Hallucinations of musical notation: new paper for neurology journal Brain by Oliver Sacks

Professor of neurology, physician, and author Oliver Sacks M.D. has outlined case studies of hallucinations of musical notation, and commented on the neural basis of such hallucinations, in a new paper for the neurology journal Brain.

In this paper, Dr Sacks is building on work done by Dominic ffytche et al in 2000, which delineates more than a dozen types of hallucinations, particularly in relation to people with Charles Bonnet syndrome (a condition that causes patients with visual loss to have complex visual hallucinations). While ffytche believes that hallucinations of musical notation are rarer than some other types of visual hallucination, Sacks says that his own experience is different.

“Perhaps because I have investigated various musical syndromes,” writes Dr Sacks, “and people often write to me about these… I have seen or corresponded with a dozen or more people whose hallucinations include – and sometimes consist exclusively of – musical notation.”

Sacks goes on to detail eight fascinating case studies of people who have reported experiencing hallucinations of musical notation, including:

• A 77 year old woman with glaucoma who wrote of her “musical eyes”. She saw “music, lines, spaces, notes, clefs – in fact written music on everything [she] looked at.”

• A surgeon and pianist suffering from macular degeneration, who saw unreadable and unplayable music on a white background.

• A Sanskrit scholar who developed Parkinson’s disease in his 60s and later reported hallucinating ornately-written music, occurring with a Sanskrit script. “Despite the exotic nature of the script the result is still western music,” he said.

• A woman who reported seeing musical notation on her ceiling upon waking in the morning.

• A woman who said she wasn’t a musician, but would hallucinate when she had high fevers as a child. She said that the notes were “angry, and [she] felt unease. The lines and notes were out of control and at times in a ball.”

It is striking that, of Dr Sacks’ eight case studies, seven were gifted musicians. Sacks comments, “This is perhaps a coincidence, but it makes one wonder whether there is something about musical scores that is radically different from verbal texts.” Musical scores are far more visually complex than standard (English) text, with not just a variety of notes, but also many symbols that indicate how the notes should be played.

Dr Sacks also says that he has a mild form of Charles Bonnet syndrome himself, in which he sees a variety of simple forms whenever he gazes at a blank surface. “When I recently returned to playing the piano and to studying scores minutely, I began to ‘see’ showers of flat signs along with the letters and runes on blank surfaces.”

Another striking feature of these hallucinations is that – like text hallucinations – they are generally unreadable. They can seem playable at first, but on closer inspection it transpires that the music is often nonsensical or impossible to play, such as an example reported in one of the case studies: a melody line three or more octaves above middle C, and so may have half a dozen or more ledger lines above the treble staff.

Usually, the early visual system analyses forms and sends the information it has extracted to higher areas, where it gains coherence and meaning. Normally, in the act of perception, the entire visual system is engaged. Paradoxically, according to Sacks, “one may have to study disorders of the visual system to see how complex perceptual and cognitive processes are analysed and delegated to different levels… and hallucinations of musical notation can provide a very rich field of study here.”

Scary Faces Terrify Woman with Unusual Condition

When the 67-year-old woman came to the hospital, she was deeply afraid of two things — the visions of odd-looking faces that appeared hovering before her, and that the hallucinations might mean she was losing her mind.

But this retired teacher wasn’t going crazy, and laboratory tests also ruled out two common culprits of hallucinations — infection and drug interactions.

"She was absolutely terrified by what she was seeing," said Dr. Bharat Kumar, an internal medicine resident at the University of Kentucky who treated the woman. In fact, the patient and her family were so concerned in the days before she came to the hospital, they asked a priest about performing an exorcism, Kumar said.

The woman drew a picture of what she saw. The faces had large teeth, eyes and ears, and a horizontally elongated shape, like a football.

That peculiar shape and the fact that the patient recognized that she was hallucinating (rather than believing the visions to be real) provided two important clues in making a diagnosis, Kumar said. He determined that the woman had condition called Charles Bonnet syndrome.

Patients with the syndrome may see small people and animals, bright moving shapes or distorted faces. These hallucinations are purely visual; no sounds accompany them.

In the woman’s case, the condition developed because she had macular degeneration. Tissue within the retinas of her eyes was deteriorating, and her ability to see was declining.

Charles Bonnet syndrome results from the absence of such sensory input to the brain. “When it expects sensory input and receives nothing, it often creates its own input,” Kumar explained.

The brain isn’t a sophisticated computer that processes information objectively and efficiently, he said. “It’s more of a wibbly-wobbly, messy-guessy ball of goo.”

There is no treatment for the condition, but in many cases the hallucinations stop happening as the brain becomes used to vision loss. Patients who are very frightened might be given anti-psychotic medications, but these drugs have serious side effects and aren’t appropriate for everyone.

The woman was grateful to receive her diagnosis and learn that she was not losing her mind, Kumar said. When he followed up with her three months later, she was still having the hallucinations, but they were happening less often.

A 2010 study showed that 10 to 40 percent of elderly patients with visual impairments may have Charles Bonnet syndrome.

Kumar had never before seen a patient with the condition, although he noted that it may occur more commonly than it is diagnosed. “Patients are often hesitant to say that they see things because they are afraid that they will be called crazy,” he said.

The case report was published online Feb. 25 in the journal Age and Aging.

Seeing Things? Hearing Things? Many of Us Do

HALLUCINATIONS are very startling and frightening: you suddenly see, or hear or smell something — something that is not there. Your immediate, bewildered feeling is, what is going on? Where is this coming from? The hallucination is convincingly real, produced by the same neural pathways as actual perception, and yet no one else seems to see it. And then you are forced to the conclusion that something — something unprecedented — is happening in your own brain or mind. Are you going insane, getting dementia, having a stroke?

In other cultures, hallucinations have been regarded as gifts from the gods or the Muses, but in modern times they seem to carry an ominous significance in the public (and also the medical) mind, as portents of severe mental or neurological disorders. Having hallucinations is a fearful secret for many people — millions of people — never to be mentioned, hardly to be acknowledged to oneself, and yet far from uncommon. The vast majority are benign — and, indeed, in many circumstances, perfectly normal. Most of us have experienced them from time to time, during a fever or with the sensory monotony of a desert or empty road, or sometimes, seemingly, out of the blue.

Many of us, as we lie in bed with closed eyes, awaiting sleep, have so-called hypnagogic hallucinations — geometric patterns, or faces, sometimes landscapes. Such patterns or scenes may be almost too faint to notice, or they may be very elaborate, brilliantly colored and rapidly changing — people used to compare them to slide shows.

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