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Bipolar Disorder Epilepsy & Seizures Featured

The Curious Case of Vincent van Gogh

Vincent van Gogh is one among many famous personalities in history who have rightly or wrongly been credited with having suffered from epilepsy. It seems fairly clear that Vincent van Gogh did suffer from symptoms of brain and mind; seizures, hallucinations, mood swings and explosive impulsive behavior that have been variously attributed to bipolar disorder, Meniere’s disease and interestingly, personality features linked with epilepsy.

Van Gogh was not just a productive painter (over 2000 works in a relatively short lifetime); he was a very prolific letter writer. Indeed, in one very productive period in Arles (1888-1889) he is believed to have produced 200 paintings and 200 watercolors, a painting every 36 hours; he also managed to write to his brother Theo, an art dealer in Paris, and to fellow impressionists, 200 letters filling 1700 pages, the shortest six pages long.

van Gogh was probably hypergraphic, both in letter and painting, the latter having been described as a manifestation of hypergraphia by Michael Trimble, the eminent London-based Behavioral Neurologist. van Gogh had a history of seizures, probably even experiencing one while painting the portrait “Over the Ravine” revealed in the rough brush strokes and resulting in a torn canvas.

He also probably demonstrated other traits of the Geschwind Syndrome: intense mood swings, with irritability and anger; and a spectrum of sexual behavior (hyposexuality, hypersexuality, bisexuality and homosexuality). The last (among others) was with Paul Gauguin, in an intense argument with whom he experienced hallucinations (a voice that asked him to kill).

Provoked to be aggressive, he then experienced a biblical injunction “And if thine offend thee, pluck it out” and turned the razor, famously, on to his own ear (self portrait with a bandaged ear).

Indeed, his relationship with Gauguin was typically intense. van Gogh was observed by Gauguin to experience difficulty in terminating arguments and discussions (emotional stickiness). Another intense argument is thought to have resulted in van Gogh’s suicide: he threatened his physician with a pistol, was rebuffed, left the office, and shot himself in the chest.

He died two days later. It is noteworthy that van Gogh was the son of a preacher and started his life as one (probable hyper-religiosity). Indeed, it has been proposed by the neurologist and art scholar Prof. Khoshbin that van Gogh had all the five core traits of Geschwind Syndrome ( http://goo.gl/VyjxzK ). His extraordinary creativity and inspired genius makes his case all the more curious, indeed!

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Bipolar Disorder Featured Unexplained Medical Symptoms

Falling men, Failing Neurons

Clinical Autonomic Dysfunction with a plethora of systemic complaints often goes unrecognised. But the right diagnosis and treatment can help speed up the recovery process.

Most of us take standing up for granted. Only when we cannot stand for some reason are we reminded of its importance. Oliver Sacks, the legendary neurologist and author, addressed this rather poignantly in his story On standing on one leg, which documented his experiences after a fall in the Alps. The human species started ‘standing on two legs’ rather late in its evolution. As a consequence, body mechanisms that enable standing — for example ‘preventing all the blood from pooling in our feet, thanks to gravity’ — developed rather late. A complex neural network rich in chemicals and hormones controls postural changes in blood pressure, as it does heart rate, body temperature, digestion, urinary and sexual function… a host of human activities performed, often unthinkingly. This complex network — the autonomic nervous system or ANS — is ‘autonomic’ i.e. ‘independent’ of our conscious control, yet to some extent modifiable. For example, we can hold our urine until we reach the bathroom, well, most of the time!V, a 64-year-old retired headmaster, came to us with a rather peculiar problem. For almost a year, he had been unable to stand up. He would collapse and transiently lose consciousness. Starting with giddiness on standing up, the problem had progressed to intolerable vertigo and eventually episodes of syncope (fainting), leaving him most comfortable when flat on his back. Not surprisingly, V had taken himself to bed, occupying supine repose, in which he was most comfortable. Not surprisingly also, this rendered him severely disabled, dependant on his wife of almost four decades, for all activities of daily life.

When we first met V, he was petrified of standing up, even with our persuasive encouragement and promise of medical support. We had to, therefore, admit him to a partner hospital, and begin attending to him there. Our detailed 360° evaluation confirmed that he had a rare but disabling condition — progressive autonomic failure — with the background of long-standing depression, under treatment with psychotropic medication and a history of generalised seizures (in remission). He had many symptoms of clinical autonomic dysfunction: his blood pressure when taken lying down was 90/50 mmHg; when he stood up, however, his blood pressure plummeted to 50/? — the diastolic so low that it was unrecordable. His postural vertigo, variable heart rate, altered patterns of sweating, pain in the neck and shoulders (coat hanger distribution), unpredictable bowel movements were all symptomatic of his underlying condition: Clinical Autonomic Dysfunction. In addition V had slurred speech and diminished swallowing ability without apparent neuromuscular weakness.

Following diagnosis, V was started on one of the few drugs that can help prevent postural fall in blood pressure. He also was enrolled into our interdisciplinary and integrative rehabilitation programme for autonomic dysfunction. Extended physiotherapy sessions including passive mobilisation, electrotherapy for pain, postural exercise paradigms, gait and balance training, and active exercise protocols delivered over three weeks. He also received acupuncture targeting his neurological symptoms and therapeutic mud for his gastro-intestinal symptoms. Sessions of Jacobson’s Progressive Muscle Relaxation as well as supportive counselling to build confidence and motivation and address caregiver distress were included. At the end of the treatment period, aided no doubt by both drug and alternative therapy approaches, V was back on his feet.

Clinical Autonomic Dysfunction with a plethora of systemic complaints often goes unrecognised as a medical diagnosis; so little being known about ANS and it being difficult to test. Many patients with autonomic symptoms are labelled as ‘psychosomatic’ and do not receive necessary medical attention, leading to avoidable delays in treatment. Indeed the ANS is perhaps one of the last frontiers of neuroscience, requiring significant research focus, as concluded in the recent TS Srinivasan-NIMHANS Conclave on the subject. Not just neurological and psychiatric, ANS symptoms can present with vertigo (ENT), cardiac (heart), respiratory (lungs), gastroenterological (abdomen), genitourinary (urinary and sexual), orthopaedic and rheumatology (bones, joints, musculoskeletal) complaints. A clinical diversity that can test the most accomplished physicians. While falling men like V could well have failing neurons, we also learn from him that people with a plethora of unexplained medical symptoms do deserve an ‘autonomic’ approach and may well benefit from therapy and rehabilitation.