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.
* * *
DWIGHT 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.
JOHN C., an eminent composer in his sixties with no deafness or significant health problems, came to see me because, as he put it, he had “an iPod” in his head which played music, mostly popular tunes from his childhood or adolescence. It was music he had no taste for but which he had been exposed to when growing up. He found it intrusive and annoying. Though it was inhibited when he was listening to music, reading, or conversing, it was apt to return the moment he was not otherwise engaged. He sometimes said, “Stop!” to himself (or even aloud), and the internal music would stop for thirty or forty seconds but then resume.
John never thought his “iPod” was anything external, but he did feel that its behavior was quite unlike the normal imagery (voluntary or involuntary) which was so much a part of his mind and which was especially active when he was composing. The “iPod” seemed to go on by itself— irrelevantly, spontaneously, relentlessly, and repetitively. It could be quite disturbing at night.
John’s own compositions are particularly complex and intricate, both intellectually and musically, and he said that he had always struggled to compose them. He wondered whether, with the “iPod” in his brain, he was taking “the easy way out,” indulging secondhand tunes from the past instead of wrestling with new musical ideas. (This interpretation seemed unlikely to me, because though he had worked creatively all his life, he had only had the “iPod” for six or seven years.)
Interestingly, though the music he hallucinated was usually vocal or orchestral in origin, it was instantly and automatically transcribed into piano music, often in a different key. He would find his hands physically “playing” these transcriptions “almost by themselves.” He felt that there were two processes involved here: the refluxing of old songs, “musical information from the memory banks,” and then an active reprocessing by his composer’s (and pianist’s) brain.
* * *
MY INTEREST IN musical hallucinations goes back more than thirty years. In 1970, my mother had an uncanny experience at the age of seventy-five. She was still practicing as a surgeon, with no hearing or cognitive impairment, but she described to me how one night she had suddenly started to hear patriotic songs from the Boer War playing incessantly in her mind. She was amazed by this, for she had not thought of these songs at all for nearly seventy years and doubted if they had ever held much significance for her. She was struck by the accuracy of this replaying, for normally she could not keep a tune in her head. The songs faded after a couple of weeks. My mother, who had had some neurological training herself, felt that there must have been some organic cause for this eruption of long-forgotten songs: perhaps a small, otherwise asymptomatic stroke, or perhaps the use of reserpine to control her blood pressure.
Something similar happened with Rose R., one of the post-encephalitic patients I described in Awakenings. This lady, whom I had put on L-dopa in 1969, reanimating her after decades in a “frozen” state, immediately requested a tape recorder, and in the course of a few days she recorded innumerable salacious songs from her youth in the music halls of the 1920s. No one was more astonished by this than Rose herself. “It’s amazing,” she said. “I can’t understand it. I haven’t heard or thought of these things for more than forty years. I never knew I still had them. But now they keep running through my mind.” Rose was in a neurologically excited state at this time, and when the L-dopa dosage was reduced she instantly “forgot” all these early musical memories and was never again able to recall a single line of the songs she had recorded.
Neither Rose nor my mother had used the term “hallucination.” Perhaps they realized, straightaway, that there was no external source for their music; perhaps their experiences were no
t so much hallucinatory as a very vivid and forced musical imagery, unprecedented and astonishing to them. And their experiences were, in any case, transient.
Some years later, I wrote about two of my nursing home patients, Mrs. O’C. and Mrs. O’M., who had very striking musical hallucinations.5 Mrs. O’M. would “hear” three songs in rapid succession: “Easter Parade,” “The Battle Hymn of the Republic,” and “Good Night, Sweet Jesus.”
“I came to hate them,” she said. “It was like some crazy neighbor continually putting on the same record.”
Mrs. O’C., mildly deaf at eighty-eight, dreamt of Irish songs one night and woke to find the songs still playing, so loud and clear she thought that a radio had been left on. Virtually continuous for seventy-two hours, the songs then became fainter and more broken up. They ceased entirely after a few weeks.
My account of Mrs. O’C. and Mrs. O’M., when it was published in 1985, seemed to have a wide resonance, and a number of people, after reading it, wrote in to the widely syndicated newspaper column “Dear Abby,” to report that they, too, had experienced such hallucinations. “Abby” in turn asked me to comment on the condition in her column. I did this in 1986, stressing the benign, nonpsychotic nature of such hallucinations— and was surprised by the volume of mail that soon flooded in. Scores of people wrote to me, many of them giving very detailed accounts of their own musical hallucinations. This sudden influx of reports made me think that the experience must be much more common than I had thought— or than the medical profession had recognized. In the twenty years since, I have continued to receive frequent letters on the subject, and to see this condition in a number of my own patients.
As early as 1894, W. S. Colman, a physician, published his observations on “Hallucinations in the Sane, Associated with Local Organic Disease of the Sensory Organs, Etc.” in the British Medical Journal. But notwithstanding this and other sporadic reports, musical hallucinations were considered to be very rare, and there was scarcely any systematic attention to them in the medical literature until 1975 or so.6
Wilder Penfield and his colleagues at the Montreal Neurological Institute had written famously in the 1950s and early ’60s of “experiential seizures,” in which patients with temporal lobe epilepsy might hear old songs or tunes from the past (though here the songs were paroxysmal, not continuous, and were often accompanied by visual or other hallucinations). Many neurologists of my generation were strongly influenced by Penfield’s reports, and when I wrote about Mrs. O’C. and Mrs. O’M., I attributed their phantom music to some sort of seizure activity.
But by 1986, the torrent of letters I received showed me that temporal lobe epilepsy was only one of many possible causes of musical hallucination and, indeed, a very rare one.
THERE ARE MANY different factors that may predispose one to musical hallucinations, but their phenomena are remarkably unvarying. Whether the provocative factors are peripheral (such as hearing impairment) or central (such as seizures or strokes), there seems to be a final common path, a cerebral mechanism common to all of them. Most of my patients and correspondents emphasize that the music they “hear” seems at first to have an external origin— a nearby radio or television, a neighbor putting on a record, a band outside the window, whatever— and it is only when no such external source can be found that patients are compelled to infer that the music is being generated by their brain. They do not speak of themselves “imagining” the music, but of some strange, autonomous mechanism set off in the brain. They speak of “tapes,” “circuits,” “radios,” or “recordings” in their brains; one of my correspondents called it his “intracranial jukebox.”
The hallucinations are sometimes of great intensity (“This problem is so intense it is wrecking my life,” wrote one woman), yet many of my correspondents are reluctant to speak of their musical hallucinations, fearing that they will be seen as crazy— “I can’t tell people, because God knows what they would think,” one person wrote. “I have never told anyone,” wrote another, “afraid they would lock me in a mental ward.” Others, while acknowledging their experiences, are embarrassed by the use of the term “hallucination” and say they would be much more at ease with these unusual experiences, much readier to acknowledge them, if they could use a different word for them.7
And yet while musical hallucinations all share certain features— their apparent exteriority, their incessancy, their fragmentary and repetitive character, their involuntary and intrusive nature— their particulars can vary widely. So too can their role in people’s lives— whether they assume importance or relevance, become part of a personal repertoire, or remain alien, fragmentary, and meaningless. Each person, consciously or unconsciously, finds their own way of responding to this mental intrusion.
* * *
GORDON B., a seventy-nine-year-old professional violinist in Australia, had fractured his right eardrum as a child, and subsequently had progressive hearing loss following mumps in adulthood. He wrote to me about his musical hallucinations:
About 1980, I noticed the first signs of tinnitus, which manifested itself as a constant high note, an F-natural. The tinnitus changed pitch several times during the next few years and became more disturbing. By this time, I was suffering quite a substantial hearing loss and distortion of sounds in my right ear. In November 2001, during a two-hour train trip, the sound of the diesel engine started up the most horrific grinding in my head, which lasted for some hours after I left the train. For the next few weeks I heard constant grinding noises.8
“The following day,” he wrote, “the grinding was replaced by the sound of music, which has since been with me twenty-four hours a day, rather like an endless CD…. All other sounds, the grinding, the tinnitus, disappeared.”9
For the most part, these hallucinations are “musical wallpaper, meaningless musical phrases and patterns.” But sometimes they are based on the music he is currently studying and creatively transformed from this— a Bach violin solo he is working on may turn into “a hallucination played by a superb orchestra, and when this happens, it goes on to play variations on the themes.” His musical hallucinations, he pointed out, “cover the full gamut of moods and emotions…the rhythmic patterns depend on my state of mind at the time. If I’m relaxed…[they are] very gentle and discreet…. During the day the musical hallucinations can get loud and remorseless and very violent, often with tympani beating an insistent rhythm underneath.”
Other, nonmusical sounds may influence the musical hallucinations: “Whenever I mow the lawns, for example, I get a motif starting up in my head which I recognize as only ever happening when the mower is on…. It’s evident that the sound of them ower stimulated my brain to select precisely that composition.” Sometimes reading the title of a song would cause him to hallucinate the song.
In another letter he said, “My brain makes up patterns which go on incessantly for hours on end, even while I am playing the violin.” This comment intrigued me, as it was a striking example of how two quite different processes— the conscious playing of music and a separate and autonomous musical hallucination— can proceed simultaneously. It was a triumph of will and concentration that Gordon could continue to play and even perform under these circumstances, so effectively, he reported, that “my cellist wife, for instance, wouldn’t know I had any problems…. Perhaps,” he wrote, “my concentration on what I’m currently playing mutes the musical hallucinations.” But in a less active context, such as listening to a concert rather than performing, he has found that “the music in my head just about equalled the sounds coming from the platform. This stopped me from attending any more concerts.”
Like several other hallucinators, he found that although he could not stop the musical hallucinations, he could often change them:
I can change the music at will by simply thinking of the theme of another musical composition, whereupon for a few moments I will have several themes running in my head until the new one which I have selected takes over completely.
These hallucinatory performances, he noted, are “always perfect in terms of accuracy and tonal quality, and never suffer from any of the distortion which my ears are subject to.”10
Gordon, trying to account for his hallucinations, wrote that before concerts he would find himself “mentally rehearsing” the passage he had just worked out, to see if he could find better ways of fingering or bowing, and that imagining different ways of playing might cause the music to go round and round in his mind. He wondered whether this “obsessive” mental rehearsal predisposed him to hallucinations. But there were absolute differences, he felt, between his rehearsal imagery and the involuntary musical hallucinations.
Gordon had consulted several neurologists. He had had MRI and CT scans of his brain and twenty-four-hour EEG monitoring, all of which were normal. Hearing aids had not reduced his musical hallucinations (though they had greatly improved his hearing), nor had acupuncture or various drugs, including clonazepam, risperidone, and Stelazine. His musical hallucinations were keeping him awake at night. Did I have any other ideas? he asked. I suggested that he speak to his physician about quetiapine, which had helped some patients, and he wrote back to me, excitedly, a few days later:
I wanted to let you know that on the fourth night after starting the medication, about three in the morning, I lay awake for two hours with no music in my head! It was incredible— the first break I have had in four years. Although the music returned the following day, it has been generally more subdued. It looks promising.
A year later Gordon wrote to say that he continued to take a small dose of quetiapine before bed, which damped down the musical hallucinations enough for him to sleep. He does not take quetiapine during the day— it makes him too drowsy— but he continues to practice the violin through his hallucinations. “You could say,” he summarized, “I have learned to live with them by now, I suppose.”