The Musical Brain Conference 2014: Mozart and the Power of Music:Memory, Myth & Magic

Friday 24 October 2014, Senate House

TRANSCRIPT

Music, Memory and Cognition – Chaired by Prof. Michael Trimble

IAN RITCHIE: This afternoon, we're in the excellent hands of Michael Trimble, taking usthrough a two part session on music, memory and cognition. Michael is a leading behaviouralneurologist, expert on arts and emotions, author, music lover, and he will lead us throughthese sessions, on the power of music to affect the brain and various human conditions, bothmental and physical. He will introduce the other expert speakers, including Professor NigelOsborne, and their contributions as the two sessions unfold.

MICHAEL TRIMBLE: Thank you very much, and I'm very honoured and delighted to bespeaking here at this symposium. I want to emphasise now a very important part of music andthe brain, which has to do with music as brain stimulation. At first sight, you may think that'sa bit strange. I know that music stimulates my brain, we have just heard about that with theMozart Effect, but most people don't consider music to be something to do with brainstimulation specifically. For the next couple of sessions this will be considered in relationshipto various neurological disorders. I will discuss music as brain stimulation, part one, andyou'll hear music as brain stimulation, part two, from Dale Hesdorffer and Nigel.

Initially I just have to say something about the brain, and this is not a lecture of neuroanatomyso don't go to sleep. But I have to reveal parts of the brain which are important to what I haveto say, differences between parts of the brain that are damaged or altered in various diseasestates.

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Over here, this is coloured in these various colours, is what is called part of the limbic brain,which we associate with our emotions. What you can see in particular is something that iscalled the hippocampus, coloured in this nice colour here, and it's important in laying downmemories, especially laying down of episodic memories, day-to-day memories - in otherwords when you go home you will say, yes, I went to that meeting and I heard so and so - youcan relate what happened to you. The hippocampus is extremely important. The other areaI want to show to you is this area here, frontal cortex. Of course, there are two sides to thebrain, this is the medial side of the brain, and this is the lateral side of the brain and you cansee here that part of the frontal cortex and other bits have been removed. The importanceabout this particular image is that it shows you parts of the brain which are damaged in certaindisorders that I'm coming on to. You get disorders that damage this part of the brain which isthe cortex, you get disorders which damage this part of the brain, the hippocampus. Then, ifyou just take a cut through the brain at that level, just going across here, one comes acrossareas of the brain which are called the basal ganglia and all I want you to know about thebasal ganglia is that they are deep structures within the brain. Here is the cortex I have beentalking about, and here is the hippocampus, but here are the so-called basal ganglia.

The importance about the basal ganglia is that they represent the part of the brain thatregulates our motor output; they are related to the laying down of motor programmes. Whatwe have been listening to already has to do with motor programmes in terms of learningmusic, and so it won't surprise you to hear that there are disorders of the basal ganglia whereresponses to music may well be impaired, or may be affected. The classic is Parkinson'sdisease, which I am going to come on to in a while. So that's the basal ganglia as opposed tothe cortex. Of course, they are linked together, and again, a cartoon is the easiest way to do it,Here is the motor cortex, the frontal areas of the cortex, which motor programmes are in partderived from, but they play into and around these basal ganglia structures.

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We have heard a little bit today about the idea that expectancy plays a role in learning, butalso expectancy plays a role in our appreciation of music. This is extremely relevant, I think,from an evolutionary perspective. It is not shown on this particular image, but there are areasof the cortex in the human brain which are not present in, say, the chimpanzee brain, that haveconnections to these basal ganglia structures. There is a part of this cortex in the human brainwhich has to do with expectation of rhythm. In other words, if you do these experiments thatJessica was talking about, looking at what happens in the brain when certain things are donein an experimental situation, you can play rhythms and there is an expectation in the listener'sbrain of the rhythm and what comes next. It is as if the rhythm continues, but then if you putin an anomalous rhythm, the expectation of the next beat, if you like, is incorrect, this corticalarea is activated. So there is an area of that cortex which is rather specific to rhythmexpectation, and of course we just heard that expectation is so important in musicalappreciation.

There are lots of brain stimulation techniques that have been used, going back a number ofyears, but still in use today is electroconvulsive therapy, where an electrical stimulus is giventhrough the scalp and a seizure is precipitated. Dale will talk a little later about seizures. Morerecently there is something called transcranial magnetic stimulation, and I am sure some ofyou have read about it in the newspapers. It is a little bit like Jessica's Mozart Effect, you'llsoon be able to buy a magnetic stimulator in a shop down the road and put it on yourself andstimulate your brain with the hope it does not give you a seizure. Nevertheless it is nowactually officially recognised by the FDA in America; transcranial magnetic stimulation fortreatment of depression. The magnetic pulses are put on the brain here in the frontal areas andthe magnetic pulses translate into electrical stimulation in the brain, and you get pathwaysfired. Brain stimulation is part of everyday neuropsychiatric practice.

There is another one, which is stimulation of the nerves going into the brain, vagus nervestimulation. I don't want to go into it, but it's one of the nerves that goes directly into thebrain and you can stimulate this peripherally by putting a stimulator on the vagus nerve in theneck, and this has been used to treat epilepsy and depressive disorders. Then you can putan electrode deep in the brain, through the cortex, into those basal ganglia areas, and stimulatedirectly in those brain areas, and this is used for the treatment of dystonia and Parkinson'sdisease.

But then what about music? I want to just briefly mention the use of brain stimulation intraumatic brain injury, stroke, Parkinson's disease and two forms of dementia. Other aspects,in particular issues to do with learning disability and seizure disorders, will be covered by thenext two speakers.

I'm saying nothing about traumatic brain injury. This is, of course, an extremely commonproblem, the neurological and psychiatric deficits that occur following traumatic brain injuryare often a complete tragedy. However attempts to use music in any therapeutic way havebeen totally useless, partly because the problem is so diverse. In other words, if you havea head injury, you can get damage to all different parts of the brain and any studies that havebeen attempted really have not shown anything because of the wide spectrum of pathologythat occurs.

So I want to talk about stroke leading to aphasia. I've talked a little bit about the inside of thebrain, but there is a left side and a right side. I don't want this to be interpreted that you'reeither a left-brained person or a right-brained person. The brain acts as a pattern detector and

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guides the way we act on the environment, the two sides of the brain act in harmony and notdiversity.

By 1973, melodic intonation therapy was tried for people with strokes. Now, I put up thename, because it stuck, but 1973 is of interest. It's of interest because as you will see, at theend of the next couple of slides, it isn't used very much, and very little progress has beenmade in this area. This is not to say it isn't available and isn't used, it certainly is, but if it wasgoing to be so good, one might expect its use to be much more popular in stroke units.

There are differences between the left and the right sides of the brain in terms of the way thatthose two sides of the brain manipulate and operate on the world around us, and it's the leftside which is related particularly to our propositional language which I am using to speakwith you today, with syntax. The right side of the brain is much more related to the other wayof using language, poetic expression, but also the rhythm and intonation that people use whenthey talk. If I spoke to you a little bit like this [in monotone] you would probably go off tosleep fairly quickly, but speech normally has an intonation, and this is really the basis ofmelodic intonation therapy. Aphasia, following damage to the left side of the brain, in righthanded people is loss of ability to use syntax and propositional language. It is of interest thatpeople who lose that ability still have ability, and remember their right hemisphere is intact, toappreciate music.

The idea of the melodic intonation therapy is to try to get the remnants of speech, that theaphasic person still has, after damage to the left hemisphere, activated. The way they tried todo this was to get people to try to speak common words or phrases in a melodic fashion,particularly with rhythmic patterns. As time has gone on, there have been some studies in thisarea, but not a great deal. If you get the patient to sing, apparently this produces the sametherapeutic results as speaking in a rhythmic lyrical way, but the whole point is to activate asfar as possible the abilities of the right side of the brain, its musical abilities, to try to improvespeech output. But really, the mechanisms and therapeutic effects are still unclear.

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In terms of this presentation, many people with aphasia, left-sided brain damage, can singaccurately and fluently, and there is a famous case of the composer Shebalin who in his 50shad two strokes and developed a dense aphasia. He lost his ability to speak the kind oflanguage I am talking about, but he continued to compose, and a no less great master thanShostakovich reported his Fifth Symphony as being "brilliant, filled with the highestemotions, the creation of a great master", and this was written after he had had the stroke. Thepoint I want to make here is that with a dense abnormality of the left side of the brain and lossof abilities to speak, the possibility for musical composition continues, and the ability to becreative continues. Incidentally, Benjamin Britten had a stroke. This was after he had cardiacsurgery. A little embolus from his heart went up into his brain and for a while he was aphasic,thank goodness it was only transitory, but it did actually affect his motor abilities in terms ofplaying the piano. There are a number of anecdotal reports of conductors who have remainedactive and able to conduct successfully after aphasia.

Let's move on to Parkinson's disease. This is not to do with damage to the cerebral cortex onthe left side of the brain that I have been talking about, but it's due to a loss ofa neurotransmitter, dopamine, in the basal ganglia, remember those deep structures of thebrain, Parkinson's disease is so common that I'm sure a number of people have relatives whohave had Parkinson's disease. Basically, there’s slowing of movements, there's some posturechanges towards flexion, there's loss of rhythm and fluidity, and classically, people withParkinson's disease can freeze, so they just simply can't move. There are ways that people tryto get them to move, and as I will show you one of the ways is through music, or at leastthrough rhythmic stimulation.

Oliver Sacks has written enormously about many things including music. When he left theUnited Kingdom to go to America, he had done some neurology here and he found himself incharge of a nursing home where the people there had a form of Parkinson's disease called postencephalitic Parkinson's disease. This was secondary to an encephalitic infection, secondaryto flu, and it's pretty much died out now. These were people who were affected just after theFirst World War, with these flu infections. Sacks was given a drug called L-dopa, and in thosedays there were no regulatory agencies telling you what you could and couldn't do withpatients, and the idea that dopamine was linked to Parkinson's disease was around in theacademic circles. He gave people with post encephalitic Parkinson's disease L-dopa. Hemassively overdosed them, but he did not know that at the time, and a number of them whowere frozen, literally in time and space, because of their motor rigidity, and their basal gangliaabnormalities, were suddenly awoken, and he became famous. Oliver Sacks, in his bookAwakenings, described what happened to these people when they were woken in this way,and it was clearly very traumatic. In his studies in this centre, he also looked at the effect ofmusic on some of these people, and he describes a small number who responded dramaticallyto music. He said the music needed to be legato not staccato.

There were other people who looked at the issue of personal time and clock time in peoplewith Parkinson's disease. Everything is slowed in their world. They don't think they aremoving slowly but they are moving slowly in relation to clock time. There is a study justpublished showing with intonation or entrainment to rhythms you get improved perceptionand motor timing. Also auditory facilitation of gait. Here is an interesting example of apatient with Parkinson's disease who you can see freezes.

[Video plays.]

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There is another one freezing. She has got on her back here a musical stimulator, which isgoing to be turned on; this is what happens with the stimulated music. So you can see quiteclearly how an auditory input leads to a dramatic effect in this particular person. It is possibleto alter the rhythm and movement of people with Parkinson's disease. This appears toimprove the gait in people both on and off medications.

There are a couple of studies that are noted. One is the Oliver Sacks study. In oneinvestigation, of the kind I have just shown you the results of, they used a 50 millisecondsquare wave pulse embedded in Renaissance music in a two four metre. What was noted wasan increase in the speed of the walk, length and the cadence, the fluidity of it. What wasextremely interesting was that Oliver Sacks commented that in one of his patients, playingmusic stimulated the patient, but also imagining music was effective. We just heard earlier onthe importance of imagination within music in terms of musical learning. I'm going to saysomething about that in just one second. Music did everything that L-dopa did, said OliverSacks, but he went on to say that the lack of organisation in Wagner’s music makes it useless.Also true plain song and various forms of chant were no good. It is quite interesting to notethat some music makes people worse. Studies asking people to choose a piece of music thatthey like actually made the situation worse. People can't say, you know I like to hear thatmusic. Actually, if you are talking about musical therapy, it has to be well thought out, wellstructured, and planned to a pastoral or rhythmic pattern.

Musical imagery is obviously within the cognitive domain, if you like, the intelligent domain,but it is non-verbal knowledge. The author of these brain imaging studies was looking atwhich areas of the brain are most activated listening to a piece of music.

You can see it is the cortex that is shown here and these are the temporal lobes and the frontallobes. The volunteers were then asked to imagine music, and what you see is virtually thesame areas of what's called auditory cortex and the surrounding areas that link to it, areactivated. There is also activity in some of those frontal areas. So imagining music hasrepresentations within the brain, and these weren't particularly musically gifted people, of thevery same nature as to when they listened to it. Whether or not that has something to do withthat conversation that went on earlier, I'm not certain. Anyway, rhythm seems to be comingout as extremely important in these areas. The pace of breathing, the beating of the heart, therhythm of walking and dancing, goodness me, that is very much a human necessity. Those ofyou who have heard me speak before know I'm interested in the evolutionary development ofall of this.

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Entrainment, entrainment to rhythm, very, very early on in our ancestors must have been veryimportant in the development of our cultures. Remember, other primates have a lot of visualinput, as we do, and this is located in the back of the cortex, it is very, very important. But inhumans the auditory areas of the cortex are considerably expanded. This has allowedorganising activity in time, and it also enhances the flow of information within the structuresof the brain. One could argue that the increase of the information flow through those basalganglia structures was extremely important in terms of the development of our abilities torespond to and use rhythm and also I pointed out an area of the brain where expectancy forrhythm links together those two.

Finally moving on to dementia, anybody in this room who has reached the age of maybe,well, I won't say, but we are all testing ourselves every day! Can you remember this, can youremember that? By the way, you musicians, dementia is less common in musicians! I want toconcentrate on small amount of research done in two different forms of brain deterioration.One is Alzheimer's disease, losing episodic memory, that autobiographical memory thatJessica talked about already, memory for the day-to-day events. Quite early on, episodicmemory is lost in Alzheimer's disease and this is the result of the fact that it affects thehippocampus part of the brain. It is quite well established now that you can lose episodicmemory, for day-to-day events, but people with Alzheimer's disease do not lose memory forfamiliar songs, old songs. Personal favourites are recalled. Therefore, what is particularlyinteresting is when they lose this ability to lay down those memories of every day events inAlzheimer's disease, they still retain the ability to tap into music. One study showed thatstimulating the brain with music in Alzheimer's disease actually improved autobiographicalrecall. If one goes to a home, a sad home, with a lot of elderly people who have thesedementias, music is a very, very important aspect of the day-to-day programme. Althoughwhether it has any lasting effect beyond the time it has been played has never been tested. Tofollow Jessica's presentation, there is no Mozart Effect, people have tried to see if they canimprove memory with this music and it doesn't work.

Now I would like to contrast with another dementia, frontotemporal dementia. I showed youthe frontal cortex, we are talking about the outside structures of the brain, not the basalganglia. There is a form of frontotemporal dementia that affects language, called semanticdementia. In people with semantic dementia, and these are images of the brain of twopatients at the top, you can see here that this part of the brain, particularly here and here, iscompletely atrophic. It is very different from Alzheimer's disease. The hippocampus is notaffected. As I pointed out with Alzheimer's disease, people continue to get recognition formusical things, musical attributes but in particular, in Alzheimer's disease, you still get therecognition of musical emotion, remembering things that were happening in your life, withcertain pieces of music. With frontotemporal dementia you get loss of language skills, like anaphasia, but unlike a stroke that comes on suddenly, the loss of language comes on relativelyslowly. This is a form of dementia, not affecting the hippocampus, but affecting the areas,particularly on the left side of the brain, that relates to propositional language.

I now want to talk for a second about a celebrated patient, Ravel. You can see on this slidehere there is another picture, it is not the brain of Ravel, but of frontotemporal, and you cansee the huge tissue loss. Something happened to Ravel between 1901 and 1933. This is whathappened. Ravel in 1922, 1925, 1927 and 1928 underwent notable creative lapses. It is notedin 1927 he lost his place in one of his own violin sonatas, he was observed to make blundersin his writing as you saw on the last letter, and his hand was trembling. Then, it was said, helost his place playing his Sonatine. Then there is Bolero. Some people have interpreted this asone of the early signs of Ravel's dementia.

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[CLICK HERE to listen to Ravel’s Bolero]

STEPHEN JOHNSON: You should be able to hear in the back the side drum rhythm. Thatrhythm is repeated almost throughout the entire piece, which lasts well over a quarter of anhour. Basically what the piece is is this tune we're hearing on the flute now and a very simplepizzicato accompaniment. As you can hear, it is about as simple a set of variations as you canimagine. We have the folk song, like the theme on the flute we started with and now on theclarinet. More or less what Ravel does for the course of the piece is to change the colour ofthe tune. So now we have got flute and low clarinet. Little bit of extra harp colour there.High bassoon, I'm sorry, very high up, but basically we have now heard all the music, of a 15minute piece. It builds and builds and builds on the repetition of these ideas, the colouringgetting more and more complex until there comes a point when the full orchestra comes inand then they are plunged back to the opening and the whole thing comes back to a marriageof conclusion, and everyone who saw Torvill and Dean skate to this will know it makes asimple but effective ballet. There have been all sorts of objections about the Bolero - that it isstaggeringly simple in its conception, and this has been adduced by some people as a sign thatpoor Ravel was losing his creative powers. I think there is an awful lot of snobbery in this. Itactually takes a great deal of skill to contrive an effective simple piece. Sometimescomplexity can be a good way of disguising lack of originality rather than focusing it. It isextremely well timed. The build-up is masterly. I think that the way he adjusts the colouringis just enough to keep you interested. There are some beautiful effects, at one point he has themuted trumpet play and he has the piccolo play an octave and a fifth above so it sounds likean organ stop. I haven't come across it in another musical piece sustained like that, if youhave, let me know, it is wonderful.

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There are all sorts of reasons why Ravel might have wanted to simplify like this, which werenot a sign that he was losing his creative faculties. One of them is that he seems to be intenton writing something. Roger Nichols knows more about Ravel than anybody and the culturehe belonged to, and has written fabulously about him. He thinks that actually what Ravel wastrying to do was come to terms with the loss of his mother. His mother was of Basque origin,and the idea of something simple and repetitive goes back to childhood games, he might havehad an emotional need to do that. He was not the first composer to build on reputation. If youhave seen the film Grand Budapest Hotel, it works very well at the end of that and workseffectively today. The long build-up of the Leningrad Symphony is built on a repetitivepattern and it is deadly. The thing for me that finally shoots down this being an idea of acomposer losing his faculties is after the Bolero, he wrote the two piano concertos, for the lefthand and in G major, two of his most brilliant, sophisticated, rich and remarkable pieces andalso beautifully conceived as wholes. So you have got to explain how his brain thenrecovered enough to be able to write two of his greatest and most sophisticated masterpieces.I think something about him creatively enjoyed this holiday, in a way, from writing highlysophisticated music and going back to an idea of music more connected with childhood,which may, and Roger Nichols is a writer much given to psychotherapy explanations, havehad a lot to do with the need for him to make some sort of sense of the loss of his mother andthe memories of childhood that evoked.

MICHAEL TRIMBLE: Thank you very much. This has been part of a controversy abouthow mysterious it all was, the Bolero - and what had happened to Ravel? He became aphasic.Maybe more significant was the car accident he had, with quite a bad head injury, whichadded to the development of a dementia. I will not go through the rest of that slide exceptthat I just want to point out that he was still at the very end before he died, able to notice thathis doctor's piano was out of tune. He recognised pieces of music played to him and he wasable to faultlessly identify his own compositions. His friends considered that he probably hada brain tumour. They didn't want to accept a diagnosis of dementia. He was persuaded to havea craniotomy, that is a removal of part of the skull, and died ten days later. Thank you Stephenfor that.

I must press on. I just want to make an interesting point to do with dementia and the MusicalBrain. Some studies have been done by my colleagues at the Institute of Neurology, London.This has to do with the loss of the left-sided activity in this form of dementia, and Ravel losthis ability for propositional speech but he retained abilities for music. The question is, whatkind of abilities did he continue to have? The kind of experiments they were doing are fairlyclear. Patients were shown faces of different emotions, they were shown vocal examples ofdifferent emotions, and they were shown musical examples of different emotions. I am notgoing to play them because of time, but what we're looking at here is whether or not thisgroup of people with this form of dementia, loss of their verbal abilities, managed to retainmusical abilities.

All I want you to do here is to look at this slide, showing controls, aged-matched people, andpeople with frontotemporal dementia. What you can see here is the latter do reasonably wellin terms of identifying the emotion of faces and voices but very poorly identifying theemotion within music. So although Ravel may well have been able to continue to understandmusic, recognise mistakes and errors, it is highly likely, if he fell into this group, that he lostthe ability for the understanding of the emotion within music.

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I'll just finish with another biography. I'm sure you all know this man, Friedrich Nietzsche,who was widely thought to have died of syphilis. I published a paper some time ago, whichnobody has taken the slightest bit of notice of suggesting a diagnosis of frontotemporaldementia. It showed that there was a family history of mental illness and his father died ata young age of softening of the brain. The thing about frontotemporal dementia is that it doesrun in families. Ravel had a concern that his father had also died of some debilitating illness.Nietzsche was a writer and composer, and was deeply embedded in the musical world throughhis connection with Wagner. His final illness started in the 1880s. He had a bout of writingproductivity before he developed his mental illness and then he lived for another 12 years. Hebecame totally mute, but towards the end was still able to play the piano.

What I've tried to unravel here is that the work on stroke and dementia has looked particularlyat right hemisphere activity in terms of the ability of the brain to continue to understandcertain aspects of music, when the left hemisphere is compromised.

I've commented on the possible evolutionary significance of music. It is interlinked with ourability to have empathy for others. I believe the work that goes on in terms of looking at theeffect of neurological diseases and music really is to study the intimate relationships betweenthe human brain and the arts. Music is a different domain of knowledge from, for example,the episodic memory, the biographical memory that is lost in Alzheimer's disease. Musicalmemory is different, I believe, from neurological models to other domains of memory, andsophisticated musical understanding can survive following grave impairments of the lefthemisphere's eloquent language abilities. Only music encodes certain kinds of non-verbalsymbolic information linked in with empathy, and this neural substrate has survivedevolutionary pressures.

I'd like to thank you very much, and invite Professor Dale Hesdorffer from Columbia,New York, to take the story further.

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