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R E V I E W A RT I C L Esong with another (musical displacementstrategy), are effective in modulating thefrequency, duration, or disruptiveness of INMI.An important characteristic of INMI is highinter-individual variability. Even thoughnearly everyone has experienced it, thefrequency and the nature of the experienceis different from person to person. 1 It is noteworthythat the majority of people experiencingINMI several times a day find itcompatible with everyday life. 1,12 An interestingparallel between INMI 1 and musicalhallucinations 13 is the female preponderance,although this is not characteristic ofmental illness such as schizophrenia ingeneral. For clinical practice, it is important tounderstand that even nearly constant, involuntarymusical imagery may not indicatemental disorder if it does not impedeeveryday life. I believe future work on thetopic is needed to clarify diagnostic criteriafor OCD and schizophrenia to distinguishtheir features from “normal” INMI. Thus far,brain research techniques successfully usedfor imaging voluntary imagery and hallucinationshave not been able to capture INMI, butwe can hope future efforts will bring insightsfrom the neural level to help diagnose involuntarymusic phenomena. lReferences1. Liikkanen LA. Musical activities predispose to involuntary musical imagery. Psychology of Music 2012;40(2):236-56.2. Williamson VJ, Jilka SR, Fry J, Finkel S, Müllensiefen D & Stewart L. How do "Earworms" Start? Classifying the everydaycircumstances of involuntary musical imagery. Psychology of Music 2012;40(3):259-84.3. Vogeley K. Hallucinations emerge from an imbalance of self-monitoring and reality modelling. Monist 1999;82(4):626.4. Zungu-Dirwayi N, Hugo F, van Heerden BB & Stein DJ. Are musical obsessions a temporal lobe phenomenon? Journal OfNeuropsychiatry And Clinical Neurosciences 1999;11(3):398-400.5. Evers S & Ellger T. The clinical spectrum of musical hallucinations. Journal of the Neurological Sciences2004;227(1):55-65.6. Podoll K. Musical palinacousis as an aura symptom. In: Neurology of music, ed. Rose, F.C. 2010; 221-35. London:Imperial College Press.7. Hubbard TL. Auditory imagery: Empirical findings. Psychol. Bull. 2010;136(2):302-29.8. Halpern AR & Zatorre RJ. When that tune runs through your head: A pet investigation of auditory imagery for familiarmelodies. Cerebral Cortex 1999;9(7):697-704.9. Liikkanen LA. Inducing involuntary musical imagery: An experimental study. Musicae Scientiae 2012;16(2):217-34.10. Kvavilashvili L & Mandler G. Out of one's mind: A study on involuntary semantic memories. Cognitive Psychology2004;48(1):47-94.11. Bailes F. The prevalence and nature of imagined music in the everyday lives of musical students. Psychology of Music2007;35(4):1-16.12. Beaman CP & Williams TI. Earworms (‘stuck song syndrome’): Towards a natural history of intrusive thoughts. BritishJournal of Psychology 2010;101(4):637–53.13. Berrios GE. Musical hallucinations. A historical and clinical study. The British Journal of Psychiatry 1990;156(2):188-94.14. Hermesh H, Konas S, Shiloh R, Dar R, Marom S, Weizman A & Gross-Isseroff R. Musical hallucinations: Prevalence inpsychotic and nonpsychotic outpatients. Journal Of Clinical Psychiatry 2004;65(2):191-7.15. van der Zwaard R & Polak M A. Pseudohallucinations: A pseudoconcept? A review of the validity of the concept, related toassociate symptomatology. Comprehensive Psychiatry 2001;42(1):42-50.16. Terao T & Ikemura N. Musical obsessions or hallucinations? Journal Of Neuropsychiatry And Clinical Neurosciences2000;12(4):518-9.17. Griffiths TD. Musical hallucinosis in acquired deafness - phenomenology and brain substrate. Brain 2000;123(10):2065-76.18. Murata S, Naritomi H & Sawada T. Musical auditory hallucinations caused by a brainstem lesion. Neurology1994;44(1):156.19. Reik T. The haunting melody: Psychoanalytic experiences in life and music, 1953; 380. New York: Farrar, Straus and Young.20. Hannett F. The haunting lyric - the personal and social significance of american popular songs. Psychoanalytic Quarterly1964;33:226-69.www.st-annes.ox.ac.ukBNPA 26thAnnual GeneralMeeting7 to 8 February 2013Venue: The Institute of Child Health, Guilford St, LondonTopics to include: The neuroscience of stress on brainfunction • stress and cognition and emotional processes• stress and epilepsy • neurophysiology of epilepsy• progressive memory loss and epilepsy • depression anxietyand epilepsy • neuroscience of consciousness• revelation and psychiatric drugsCall for research abstracts and registration now open:www.bnpa.org.ukFor details of exhibition/sponsorship opportunities,contact: Jackie Ashmenall onPhone/Fax: 020 8878 0573/Phone: 0560 1141307Email: admin@bnpa.org.uk or jashmenall@yahoo.com14 > ACNR > VOLUME 12 NUMBER 4 > SEPTEMBER/OCTOBER 2012
S P E C I A L F E AT U R EThe EuroInf surveyProf Ray Chaudhuri, who spoke at thewebinar, is a neurologist with expertisein movement disorders and non-motorissues, particularly in relation toParkinson’s disease. Based at theNational Parkinson Foundation Centreof Excellence at King’s College Hospital,King’s College, London, he works forKing’s Health Partners, which includesLondon’s King’s College Hospital, and StThomas’s and Guy’s Hospitals.Dr Prash Reddy who presented theposter at MDS.Speaking at an interactive webinar, Professor RayChaudhuri discussed the European Infusion(EuroInf) survey, part of the EUROPAR projectendorsed by the EPDA and involving over 14 centresacross Europe. This survey was presented as aposter at the MDS meeting in Dublin and alsopresented as one of the highlights at the Dublincongress earlier this year in June. This ongoing multicentreobservational study across several centres inthe UK and Europe compares the two infusionaltherapies for advanced Parkinson's disease - subcutaneousapomorphine and intrajejunal levodopa.The study focuses on motor and non-motor symptomsand their cumulative effect, namely quality oflife. While not a randomised placebo-controlledstudy, the outcome measures used (UPDRS III and IVfor motor symptoms, NMSS for non-motor symptomsand PDQ-8 for quality of life) reflect good clinicalpractice in a ‘real-life’ population. Aiming ultimately tohave 50 patients in each treatment arm, the study hasalready recruited over 40 patients on levodopa and37 on apomorphine. Because the two groups do notmatch identically, the study looks at the effect size ofthe two interventions and numbers needed to treat.With regard to inclusion criteria, these reflectexisting clinical practice across Europe for treatmentwith advanced therapies, said ProfessorChaudhuri. Not included are patients who aredemented or have significant cognitive problems,those with a diagnosis other than Parkinson'sdisease or where the Parkinson's diagnosis is uncertain,and patients whose response to levodopa isfailing. Patients included in the study are thereforeessentially those considered fit for further therapyin whom deep brain stimulation using the subthalamicnucleus or globus pallidus internus is notappropriate.Summarising the observations from the EuroInfsurvey Professor Chaudhuri outlined that infusionsof both apomorphine and levodopa worked well interms of UPDRS-III, but apomorphine had a verystrong effect on motor symptoms, perhaps notsurprisingly since previous studies have shown thatapomorphine can often quite dramatically return apatient who is otherwise ‘off’ and bradykinetic toessentially normal motor function. In addition, thestudy found that apomorphine improved certainnon-motor symptoms, though the effect on dyskinesiaswas not quite as good as might have beenexpected, perhaps because apomorphine therapywas given as monotherapy in only a few centres andwas often associated with concomitant use of oraldopaminergic treatment. Levodopa on the otherhand was generally given as monotherapy. However,the effect of apomorphine on the non-motor symptomsscale, as well as on quality of life, was as strongas in the levodopa arm.Addressing the availability of infusion treatmentsProfessor Chaudhuri noted that even in well establishedParkinson's disease treatment centres thenumber of patients receiving these therapies is low.Clearly a significant number of patients suitable forapomorphine or levodopa are not being offeredthese interventions. This may be due to non-availabilityof the relevant expertise or the supportingservices required, but perhaps also because cliniciansare not familiar with these treatment strategies.By contrast, deep brain stimulation is a well recognisedtherapeutic option with a good evidence basefrom randomised controlled trials. However, toProfessor Chaudhuri’s knowledge, deep brain stimulationtherapy has yet to be examined holisticallyusing the validated non-motor scale used forapomorphine and levodopa in the EuroInf survey.For patients who cannot undergo deep brain stimulationbecause of their age, or because they havecognitive impairment or depression, infusion withapomorphine or levodopa provides an alternativetherapeutic option.Looking to the future the aim is therefore to add athird arm to the EuroInf survey to compare amatched group of patients undergoing deep brainstimulation, as well as a fourth comparator armcomprising patients who have not received any ofthese advanced therapies and who instead continueon conventional best medical therapy. Such a cohortexists in the UK, where funding streams are somewhatdifferent to other countries in Europe.Professor Chaudhuri stressed that access to treatmentwith apomorphine, levodopa and deep brainstimulation is very variable. A good state-of-the-artParkinson's disease centre should be able toprovide access to all three therapies, based oninformed patient choice. This is not currently thecase. Patients can be influential here. ProfessorChaudhuri noted that, empowered by initiativessuch as expert patient groups, patients arebecoming better educated about Parkinson'sdisease and its potential treatments. In addition, themedia has considerable influence in this area.Impulse control disorders continue to be a majortopic of discussion in Parkinson's disease. ProfessorChaudhuri outlined that the relationship betweenimpulse control disorders and oral therapy, particularlydopamine agonist therapy, remains unclear.However data from his own group suggest that therate of impulse control disorders occurring withlonger-acting dopaminergic therapies, particularlydopamine agonists, is actually low compared to theoverall prevalence. Single infusional therapies (aspossible with apomorphine) appear not to be associatedwith a high rate of impulse control disorders.Professor Chaudhuri stressed that this is an anecdotalobservation, however, which needs to besupported by evidence from a controlled study ordata from a large case series like the EuroInf survey.A grant was provided by Britannia Pharmaceuticals Ltd as a contribution towards the production and design costs of thisarticle. Britannia Pharmaceuticals sponsored the Webinar held during the Movement Disorder Society’s 16th InternationalCongress of Parkinson’s Disease and Movement Disorders held 17-21 June 2012.ACNR > VOLUME 12 NUMBER 4 > SEPTEMBER/OCTOBER 2012 > 15
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