Dialoguri între artă și psihiatrie (II) – o incursiune patografică în Postimpresionism

Introduction

The exploration of the intersection between psychiatry and art continues in this second part of the study with another pathobiographic analysis, this time focusing on famous Post-Impressionist artists. It should be noted that Post-Impressionism is not an official school of art or a conceptually well-defined art movement, as no common manifesto, shared set of artistic theories, or standardized painting techniques exists. Under this umbrella term, art critics and art historians have gathered a quite heterogeneous constellation of painters who revolutionized the art world beyond the advancements introduced by the Impressionists, preparing the terrain for the emergence of new currents, such as Expressionism or Cubism.

The analysis of relevant aspects from the lives of artists included in this group, by a psychological and psychopathological perspective, takes into account the same limitations and warnings presented in the first part of this analysis⁽¹⁾. Building on the aspects already mentioned, one of the inherent conundrums of such pathobiographical analyses concerns the possibility of making accurate assumptions about the art products based on the artist’s psychological profile and life events. On the one hand, the endeavor to understand the art of famous painters through the lens of their potential psychopathological features is a pitfall that has been frequently highlighted. For example, from a phenomenological perspective, Merleau-Ponty’s essay on Cézanne illustrates the conundrums of such an attempt⁽²⁾. According to the cited author, the purpose of art is irreducible to random facts of the artist’s life or to psychological factors that occur independently of the artistic expression, in the sense that they could not be considered obvious causes or effects of the art production⁽²⁾. On the contrary, Sigmund Freud is one of the pioneers in the psychological investigation of art through the lens of the psychological dynamics of its creator. According to the founder of psychoanalysis, understanding the artist’s inner life and conflicts is quintessential to understanding their art^(3,4). To support this perspective, Freud analyzed one of Leonardo da Vinci’s notebooks and found elements to support an unsolved Oedipus complex, the existence of a screen memory and the use of sublimation of sexual impulses into intellectual and artistic activities; an intense curiosity for nature and anatomy, reflected in the artists’ masterpieces, was correlated by Freud with da Vinci’s illegitimacy⁽⁴⁾. In the same line of analysis, using the framework of psychoanalysis, Freud identified internal conflicts, struggling with father figures and repression in Michelangelo’s work, particularly in the statue of Moses the artist created; the Freud’s hypothesis is that Michelangelo identified himself with Moses, therefore the interpretation of the statue is, in the same time, a reflection on the artist’s psychological status, the art being the projection of the artist’s inner dynamics⁽³⁾.

Another inherent limitation lies in the impossibility of accessing all the variables that may have influenced an artist’s health status during their life. For example, the effect of organic or toxic factors on the mental status and even on the ability to paint is a subject of controversy in many pathobiographical analyses. To limit this discussion to the Post-Impressionist artists, xanthopsia induced by the prolonged treatment with digitalis (from the foxglove plant), the administration of santonin for gastrointestinal dysfunctions, and the abuse of absinthe has been invoked as an explanation for van Gogh’s preference for the yellow color in many of his compositions (e.g., The Sunflowers, Self Portraits, The Bedroom, The Yellow House, etc.)⁽⁵⁾. In the case of Cézanne, myopy was also invoked as an explanation for the details on the close objects in his paintings and for the blurry landscapes; the combination of nearsightedness and diabetic retinopathy could thus have influenced his vision, and while insulin was not available at the time, Cézanne allegedly refused the use of corrective lenses, as he preferred to paint the world as he saw it^(5-7). The psychotoxic effect of absinthe (nicknamed “la fée verte”, a beverage derived from Artemisia absinthium L., anise, fennel and other plants) was associated with Impressionism and Post-Impressionism, becoming a symbol of bohemian life and creativity. However, the effect of the high concentration of alcohol in this beverage (45-74%) is considered the cause of the toxic effects, while thujone, a monoterpene ketone invoked as the neurodamaging ingredient of absinthe, was proven toxic only in large amounts, unlikely to be found in everyday use^(8,9). The substance use disorders in artists are not at all an isolated scourge that could be met only in the era of Impressionists and Post-Impressionists, but represent a common challenge and even an epidemiologically researched topic^(10-14). For instance, the artists scored significantly higher than non-artists on substance use on an online questionnaire (N=118 participants) in a 2021 survey⁽¹¹⁾. Whether consumed as a component of cultural practices, such as the widespread use of absinthe in late 19^th-century Parisian society, or employed as a means of managing physical discomfort during a period when analgesic substances were also highly addictive (i.e, opioid derivatives and cocaine), alcohol was extensively abused during the era in which the Post-Impressionist artists lived and produced their works. It was often perceived, albeit inaccurately, as a catalyst for enhanced creativity, among various other individual motivations for its consumption.

To conclude, pathobiographic analyses are based on available data, including documents written by the artists themselves, such as diaries, notes and letters, as well as authorized biographies, medical comments and observations made by family members or other contemporaries, where applicable. Outside of this type of evidence, direct and scientific data, such as the results of an autopsy or detailed psychiatric and psychological reports, are very rarely available for independent analysis. This limitation is even more striking when a century or more has passed since the death of the artists whose lives are explored, as is the case in this study.

From the pure colors of light in Impressionist paintings to the deconstruction of reality in Post-Impressionist art

Impressionism was a revolution in the field of visual arts, because it basically changed the environment of painting (encouraging the artists to paint outside their studios, in nature), the matter (moving from the historical and mythological themes to everyday landscapes and life scenes), the painting technique itself (by using visible brushstrokes, spontaneous, dynamic movements in contrast to the smooth and polished brushstrokes of academic art), the use of colors (pure and unmixed colors were preferred) and light (the impressionists were keen on capturing the fleeting moments), and the overall perspective on the painting (freedom of expression versus conventions, modernism versus tradition)^(15-20). From a psychological perspective, Impressionism is characterized by the predominance of subjective perception over objective reality, with an emphasis on how things appear, rather than their materiality^(15-17). The viewer became an ­active participant in the making of the art’s meaning, and the mindful, immediate awareness of the stimuli is promoted^(15-20). Advancements in physiological optics and color theory, including the exploration of simultaneous contrast, afterimage effect and color relativity, provided a foundational framework for the theorists of the new school of art^(15,16).

In Post-Impressionism, the dynamic shifts from the dialogue between light and shadow to one between construction and deconstruction. Postimpressionist painters developed new systems of representation, characterized by structured, symbolic or expressive elements, thereby moving beyond optical realism^(16-18). For example, Cézanne used the cone, sphere and cylinder as geometrical core shapes in his paintings, while Seurat employed juxtaposing dots of opposite colors, and Gauguin introduced bold colors and abstract shapes^(18,19). The deconstruction applied by Post-Impressionist artists refers to the distance taken from Impressionism, challenging naturalistic representation (e.g., van Gogh), inserting “primitive” motifs (e.g., Gauguin), or emphasizing extreme emotions (e.g., Toulouse-Lautrec)^(15-20). From a psychological perspective, Post-Impressionism is more concerned with the internal experiences of the painters, rather than external perception, unlike their Impressionist predecessors^(15-17). Inner turmoil and all significant emotional content were translated in intense colors and vigorous brushstrokes (e.g., van Gogh), symbolic features (e.g., Gauguin), line and exaggeration (e.g., Toulouse-Lautrec), or geometric shapes (e.g., Cézanne)^(15-20). 

Objective and methodology

To find the most relevant data on the Post-Impressionist artists from a pathobiographical perspective, a search of the literature was conducted in three electronic databases (i.e., PubMed, Google Scholar and MEDLINE), using the keywords: “Post-Impressionism”, “Postimpressionism”, individual names of the representatives of this group, AND “mental disorders”, “psychopathology”, “psychiatric illnesses”. All primary and secondary reports were included in the analysis. The list of references for each article was consulted, and relevant sources were explored further. Additional sources of information were added if they corresponded to the purpose of the study, including grey literature. No limitation on the language of publication was applied, and the research interval spanned from the inception of each database to July 2025.

Results

Based on the analysis of the search results, data on three representatives of Post-Impressionism were found to be relevant from a pathobiographical perspective: Paul Cézanne (1839-1906), Vincent van Gogh (1853-1890) and Henri de Toulouse-Lautrec (1864-1901). A total of seven biographies, one volume of collected letters, seven articles and three other sources were found for Paul Cézanne, while for van Gogh, three biographies, 17 articles and one volume of letters were retrieved. As for Toulouse-Lautrec, four biographies, nine articles, two volumes of letters and three other sources were consulted.

Paul Cézanne

The artist who revolutionized Western painting at the end of the 19^th century, by reconstructing the “experience of seeing” on the canvas, Paul Cézanne is considered, according to Picasso (or Matisse, depending on the cited source), “the father” of the Modernist painters^(21-23). Additionally, Matisse reportedly kept one of Cézanne’s paintings in his studio throughout his creative life, serving both as a symbol of his admiration for the artist and a source of inspiration⁽²¹⁾. Cézanne is famous for his efforts to develop a synthesis between naturalistic representation, personal expressivity and abstract perspective⁽²⁴⁾. That is to say, he questioned the traditional perspective on painting, and chose not to distinguish between feelings and thoughts, but to focus on overlapping cognitive processes and perception, “soul” and “body”, or “thought” and “vision” in a sort of “primordial experience”, in which all of these elements are originated⁽²⁾. Thus, his revolutionary approach to painting became the source of inspiration for Cubism – through the de-composition of natural forms into geometric shapes and flattening of perspective, Fauvism – by the use of color and rejection of linear perspective, and Abstract Expressionism – due to the accent put on the inner structure, emotions of the artist and simplification of forms⁽²⁵⁾. Not interested in being in the spotlight and preferring an isolated life devoted to painting, the personality of Cézanne was questioned for excessive introversion, and different suspicions of social anxiety, obsessionality and depression have been raised by various scientists and biographers^(2,26).

Cézanne was born to a wealthy banker and a supportive, affectionate mother. While his nurturing maternal figure encouraged him to pursue an artistic career, his dominating father disapproved of such a profession, but still funded him⁽²⁶⁾. His parents married five years after the birth of their son, a fact that was correlated with Cézanne’s marriage to one of his models, years after their son was born, as a sign that the artist was, at least unconsciously, preoccupied with this aspect^(21,26). From a young age, Cézanne exhibited traits of social withdrawal, intense sensitivity and mood swings, being reportedly shy, irritable and having only a pair of close friends, one of whom was Émile Zola⁽²⁶⁾. However, no significant medical or psychiatric history could be determined during Cézanne’s childhood, adolescence and youth.

Cézanne had moments of doubt regarding his mental health, asking rhetorically: “Tell me, do you think I’m going mad? I sometimes wonder, you know”, and it looks like these ruminations had their onset when his perspective on social relationships changed⁽²⁷⁾.

 He also wrote during his final years about his “state of mental agitation”, “great confusion” and fear about the possibility that his reason would be overwhelmed by such states⁽²⁾. Doubts also concerned the novelty of his art, which he believed could be due to eye pathology (not well-documented, but inferred by some from the construction of space and the use of colors visible in many of the artist’s paintings)⁽⁵⁾.

Perfectionism was a core feature of Cézanne’s personality, as he found it difficult to declare each of his works as “finished”, while constantly creating new paintings and destroying them, even after working on each for a considerable amount of time⁽²⁷⁾. As an indicator of this tendency, he is said to require hundreds of working sessions to complete a still life, and even more for a portrait⁽²⁾. Doubts about the quality of his work, fear of presenting his canvases to the public, excessive self-criticism and a sense of lacking artistic accomplishment can be easily derived from his “Letters”, a significant source of information about the artist’s inner struggles⁽²⁸⁾. In one of these letters (sent in 1887), he stated that he cannot take part in exhibitions due to a lack of canvases that “might be submitted for the delectation of art lovers”⁽²⁸⁾. Additionally, the intense involvement in work activities, which frequently reached an obsessive level in his life, is evident in these letters⁽²⁸⁾.

Hypersensitivity, suspicion, feelings of betrayal and irascibility are described as being part of Cézanne’s regular repertoire of emotions⁽²¹⁾. He reluctantly accepted compliments and sometimes reacted inappropriately, such as the occasion when Monet threw a little party for Cézanne and told him how much his art is appreciated by those guests; Cézanne is reported to have just taken his coat and left, saying: “You too are making fun of me”^(21,23).

The tendency to self-isolation worsened to the end of his life, as he stated: “The world doesn’t understand me, and I don’t understand the world, that’s why I’ve withdrawn from it”⁽²⁷⁾.

Depression and suspiciousness or interpretability were aggravated by his diabetes, in the final stage of his life, when he became more and more disgusted with human beings⁽²⁷⁾. However, fits of anger and depression were reported from the college years in 1852, and it looks like a feeling of dissatisfaction was constantly accompanying him during his youth⁽²⁾. He admitted that, even though he changed his place and moved to Paris, his “ennui” followed him⁽²⁾. He was also preoccupied with the possibility of an early death, and made his will at the age of 42⁽²⁾.

According to the analysis of Merleau-Ponty, Cézanne’s nature “was basically anxious”, and he was unable to engage in public discussions⁽²⁾, suggesting a probably significant level of social anxiety. Social avoidance, mistrust and sensitivity appear to worsen with age in the case of Cézanne⁽²⁾. Anxiety was identified in Cézanne’s life by the term “inquiétude” as early as 1873, by Zola, who described it in one of the characters of his novels who impersonated the artist⁽²⁾. This was further acknowledged by other contemporaries, such as Gustave Geffroy⁽²⁶⁾. However, as the biography of Cézanne written by Alex Danchev states, the artist’s life story can be considered “a moral victory – a victory of temperament, perhaps, over doubt, discouragement and dismay”⁽²⁶⁾.

Also, a “schizoid temperament” was suggested in this case, and “a way of seeing the world reduced to the totality of frozen appearances, with all expressive values suspended” was considered by Merleau-Ponty the most relevant feature of this personality type⁽²⁾. The lack of eye contact in many of his paintings and the preference for inanimate scenes, together with the wearing of the same clothes repeatedly and the ritualized daily life, led Michael Fitzgerald to consider that Cézanne had features of autistic spectrum disorder⁽²⁹⁾.

The portrayal of Cézanne in the “L’Oeuvre” (1886) by Zola, which led to the break of their long-term friendship, included a mix of real and fantasized features of the painter’s personality⁽³⁰⁾. This fictional character, Claude Lantier, is a passionate but failed artist, obsessed with the perfect painting of nature, but indebted to a perfectionism that finally led him to madness and suicide⁽³⁰⁾. Real characteristics of Cézanne, such as emotional instability, social withdrawal and perpetual self-doubt, are entangled with fantasized features, such as the neglect of his family and suicidal tendencies, for dramatic reasons by Zola. However, it appears that the most painful aspect for Cézanne was Zola’s portrayal of Lantier as a failed artist, unable to produce significant art^(26,30).

In an essay dedicated to one of Cézanne’s still lifes (i.e., The Judgement of Paris), Meyer Shapiro attempts a psychoanalytic approach to the potential “displaced sexual interest” stemming from the apples represented in this painting⁽³¹⁾. In the same line of analysis, Shapiro mentions that in the nudes painted by Cézanne, either violence or emotional constrainment appears, suggesting the painter could not express his feelings toward women without anxiety⁽³¹⁾. The interest of Cézanne for still life is associated by Shapiro with the need of an introverted personality to avoid disturbing impulses or negative emotions triggered by other human beings⁽³¹⁾. In this context, the constant representation of apples in the artist’s works became a symbol for his internal conflicts, a link between interior turmoil and creative process⁽³¹⁾. Other specialists argue that the use of geometric shapes in Cézanne’s masterpieces is a consequence of an underlying need to structure and order inner turmoil or chaotic emotions^(26,32-34). As Shapiro puts it, Cézanne’s brushwork was a “moral discipline of vision” in this effort to stabilize an overflow of emotions^(34,35). A sado-masochistic tendency was suggested by biographers, deduced from the early paintings showing “scenes of abduction, rape, and murder”, coupled with the proneness to destroy his own paintings^(29,36).

Synthetized by Merleau-Ponty, the essential vulnerabilities of the artist were: (a) lack of flexibility during human contact; (b) difficulty in coping with new situations; (c) strong adherence to habits and rigid behaviors; (d) close attention to the nature and color, with the tendency to objectify all human characteristics (e.g., “painting a face as an object”), as a reflection to the alienation of his humanity⁽²⁾.

In conclusion, elements for social anxiety disorder (discomfort in social situations, avoidance of such circumstances) and episodes of major depression (withdrawal, negative perspective over self, world and future), obsessive-compulsive personality disorder (perfectionism, rigidity, overinvolved in work), schizoid personality disorder or autism spectrum traits (social awkwardness, emotional detachment, focused interests) can be found in the major biographies and studies reviewed^{(2,26,29,32-36)}. The level of evidence, however, to support any of these diagnoses is low, since data are derived only from letters, biographies, and a few reports of his contemporaries. There are no medical records to be analyzed in the case of Cézanne, and he was not brought to the attention of the psychiatrists of his time. The artist remained functional and productive until his final years, demonstrating a level of self-control and emotional mastery.

Vincent van Gogh

One of the most famous painters in the world was also one of the most prolific, as Vincent Willem van Gogh created more than 850 artworks in just 10 years of artistic plenitude⁽³⁷⁾. Van Gogh’s paintings are easily recognizable due to their spiraling forms, distinctive layout, bold brushstrokes, and vivid, sharp color contrasts⁽³⁸⁾. The life of the Dutch painter was intensively scrutinized by generations of mental health specialists, well over 150 physicians, each trying to identify the most relevant psychopathological aspects in the various biographies, correspondence (letters to his brother, Theo, but also to doctors and friends) and other reports, with the purpose of making a clear-cut diagnosis^(39,40). Unfortunately, the pathobiographical elements in this case reflect the inherent difficulties of any posthumous attempt at a diagnosis which, for van Gogh, oscillates between bipolar disorder, various types of personality disorders, “cycloid psychosis”, epilepsy, a psycho-organic disorder, unspecified, and so on⁽³⁹⁾.

Vincent van Gogh was born to a middle-class family in the Netherlands, with his father being a minister, and he received a very good education in the local schools⁽³⁷⁾. One of his brothers is supposed to have committed suicide at the age of 33, another brother, Theo, presented bouts of severe anxiety and depression, while the youngest sister was admitted to an asylum at the age of 35 years old (possibly with schizophrenia)‌^(40,41). As a child, Vincent was moody and self-willed⁽⁴⁰⁾. He started to work as an apprentice at the age of 16 for an art dealer, but after only a few years, he grew passionate about religion and served as a preacher for four years⁽⁴⁰⁾. Failing to obtain a formal theological degree, he worked as an evangelist in a very poor mining district in Belgium⁽⁴⁰⁾. After a disappointment related to his superiors, he became depressed, abandoned his religious beliefs, and switched to socialist and agnostic perspectives⁽⁴⁰⁾. 

He began his artist career in 1880 and, although he was remarkably productive, he only sold one painting during his lifetime⁽³⁷⁾. Fortunately for him, his brother, who was an art dealer, supported him constantly, since the van Gogh’s paintings were considered too unconventional for that time to be attractive to the art-buying public⁽³⁷⁾. After meeting important representatives of the avant-garde, such as Impressionist painters (e.g., Claude Monet and several key Post-Impressionist figures, including Paul Gauguin and Henri de Toulouse-Lautrec), he moved to Arles and began to change his painting style by incorporating more vivid colors, predominantly yellow⁽³⁷⁾. Gauguin moved to Arles at the insistence of van Gogh’s brother, Theo, who promised to sponsor this travel, but, after only two months, the intense arguments arose between the two artists, which led to van Gogh slicing off part of his left earlobe (at the age of 35)^(37,40). Immediately hospitalized, he was diagnosed with a type of “extreme agitation” (“fiévre chaud”), of which he recovered with partial anterograde amnesia⁽³⁷⁾. During this episode, he was psychotic, with hallucinations, delusions and psychomotor agitation that required three days of solitary confinement⁽⁴⁰⁾. The self-aggressive act was preceded by a murderous attempt against Gauguin, whom van Gogh wanted to approach with the same razor with which he cut part of his ear⁽⁴⁰⁾. Both self- and hetero-aggressive gestures have been supposedly related to imperative hallucinations by several specialists⁽⁴⁰⁾.

Seven episodes of illness and four admissions are acknowledged, all of them between December 1888 and May 1890, with psychopathological symptoms ranging from clouded consciousness, psychomotor agitation, anxiety, hallucinations, depression, mutism, to disorganized speech and thoughts, disorientation, delusions of persecution, but also including neurological and organic signs, such as seizures, most likely epileptic in their nature; however, difficult to be precise, due to the lack of adequate tools for diagnosis in that time⁽³⁹⁾. Episodes of ingestion of nonedible substances, like paint, turpentine and oil lamp during his nervous breakdowns, accompanied by confusion, are reported^(37,40). Although living in an asylum in his final year, he continued to paint and create famous canvases at Saint-Rémy⁽³⁷⁾. Two distinct episodes of depression could be identified, and these were followed by periods of high energy and enthusiasm, during which he became an evangelist and an artist, respectively^(40-45). In his own words, “now and then there are horrible fits of anxiety… a feeling of emptiness and fatigue in my head… attacks of melancholy and atrocious remorse”, “I am twisted by enthusiasm or madness or prophecy”, “I have great readiness of speech”, “three fainting fits… without retaining the slightest remembrance of what I felt”⁽⁴⁶⁾. Out of the psychiatric symptoms, visual and auditory hallucinations, depression, followed by hypomania, paranoia and self/hetero-aggressive behaviors are the most supported by evidence in this case⁽⁴⁷⁾. Complex partial seizures, aphasia, impotence, fever, constipation and abdominal pains are supported by a pathographic analysis⁽⁴⁷⁾.

At the age of 37, he died from a self-inflicted gunshot wound after a two-day agony⁽³⁷⁾. As an author puts it, the artist’s life was defined by “tragedy, loneliness, depression and ultimate self-destruction”⁽³⁷⁾. Out of the four attempted romantic relationships (in 1870, 1881, 1882 and 1884), none succeeded, as Vincent was either refused by the woman, or the families objected to the potential partners^(40-44).

The severity and negative impact of alcohol use disorder (addiction to absinthe plus cognac) on the personal and professional life of van Gogh is mentioned in various sources, both self-reports and observations of his behavior made by others⁽³⁹⁾. Absinthe has been invoked as a potential contributor to the onset of epileptic seizures, although, as mentioned in the introductory chapter, only very large concentrations of thujone could lead to such phenomena, according to animal experiments^(8,37). However, even the use of alcohol (not necessarily absinthe) on an epileptic background would be responsible for worsening the neurological condition.

More than 30 diagnoses were attributed to van Gogh, such as “interictal dysphoric disorder”, late-onset schizophrenia, schizoaffective disorder, “epileptoid temperament”, “cyclothymic temperament”, Ménière’s disease, neurosyphilis, brain tumor, tuberculous meningoencephalitis, alcohol-induced dementia, intoxication with digitalis, lead intoxication (from the paints he occasionally ingested), glaucoma/corneal atrophy/cataract, and acute intermittent porphyria (AIP)^(40,47-50). He was treated for gonorrhea in 1882, so the inference of neurosyphilis is based on the artist’s presumed lifestyle⁽⁴⁰⁾. Ménière’s disease was considered possible based on the existence of vertigo and tinnitus deduced from his letters; however, this hypothesis was refuted by several scientists based on the confused interpretation of the artist’s letters’ content, between tinnitus and auditory hallucinations, and a lack of sufficient support for the existence of vertigo as a significant symptom^(51,52). The diagnosis of schizophrenia can be safely excluded, because the artist remained creative until his last days, and the confusional aspects of his psychotic episodes are poorly compatible with the diagnosis of a chronic psychosis⁽⁵¹⁾. The diagnosis of acute intermittent porphyria was suspected based on sudden attacks of abdominal pain, nausea, anxiety and anorexia, but it is not supported by available data, as no clear AIP physical symptoms exist in van Gogh’s correspondence⁽⁵³⁾. The existence of xanthopsia in the case of van Gogh is another area of dispute between specialists, since reasons for this condition were plenty in the artist’s environment, starting with santonin, digitalis, phenacetin, ether, chromic and picric acids, and ending with thujone and lead⁽³⁷⁾. The presence of halos and the abundance of yellow color in his last series of paintings were attributed to other causes, as well, for example, chronic solar injury, glaucoma, or cataracts⁽⁵⁴⁾.

The conclusions of an expert meeting (N=14 medical specialists and 13 art historians) showed that focal seizures (staring eyes, ingesting non-edible items, contortion of his hands, falling on the ground) and a Gastaut-Geschwind syndrome were possible in the case of van Gogh, supported by a background of epilepsy in his family⁽³⁹⁾. However, the same expert consensus also lists a number of counterarguments for the possibility of epilepsy, like the low validity of cited sources, duration of symptoms, absence of solid documentation to support this diagnosis, etc.‌⁽³⁹⁾. It is worth noting that one of van Gogh’s treating physicians, Dr. Felix Rey, prescribed to him potassium bromide, an agent that could suppress seizures, with a favorable and relatively rapid effect in that case⁽³⁷⁾. Also, according to Henri Gastaut (1956), the last two years in the artist’s life were marked by the presence of temporal lobe epilepsy precipitated by the abuse of absinthe and the existence of an early limbic lesion^(40,42). Episodes of sudden terror, strange epigastric sensations and lapses of consciousness, preceded by an initial tonic spasm of the hand and a peculiar gaze, followed by a confusional-amnestic stage, were all described by the observers of van Gogh during his Parisian period⁽⁴⁰⁾. Intellectual and emotional auras (e.g, déjà vu, jamais vu, illusions, delusions, hallucinations and intense emotions) have been reported in relation to the diagnosis of epilepsy⁽⁵⁵⁾.

One of the hypotheses explored in the case of van Gogh’s mental status was derived from the influence of visual perception on triggering neuromodulation – i.e., the activation of specific neural networks that were discordant with the painter’s personal emotional system in stressful situations, conjugated with the neurotoxicity of alcohol abuse and sleep deprivation⁽³⁹⁾. A GABA interneuron deficit hypothesis – specifically, a deficiency in the functionality of parvalbumin neurons – was proposed as an explanation for the technique used in van Gogh’s painting⁽⁵⁶⁾. The tendency of van Gogh to become addicted to substances that interfere with the GABA neurotransmission, such as absinthe, via the active ingredient thujone, and the increasing amplification of brushstrokes as his disease progressed, as well as the tendency to merge aesthetic and personal experiences into a new form of abstraction are considered elements to support this hypothetical model⁽⁵⁶⁾. However, it must be kept in mind that these are only hypotheses for which irrefutable demonstrations cannot be conducted retrospectively.

The therapeutic power of painting in the case of van Gogh was highlighted by several authors, in relation to the depressive episodes and alcohol addiction⁽⁵⁵⁾. The paintings are considered the result of an emotional explosion, and the therapeutic value is acknowledged by the artist himself: “I must work and work steadily – forgetting myself in the work, otherwise it [the melancholy] would overwhelm me”⁽⁵⁵⁾. Also, Dr. Gachet, one of van Gogh’s treating physicians, recommended the painting as a means of therapy for the artist⁽⁵⁵⁾.

In conclusion, psychologists, doctors, art critics and art historians are still puzzled about the complexity of van Gogh’s case, about the mixture of flamboyant creativity and continuous struggle with psychiatric and neurological illnesses. This puzzlement persists, despite the existence of multiple sources of information, such as the artist’s letters, reports from contemporaries and partial medical reports (most of which are accessible through secondary sources). Was van Gogh’s creativity shaped by the artist’s illness, or were his health problems merely a poisonous intrusion that continually undermined his genius?^(49,50) As his letters show, it looks like the artist was in a constant fight with his health problems and still succeeded in coping with most of these, remaining creative throughout his lifetime, except for several of his hospitalizations⁽³⁸⁾. Most data support the possibility of multiple comorbidities, since no single disorder can explain the complexity of van Gogh’s symptoms, as reflected in his letters, family medical history, or historical accounts. The existence of an alcohol use disorder is unlikely to be debated, but if a temporal lobe epilepsy and/or bipolar disorder or a schizoaffective disorder were also present, this may be a question to which a definitive answer will probably never be found.

Henri de Toulouse-Lautrec

Famous Post-Impressionist painter, printmaker and illustrator, Count Henri Marie-Raymond de Toulouse-Lautrec-Montfa is most renowned for his vivid depictions of Parisian nightlife in the late 19^th century. He preferred to illustrate, at odds with fellow artists of his time, the working class (e.g., laundresses, seamstresses, housemaids, cooks) and its entertainment, more specifically, actresses, famous can-can dancers, horse races, sex workers, etc.^(57,58) The French painter was an illustrator of daily life, capturing the immediacy of Parisian evening scenes with a unique ability to convey the vibrancy of bohemian culture^(57,59,60). He employed free-flowing, expressive lines to create rhythmic compositions, and his extreme simplification of outline and movement, combined with the use of broad areas of color, transformed his posters into striking works of art⁽⁶¹⁾. His series “Elles” reveals an artist who deeply understood and favored people who were at the fringe of society, showing them sympathy and focusing on the qualities they shared with the rest of humanity⁽⁶²⁾.

From a pathobiographic perspective, his artistic legacy is intertwined with physical and psychiatric illnesses that led him to a continuous struggle and to a premature and tragic death. He was extremely productive, in just 15 years of artistic career producing 737 paintings, 275 watercolors, 363 prints and posters, besides the 5084 drawings, ceramics and stained-glass windows^(62-64).

Toulouse-Lautrec was born with pycnodysostosis, an autosomal-recessive genetic condition characterized by short-limbed stature, osteosclerosis with high bone fragility, acroosteolysis of the distal phalanges, a typical facial appearance, delayed closure of the cranial sutures, and clavicular dysplasia^(64-66). This disease was first described by Robert Weissman-Netter in 1954 and named by French physicians Pierre Maroteaux and Maurice Lamy as late as 1962; pycnodysostosis was later nicknamed “Toulouse-Lautrec syndrome”^(57,63). This is a rare disease, with an estimated incidence of 1.7 per million births⁽⁶⁶⁾. The cause of this disease is an enzyme deficiency, cathepsin K, due to mutations in the CTSK gene, which reduces the normal bone resorption and leaves the matrix decomposition incomplete^(63-67).

Although intelligence is typically normal in this disease, mild psychomotor difficulties may be reported; however, in the case of the famous French painter, no cognitive problems could be identified, as he presented a vivid intelligence as reflected by his letters and acknowledged by contemporaries’ reports⁽⁶⁵⁾. Alternative theories consider that achondroplasia or osteogenesis imperfecta could be taken into consideration as possible explanations for Toulouse-Lautrec’s condition, but these do not explain all the complexity of his physical signs⁽⁶⁸⁾.

The consanguinity of his parents may have contributed to the appearance of this genetic disease, as they were first cousins; also, it looks like at least three of Henri de Toulouse-Lautrec’s cousins were presenting dwarfism and other congenital and skeletal defects⁽⁵⁷⁾. Henri was extremely fragile from his birth, very sickly, and during his puberty and adolescence he suffered repeated fractures to the femur, successively on both legs, which never consolidated properly and stopped the bone growth⁽⁵⁷⁾. As a consequence, Henri had to walk with the support of a cane for the rest of his life, and his maximum height reached only 1.50 m^(57,69). The consequences of these facts on the artist’s self-image can only be imagined, and the negative impact on his societal perception must have been dramatic, especially in an era where physical “normalcy” was closely tied to social and marital success. Even more, he experienced recurrent sinusitis, headaches, impaired vision and hearing, which constantly troubled his daily life⁽⁶⁸⁾.

Besides the impairments due to this genetic disease and early, complicated fractures, lifestyle factors such as abuse of alcohol (mainly absinthe), allegedly used to compensate for physical pain and chronic depression, contributed to his premature death. Also, due to his lifestyle, which included frequent visits to brothels, the artist contracted syphilis in 1888, which accelerated his physical and mental deterioration⁽⁵⁹⁾. Complications of chronic alcohol use arose, such as paranoia (he believed the police were keen to arrest him), hallucinations (friends have found him shooting with his pistol at invisible spiders), aggressiveness, delirium and psychomotor agitation, leading to a three-month stay in a mental asylum in 1889, after an incident in a brothel^(57,59). Soon after the discharge from the hospital for this episode of delirium tremens, he resumed drinking and carried a supply of absinthe in his hollow walking stick, so as to have it readily available at all times^(57,70).

Prior to his death, it is assumed that he had a series of strokes, which further reduced his mobility⁽⁵⁷⁾. In 1901, he suffered a seizure, complicated shortly after by a stroke, leaving him with hemiparesis, and he died a few months prior to his 37^th anniversary^(59,71). Neurosyphilis most likely contributed decisively to the cerebrovascular pathology in his case⁽⁶³⁾. A Wernicke-Korsakoff syndrome could be excluded, since characteristic neurological signs were not documented^(63,72-74). Also, during his fight with all these debilitating physical and mental conditions, he continued to create art until his final months, indicating at least partially preserved functionality.

Toulouse-Lautrec had demonstrated profound empathy and a deep psychological understanding of his models, which may be a consequence of his own marginalization. He painted prostitutes in their moments of boredom, camaraderie and melancholy, thus avoiding moralizing or sensational approaches. Dancers and performers are also depicted on stage or in rehearsal, showing not only glamour but also fatigue. Art historian Julia Frey argues that Lautrec’s works “externalize the pain and loneliness of an individual who saw himself as grotesque”⁽⁷⁵⁾. Or, otherwise put, he used his art to cope with the perceived sense of exclusion⁽⁶⁸⁾. Toulouse-Lautrec’s life illustrates the intricate interplay of hereditary illness, social isolation, addiction and psychological distress. Through his art, he succeeded in capturing the lively essence of fin-de-siècle Paris, but he also reflected his personal anguish – an enduring reminder of the human ability to create amid suffering. The legacy left by Toulouse-Lautrec, despite all his sufferings, was significant, as he influenced French art of the late 19^th and early 20^th centuries, setting the course of the avant-garde far beyond his early death⁽⁶¹⁾.

In conclusion, Toulouse-Lautrec’s own physical and mental sufferings, while severely influencing his quality of life, may have facilitated his understanding of the frailty of human nature and the psychological condition of his vulnerable characters^(57,59). The reviewed data are derived from the artist’s letter, family letters, very few medical records and contemporaries’ notes, supporting the existence of an alcohol use disorder, neurosyphilis, childhood fractures that stopped his growth, and a genetic disease, most likely pycnodysostosis (retrospectively made diagnosis).

Conclusions

Biographies, volumes of letters, articles and other relevant sources were supportive, although at a low to medium level of evidence, for the existence of psychopathological factors in the lives of three major representatives of Post-Impressionism. Although Cézanne was never formally psychiatrically examined, based on the retrieved information, elements for social anxiety disorder, possible episodes of major depression, and features of anankastic and schizoid personality can be extracted from self-reports (in his letters) and hetero-observations (from acquaintances and contemporaries). The data to support an autism spectrum disorder in the case of Cézanne are not strong enough, and are is based on a single, retrospective report⁽²⁹⁾.

As for van Gogh’s possible diagnosis, this is probably one of the most debated topics in the field of pathography. Despite the fact that the amount of research dedicated to this subject is enormous, and even conspiracy theories flourished on this ground (suicide versus accident, lack of documented treatments in the early phase of his life versus intentionally destruction of such evidence, etc.), there is no certainty about the specific pathology that troubled continuously the life of the Dutch painter^(37-56). However, it is possible that no single diagnosis could cover the complexity of van Gogh’s clinical manifestations, and at least an alcohol use disorder overimposed on a temporal lobe epilepsy and/or bipolar disorder or a schizoaffective disorder could be presumed.

Toulouse-Lautrec’s life offers us insight into the sensitive domain of how individuals with invalidating, rare genetic disorders can fight their vulnerabilities and remain productive and creative, despite their continuous sufferings. Unfortunately, in the case of the French painter, the same sufferings, which facilitated his understanding of the frailty of human nature and allowed him to create wonderful pieces of art, caused him to slip into alcohol abuse and the frequent visits to brothels, which finally led to his premature death (neurosyphilis, strokes, delirium tremens). The societal rejection and even self-exclusion from the high-class Parisian society, where “normalcy” was considered an essential attribute for membership, contributed to his depression and self-aggressive acts (i.e., continuous use of alcohol, albeit discharged from hospital after a complicated alcohol withdrawal).

Further investigations in the field of pathography of Post-Impressionists are warranted, based on the continuous dialogue between psychopathology and artistic expression; some of the unanswered questions are already listed in this study. Did van Gogh’s claimed xantopsia induced by an intoxication with digitalis influence his color choice in the last ten years of his life, or was this a voluntary, artistic taste-based choice? Was the intense productivity of van Gogh related to his presumed bipolar disorder? Was Cézanne’s pioneering technique of drawing influenced by his visual deficits, by his potential obsessional and schizoid personality features, or, again, was all deliberate and justified only by an artistic rationale? Could the heightened sensitivity and empathy exhibited by Toulouse-Lautrec toward his subjects be interpreted as originating from the psychological and physical suffering he endured, as well as from his perceived social exclusion and stigmatization by the upper-class milieu into which he was born?    

Corresponding author: Octavian Vasiliu E-mail: octavvasiliu@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.