Musicophilia: Tales of Music and the Brain (7 page)

After about an hour, this clangor was replaced by music: tunes from
The Sound of Music
and part of “Michael, Row Your Boat Ashore”— three or four bars of one or the other, repeating themselves with deafening intensity in her mind. “I was well aware that there was no orchestra playing, that it was
me,
” she emphasized. “I was afraid I was going mad.”

Mrs. C.’s physician suggested that she taper off the prednisone, and a few days later the neurologist whom she had now consulted suggested a trial of Valium. Mrs. C.’s hearing, meanwhile, had returned to its previous level, but neither this nor the Valium nor the tapering of the prednisone had any effect at all on her hallucinations. Her “music” continued to be extremely loud and intrusive, stopping only when she was “intellectually engaged,” as in conversation or in playing bridge. Her hallucinatory repertoire increased somewhat but remained fairly limited and stereotyped, confined mostly to Christmas carols, songs from musicals, and patriotic songs. All of these were songs she knew well— musically gifted and a good pianist, she had often played them in her college days and at parties.

I asked her why she spoke of musical “hallucinations” rather than musical “imagery.”

“They are completely unlike each other!” she exclaimed. “They are as different as thinking of music and actually hearing it.” Her hallucinations, she emphasized, were unlike anything she had ever experienced before. They tended to be fragmentary— a few bars of this, a few bars of that— and to switch at random, sometimes even in mid-bar, as if broken records were being turned on and off in her brain. All of this was quite unlike her normal, coherent, and usually “obedient” imagery— though it did have a little resemblance, she granted, to the catchy tunes that she, like everyone, sometimes heard in her head. But unlike catchy tunes, and unlike anything in her normal imagery, the hallucinations had the startling quality of actual perception.

At one point, sick of carols and popular songs, Mrs. C. had tried to replace the hallucinations by practicing a Chopin étude on the piano. “
That
stayed in my mind a couple of days,” she said. “And one of the notes, that high F, played over and over again.” She started to fear that all of her hallucinations would become like this— two or three notes, or perhaps a single note, high, piercing, unbearably loud, “like the high A Schumann heard at the end of his life.”
1
Mrs. C. was fond of Charles Ives, and another worry she had was that she might have “an Ives hallucination.” (Ives’s compositions often contain two or more simultaneous melodies, sometimes completely different in character.) She had never yet heard two hallucinatory tunes simultaneously, but she started to fear that she would.

She was not kept awake by her musical hallucinations or prone to musical dreams, and when she awoke in the morning, there would be an inner silence for a few seconds, during which she would wonder what the “tune du jour” was going to be.

When I examined Mrs. C. neurologically, I found nothing amiss. She had had EEG and MRI studies to rule out epilepsy or brain lesions, and these had been normal. The only abnormality was her rather loud and poorly modulated voice, a consequence of her deafness and impaired auditory feedback. She needed to look at me when I spoke, so that she could lip-read. She seemed neurologically and psychiatrically normal, though understandably upset by the feeling that something was going on inside her that was beyond her control. She had been upset, too, by the idea that these hallucinations might be a sign of mental illness.

“But why only music?” Mrs. C. asked me. “If these were psychotic, wouldn’t I be hearing voices, too?”

Her hallucinations, I replied, were not psychotic but neurological, so-called “release” hallucinations. Given her deafness, the auditory part of the brain, deprived of its usual input, had started to generate a spontaneous activity of its own, and this took the form of musical hallucinations, mostly musical memories from her earlier life. The brain needed to stay incessantly active, and if it was not getting its usual stimulation, whether auditory or visual, it would create its own stimulation in the form of hallucinations. Perhaps the prednisone or the sudden decline in hearing for which it was given had pushed her over some threshold, so that release hallucinations suddenly appeared.

I added that brain imaging had recently shown that the “hearing” of musical hallucinations was associated with striking activity in several parts of the brain: the temporal lobes, the frontal lobes, the basal ganglia, and the cerebellum— all parts of the brain normally activated in the perception of “real” music. So, in this sense, I concluded to Mrs. C., her hallucinations were not imaginary, not psychotic, but real and physiological.

“That’s very interesting,” said Mrs. C., “but rather academic. What can you do to
stop
my hallucinations? Do I have to live with them forever? It’s a dreadful way to live!”

I said we had no “cure” for musical hallucinations, but perhaps we could make them less intrusive. We agreed to start a trial of gabapentin (Neurontin), a drug that was developed as an antiepileptic but is sometimes useful in damping down abnormal brain activity, whether epileptic or not.

The gabapentin, Mrs. C. reported at her next appointment, actually exacerbated her condition and had added a loud tinnitus, a ringing of the ears, to the musical hallucinations. Despite this, she was considerably reassured. She knew now that there was a physiological basis for her hallucinations, that she was not going mad, and she was learning to adapt to them.

What did upset her was when she heard fragments repeated again and again. She instanced hearing snatches of “America the Beautiful” ten times in six minutes (her husband had timed this), and parts of “O Come, All Ye Faithful” nineteen and a half times in ten minutes. On one occasion, the iterating fragment was reduced to just two notes.
2
“If I can hear a whole verse, I’m very happy,” she said.

Mrs. C. was now finding that though certain tunes seemed to repeat themselves at random, suggestion and environment and context played an increasing part in stimulating or shaping her hallucinations. Thus, once as she was approaching a church, she heard a huge rendering of “O Come, All Ye Faithful” and thought at first that it was coming from the church. After baking a French apple cake, she hallucinated bits of “Frère Jacques” the next day.

There was one more medication that I felt might be worth a trial: quetiapine (Seroquel), which had been successfully used in one case to treat musical hallucinations.
3
Though we only knew of this single report, the potential side effects of quetiapine were minimal, and Mrs. C. agreed to try a small dose. But it had no clear effect.

Mrs. C. had been trying, in the meantime, to enlarge her hallucinatory repertoire, feeling that if she did not make a conscious effort it would contract to three or four endlessly repeated songs. One hallucinatory addition was “Ol’ Man River” sung with extreme slowness, almost a parody of the song. She did not think she had ever heard the song performed in this “ludicrous” way, so this was not so much a “recording” from the past as a memory that had been revamped, recategorized in a humorous way. This, then, represented a further degree of control, not merely switching from one hallucination to another, but modifying one creatively, if involuntarily. And though she could not stop the music, she could sometimes switch it now by an effort of will. She no longer felt so helpless, so passive, so put upon; she had a greater sense of control. “I still hear music all day long,” she said, “but either it has become softer or I’m handling it better. I haven’t been getting as upset.”

Mrs. C. had been thinking about a cochlear implant for her deafness for years but had postponed this when the musical hallucinations began. Then she learned that one surgeon in New York had performed a cochlear implant in a severely hard-of-hearing patient with musical hallucinations and found that it not only provided good hearing, but had eliminated the musical hallucinations. Mrs. C. was excited by this news and decided to go ahead.

After her implant had been inserted and, a month later, activated, I phoned Mrs. C. to see how she was doing. I found her very excited and voluble over the phone. “I’m terrific! I hear every word you say! The implant is the best decision I ever made in my life.”

I saw Mrs. C. again two months after her implant was activated. Her voice before had been loud and unmodulated, but now that she could hear herself speak, she spoke in a normal, well-modulated voice, with all the subtle tones and overtones that were absent before. She was able to look around the room as we spoke, where previously her eyes had always been fixed on my lips and face. She was manifestly thrilled with this development. When I asked how she was, she responded, “Very, very well. I can hear my grandchildren, I can distinguish male from female voices on the telephone…. It’s made a world of difference.”

Unfortunately, there was a downside, too: she could no longer enjoy music. It sounded crude, and with the relative pitch-insensitivity of her implant, she could hardly detect the tonal intervals that are the building blocks of music.

Nor had Mrs. C. observed any change in the hallucinations. “My ‘music’— I don’t think the increasing stimulation from the implant will make any difference. It’s
my
music, now. It’s like I have a circuit in my head. I think I am landed with it forever.”
4

Though Mrs. C. still spoke of the hallucinating part of herself as a mechanism, an “it,” she no longer saw it as wholly alien— she was trying, she said, to reach an amicable relation, a reconciliation, with it.

D
WIGHT MAMLOK
was a cultivated man of seventy-five with mild high-frequency deafness who came to see me in 1999. He told me how he had first started to “hear music”— very loud and in minute detail— ten years earlier, on a flight from New York to California. It seemed to have been stimulated by the drone of the plane engine, to be an elaboration of this— and, indeed, the music ceased when he got off the plane. But thereafter, every plane trip had a similar musical accompaniment for him. He found this odd, mildly intriguing, sometimes entertaining, and occasionally irritating but gave it no further thought.

The pattern changed when he flew to California in the summer of 1999, for this time the music continued when he got off the plane. It had been going on almost nonstop for three months when he first came to see me. It tended to start with a humming noise, which then “differentiated” into music. The music varied in loudness; it was at its loudest when he was in a very noisy environment, such as a subway train. He found the music difficult to bear, for it was incessant, uncontrollable, and obtrusive, dominating or interrupting daytime activities and keeping him awake for hours at night. If he woke from deep sleep, it came on within minutes or seconds. And though his music was exacerbated by background noise, he had found, like Sheryl C., that it might be lessened or even go away if he paid attention to something else— if he went to a concert, watched television, engaged in animated conversation or some other activity.

When I asked Mr. Mamlok what his internal music was like, he exclaimed, angrily, that it was “tonal” and “corny.” I found this choice of adjectives intriguing and asked him why he used them. His wife, he explained, was a composer of atonal music, and his own tastes were for Schoenberg and other atonal masters, though he was fond of classical and, especially, chamber music, too. But the music he hallucinated was nothing like this. It started, he said, with a German Christmas song (he immediately hummed this) and then other Christmas songs and lullabies; these were followed by marches, especially the Nazi marching songs he had heard growing up in Hamburg in the 1930s. These songs were particularly distressing to him, for he was Jewish and had lived in terror of the Hitlerjugend, the belligerent gangs who had roamed the streets looking for Jews. The marching songs lasted for a month or so (as had the lullabies that preceded them) and then “dispersed,” he said. After that, he started to hear bits of Tchaikovsky’s Fifth Symphony— this was not to his taste either. “Too noisy…emotional…rhapsodic.”

We decided to try using gabapentin, and at a dose of 300 milligrams three times a day, Mr. Mamlok reported that his musical hallucinations had greatly diminished— they hardly occurred at all spontaneously, though they might still be evoked by an external noise, such as the clatter of his typewriter. At this point, he wrote to me, “the medicine has done wonders for me. The very annoying ‘music’ in my head is virtually gone…. My life has changed in a truly significant way.”

After two months, however, the music started to escape from the control of the gabapentin, and Mr. Mamlok’s hallucinations became intrusive again, though not as much so as before the medication. (He could not tolerate larger doses of gabapentin, because they caused excessive sedation.)

Five years later, Mr. Mamlok still has music in his head, though he has learned to live with it, as he puts it. His hearing has declined further and he now wears hearing aids, but these have made no difference to the musical hallucinations. He occasionally takes gabapentin if he finds himself in an exceptionally noisy environment. But the best remedy, he has discovered, is listening to real music, which, for him, displaces the hallucinations— at least for a while.