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Musical Hallucinations After Living-Donor Liver Transplantation
Letters tients described themselves as significantly more “action-prone” than the medical and psychiatric control groups;6 moreover, the patients’ selfdescriptions were highly confirmed by their significant others.7 The aforementioned clinical and research data call attention to the possible role of ergomania as a predisposing factor for chronic pain syndromes (such as fibromyalgia) and CFS. In this respect, one should first realize that people may lead overactive lives because of a variety of personal, familial, or social reasons. For example, some persons are from a young age compelled to do strenuous labor, others engage in a hectic life-style because of materialistic aims or social pressures, and still others need (over)activity as a coping strategy to avoid painful emotions or as a self-regulatory mechanism (e.g., to maintain self-esteem). Furthermore, the relationship between ergomania and later chronic pain or fatigue may be mediated via several pathways: somatic (e.g., musculoskeletal overuse), psychobiological (e.g., sleepwake cycle disturbances or neurohormonal changes), cognitive (e.g., somatic attribution of failure), and psychodynamic (e.g., reversal of a selfsacrifying life-style into overdependent illness behavior). Recognition of this premorbid factor may have important implications for the therapeutic management and rehabilitation of chronic pain and fatigue patients, who, as a rule, have to adapt to a more balanced activity-rest schema.8 Finally, further research on relevant variables such as gender, personality, job characteristics, sociocultural differences, and mediating psychobiogical systems (such as the hypothalamo-pituitary-adrenal axis) could provide more information on the complex conditions under which ergo530
mania may increase the vulnerability for chronic pain and fatigue. Boudewijn Van Houdenhove, M.D. Eddy Neerinckx, Ph.D. Psychosomatische Revalidatie Universitaire Ziekenhuizen Leuven Leuven, Belgium
gradual trend for adult patients to receive partial-liver transplants from their own children, although the total number is still small. We report a patient with musical hallucinations after a successful partial-liver transplantation from a living donor. Case Report
References
1. Van Houdenhove B: Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychother Psychosom 1986; 45:195–200 2. Blumer D, Heilbronn M: Chronic pain as a variant of depressive disease : The painprone disorder. J Nerv Ment Dis 1982; 170:381–406 3. Gamsa A, Vikis-Freiberg V: Psychological events are both risk factors in, and consequences, of chronic pain. Pain 1991; 44:271– 277 4. Van Houdenhove B, Stans L, Verstraeten D: Is there a relationship between pain-proneness and action-proneness? Pain 1987; 29:113–117 5. Ware NC: Society, mind and body in chronic fatigue syndrome: an anthropological view, in Chronic Fatigue Syndrome. Ciba Foundation Symposium, Vol 173, edited by Bock GR, Whelan J. Chichester, UK, Wiley, 1993, pp. 62–82 6. Van Houdenhove B, Neerinckx E, Onghena P, et al: Does high “action-proneness” make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J Psychosom Res 1995; 39:633–640 7. Neerinckx E, Van Houdenhove B, Lysens R, et al : Premorbid overactive lifestyle in chronic fatigue syndrome and fibromyalgia: a vulnerability factor, or a proof of good citizenship? (in press) 8. Van Houdenhove B, Stans L, Dequeker JV: Premorbid physical hyperactivity and chronic idiopathic musculoskeletal pain. Eur J Pain 1992; 13:71–76
Musical Hallucinations After Living-Donor Liver Transplantation TO THE EDITOR: Almost all liver transplants in Japan are from living donors. Ninety percent of the recipients are children with liver failure. There is little chance for adult patients to receive a transplant. Recently, there has been a
A 54-year-old woman received a living-donor partial-liver transplant from her son. She had suffered from familial amyloid polyneuropathy (FAP) for 2 years. Her complaints were hypogeusia, dysuria, and gait disturbance. Thereafter, she exhibited congestive heart failure, with pleural effusion and systemic edema. Amyloid deposition was noted on cardiac scintigram. Genetic analysis revealed a transthyretin mutation. Circulating transthyretin is derived from the liver, and liver transplantation is performed for variant transthyretin-associated FAP.1 The patient has one son (age 36) who offered to be a liver donor to save his mother’s life. Although the mother hesitated to receive a partial liver from her son, he expressed a strong desire to become her donor. She was obliged to accept the transplant because of the life-threatening amyloidosis. Before surgery, the patient was found to harbor strong guilt feelings over the receipt of a portion of her son’s liver, but the relationship between the mother and son was positive and strong. No psychiatric symptoms were observed in either donor or recipient. The medical course posttransplantation was unremarkable. On the fifth day postoperatively, the recipient complained of suicidal ideation associated with guilt feelings for her son. Three days later, these complaints disappeared. One month after the transplant, musical hallucinations appeared. The hallucinations lasted 3 weeks and were
Psychosomatics 40:6, November-December 1999
Letters unaffected by day or night. She heard Enka (traditional Japanese ballads) for several hours daily, two or three times a day. She felt comforted because she enjoys Enka very much. She was reluctant to undergo psychiatric treatment for the hallucinations. Since the transthyretin mutation was not present in the donor liver, transplantation prevented further amyloid deposition. However, the accumulated cardiac and systemic amyloidosis from prior to the transplant remained, and the patient’s symptoms of congestive heart failure and neuropathy continued despite the successful liver transplant. A sibling suffering from the same FAP had died of heart failure. Information on the sibling’s death and the prognosis of systemic amyloidosis caused considerable anxiety. The patient was reporting musical hallucinations, including Enka and Okyo (Buddhist hymns), which would appear alternatively for 4 to 5 hours a day. She revealed that she feared for her own death but admitted that the musical hallucinations comforted her, and she experienced the music, in particular the Enka, with great relief. Haloperidol (1.5 mg/day orally) was prescribed, but the musical hallucinations did not disappear. As her anxiety and fear of death decreased with counseling, the comforting musical hallucinations gradually disappeared.
Discussion Recent studies have described “paradoxical psychiatric symptoms,” which can occur after successful transplantation in the absence of tissue rejection or other medical complications. The hallucinations sometimes appear after living-donor transplantation and may be expressed by various forms of depression or psychological pain.2,3 Moreover, living-donor recipients have strong feelings of guilt toward their donors but cannot verbalize their inner feelings.2,3 In this case, the recipient’s son offered his own liver to save his mother’s life. Although the recipient had strong guilt feelings, the recipient suppressed these guilt feelings and conflicts. Indeed, the clinical course was positive after transplant, and the suppressed feelings manifested as musical hallucinations. Guilt and anxiety over death appear to be closely associated with the manifestation of musical hallucinations. Musical hallucinations, such as the hearing of melodies, are rare.4,5 These hallucinations may occur in various diseases.4,5 In this case, the experience of the musical hallucinations was comforting to the recipient, suggesting that they may have played a role as a psychological defense for her strong guilt feelings toward the donor and anxiety and fear over death. In Japan, parentrecipient to child living-donor trans-
Psychosomatics 40:6, November-December 1999
plantation has sometimes been performed as a lifesaving measure in adult patients with liver failure. This case suggests that consultation-liaison psychiatrists should carefully evaluate the psychological condition of recipients and donors before transplantation, with particular attention to nonverbalized feelings of anxiety and conflict. Iao Fukunishi, M.D. Tokyo Institute of Psychiatry Yoshiaki Kita, M.D. Yasushi Harihara, M.D. Keiichi Kubota, M.D. Tadatoshi Takayama, M.D. Hideo Kawarasaki, M.D. Masatoshi Makuuchi, M.D. Department of Second Surgery, Tokyo University School of Medicine, Tokyo, Japan
References
1. Stangou AJ, Hawkins PN, Heaton ND, et al: Progressive cardiac amyloidosis following liver transplantation for familial amyloid polyneuropathy. Transplantation 1998; 66:229–233 2. Fukunishi I: Japanese consultation-liaison psychiatry in the areas of organ transplantation and cancer care. Psychiatric Times 1998, Vol XV, pp 48–49 3. Fukunishi I, Ohara T, Kobayashi M, et al: “Paradoxical depression” in a female donor after living kidney transplantation. Psychosomatics 1998; 39:396–397 4. Berrios GE: Musical hallucinations: a historical and clinical study. Br J Psychiatry 1990; 156:188–194 5. Berrios GE: Musical hallucinations: a statistical analysis of 46 cases. Psychopathology 1991; 24:356–360
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mania may increase the vulnerability for chronic pain and fatigue. Boudewijn Van Houdenhove, M.D. Eddy Neerinckx, Ph.D. Psychosomatische Revalidatie Universitaire Ziekenhuizen Leuven Leuven, Belgium
gradual trend for adult patients to receive partial-liver transplants from their own children, although the total number is still small. We report a patient with musical hallucinations after a successful partial-liver transplantation from a living donor. Case Report
References
1. Van Houdenhove B: Prevalence and psychodynamic interpretation of premorbid hyperactivity in patients with chronic pain. Psychother Psychosom 1986; 45:195–200 2. Blumer D, Heilbronn M: Chronic pain as a variant of depressive disease : The painprone disorder. J Nerv Ment Dis 1982; 170:381–406 3. Gamsa A, Vikis-Freiberg V: Psychological events are both risk factors in, and consequences, of chronic pain. Pain 1991; 44:271– 277 4. Van Houdenhove B, Stans L, Verstraeten D: Is there a relationship between pain-proneness and action-proneness? Pain 1987; 29:113–117 5. Ware NC: Society, mind and body in chronic fatigue syndrome: an anthropological view, in Chronic Fatigue Syndrome. Ciba Foundation Symposium, Vol 173, edited by Bock GR, Whelan J. Chichester, UK, Wiley, 1993, pp. 62–82 6. Van Houdenhove B, Neerinckx E, Onghena P, et al: Does high “action-proneness” make people more vulnerable to chronic fatigue syndrome? A controlled psychometric study. J Psychosom Res 1995; 39:633–640 7. Neerinckx E, Van Houdenhove B, Lysens R, et al : Premorbid overactive lifestyle in chronic fatigue syndrome and fibromyalgia: a vulnerability factor, or a proof of good citizenship? (in press) 8. Van Houdenhove B, Stans L, Dequeker JV: Premorbid physical hyperactivity and chronic idiopathic musculoskeletal pain. Eur J Pain 1992; 13:71–76
Musical Hallucinations After Living-Donor Liver Transplantation TO THE EDITOR: Almost all liver transplants in Japan are from living donors. Ninety percent of the recipients are children with liver failure. There is little chance for adult patients to receive a transplant. Recently, there has been a
A 54-year-old woman received a living-donor partial-liver transplant from her son. She had suffered from familial amyloid polyneuropathy (FAP) for 2 years. Her complaints were hypogeusia, dysuria, and gait disturbance. Thereafter, she exhibited congestive heart failure, with pleural effusion and systemic edema. Amyloid deposition was noted on cardiac scintigram. Genetic analysis revealed a transthyretin mutation. Circulating transthyretin is derived from the liver, and liver transplantation is performed for variant transthyretin-associated FAP.1 The patient has one son (age 36) who offered to be a liver donor to save his mother’s life. Although the mother hesitated to receive a partial liver from her son, he expressed a strong desire to become her donor. She was obliged to accept the transplant because of the life-threatening amyloidosis. Before surgery, the patient was found to harbor strong guilt feelings over the receipt of a portion of her son’s liver, but the relationship between the mother and son was positive and strong. No psychiatric symptoms were observed in either donor or recipient. The medical course posttransplantation was unremarkable. On the fifth day postoperatively, the recipient complained of suicidal ideation associated with guilt feelings for her son. Three days later, these complaints disappeared. One month after the transplant, musical hallucinations appeared. The hallucinations lasted 3 weeks and were
Psychosomatics 40:6, November-December 1999
Letters unaffected by day or night. She heard Enka (traditional Japanese ballads) for several hours daily, two or three times a day. She felt comforted because she enjoys Enka very much. She was reluctant to undergo psychiatric treatment for the hallucinations. Since the transthyretin mutation was not present in the donor liver, transplantation prevented further amyloid deposition. However, the accumulated cardiac and systemic amyloidosis from prior to the transplant remained, and the patient’s symptoms of congestive heart failure and neuropathy continued despite the successful liver transplant. A sibling suffering from the same FAP had died of heart failure. Information on the sibling’s death and the prognosis of systemic amyloidosis caused considerable anxiety. The patient was reporting musical hallucinations, including Enka and Okyo (Buddhist hymns), which would appear alternatively for 4 to 5 hours a day. She revealed that she feared for her own death but admitted that the musical hallucinations comforted her, and she experienced the music, in particular the Enka, with great relief. Haloperidol (1.5 mg/day orally) was prescribed, but the musical hallucinations did not disappear. As her anxiety and fear of death decreased with counseling, the comforting musical hallucinations gradually disappeared.
Discussion Recent studies have described “paradoxical psychiatric symptoms,” which can occur after successful transplantation in the absence of tissue rejection or other medical complications. The hallucinations sometimes appear after living-donor transplantation and may be expressed by various forms of depression or psychological pain.2,3 Moreover, living-donor recipients have strong feelings of guilt toward their donors but cannot verbalize their inner feelings.2,3 In this case, the recipient’s son offered his own liver to save his mother’s life. Although the recipient had strong guilt feelings, the recipient suppressed these guilt feelings and conflicts. Indeed, the clinical course was positive after transplant, and the suppressed feelings manifested as musical hallucinations. Guilt and anxiety over death appear to be closely associated with the manifestation of musical hallucinations. Musical hallucinations, such as the hearing of melodies, are rare.4,5 These hallucinations may occur in various diseases.4,5 In this case, the experience of the musical hallucinations was comforting to the recipient, suggesting that they may have played a role as a psychological defense for her strong guilt feelings toward the donor and anxiety and fear over death. In Japan, parentrecipient to child living-donor trans-
Psychosomatics 40:6, November-December 1999
plantation has sometimes been performed as a lifesaving measure in adult patients with liver failure. This case suggests that consultation-liaison psychiatrists should carefully evaluate the psychological condition of recipients and donors before transplantation, with particular attention to nonverbalized feelings of anxiety and conflict. Iao Fukunishi, M.D. Tokyo Institute of Psychiatry Yoshiaki Kita, M.D. Yasushi Harihara, M.D. Keiichi Kubota, M.D. Tadatoshi Takayama, M.D. Hideo Kawarasaki, M.D. Masatoshi Makuuchi, M.D. Department of Second Surgery, Tokyo University School of Medicine, Tokyo, Japan
References
1. Stangou AJ, Hawkins PN, Heaton ND, et al: Progressive cardiac amyloidosis following liver transplantation for familial amyloid polyneuropathy. Transplantation 1998; 66:229–233 2. Fukunishi I: Japanese consultation-liaison psychiatry in the areas of organ transplantation and cancer care. Psychiatric Times 1998, Vol XV, pp 48–49 3. Fukunishi I, Ohara T, Kobayashi M, et al: “Paradoxical depression” in a female donor after living kidney transplantation. Psychosomatics 1998; 39:396–397 4. Berrios GE: Musical hallucinations: a historical and clinical study. Br J Psychiatry 1990; 156:188–194 5. Berrios GE: Musical hallucinations: a statistical analysis of 46 cases. Psychopathology 1991; 24:356–360
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