no laboratory tests that can diagnose
schizophrenia, simple blood and urine tests can rule out other medical causes of
symptoms. The doctor may also order brain-imaging studies, such as an MRI or a CT
scan, in order to look for brain abnormalities associated with schizophrenia.

Criteria to diagnose schizophrenia

The presence of two or more of the following symptoms for at least 30 days:
1. Hallucinations
2. Delusions
3. Disorganized speech
4. Disorganized or catatonic behavior
5. Negative symptoms (emotional flatness, apathy, lack of speech)

Significant problems functioning at work or school, relating to other people, and taking
care of oneself.
Criteria to diagnose schizophrenia

Continuous signs of schizophrenia for at least six months, with active symptoms
(hallucinations, delusions, etc.) for at least one month.

No other mental health disorder, medical issue, or substance abuse problem is causing
the symptoms.

Conditions that can look like schizophrenia

The medical and psychological conditions the doctor must rule out before diagnosing
schizophrenia include:

Other psychotic disorders Schizophrenia is a type of psychotic disorder, meaning it

involves a significant loss of contact with reality. But there are other psychotic disorders
that cause similar symptoms of psychosis, including schizoaffective disorder,
schizophreniform disorder, and brief psychotic disorder. Because of the difficulty in
differentiating between the psychotic disorders, it may take six months or longer to arrive
at a correct diagnosis.

Substance abuse Psychotic symptoms can be triggered by many drugs, including

alcohol, PCP, heroin, amphetamines, and cocaine. Some over-the-counter and
prescription drugs can also trigger psychotic reactions. A toxicology screen can rule out
drug-induced psychosis. If substance abuse is involved, the physician will determine
whether the drug is the source of the symptoms or merely an aggravating factor.

Medical conditions Schizophrenia-like symptoms can also result from certain

neurological disorders (such as epilepsy, brain tumors, and encephalitis), endocrine and
metabolic disturbances, and autoimmune conditions involving the central nervous
system.

Mood disorders Schizophrenia often involves changes in mood, including mania and
depression. While these mood changes are typically less severe than those seen in
bipolar disorder and major depressive disorder, they can make diagnosis tricky.
Schizophrenia is particularly difficult to distinguish from bipolar disorder. The positive
symptoms of schizophrenia (delusions, hallucinations, and disorganized speech) can
look like a manic episode of bipolar disorder, while the negative symptoms of
schizophrenia (apathy, social withdrawal, and low energy) can look like a depressive
episode.

Post-traumatic stress disorder (PTSD) PTSD is an anxiety disorder that can

develop after exposure to a traumatic event, such as military combat, an accident, or a
violent assault. People with PTSD experience symptoms that are similar to
schizophrenia. The images, sounds, and smells of PTSD flashbacks can look like
psychotic hallucinations. The PTSD symptoms of emotional numbness and avoidance
can look like the negative symptoms of schizophrenia.

Hope for schizophrenia

Treatment options for schizophrenia are good, and the outlook for the disorder continues
to improve. With medication, therapy, and a strong support network, many people with
schizophrenia are able to control their symptoms, gain greater independence, and lead
fulfilling lives.

If you think that someone close to you has schizophrenia, you can make a difference by
showing your love and support and helping that person get properly evaluated and
treated. To learn more, see the related articles below.

Common misconceptions about schizophrenia

Myth: Schizophrenia refers to a "split personality" or multiple personalities.

Fact: Multiple personality disorder is a different and much less common disorder than
schizophrenia. People with schizophrenia do not have split personalities. Rather, they are
split off from reality.

Myth: Schizophrenia is a rare condition.

Fact: Schizophrenia is not rare; the lifetime risk of developing schizophrenia is widely
accepted to be around 1 in 100.

Myth: People with schizophrenia are dangerous.

Fact: Although the delusional thoughts and hallucinations of schizophrenia sometimes

lead to violent behavior, most people with schizophrenia are neither violent nor a danger
to others.
 Common misconceptions about schizophrenia

Myth: People with schizophrenia cant be helped.

Fact: While long-term treatment may be required, the outlook for schizophrenia is not
hopeless. When treated properly, many people with schizophrenia are able to enjoy life
and function within their families and communities.

Schizophrenia is a mental disorder that generally appears in late adolescence or early

adulthood. Characterized by delusions, hallucinations, and other cognitive difficulties,
schizophrenia can often be a life-long struggle.

Fast facts on schizophrenia

Here are some key points about schizophrenia. More detail and supporting information
is in the main article.
Schizophrenia effects and estimated 1 percent of the population

Symptoms include delusions, hallucinations, and disorganized thoughts

Diagnosing schizophrenia comes only after other disease have been ruled out

What is schizophrenia?
 Schizophrenia is often a life-long condition.

Individuals with schizophrenia may hear voices that are not there. Some may be
convinced that others are reading their minds, controlling how they think, or plotting
against them.
This can distress patients severely and persistently, making them withdrawn and, at
times, frantic.

Others may find it hard to make sense of what a person with schizophrenia is talking
about. In some cases, the individual may spend hours completely still, without talking.

On other occasions, he or she may seem fine until they start explaining what they are
truly thinking.
 The effects of schizophrenia reach far beyond the patient - families, friends, and society
are affected too.

A sizable proportion of people with schizophrenia have to rely on others because they
are unable to hold a job or care for themselves. Many may also resist treatment, arguing
that there is nothing wrong with them.

With proper treatment, patients can lead productive lives. Treatment can help relieve
many of the symptoms of schizophrenia. However, the majority of patients with the
disorder have to cope with the symptoms for life.
Schizophrenia most commonly strikes between the ages of 16 and 30, and males tend
to show symptoms at a slightly younger age than females. In many cases, the disorder
develops so slowly that the sufferer does not know they have it for many years.
However, in other cases, it can strike suddenly and develop quickly.
Schizophrenia affects approximately 1 percent of all adults, globally. Experts say
schizophrenia is probably many illnesses masquerading as one. Research suggests
that schizophrenia may be the result of faulty neuronal development in the brain of the
fetus, which later in life emerges as a full-blown illness.

Symptoms of schizophrenia
Symptoms and signs of schizophrenia will vary, depending on the individual. The
symptoms are classified into four categories:

Positive symptoms - also known as psychotic symptoms. For example, delusions and
hallucinations.

Negative symptoms - these refer to elements that are taken away from the individual.
For example, absence of facial expressions or lack of drive to do things.

Cognitive symptoms - these affect the person's thought processes. They may be positive
or negative symptoms, for example, poor concentration is a negative symptom.

Emotional symptoms - these are usually negative symptoms, such as blunted emotions.

Below is a list of the major symptoms:

Delusions - The patient has false beliefs which can take many forms, such as delusions
of persecution, or delusions of grandeur. They may feel others are attempting to control them
through remote control. Or, they may think they have extraordinary powers and gifts.
 Hallucinations - hearing voices is much more common than seeing, feeling, tasting, or
smelling things which are not there, however, people with schizophrenia may experience a
wide range of hallucinations.

Thought disorder - the person may jump from one subject to another for no logical
reason. The speaker may be hard to follow.

Other symptoms may include:

Lack of motivation (avolition) - the patient loses their drive. Everyday actions, such as
washing and cooking, are abandoned.

Poor expression of emotions - responses to happy or sad occasions may be lacking, or

inappropriate.

Social withdrawal - when a patient with schizophrenia withdraws socially, it is often

because they believe somebody is going to harm them.

Unaware of illness - as the hallucinations and delusions seem so real for patients, many
of them may not believe they are ill. They may refuse to take medication for fear of side-
effects, or for fear that the medication may be poison, for example.

Cognitive difficulties - the patient's ability to concentrate, remember things, plan ahead,
and to organize their life are affected. Communication becomes more difficult.

What causes schizophrenia?

Nobody has been able to pinpoint one single cause. Experts believe several factors are
generally involved in contributing to the onset of schizophrenia.

Evidence suggests that genetic and environmental factors act together to bring about
schizophrenia. The condition has an inherited element, but it is also significantly
influenced by environmental triggers.

Below is a list of the factors that are thought to contribute towards the onset of
schizophrenia:

Genes
If there is no history of schizophrenia in a family, the chances of developing it are less
than 1 percent. However, that risk rises to 10 percent if a parent was diagnosed.
Chemical imbalance in the brain
Experts believe that an imbalance of dopamine, a neurotransmitter, is involved in the
onset of schizophrenia. Other neurotransmitters, such as serotonin, may also be
involved.

Family relationships
Although there is no evidence to prove or even indicate that family relationships might
cause schizophrenia, some patients with the illness believe family tension triggers
relapses.

Environment
Although there is no definite proof, many suspect that prenatal or perinatal trauma and
viral infections may contribute to the development of the disease.

Stressful experiences often precede the emergence of schizophrenia. Before any acute
symptoms are apparent, people with schizophrenia habitually become bad-tempered,
anxious, and unfocused. This can trigger relationship problems, divorce, and
unemployment.

These factors are often blamed for the onset of the disease, when really it was the other
way round - the disease caused the crisis. Therefore, it is extremely difficult to know
whether schizophrenia caused certain stresses or occurred as a result of them.

Some drugs
Cannabis and LSD are known to cause schizophrenia relapses. For people with a
predisposition to a psychotic illness such as schizophrenia, usage of cannabis
may trigger the first episode.
Some researchers believe that certain prescription drugs, such as steroids and
stimulants, can cause psychosis.

Schizophrenia diagnosis
 Before diagnosing schizophrenia, other conditions need to be ruled out first.

A schizophrenia diagnosis is reached by observing the actions of the patient. If the

doctor suspects possible schizophrenia, they will need to know about the patient's
medical and psychiatric history.

Certain tests will be ordered to rule out other illnesses and conditions that may trigger
schizophrenia-like symptoms. Examples of some of the tests may include:

Blood tests

Imaging studies - to rule out tumors and problems in the structure of the brain

Psychological evaluation - a specialist will assess the patient's mental state by asking
about thoughts, moods, hallucinations, suicidal traits, violent tendencies or potential for
violence, as well as observing their demeanor and appearance

Schizophrenia - diagnostic criteria

 Patients must meet the criteria outlined in the DSM (Diagnostic and Statistical Manual of
Mental Disorders). This is an American Psychiatric Association manual used by
healthcare professionals to diagnose mental illnesses and conditions.

The health care professional needs to exclude other possible mental health disorders,
such as bipolar disorder or schizoaffective disorder.
It is also important to establish that the signs and symptoms have not been caused by,
for example, a prescribed medication or substance abuse.

Also, the patient must:

1) Have at least two of the following typical symptoms of schizophrenia -

Delusions

Disorganized or catatonic behavior

Disorganized speech

Hallucinations

Negative symptoms that are present for much of the time during the last 4 weeks

2) Experience considerable impairment in the ability to attend school, carry out their
work duties, or carry out everyday tasks
3) Have symptoms which persist for 6 months or more

Treatments for schizophrenia

Psychiatrists say the most effective treatment for schizophrenia patients is usually a
combination of medication, psychological counseling, and self-help resources. Anti-
psychosis drugs have transformed schizophrenia treatment. Thanks to them, the
majority of patients are able to live in the community, rather than stay in hospital.

The primary schizophrenia treatment is medication. Sadly, compliance (following the

medication regimen) is a major problem. People with schizophrenia often come off their
medication for long periods during their lives, at huge personal costs to themselves and
often to those around them.
 Ensuring the patient continues with medication is the key to successful treatment.

The patient must continue taking medication even when symptoms are gone,
otherwise they will come back.
The majority of patients come off their medication within the first year of treatment. To
address this, successful schizophrenia treatment needs to consist of a life-long regimen
of both drug and psychosocial support therapies.

The medication can help control the patient's hallucinations and delusions, but it cannot
help them learn to communicate with others, get a job, and thrive in society.

Although one may readily suggest that all a person with schizophrenia has to do is
"comply with treatment" and they will live a happy and productive life. Unfortunately,
impaired insight is one of the symptoms of schizophrenia.

The person with schizophrenia often does not have insight into their condition and, as a
result, does not believe that they are sick. This often contributes to non-compliance with
medication.
 The first time a person experiences schizophrenia symptoms, it can be very unpleasant.
They may take a long time to recover, and that recovery can be a lonely experience. It is
crucial that a schizophrenia sufferer receives the full support of their family, friends, and
community services when onset appears for the first time.

Medications for schizophrenia

The medical management of schizophrenia generally involves drugs
for psychosis, depression, and anxiety. The most common antipsychotic drugs are:
Risperidone (Risperdal) - less sedating than other atypical antipsychotics. Weight gain
and diabetes are possible side effects, but are less likely to happen, compared with
Clozapine or Olanzapine.

Olanzapine (Zyprexa) - may also improve negative symptoms. However, the risks of
serious weight gain and the development of diabetes are significant.
Quetiapine (Seroquel) - risk of weight gain and diabetes, however, the risk is lower than
Clozapine or Olanzapine.

Ziprasidone (Geodon) - the risk of weight gain and diabetes is lower than other atypical
antipsychotics. However, it might contribute to cardiac arrhythmia.

Clozapine (Clozaril) - effective for patients who have been resistant to treatment. It is
known to lower suicidal behaviors in patients with schizophrenia. The risk of weight gain and
diabetes is significant.

Other newer agents also exist, and still more agents are currently being examined for
their use in treating schizophrenia.

While van Gogh was praised as a genius after his death, his mental stability has long been a subject of debate.
Medical professionals and art historians have now concluded that van Gogh suffered from a form of psychosis,
although they could not pinpoint the underlying cause of his mental illness.
The theory comes from a group of 35 international psychiatrists, doctors and art historians, who recently met at the
Van Gogh Museum in Amsterdam.
The experts debated their ideas, which were sometimes 'fierce', according to Louis van Tilborgh, a professor of art
history at the University of Amsterdam.
Mr Tilborgh told The New York Times: 'It's difficult to make a diagnosis, so the real progress we've made is that
specialists in the field are talking about it, and they've never done this before.'
Van Gogh was born in 1853, and died in 1890 of a gunshot wound, which was apparently self-inflicted.
His illness has been the subject of much speculation, with some people suggesting he suffered from bipolar disorder,
or schizophrenia, highlighting incidents such as when he cut off his own ear.
Now for the first time, the Van Gogh Museum gathered all the medical evidence of his case, as well as some personal
letters, to provide the panel of experts a basis for their debate.
The findings were presented to the group by Arko Oderwald, a lecturer in philosophy and medical ethics at the Vrije
University Medical Centre in Amsterdam last week.
He said that the experts had ruled out a number of mental illnesses, and instead, suggested that van Gogh had
suffered from psychotic episodes.
They did not give an explanation for the underlying cause of this mental illness.

Who was Vincent Van Gogh?

Vincent van Gogh was born on March 30, 1853 in Zundert, a town in the southern
Netherlands. Van Gogh died at his own hand in France at the age of 37. The son of a
Protestant pastor, he was the eldest of six children and, by all accounts, had a normal,
happy childhood. Van Gogh came from an upstanding family of clergymen, art-
dealers, and military officers, and his parents wished for him to follow in this
tradition. As a child, he was an insatiable reader, with wide-ranging interests,
including religion. Although his mother was a talented artist, van Gogh did not pursue
art in his early life. He was especially close to his younger brother, Theodore (Theo),
his most staunch supporter.

In 1873, at age 20, van Gogh traveled to London, fell in love with an English girl by
whom he was rejected. Saddened and disillusioned, he resigned himself to a solitary
life as a language teacher and a lay preacher in England. From 1879 to 1880, van
Gogh did missionary work in southwestern Belgium. He had deep sympathy for the
poor and unfortunate. He gave away all of his possessions and fell into despair and
poverty. In his solitude, van Gogh began to draw. He also underwent a spiritual
awakening and decided that his mission in life was to console humanity through art.

Van Gogh moved to Paris, where his brother Theo worked as an art-dealer. Theo
introduced him to many of the popular painters of the time, including Paul Gaugin,
Camille Pissarro, and Georges Seurat. In 1888 he settled in Arles in Provence, where
he painted his famous series of Sunflowers. He invited Gaugin to live with him, but
the relationship suffered because of extreme conflict and personality differences.
Gaugin left shortly thereafter. In extreme despair, at the age of 35, on Christmas Eve
of 1888, Van Gogh cut off a part of his left ear. Mentally ill, he was treated at the
hospital in Arles shortly after this event. He was then committed to the asylum in St.
Remy, where he was under medical supervision for 12 months. He continued to paint
while in the asylum.

Vincent van Gogh shot himself on July 27, 1890. He died two days later with his
brother Theo present. (Theo died only six months later). Although he sold only one
painting during his life, van Gogh is now considered one of the greatest Dutch
painters since Rembrandt. His fame was probably enhanced by his well-documented
mental difficulties.

The whole of van Goghs impressive portfolio was completed in 10 years This
included approximately 800 oil paintings and 700 drawings. His working life can be
broken into two periods. Many apprenticeships, failures and changes in direction
characterize the first period, from 1873 to 1885. The second period, from 1886 to
1890, is a period of dedication, rapid development and fulfillment in his work. He is
considered a post-Impressionist painter, his style quite different from that of the
Impressionists. His work is heavily concerned
with the expressionism characteristic of
modern art.

Around the time that Tolstoy was tussling

with depression and his spiritual
crisis, on the other side of Europe another
creative icon was struggling with the darkness
of his own psychoemotional landscape. As he
was painting some of the most celebrated and
influential art of all time, Vincent Van
Gogh was combating his anguishing mental
illness frequent episodes of depression, paralyzing anxiety and, according to
some accounts, the symptoms of bipolar disorder which would eventually claim his
life in 1890, shortly after his 37th birthday.
Van Goghs most direct and honest account of his psychoemotional turmoil comes
from the letters to his brother Theo, originally published in 1937 as the hefty
tome Dear Theo: The Autobiography of Vincent van Goghand later
excerpted in My Life & Love Are One (public library) the same
wonderful 1976 gem that gave us his thoughts on love, tracing the magic and
melancholy of Vincent van Gogh. The title comes from a specific letter written
during one of the painters periods of respite from mental illness, in which he
professes to his brother: Life has become very dear to me, and I am very
glad that I love. My life and my love are one.

Dutch newspaper report from December 30, 1888: Last Sunday night at half past eleven a
painter named Vincent Van Gogh, appeared at the maison de tolrance No 1, asked for a girl
called Rachel, and handed her his ear with these words: Keep this object like a treasure.
Then he disappeared. The police, informed of these events, which could only be the work of an
unfortunate madman, looked the next morning for this individual, whom they found in bed with
scarcely a sign of life. The poor man was taken to hospital without delay.
In one of the early letters, Van Gogh expressed an aspiration that remained significant
for him throughout his life:

Let us keep courage and try to be patient and gentle. And not
mind being eccentric, and make distinction between good and
evil.

Its also a thought bittersweet in hindsight, given the self-compassion it implies for
being eccentric. Years later, that very eccentricity would be interpreted as madness by
his neighbors, who would evict him from his house and lead to his checking into an
insane asylum.

Meanwhile, his bouts of depression, when they descended upon him, were
unforgiving. In another letter to Theo, he writes:

I am so angry with myself because I cannot do what I should

like to do, and at such a moment one feels as if one were lying
bound hand and foot at the bottom of a deep dark well, utterly
helpless.
 Self-
Portrait with Straw Hat by Vincent van Gogh, winter 1887/1888
But underlying his deep despair is a subtle sense of optimism that carries him and
enables him to continue painting despite the mental anguish:

This is my ambition, which is founded less on anger than on

love, founded more on serenity than on passion. It is true that I
am often in the greatest misery, but still there is within me a
calm, pure harmony and music. In the poorest huts, in the
dirtiest corner, I see drawings and pictures. And with irresi
stible force my mind is drawn towards these things. Believe me
that sometimes I laugh heartily because people suspect me of
all kinds of malignity and absurdity, of which not a hair of my
head is guilty I, who am really no one but a friend of nature,
of study, of work, and especially of people.

Like artist Maira Kalman, who asserted nearly a century and a half later that work
and love are the two keys to a full life, Van Gogh begins to see his work as
his unflinching sense of purpose, his salvation:
How much sadness there is in life! Nevertheless one must not
become melancholy. One must seek distraction in other things,
and the right thing is to work.

Having at one point subsisted primarily on bread, coffee and absinthe, he embraces
work as lifes highest reward, worth any sacrifice:

I believe more and more that to work for the sake of the work is
the principle of all great artists: not to be discouraged even
though almost starving, and though one feels one has to say
farewell to all material comfort.
 Self-
Portrait with Bandaged Ear, 1889, painted shortly after he sliced off his own ear
But in reflecting as Kurt Vonnegut memorably did on what makes life
fulfilling, it seems that rather than conveying a conviction to his brother, Van Gogh is
trying to convince himself:
I have nature and art and poetry, and if that is not enough,
what is enough?
And yet, Van Gogh ultimately sees his psychological struggles not as something to
negate but as his artistic truth, as a vital part of his honest experience, which is the
necessary foundation of great art:

Do you know that it is very, very necessary for honest people to

remain in art? Hardly anyone knows that the secret of beautiful
work lies to a great extent in truth and sincere sentiment.

The Illness of Vincent van Gogh

Introduction

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

The Life of van Gogh

Origins

Vincent van Goghs ancestry includes Dutch preachers, art dealers, and artisans. Both his father and
paternal grandfather were preachers; his paternal great-grandfather was a gold wiredrawer who also was a
catechism teacher. No incidences of mental illness are recorded among van Gogh s ancestors. His mother
married at the age of 31, had a stillborn first son, and 1 year later gave birth to Vincent. Vincent was a moody
child, self-willed, and often annoying. At the age of 12, he was sent to a boarding school for the next 4 years. A
photograph of Vincent as an adolescent and later self-portraits suggest a significant craniofacial asymmetry.
Gastaut (1) submitted that this physical feature and early temperamental changes suggest that Vincent had
suffered an early brain injury, probably at birth. His intense emotionality, which was evident early and became
frequently unbearable in his adult life, is set forth in his own statement: "I am a man of passion, capable and
prone to undertake more or less foolish things which I happen to repent more or less" (3).

Vincent had five younger siblings, three sisters and two brothers. The steadfast support of his brother Theo
made Vincents work possible; Theo died 6 months after Vincent s suicide. After a failed marriage,
Cornelis, the youngest sibling, enlisted as a volunteer in the Boer army in South Africa; he may have committed
suicide or been killed in battle. The youngest sister, Wilhelmina, to whom Vincent wrote a series of letters, was
interned in a psychiatric asylum at the age of about 35, a few years after Vincent s death; she was said to
suffer from schizophrenia and died in the asylum at the age of 79. His mother, with whom Vincent exchanged
occasional letters, lived to the age of 87, surviving not only her husband but all of her sons. Her three sons all
died in their 30s, while the three daughters lived into their 70s.

Failed Careers and Beginnings as an Artist

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

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

Paris: Onset of Illness

After 6 years as an artist in the Netherlands and Belgium, Vincent joined Theo in Paris for 2 years
(18861888). There he met many painters who were to become famous, Paul Gauguin among them, and
was strongly influenced by the impressionist movement. While in Paris, he began to suffer from minor
paroxysms consisting of episodes of sudden terror, peculiar epigastric sensations, and lapses of
consciousness. Observers reported occasions of an initial tonic spasm of the hand and a peculiar stare,
followed by a confusional- amnestic phase. His use of absinthe, an alcoholic beverage with convulsant
properties favored by French artists, appears to have played a crucial role in the precipitation of van
Goghs illness. He tended to be untidy and quarrelsome; his irascible temper caused many unpleasant
scenes and rendered him an undesirable in a number of places. He lived with his brother and often kept him up
much of the night with endless disputes. Theo remained sympathetic, yet increasingly felt his brother s
presence a burden. Theo described Vincent in a letter to their younger sister as follows: "It seems as if he were
two persons: one, marvelously gifted, tender and refined, the other, egotistic and hard hearted. They present
themselves in turns, so that one hears him talk first in one way, then in the other, and always with arguments on
both sides. It is a pity that he is his own enemy, for he makes life hard not only for others but also for himself"
(3). All along, Vincent persisted in perfecting his art.

Provence: A Major Illness Unfolds

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

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

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

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

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

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

Auvers: The Suicide

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

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

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

Epilogue

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

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

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

Discussion

The illness of van Gogh has perplexed 20th-century physicians, as is evident from the nearly 30 different
diagnoses that have been offered, from lead poisoning or Mnire s disease to a wide variety of
psychiatric disorders. Many writers have acknowledged the epilepsy but considered the psychiatric disorder an
independent mental illness. Monroe (7, 8) recognized the unique episodicity of van Gogh s mental
changes, the role of absinthe in his illness, and an underlying epileptoid limbic dysfunction that was associated
with his creativity but also, if overly intense, would render him ill. Earlier, in an exceptionally well-documented
study, Gastaut (1) reasoned that the artists psychiatric changes were based on temporal lobe epilepsy
produced by the use of absinthe in the presence of an early limbic lesion.
Earlier in his life, van Gogh experienced two prolonged episodes of reactive depression. Both episodes were
followed by a prolonged period of hypomanic or even manic behavior: first as evangelist to the poor miners in
Belgium and then as the quarrelsome and overly talkative artist in exciting Paris. The major illness of his last 2
years developed in the presence of seizures, and its nature has remained controversial. The known details of
his psychiatric illness will be reviewed together with what is known about the psychopathology of individuals
with epilepsy, and differential diagnostic considerations will follow.