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.”

Innovative neurology text includes patient videos

Practical Neurology Visual Review, a powerful educational tool for mastering the clinical practice of neurologic diagnosis, is now available in a fully revised and updated Second Editon.

Co-authors are neurologists Jose Biller, MD, of Loyola University Chicago Stritch School of Medicine and Alberto J. Espay, MD, of the University of Cincinnati.

The book previously was known as Practical Neurology DVD Review. It includes online videos of 131 real-world scenarios, and more than 370 multiple-choice questions. QR codes in the book allow easy access to videos via smart phone scanning.

Neurological problems are increasing due to the growing elderly population. But current assessment formats for the education of resident doctors, fellows and medical students underemphasize bedside teaching, Biller and Espay write in the introduction. “Faculty members strained by the pressures of many competing demands may not be in a position to oversee trainees performing physical examinations during their training.”

Practical Neurology Visual Review provides new venues for teaching and learning the essentials of neurology. The videos show patients with both common and unusual neurological problems, ranging from very easy to extremely challenging. The videos are used to teach five fundamental principles of bedside neurology: description and localization of findings, differential diagnosis, evaluation, management and counseling. Each clinical vignette is accompanied by a succinct written discussion.

"This audiovisual electronic teaching format may be somewhat unorthodox," Biller and Espay write. "However, it is actually more effective in its approach because the technology lends itself to displaying the skills necessary for a physician to form a patient’s neurological diagnosis."

AAN Issues Updated Sports Concussion Guideline: Athletes with Suspected Concussion Should Be Removed from Play

With more than one million athletes now experiencing a concussion each year in the United States, the American Academy of Neurology (AAN) has released an evidence-based guideline for evaluating and managing athletes with concussion. This new guideline replaces the 1997 AAN guideline on the same topic. The new guideline is published in the March 18, 2013, online issue of Neurology®, the medical journal of the American Academy of Neurology, was developed through an objective evidence-based review of the literature by a multidisciplinary committee of experts and has been endorsed by a broad range of athletic, medical and patient groups.

“Among the most important recommendations the Academy is making is that any athlete suspected of experiencing a concussion immediately be removed from play,” said co-lead guideline author Christopher C. Giza, MD, with the David Geffen School of Medicine and Mattel Children’s Hospital at UCLA and a member of the AAN. “We’ve moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually. There is no set timeline for safe return to play.”

The updated guideline recommends athletes with suspected concussion be immediately taken out of the game and not returned until assessed by a licensed health care professional trained in concussion, return to play slowly and only after all acute symptoms are gone. Athletes of high school age and younger with a concussion should be managed more conservatively in regard to return to play, as evidence shows that they take longer to recover than college athletes.

The guideline was developed reviewing all available evidence published through June 2012. These practice recommendations are based on an evaluation of the best available research. In recognition that scientific study and clinical care for sports concussions involves multiple specialties, a broad range of expertise was incorporated in the author panel. To develop this document, the authors spent thousands of work hours locating and analyzing scientific studies. The authors excluded studies that did not provide enough evidence to make recommendations, such as reports on individual patients or expert opinion. At least two authors independently analyzed and graded each study.

According to the guideline:

• Among the sports in the studies evaluated, risk of concussion is greatest in football and rugby, followed by hockey and soccer. The risk of concussion for young women and girls is greatest in soccer and basketball.

• An athlete who has a history of one or more concussions is at greater risk for being diagnosed with another concussion.

• The first 10 days after a concussion appears to be the period of greatest risk for being diagnosed with another concussion.

• There is no clear evidence that one type of football helmet can better protect against concussion over another kind of helmet. Helmets should fit properly and be well maintained.

• Licensed health professionals trained in treating concussion should look for ongoing symptoms (especially headache and fogginess), history of concussions and younger age in the athlete. Each of these factors has been linked to a longer recovery after a concussion.

• Risk factors linked to chronic neurobehavioral impairment in professional athletes include prior concussion, longer exposure to the sport and having the ApoE4 gene.

• Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing (paper-and-pencil and computerized) and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis.

Signs and symptoms of a concussion include:

Headache and sensitivity to light and sound Changes to reaction time, balance and coordination Changes in memory, judgment, speech and sleep Loss of consciousness or a “blackout” (happens in less than 10 percent of cases)

“If in doubt, sit it out,” said Jeffrey S. Kutcher, MD, with the University of Michigan Medical School in Ann Arbor and a member of the AAN. “Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor. You only get one brain; treat it well.”

The guideline states that while an athlete should immediately be removed from play following a concussion, there is currently insufficient evidence to support absolute rest after concussion. Activities that do not worsen symptoms and do not pose a risk of repeat concussion may be part of concussion management.

The guideline is endorsed by the National Football League Players Association, the American Football Coaches Association, the Child Neurology Society, the National Association of Emergency Medical Service Physicians, the National Academy of Neuropsychology, the National Association of School Psychologists, the National Athletic Trainers Association and the Neurocritical Care Society.

Researchers Halt Autoimmune Disease Myasthenia Gravis in Mice

Working with mice, Johns Hopkins researchers say they have developed a gene-based therapy to stop the rodent equivalent of the autoimmune disease myasthenia gravis by specifically targeting the destructive immune response the disorder triggers in the body.

The technique, the result of more than 10 years of work, holds promise for a highly specific therapy for the progressively debilitating muscle-weakening human disorder, one that avoids the need for long-term, systemic immunosuppressant drugs that control the disease but may create unwanted side effects.

The research, if replicated in humans, could be a big leap in treating not only myasthenia gravis, but also other autoimmune disorders, the researchers say.

“To treat autoimmune diseases, we normally give drugs that suppress not only the specific antibodies and cells we want to inhibit, but that also broadly interfere with other functions of the immune system,” says Daniel B. Drachman, M.D., a professor of neurology and neuroscience at the Johns Hopkins University School of Medicine and leader of the study published this month in the Journal of Neuroimmunology. “Our goal was to suppress only the abnormal response, without damaging the remainder of the immune system, and that’s what we did in these mice.”

A Neurologist Makes the Case for Teaching Teachers About the Brain

Do you recall some of your college professors who knew their subject matter but had zero teaching skills? Staying awake in their one-way-directed lecture classes required Herculean strength (or lots of coffee). They were never trained to develop the skillset of engagement strategies.

Even though I was a physician with a strong science background, when I decided to become a classroom teacher (and thought I’d teach science), I did not want to make that career change without the benefit of instruction and guided student teaching. The year I spent in my graduate school of education program was invaluable in my transition to becoming a professional educator.