A detailed review of his birth, early and late life, especially his progress as an artist has been discussed in the previous section. All this information is the basis on which a case was formulated and evaluated in the coming sections.

Case Formulation

This patient, Vincent Van Gogh, is a 37-year-old, single, Dutch, male artist. He is the second-eldest of 6 siblings - where the first was a still-born. Vincent voluntarily admitted himself for the first time at Saint-Paul asylum in Saint Remy, France in 1889.The patient described himself as a moody, solitary child, often disobedient and with few friends. His early interests were flowers, birds, and insects, but he preferred to play alone.

The patient entered the city hospital at Brouwersgracht at the Hague, in the Netherlands in 1882 with a gonorrheal infection. He was admitted for 25 days. After 14 days, he complained by letter on of his "dreadful weakness." At the time of his initial hospitalization, he displayed suicidal acts. These acts were carried out while he had a confused state of mind, wherein he described his thoughts as increasingly becoming more jumbled, to the point that 'the noise inside has become unbearable.' First indications of neuroses and psychoses occurred at age 27. On Christmas Eve of 1888, he became physically and emotionally exhausted because of opposing ideas and conflicts with fellow artist Paul Gauguin. He reportedly chased Gauguin with a razor and cut off the lower half of his own left ear.

His life history indicates that his ailment revolved around episodes of critical mental derangement and disability, separated by intervals of sanity and creativity. Vincent has an extremely unconventional personality with frequent unstable moods and character swings. He suffers from recurrent psychotic episodes.

He suffered two very distinct episodes of reactive depression in his life, and there are clear bipolar evidences to his mental history. Both episodes of depression were followed by constant periods of increasingly high energy and enthusiasm, once as an evangelist and then as an artist.

Cultural Formulation

The cultural formulation for a particular case under the DSM IV TR criteria includes giving all information about the cultural background of the patient. It includes knowing the cultural and social identity of the patient, cultural explanations to an individual's illness, cultural elements of relationship between the clinician and the patient etc. (Lewis-Fernandez and Diaz, 2002).

Vincent Van Gogh belongs to a Dutch family with strict religious and moral values. His socioeconomic status in the society has not been impressive as at around 33 years of age, he was almost penniless in spite of his brother sending him some money quite often. He worked with the poor miners in Belgium and was highly fascinated by them. He was deeply involved with Brothels while he lived in Paris and London. He had deep sympathy for the impoverished and unfortunate people.

Not much information regarding his cultural background is available to produce a solid cultural formulation.

Diagnosis

The DSMIV TR Codes are derived from Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association and it includes all known mental health disorders under certain numeric codes for all. In order to understand and diagnose the illness of this artist it is necessary to find out all detailed information about his life. A summary of diagnosis after evaluation of symptoms is given in Table 1 (Tan, 2011).This research has been carried out on the basis of information in the first section through methods elaborated under Evaluation Procedures.

Multi-axial Diagnosis of Vincent Van Gogh (Table 1)

DSMIV TR

Axis I

Bipolar I Disorder, most current episode Mixed, with psychotic features

Polydrug Abuse (alcohol, nicotine, and caffeine)

Axis II

Paranoid Personality Disorder

Axis III

Acute intermittent porphyria, gastrointestinal irritability, gonorrhea, temporal lobe epilepsy, sexual impotence

Axis IV

Poverty, parental con-icts, con-icts with his peers

Axis V

GAF: 30

Certain major diagnoses on the basis of information collected are mentioned below:

One -- Bipolar Disorder Diagnosed: Vincent's condition worsened from depression starting after rejection by his beloved woman. Dr. Blumer has discussed the feelings that he wrote to his brother Theo:

"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…. There are moments when I am twisted by enthusiasm or madness or prophecy, like a Greek oracle on the tripod. And then I have a great readiness of speech."

During and after this period that Vincent lived in Paris and went to Arles, he suffered from deep depression, anguish and anxiety along with periods of sheer contention, grandiosity and creativity.This behavior of Vincent can be attributed to Bipolar Disorder according to the criteria set for the said disease in axis I of DSM IVTR (American Psychiatric Association, 2000).

Under the criteria set...

An irritable mood must be present along with several other criteria defined for the mental disorder. Vincent suffered from (i) restlessness, (ii)racing and jumbled thoughts, (iii) lack of the need to sleep, and (iii) an intensive participation in pleasurable activities (Kringet al., 2007). Vincent's letters were written in an unclear way where he was often not able to clearly portray his message and just wrote down his thoughts. He painted for days and eventually stopped by sheer exhaustion, only to enter a state of depression. Moreover, he was a frequent visitor of brothels and he flaunted about his hobby as well. He never appeared to be dysfunctional after his attacks (Loftus and Arnold, 1991).
Vincent Van Gogh also exhibited psychotic features in his mental illness including phases of severe mania, delusions and hallucinations. Amnesia and seizures were reported as well (Blumer, 2002).

Two -- Brain Abnormalities Diagnosed: During his treatment before, Vincent was diagnosed and treated for epilepsy. However, his seizures were not severe. He suffered from most of his seizures of epilepsy when he drank too much absinthe, although, it almost always left him with grief and depression (Blumer, 2002). When Vincent abstained from absinthe his symptoms of epilepsy went away and his behavior and cognitive ability became stable. Contemporaries of Vincent are known to drink much more absinthe but he was somehow more sensitive to its outcomes.Vincent was treated using Digitalis by his physician Dr. Gachet.

His mental conditions, both in late and early stages of his life, can be attributed to an early brain injury. This hypothesis is supported by pointing out craniofacial asymmetry in one of Van Gogh's self-portraits. This asymmetry is highly consistent with Van Gogh's temperamental fluctuations and emotional turmoil published in history.

An analysis of the DSM IV TR criteria for any such symptoms reveals no significant information. Vincent's epilepsy does not have any distinct reason available and so it may be classified under mental disorders due to general medical conditions. These are the situations when no apparent reason for a mental situation may be found.

Three -- Psychosocial problems: Vincent Van Goghhas psychosocial problems that are recognizable under Axis IV of DSM IV criteria. He has problems with primary support as he feels that he is not able to live up to the family's name. He is not able to settle in a proper job stably. He has remained socially and financially dependent on his brother all his life and has felt insecure about his being a burden on his brother and family.

Conclusion

Based on the diagnosis it can be said that Vincent Van Gogh has prevailing signs and core symptoms of Bipolar I disorder with recurrent mixed episodes of psychotic features (Table 2) (Tan, 2011):

Symptoms of Bipolar Disorder

Psychotic Features

Manic Phase (High Phase) usually followed by 2 to 4 depressive episodes

Depressive Phase (Low Phase)

Found in both bipolar I & bipolar II disorder

Easily distracted

Melancholia

Catatonia: abnormality of movement and behavior arising from a disturbed mental state

Reckless behavior and lack of self-control

Dif-culty concentrating, remembering, or making decisions

Delusion of Reference: the belief that random events, objects, others? behaviors, have a particular signi-cance to oneself

Poor judgment

Eating problems leading to weight gain or loss

Elevated mood

Fatigue

Hallucinations: an experience involving the apparent perception of something not present

Little need for sleep

Feelings of worthlessess, hopelessness, or guilt

Delusions: rmly held false beliefs

High involvement in activities

Anhedonia

Negativism: the tendency to be negative or skeptical in attitude while failing to offer positive views.

Feelings of self-importance

Low self-esteem

High levels of agitation

Suicidal ideations

Paranoia: delusions of persecution, unwarranted jealousy, or exaggerated self-importance

Poor temper control

Sleep problems

Appropriate Treatment Plan

A suitable treatment plan for the diagnosed mental health problems as proposed by Tan et al. is as follows:

Psychological Treatment: Informing the patient in detail about his condition may aid in getting his will and hence a rapid recovery may be expected. Patient should know about the onset and course of his illness and should be encouraged to comply with intake of medication, as well as with the life style and thought processes that he should be following have to be elaborated to the patient.

Interpersonal psychotherapy and cognitive therapy: Such treatments are known to reduce the symptoms of Bipolar Disorder.

Biological Treatment: Electroconvulsive therapy (ECT)

Medications: Certain recommended medication should be administered like:

a. Mood stabilizers: Lithium carbonate (requires…