Authors: Oliver Sacks
Musical hallucinations are quite different. With music, although there are separate functional systems for perceiving pitch, timbre, rhythm, etc., the musical networks of the brain work together, and pieces cannot be significantly altered in melodic contour or tempo or rhythm without losing their musical identity. We apprehend a piece of music as a whole. Whatever the initial processes of musical perception and memory may be, once a piece of music is known, it is retained not as an assemblage of individual elements but as a completed procedure or performance; music is
performed
by the mind/brain whenever it is recollected; and this is also so when it erupts spontaneously, whether as an earworm or as a hallucination.
1
. The real patients, however, were more observant. “You’re not crazy,” said one. “You’re a journalist or a professor.”
2
. Freud was not unsympathetic to the notion of telepathy; his “Psychoanalysis and Telepathy” was written in 1921, though published only posthumously.
3
. Recently, a number of people who hear voices have organized networks in various countries asserting their “right” to hear voices, to have them respected and not dismissed as trivial or pathological. This movement and its significance are discussed by Ivan Leudar and Philip Thomas in their book
Voices of Reason, Voices of Madness
and by Sandra Escher and Marius Romme in their 2012 review of the subject.
4
. Judith Weissman, in her book
Of Two Minds: Poets Who Hear Voices
, presents strong evidence, drawn especially from what poets themselves have said, that many of them, from Homer to Yeats, have been inspired by true auditory vocal hallucinations, not just metaphorical voices.
5
. Jaynes thought that there might be a reversion to “bicamerality” in schizophrenia and some other conditions. Some psychiatrists (such as Nasrallah, 1985) favor this idea or, at the least, the idea that the hallucinatory voices in schizophrenia emanate from the right side of the brain but are not recognized as one’s own, and are thus perceived as alien.
6
. Sarah Lipman has noted, in her blog (
www.reallysarahsyndication.com
), the phenomenon of “phantom rings” as people imagine or hallucinate the ringing of their cell phones. She links this to a state of vigilance, expectation, or anxiety, as when she thinks she may hear a knock at the door or her baby crying. “Part of my consciousness,” she wrote to me, “is straining to monitor for the sound. It seems to me that it is this hyper-alert state that generates the phantom sounds.”
7
. There may be paroxysmal musical hallucinations during temporal lobe seizures. But in such cases, the musical hallucinations have a fixed and invariable format; they appear along with other symptoms (perhaps visual or olfactory hallucinations or a sense of déjà vu) and at no other time. If the seizures can be controlled medically or surgically, the epileptic music will cease.
8
. Most people who get musical hallucinations are elderly and somewhat deaf; it is not unusual for them to be treated as if demented, psychotic, or imbecilic. Jean G. was hospitalized after she had an apparent heart attack, and a few days later, she began “hearing a male choir in the distance as if it were coming through the woods.” (Several years later, when she wrote to me, she still heard this, especially in times of stress or when she was extremely tired.) But, she said, “I quickly stopped talking about this type of music when faced with a nurse asking me, ‘Do you know your name? Do you know what day this is?’ I responded back, ‘Yes, I know what day this is—it is the day I am going home.’ ”
9
. I have written at much greater length about musical hallucinations (as well as intrusive musical imagery, or “earworms”) in my book
Musicophilia
.
J
ames Parkinson, in his famous 1817
Essay on the Shaking Palsy
, portrayed the disease that now bears his name as one that affected movement and posture, while leaving the senses and the intellect unimpaired. And in the century and a half that followed, there was virtually no mention of perceptual disorders or hallucinations in patients with Parkinson’s disease. By the late 1980s, though, physicians had begun to realize (and only in response to careful inquiry, for patients are often reluctant to admit it) that perhaps a third or more of those being treated for Parkinson’s experienced hallucinations, as Gilles Fénelon and others reported. By this time, virtually everyone diagnosed with Parkinson’s was medicated with L-dopa or other drugs that enhance the neurotransmitter dopamine in the brain.
My own experience with parkinsonism as a young doctor was predominantly with the patients I described in
Awakenings
, who did not have ordinary Parkinson’s disease but a much
more complex syndrome. They were survivors of the encephalitis lethargica epidemic that followed the First World War, and they had come down, sometimes decades later, with postencephalitic syndromes including not only a very severe form of parkinsonism but often a host of other disorders, especially sleep and arousal disorders. These postencephalitic patients were far more sensitive to the effects of L-dopa than patients with ordinary Parkinson’s disease. Many of them, once they were started on L-dopa, began to have excessively vivid dreams or nightmares; often this would be the first apparent effect of the medication. Several of them became prone to visual illusions or hallucinations, too.
When Leonard L. was started on L-dopa, he began to see faces on the blank screen of his television set, and a picture of an old western town that hung in his room would come to life as he looked at it, with people emerging from its saloons and cowboys galloping through the streets.
Martha N., another postencephalitic patient, would “sew” with hallucinatory needles and thread. “See what a lovely coverlet I have stitched for you today!” she said on one occasion. “See the pretty dragons, the unicorn in his paddock.” She traced their invisible outlines in the air. “Here, take it,” she said, and placed the ghostly thing in my hands.
With Gertie C., the hallucinations (precipitated by the addition of amantadine to her L-dopa) were less benign. Within three hours of receiving the first dose, she became intensely excited and deliriously hallucinated. She would cry out, “Cars bearing down on me, they’re crowding me!” She also saw faces “like masks popping in and out.” Occasionally she would smile rapturously and exclaim, “Look what a beautiful tree, so beautiful,” and tears of pleasure would fill her eyes.
I
n contrast to these postencephalitic patients, people with ordinary Parkinson’s disease do not usually experience visual hallucinations until they have been on medication for many months or years. By the 1970s, I had several such patients who had started to get hallucinations, which were predominantly (though not exclusively) visual. Sometimes these began as webs and filigrees or other geometrical patterns; other patients experienced complex hallucinations, usually of animals and people, from the start. Such visions might seem quite real (one patient had a nasty fall while chasing a hallucinatory mouse), but the patients soon learned to distinguish them from reality and ignore them. At the time I could find almost nothing in the medical literature about such hallucinations, although it was sometimes said that L-dopa might make patients “psychotic.” But by 1975, more than a quarter of my patients with ordinary Parkinson’s disease, while otherwise doing well on L-dopa and dopamine agonists, had found themselves living with hallucinations.
Ed W., a designer, started to get visual hallucinations after he had been on L-dopa and dopamine agonists for several years. He realized that they were hallucinations and regarded them largely with curiosity and amusement; nevertheless, one of his physicians declared him “psychotic”—an upsetting misdiagnosis.
He often feels himself “on the verge” of hallucination, and he may be pushed over the threshold at night, or if he is tired or bored. When we had lunch one day, he was having all sorts of what he calls “illusions.” My blue pullover, draped over a chair, became a fierce chimerical animal with an elephant-like head, long blue teeth, and a hint of wings. A bowl of noodles on
the table became “a human brain” (though this did not affect his appetite for them). He saw “letters, like teletype” on my lips; they formed “words”—words he could not read. They did not coincide with the words I was speaking. He says that such illusions are “made up” on the spot, instantaneously and without conscious volition. He cannot control or stop them, short of closing his eyes. They are sometimes friendly, sometimes frightening. For the most part, he ignores them.
Sometimes he moves from “illusions” to frank hallucinations. One such was a hallucination of his cat, which had gone to the vet for a few days. Ed continued to “see” her at home, several times a day, emerging from the shadows at one end of the room. She would walk across the room, paying no attention to him, and then disappear into the shadows again. Ed realized at once that this was a hallucination, and had no desire to interact with it (though it aroused his curiosity and interest). When the real cat came back, the phantom cat disappeared.
1
In addition to such isolated or occasional hallucinations, people with Parkinson’s may develop elaborate and frightening
hallucinations, often of a paranoid sort. Such a psychosis took hold of Ed toward the end of 2011. He started to have hallucinations of people who entered his apartment, emerging from “a secret chamber” behind the kitchen. “They invade my privacy,” Ed said. “They occupy my space.… They are very interested in me—they take notes, take photos, rifle through my papers.” Sometimes they had sex—one of the intruders was a very beautiful woman, and sometimes three or four of them would occupy Ed’s bed when he was not using it. These apparitions never appeared if he had real visitors or when he was listening to music or watching a favorite TV show; nor would they follow him when he left his apartment. He often regarded these persecutors as real and might say to his wife, “Take a cup of coffee to the man in my office.” She always knew when he was hallucinating—he would stare fixedly at one point or follow an invisible presence with his eyes. Increasingly, he started to talk with them—or
at
them, for they never replied.
Ed’s neurologist, on hearing this, advised him to have “a drug holiday,” to stop all his anti-Parkinson’s medications for two or three weeks, but this left Ed so incapacitated he could hardly move or speak. He then planned a gradual reduction of medication, and, two months later, on half his previous dose of L-dopa, Ed’s hallucinations, his fears, and his psychosis have cleared completely.
In 2008, Tom C., an artist, came to my office for a consultation. He had been diagnosed with Parkinson’s disease and put on medication about fifteen years earlier. Two years later, he started to experience “misperceptions,” as he calls them (like the others, he avoids the term “hallucinations”). He is fond of dancing—he finds that this can unfreeze him, releasing him, for a while, from his parkinsonism. His first misperceptions
occurred when he was in a nightclub; the skin of the other dancers, even their faces, seemed to be covered with tattoos. At first he thought the tattoos were real, but they started to glow and then to pulse and writhe; at that point he realized they must be hallucinatory. As an artist and a psychologist, he was intrigued by this experience—but frightened, too, that it might be the beginning of uncontrollable hallucinations of all sorts.
Once, while sitting at his desk, he was surprised to see a picture of the Taj Mahal on his computer monitor. As he gazed, the picture became richer in color, three-dimensional, vividly real. He heard a vague chanting, of the sort he thought might be associated with an Indian temple.
Another day, while he was lying on the floor, frozen by his parkinsonism, the reflections on a fluorescent ceiling lamp started to change into old photographs, mostly in black and white. These seemed to be photographs from earlier days, mostly of family, with some of strangers. “I had nothing else to do” in this immobilized state, he said, so he happily indulged this mild hallucinatory pleasure.
F
or Ed W. and Tom C., hallucinations usually remain on the “misperception” side, but Agnes R., a seventy-five-year-old lady who has had Parkinson’s disease for twenty years, has had frank visual hallucinations for the last decade. She is, as she says, “an old hand” at hallucinations: “I see a whole array of things, which I enjoy—they are fascinating; they don’t frighten me.” In the clinic waiting room, she had seen “women—five of them—trying on fur coats.” The size, color, solidity, and movement of these women looked perfectly natural; they seemed
absolutely real. She knew that they were hallucinations only because they were out of context: no one would be trying on fur coats on a summer day in a doctor’s office. In general, she is able to distinguish her hallucinations from reality, but there have been exceptions: on one occasion, seeing a furry black animal leap onto the dining table, she jumped. At other times, while walking, she has stopped abruptly to avoid bumping into a hallucinatory figure just in front of her.
Agnes most often sees apparitions from the windows of her twenty-second-floor apartment. From here, she has “seen” a skating rink on top of a (real) church, “people in tennis courts” on neighboring rooftops, and men working just outside her window. She does not recognize any of the people she sees, and they continue whatever they are doing without paying any attention to her. She watches these hallucinatory scenes with equanimity and sometimes with enjoyment. (Indeed, I got the impression that they help her pass the time—time which now seems to pass more slowly with her relative immobility and difficulties reading.) Her visions are not like dreams, she said; nor do they resemble fantasies. She has a great love for travel and for Egypt in particular, but she has never had “Egyptian” hallucinations or travel ones.
She sees no patterns to her hallucinations—they may come at any time of day, when she is busy with others or when she is alone. They seem to have nothing to do with current events, with her feelings, thoughts, or moods, or with the time of day she takes her medication. She cannot will them to come, or will them away. They superimpose themselves on what she is looking at and vanish, along with actual visual perception, when she closes her eyes.