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Musical hallucinations with post-pharyngolaryngoesophagectomy aphonia
Letters to the Editor The authors are grateful for the support of Drs. Hiroshi Ishino and Takahisa Matsumoto.
toshiro kishi, m.d. jun uegaki, m.d. Department of Psychiatry Shimane Medical University, Izumo, Japan
13.
14.
mitsuhiro kitani, m.d. Department of Neurology Masuda Red Cross Hospital, Masuda, Japan akihiko fujimoto, m.d. Department of Psychiatry Matsue Aoba Hospital, Matsue, Japan rokuichi naganuma, m.d., ph.d. Department of Psychiatry Matsugaoka Hospital, Masuda, Japan
References 1. Gold K, Rabins PV: Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry 30:90–98, 1989 2. Teunisse RJ, Cruysberg JR, Hoefnagels WH, Verbeek AL, Zitman FG: Visual hallucinations in psychologically normal people: Charles Bonnet’s syndrome. Lancet 347:794–797, 1996 3. Fernandez A, Lichtshein G, Vieweg WVR: The Charles Bonnet syndrome: a review. J Nerv Ment Dis 185:195–200, 1997 4. Guerra-Garcia H: Charles Bonnet syndrome and early dementia. J Am Geriatr Soc 45:893–894, 1997 5. Sichart U, Fuchs T: Visuelle Halluzinationen bei a¨lteren Menschen mit reduziertem Visus: Das Charles Bonnet-Syndrom. Klin Monatsbl Augenheilkd 200: 224–227, 1992 6. Adachi N, Nagayama M, Anami K, Arima K, Matsuda H: Asymmetrical blood flow in the temporal lobe in the Charles Bonnet syndrome: serial neuroimaging study. Behav Neurol 7:97–99, 1994 7. Lance JW: Simple formed hallucinations confined to the area of a specific visual field defect. Brain 99:719– 734, 1976 8. Ko¨lmel HW: Complex visual hallucinations in the hemianopic field. J Neurol Neurosurg Psychiatry 48: 29–38, 1985 9. Kishi T, Ishino H, Naganuma R: Insight into phosphene: a case with occipital lobe damage. Gen Hosp Psychiatry 20:260–261, 1998 10. Le Poncin-Lafitte M, Grosdemouge C, Duterte D, Rapin JR: Simultaneous study of haemodynamic, metabolic and behavioral sequelae in a model of cerebral ischemia in aged rats: effects of nicergoline. Gerontology 30:109–119, 1984 11. Pliskin NH, Kiolbasa TA, Towle VL, et al: Charles Bonnet syndrome: an early marker for dementia? J Am Geriatr Soc 44:1055–1062, 1996 12. Haddad PM, Benbow SM: Visual hallucinations as
15.
16.
the presenting symptom of senile dementia. Br J Psychiatry 161:263–265, 1992 Hof PR, Bouras C, Constantinidis J, Morrison JH: Selective disconnection of specific visual association pathways in cases of Alzheimer’s disease presenting with Balint’s syndrome. J Neuropathol Exp Neurol 49:168–184, 1990 Salanova V, Andermann F, Oliver A, Rasmussen T, Quesney LF: Occipital lobe epilepsy: electroclinical manifestations, electrocorticography, cortical stimulation and outcome in 42 patients treated between 1930 and 1991. Surgery of occipital lobe epilepsy. Brain 115:1655–1680, 1992 Williamson PD, Thadani VM, Darcey TM, Spencer DD, Spencer SS, Mattson RH: Occipital lobe epilepsy: clinical characteristics, seizure spread patterns, and results of surgery. Ann Neurol 31:3–13, 1992 Amaral DG, Price JL, Pitka¨nen A, Carmichael ST: Anatomical organization of the primate amygdaloid complex. In Aggleton JP (ed), The amygdala: Neurobiological aspects of emotion, memory, and mental dysfunction. Wiley-Liss, 1992, pp 1–66
PII S0163-8343(99)00053-5
Musical Hallucinations with PostPharyngolaryngoesophagectomy Aphonia To the Editor Musical hallucinations are a rare form of braininduced hallucinosis without demonstrable central nervous system lesions and peripheral deficits, although they can be caused by psychiatric disorders, neurological diseases, and side-effects of drugs. However, as indicated in a review by Berrios [1,2], they seem to be more common in women and are associated with age, ear diseases, deafness, and brain diseases in the right or nondominant hemisphere. Psychogenic and personality factors were thought to be unimportant. We have recently encountered a male patient without deafness who developed musical hallucinations after aphonia due to pharyngolaryngoesophagectomy. A 64-year-old male was admitted to an otolaryngology unit with a history of hypopharyngeal cancer. A pharyngolaryngoesophagectomy was performed which resulted in a lost voice followed by signs of anxiety, agitation, mild depression, insomnia, and poor appetite. He was alert and well oriented to spatial displacement and persons. Examination showed the patient to be of average intelligence without deafness. A Mini-Mental State examination demonstrated only a mild degree of disorientation of time and amnesia, considering his age, but was otherwise normal. The patient re-
135
Letters to the Editor
ported experiencing musical hallucinations of traditional Japanese songs and classical music since his surgery. The musical sounds were very loud, continuous, and uncontrollable except when sleeping; he was worried and scared by them. He experienced no hallucinations other than musical ones. After a week of drug treatment with haloperidol, the musical hallucinations decreased in intensity and duration and his mental condition gradually stabilized. Two months after the beginning of medication, the musical hallucinations disappeared. The patient was fully aware of the hallucinatory nature of his experiences. He was independent, socially active, and had no other symptoms that suggested psychiatric or neurological disorders, illicit drug use, or relevant family history. A complete blood count and tests of renal, liver, and thyroid functions revealed no abnormalities. Consistent with his age, brain CT and MRI showed only a minor degree of generalized cerebral atrophy. Electroencephalography showed no evidence of epileptic activity or consistent focal activity. Musical hallucinations are rare; the prevalence rate has been reported to be 0.16% [3]. The discriminant functions of musical hallucinations included the following clinical profiles: male, no deafness, musical hallucinations of acute onset, absence of other forms of hallucination, and no psychiatric disease [1]. All of these factors apply to our case reported here. Some investigators have stated that neuronal or end organ disease alone is sufficient to produce musical hallucinations. The construct of “sensory deprivation” is used as the primary neurophysiological mechanism. Other investigators argue for a combination of peripheral and central dysfunction, supported by the fact that these hallucinations occur most frequently in an elderly population [4]. However, neither of these possible anatomical substrates for the phenomenon apply to our case. Thus, it can be speculated that musical
136
hallucinations might be related to psychological stress induced by aphonia. It is possible that the affective state might play a contributory role [5]. The depressive mood disappeared together with the hallucinations without the administration of antidepressants. Such a relationship between the depressive mood and musical hallucinations was not apparent in this case. One may speculate that the musical hallucinations observed here may have been caused by psychogenic factors after aphonia by pharyngolaryngoesophagectomy. To our knowledge, this is the first case of musical hallucinations after pharyngolaryngoesophagectomy without any common risk factors. The present findings suggest that psychogenic factors can also cause musical hallucinations. masaaki iijima, m.d., ph.d. takahiro maeda, m.d., ph.d. ken tsubouchi, m.d. keisuke sano, m.d., ph.d. jyunichi iwamoto, m.d., ph.d. Shimane Medical University Izumo 693-8501, Japan
References 1. Berrios GE: Musical hallucinations: a historical and clinical study. Br J Psychiatry 156:188–194, 1990 2. Berrios GE: Musical hallucinations: a statistical analysis of 46 cases. Psychopathology 24:356–360, 1991 3. Fukunishi I, Horikawa N, Onai H: Prevalence rate of musical hallucinations in a general hospital setting. Psychosomatics 39:175, 1998 4. Hammeke TA, Mcquillen MP, Cohen BA: Musical hallucinations associated with acquired deafness. J Neurol Neurosurg Psychiatry 46:570–572, 1983 5. Aizenberg D, Schwartz B, Modai I: Musical hallucinations, acquired deafness, and depression. J Nerv Ment Dis 174:309–311, 1986
PII S0163-8343(99)00050-X
toshiro kishi, m.d. jun uegaki, m.d. Department of Psychiatry Shimane Medical University, Izumo, Japan
13.
14.
mitsuhiro kitani, m.d. Department of Neurology Masuda Red Cross Hospital, Masuda, Japan akihiko fujimoto, m.d. Department of Psychiatry Matsue Aoba Hospital, Matsue, Japan rokuichi naganuma, m.d., ph.d. Department of Psychiatry Matsugaoka Hospital, Masuda, Japan
References 1. Gold K, Rabins PV: Isolated visual hallucinations and the Charles Bonnet syndrome: a review of the literature and presentation of six cases. Compr Psychiatry 30:90–98, 1989 2. Teunisse RJ, Cruysberg JR, Hoefnagels WH, Verbeek AL, Zitman FG: Visual hallucinations in psychologically normal people: Charles Bonnet’s syndrome. Lancet 347:794–797, 1996 3. Fernandez A, Lichtshein G, Vieweg WVR: The Charles Bonnet syndrome: a review. J Nerv Ment Dis 185:195–200, 1997 4. Guerra-Garcia H: Charles Bonnet syndrome and early dementia. J Am Geriatr Soc 45:893–894, 1997 5. Sichart U, Fuchs T: Visuelle Halluzinationen bei a¨lteren Menschen mit reduziertem Visus: Das Charles Bonnet-Syndrom. Klin Monatsbl Augenheilkd 200: 224–227, 1992 6. Adachi N, Nagayama M, Anami K, Arima K, Matsuda H: Asymmetrical blood flow in the temporal lobe in the Charles Bonnet syndrome: serial neuroimaging study. Behav Neurol 7:97–99, 1994 7. Lance JW: Simple formed hallucinations confined to the area of a specific visual field defect. Brain 99:719– 734, 1976 8. Ko¨lmel HW: Complex visual hallucinations in the hemianopic field. J Neurol Neurosurg Psychiatry 48: 29–38, 1985 9. Kishi T, Ishino H, Naganuma R: Insight into phosphene: a case with occipital lobe damage. Gen Hosp Psychiatry 20:260–261, 1998 10. Le Poncin-Lafitte M, Grosdemouge C, Duterte D, Rapin JR: Simultaneous study of haemodynamic, metabolic and behavioral sequelae in a model of cerebral ischemia in aged rats: effects of nicergoline. Gerontology 30:109–119, 1984 11. Pliskin NH, Kiolbasa TA, Towle VL, et al: Charles Bonnet syndrome: an early marker for dementia? J Am Geriatr Soc 44:1055–1062, 1996 12. Haddad PM, Benbow SM: Visual hallucinations as
15.
16.
the presenting symptom of senile dementia. Br J Psychiatry 161:263–265, 1992 Hof PR, Bouras C, Constantinidis J, Morrison JH: Selective disconnection of specific visual association pathways in cases of Alzheimer’s disease presenting with Balint’s syndrome. J Neuropathol Exp Neurol 49:168–184, 1990 Salanova V, Andermann F, Oliver A, Rasmussen T, Quesney LF: Occipital lobe epilepsy: electroclinical manifestations, electrocorticography, cortical stimulation and outcome in 42 patients treated between 1930 and 1991. Surgery of occipital lobe epilepsy. Brain 115:1655–1680, 1992 Williamson PD, Thadani VM, Darcey TM, Spencer DD, Spencer SS, Mattson RH: Occipital lobe epilepsy: clinical characteristics, seizure spread patterns, and results of surgery. Ann Neurol 31:3–13, 1992 Amaral DG, Price JL, Pitka¨nen A, Carmichael ST: Anatomical organization of the primate amygdaloid complex. In Aggleton JP (ed), The amygdala: Neurobiological aspects of emotion, memory, and mental dysfunction. Wiley-Liss, 1992, pp 1–66
PII S0163-8343(99)00053-5
Musical Hallucinations with PostPharyngolaryngoesophagectomy Aphonia To the Editor Musical hallucinations are a rare form of braininduced hallucinosis without demonstrable central nervous system lesions and peripheral deficits, although they can be caused by psychiatric disorders, neurological diseases, and side-effects of drugs. However, as indicated in a review by Berrios [1,2], they seem to be more common in women and are associated with age, ear diseases, deafness, and brain diseases in the right or nondominant hemisphere. Psychogenic and personality factors were thought to be unimportant. We have recently encountered a male patient without deafness who developed musical hallucinations after aphonia due to pharyngolaryngoesophagectomy. A 64-year-old male was admitted to an otolaryngology unit with a history of hypopharyngeal cancer. A pharyngolaryngoesophagectomy was performed which resulted in a lost voice followed by signs of anxiety, agitation, mild depression, insomnia, and poor appetite. He was alert and well oriented to spatial displacement and persons. Examination showed the patient to be of average intelligence without deafness. A Mini-Mental State examination demonstrated only a mild degree of disorientation of time and amnesia, considering his age, but was otherwise normal. The patient re-
135
Letters to the Editor
ported experiencing musical hallucinations of traditional Japanese songs and classical music since his surgery. The musical sounds were very loud, continuous, and uncontrollable except when sleeping; he was worried and scared by them. He experienced no hallucinations other than musical ones. After a week of drug treatment with haloperidol, the musical hallucinations decreased in intensity and duration and his mental condition gradually stabilized. Two months after the beginning of medication, the musical hallucinations disappeared. The patient was fully aware of the hallucinatory nature of his experiences. He was independent, socially active, and had no other symptoms that suggested psychiatric or neurological disorders, illicit drug use, or relevant family history. A complete blood count and tests of renal, liver, and thyroid functions revealed no abnormalities. Consistent with his age, brain CT and MRI showed only a minor degree of generalized cerebral atrophy. Electroencephalography showed no evidence of epileptic activity or consistent focal activity. Musical hallucinations are rare; the prevalence rate has been reported to be 0.16% [3]. The discriminant functions of musical hallucinations included the following clinical profiles: male, no deafness, musical hallucinations of acute onset, absence of other forms of hallucination, and no psychiatric disease [1]. All of these factors apply to our case reported here. Some investigators have stated that neuronal or end organ disease alone is sufficient to produce musical hallucinations. The construct of “sensory deprivation” is used as the primary neurophysiological mechanism. Other investigators argue for a combination of peripheral and central dysfunction, supported by the fact that these hallucinations occur most frequently in an elderly population [4]. However, neither of these possible anatomical substrates for the phenomenon apply to our case. Thus, it can be speculated that musical
136
hallucinations might be related to psychological stress induced by aphonia. It is possible that the affective state might play a contributory role [5]. The depressive mood disappeared together with the hallucinations without the administration of antidepressants. Such a relationship between the depressive mood and musical hallucinations was not apparent in this case. One may speculate that the musical hallucinations observed here may have been caused by psychogenic factors after aphonia by pharyngolaryngoesophagectomy. To our knowledge, this is the first case of musical hallucinations after pharyngolaryngoesophagectomy without any common risk factors. The present findings suggest that psychogenic factors can also cause musical hallucinations. masaaki iijima, m.d., ph.d. takahiro maeda, m.d., ph.d. ken tsubouchi, m.d. keisuke sano, m.d., ph.d. jyunichi iwamoto, m.d., ph.d. Shimane Medical University Izumo 693-8501, Japan
References 1. Berrios GE: Musical hallucinations: a historical and clinical study. Br J Psychiatry 156:188–194, 1990 2. Berrios GE: Musical hallucinations: a statistical analysis of 46 cases. Psychopathology 24:356–360, 1991 3. Fukunishi I, Horikawa N, Onai H: Prevalence rate of musical hallucinations in a general hospital setting. Psychosomatics 39:175, 1998 4. Hammeke TA, Mcquillen MP, Cohen BA: Musical hallucinations associated with acquired deafness. J Neurol Neurosurg Psychiatry 46:570–572, 1983 5. Aizenberg D, Schwartz B, Modai I: Musical hallucinations, acquired deafness, and depression. J Nerv Ment Dis 174:309–311, 1986
PII S0163-8343(99)00050-X