vocalised call to prayer and has a profound The triad of papers in this issue encourage meaning for Muslims. is deeply embedded readers to understand the universal and personal in our understanding of the world and hence in aspects of the musical brain and the musical mind the understanding of patients as persons. and will, it is hoped, also enhance clinical practice.

Relevance for psychiatry References Carey, D. & McGettigan, C. (2016) Magnetic resonance imaging Music is also embedded in the history and practice of the brain and vocal tract. Applications to the study of speech of psychiatry (Rollin, 1998). Many asylums had production and learning. Neuropsychologia. https://doi. org/10.1016/j.neuropsychologia.2016.06.003. [Epub ahead of print] concert halls with orchestra and choir; Elgar Clarke, D. & Clarke, E. (eds) (2011) Music and Consciousness: conducted the Powick Asylum band and composed Philosophical, Psychological, and Cultural Perspectives. Oxford music for their concerts. Psychiatrists are consulted University Press. by musicians with mental disorders that impair Cox, J. L. (2011) Empathy, the song and the singer: the legacy of their work and performance, as reported by Matei Robert Schumann. Advances in Psychiatric Treatment, 17, 447–458. & Ginsborg in this issue. Severe stress adversely Downie, R. (2016) Medical humanities. Journal of the Royal College affects the singer’s voice and the violinist’s intona- of Physicians of Edinburgh, 46, 288–294. tion and can impair their livelihood. Temporal Friedman, S. H., Kaplan, R. S., Rosenthal, M. B., et al (2010) in perinatal psychiatry: use of lullabies for pregnant and lobe epilepsy may present with musical hallucina- postpartum women with mental illness. Music and Medicine, 2, tions, and a may be followed by . 219–225. For some psychiatrists, however, music making Ginsborg, J. (2016) in music , listening and is primarily a regenerating leisure activity that performance. In Performing the Remembered Present: The Cognition of Memory in Dance Theatre and Music (ed. P. Hansen), ch. 7. provides self-agency within an interpersonal Methuen. space. For others (such as Anthony Storr, Felix Glasziou, P. (2015) Music in hospital. Lancet, 386, 1609–1610. Post, Michael Trimble and John Cordingly) their Hole, J., Hirsch, M., Ball, E., et al (2015) Music as an aid for musical interest is expressed through their books. postoperative recovery in adults: systematic review and meta- The Royal College of Psychiatrists celebrated analysis. Lancet, 386, 1659–1671. the millennium with a Festival of Psychiatry and Mbiti, J. S. (1990) African Religions and Philosophy (2nd edn). the Arts, with commissioned vocal music, dance, Heinemann. theatre and an exhibition by the psychoanalyst Overy, K. & Molnar-Szakacs, I. (2009) Being together in time: musical experience and the system. , Ismond Rosen. The art and science of psychiatry 26, 489–504. were in juxtaposition: a blend of intuition, con- Rollin, H. (1998) Pioneers of music therapy. Journal of Medical nectivity and natural science which is at the heart Biography, 6, 160–165. of musical appreciation – and very close to the Stewart, K. A. & Swain, K. K. (2016) Global health humanities: heartland of psychiatry. defining an emerging field. Lancet, 388, 2586–2587.

THEMATIC Music and the brain: the neuroscience PAPER of music and musical appreciation Michael Trimble1 and Dale Hesdorffer2

1Institute of , Through music we can learn much about our activities, from tool-making to having a theory of University College London, UK, email [email protected] human origins and the human brain. Music is mind and empathy, have been rejected, as observa- 2Gertrude H. Sergievsky Center a potential method of therapy and a means tions of anthropologists and ethnologists continue and Department of Epidemilogy, of accessing and stimulating specific cerebral to emphasise similarities rather than differences Columbia University, New York City, USA circuits. There is also an association between placing us within the great chain of beings. There musical creativity and psychopathology. This can be no doubt about the greater development paper provides a brief review. of our cognitive attributes, linked closely with the evolutionary developments of our brain, in terms of both size and structure. Bipedalism, the use of fire, the development of effective working memory and Art history is the unfolding of subjectivity…. (T. Adorno) our vocal language efficient communication have all emerged from these genetic–environmental An evolutionary perspective adaptations over several million years (Pasternak, There have been many attempts to identify behav- 2007). iours which reliably distinguish our species, Homo Two features of our world which are universal sapiens, from our closest living cousins. Ascribed and arguably have been a feature of an earlier

28 BJPSYCH INTERNATIONAL VOLUME 14 NUMBER 2 MAY 2017 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 10:27:17, subject to the Cambridge Core terms of use. evolutionary development are our ability to create flexi­bility which accrued with expanded anatomi- and respond to music, and to dance to the beat of cal developments, not only of the brain, but also time. of the coordination of our facial, pharyngeal and Somewhere along the evolutionary way, our laryngeal muscles. Around the same time (with ancestors, with very limited language but with a precision of many thousands of years), the bi­ considerable emotional expression, began to ar- cameral brain, although remaining bipartite, with ticulate and gesticulate feelings: denotation before the two cooperating cerebral hemispheres coordi- connotation. But, as the philosopher Susanne nating life for the individual in cohesion with the Langer noted, ‘The most highly developed type surrounding environment, became differently of such purely connotational semantic is music’ balanced with regard to the functions of the two (Langer, 1951, p. 93). In other words, meaning in sides: pointing and proposition (left) as opposed to music came to us before meaning given by words. urging and yearning (right) (Trimble, 2012). The mammalian middle ear developed from the jaw bones of earlier reptiles and carries sound at The experience of music only specific frequencies. It is naturally attuned to A highly significant finding to emerge from the the sound of the human voice, although has a range studies of the effects in the brain of listening to greater than that required for speech. Further, the music is the emphasis on the importance of the frequency band which mothers use to sing to their right (non-dominant) hemisphere. Thus, lesions babies, and so-called motherese or child-directed following cerebral damage lead to impairments of speech, with exaggerated intonation and , appreciation of pitch, timbre and rhythm (Stewart corresponds to that which com­posers have tradi- et al, 2006) and studies using brain imaging have tionally used in their . In the same way shown that the right hemisphere is preferentially that there is a limited sensitive period in which the activated when listening to music in relation to the infant can learn language and learn to respond to emotional experience, and that even imagining spoken language, there must be a similar phase of music activates areas on this side of the brain (Blood brain development for the incorporation of music. et al, 1999). This should not be taken to imply that One of the differences between the developed there is a simple left–right dichotomy of functions brains of Homo sapiens and those of the great apes in the human brain. However, it is the case that is the increase in area allocated to processing traditional neurology has to a large extent ignored auditory information. Thus, in other primates the the talents of the non-dominant hemisphere, much size of the visual cortex correlates well with brain in favour of the dominant (normally left) hemi- size, but in Homo sapiens it is smaller. In contrast, sphere. In part this stems from an overemphasis increases in size elsewhere in the human brain on the role of the latter in propositional language have occurred, notably in the temporal lobes, es- and a lack of interest in the emotional intonations pecially the dorsal area that relates to the auditory of speech (prosody) that give so much meaning to reception of speech. The expansion of primary and expression. association auditory cortices and their connections, The link between music and seems to associated with the increased size of the cerebel- have been accepted for all time. Plato con­sidered lum and areas of prefrontal and that music played in different modes would arouse linked through structures, heralded different , and as a generality most of us a shift to an aesthetics based on sound, and to abili- would agree on the emotional significance of any ties to entrain to external rhythmic inputs. The particular piece of music, whether it be happy or first used by our ancestors was sad; for example, major chords are perceived to be the voice. The ear is always open and, unlike vision cheerful, minor ones sad. The tempo or movement and the eyes or the gaze, sound cannot readily be in time is another component of this, slower music averted. From the rhythmic beating within and seeming less joyful than faster . This with the mother’s body for the fetus and young reminds us that even the word motion is a signifi- infant, to the primitive drum-like beating of sticks cant part of emotion, and that in the dance we are on wood and hand clapping of our adolescent and moving – as we are moved emotionally by music. adult proto-speaking ancestors, the growing infant Until recently, musical theorists had largely is surrounded by and responds to rhythm. But, as concerned themselves with the grammar and Langer (1951, p. 93) put it, ‘being more variable syntax of music rather than with the affective than the drum, voices soon made patterns and the experiences that arise in response to music. Music, long endearing melodies of primitive song became if it does anything, arouses feelings and associ- a part of communal celebration’. Some support ated physiological responses, and these can now for these ideas comes from the work of Mithen, be measured. For the ordinary listener, however, who has argued that spoken language and music there may be no necessary relationship of the evolved from a proto-language, a musi-language emotion to the form and content of the musical which stemmed from primate calls and was used work, since ‘the real stimulus is not the progressive by the Neanderthals; it was emotional but without unfolding of the musical structure but the subjec- words as we know them (Mithen, 2005). tive content of the listener’s mind’ (Langer, 1951, p. The suggestion is that our language of today 258). Such a phenomenological approach directly emerged via a proto-language, driven by gesture, contradicts the empirical techniques of so much framed by musicality and performed by the current neuroscience in this area, yet is of direct

BJPSYCH INTERNATIONAL VOLUME 14 NUMBER 2 MAY 2017 29 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 10:27:17, subject to the Cambridge Core terms of use. concern to psychiatry, and topics such as composi- motor function can actively facilitate the recovery tional creativity. of movement in patients with stroke, Parkinson’s If it is a language, music is a language of feeling. disease, cerebral palsy and traumatic brain injury Musical rhythms are life rhythms, and music with (Thaut, 2005). Studies of people with memory tensions, resolutions, crescendos and diminuendos, disorders, such as Alzheimer’s disease, suggest major and minor keys, delays and silent interludes, that neuronal memory traces built through with a temporal unfolding of events, does not music are deeply ingrained and more resilient present us with a logical language, but, to quote to neurodegenerative influences. Findings from Langer again, it ‘reveals the nature of feelings with individual randomised trials suggest that music a detail and truth that language cannot approach’ therapy is accepted by people with depression (Langer, 1951, p. 199, original emphasis). and is associated with improvements in mood This idea seems difficult for a philosophical disorders (Maratos et al, 2008). Further, the po- mind to follow, namely that there can be knowledge tential applications of music therapy in patients without words. Indeed, the problem of describing with neuropsychiatric dis­orders, including autism a ‘language’ of feeling permeates the whole area spectrum disorders, albeit intuitive, have led to of philosophy and neuroscience research, and psychotherapeutic uses aimed at directly evoking highlights the relative futility of trying to classify emotions. our emotions – ‘Music is revealing, where words Evidence suggests that music can decrease are obscuring’ (Langer, 1951, p. 206). seizure frequency, stop refractory status epilepti- cus and decrease electroencephalographic spike Musical ability and psychiatric disorder frequency in children with epilepsy in awake There is an extensive literature attesting to some and sleep states. We know that many people with associations between creativity and psychopathol- epilepsy have electroencephalographic abnormali- ogy (Trimble, 2007). The links seem to vary with ties and, in some people, these can be ‘normalised’ different kinds of high achievement, and mood by music. In addition to the need for trials of disorders are over-represented. Although samples musical interventions in epilepsy, we should also of creative people have a significant excess of cyclo­ consider whether the results of sonification of an thymia and bipolarity, florid manic–depressive electroencephalogram, which directly reflects the illness is relatively uncommon. Biographies of time course of cerebral rhythms, may be used to famous musicians are of considerable interest in entrain ‘normal’ brain rhythms in people with exploring brain–behaviour associations. Attempts seizure disorders. Alteration of the electroenceph- to transform descriptions of people from biogra- alogram via biofeedback of different components phies into specific DSM diagnoses cannot achieve of sonified electro­encephalography, or modulation high levels of validity and reliability, since lack of of the musical input to a stimulus that affects the autobiographical materials and reliable contem- emotional state of the patient and hence cerebral porary medical accounts makes any diagnostic and limbic activity and cerebral rhythms, are formulation necessarily tentative. However, with therapeutic possibilities which are currently being regard to classical composers within the Western investigated (Bodner et al, 2012). canon, it must be of considerable significance These data suggest that the effects and cost- that there are so many who seem to have suffered effectiveness of music therapy in patients with from affective disorders, the incidence of mood neuropsychiatric disorders should be further disorders ranging between 35% and 40% (Mula & explored. To date, most work has been done with Trimble, 2009). It is possible that similar associa- Western-style compositions, and the well structured tions occur in non-Western composers, although music of Mozart and Bach has been a popular basis studies have not been published. In contrast, none for interventions. The following paper by Shantala seems to have had schizophrenia. These results Hegde notes the potential of other musical styles have importance in understanding the structure as therapy. Through music we learn much about and function of the human brain, and suggest our human origins and the human brain, and have avenues for therapeutic investigation which will a potential method of therapy by accessing and vary with diagnosis. stimulating specific cerebral circuits. Music therapy References Music provides and provokes a response, which is Blood, A. J., Zatorre, R. J., Bermudez, P., et al (1999) Emotional responses to pleasant and unpleasant music correlate with activity universal, ingrained into our evolutionary develop­ in paralimbic brain regions. Nature Neuroscience, 2, 382–387. ment, and leads to marked changes in emotions Bodner, M., Turner, R. P., Schwacke, J., et al (2012) Reduction and movement. The anatomical associ­ations of seizure occurrence from exposures to auditory stimulation in noted above suggest that music must be viewed as individuals with neurological handicaps: a randomized controlled trial. PLoS One, 7, e45303. one way to stimulate the brain. Music provides a non-invasive technique, which has attracted much Langer, S. K. (1951) Philosophy in a New Key. Harvard University Press. interest but little empirical exploration to date. The Maratos, A. S., Gold, C., Wang, X., et al (2008) Music therapy therapeutic value of music can be in part explained for depression. Cochrane Database of Systematic Reviews, (1), by its cultural role in facilitating social learning CD004517. and emotional well-being. However, a number of Mithen, S. (2005) The Singing Neanderthals. Weidenfeld and studies have shown that rhythmic entrainment of Nicholson.

30 BJPSYCH INTERNATIONAL VOLUME 14 NUMBER 2 MAY 2017 Downloaded from https://www.cambridge.org/core. 01 Oct 2021 at 10:27:17, subject to the Cambridge Core terms of use. Mula, M. & Trimble, M. R. (2009) Music and madness: Thaut, M. H. (2005) The future of music in therapy and medicine. neuropsychiatric aspects of music. Clinical Medicine, 9, 83–86. Annals of the New York Academy of Science, 1060, 303–308. Pasternak, C. (2007) What Makes Us Human. One World. Trimble, M. R. (2007) The Soul in the Brain: The Cerebral Basis of Language, Art and Belief. Johns Hopkins University Press. Stewart, L., von Kriegstein, K. & Warren, J. D. (2006) Music and the brain: disorders of musical listening. Brain, 129, 2533–2553. Trimble, M. R. (2012) Why Humans Like to Cry. Tragedy, Evolution and the Brain. Oxford University Press.

Music therapy for mental disorder and THEMATIC PAPER mental health: the untapped potential of Indian classical music Shantala Hegde

Neuropsychology Unit and Cognitive and Music is a universal human trait. The healing are combined. Certain notes in the ragas are con- Cognitive Neurosciences Laboratory, Department of power of music has been acknowledged in sidered crucial. The most important note is called Clinical Psychology, National almost all traditions of music. Music therapy the vadi-swar and the second most important note Institute of Mental Health and is moving from a social-science model Neurosciences, Bangalore, India, is called the samvadi-swar. Each raga has a unique email shantala.hegde@gmail. focusing on overall health and well-being melodic line, like a signature tune or motif, which com towards a neuroscience model focusing on is called the pakkad. Each raga is associated with a specific elements of music and its effect on specific affective theme rasa( or ras, a Sanskrit word sensorimotor, language and cognitive functions. meaning ‘the essence’). Ragas are said to evoke The handful of evidence-based music therapy one or more of these emotions (sadness, romance, studies on psychiatric conditions have shown peace, strength/courage, anger, devotion, longing, promising results. Traditional music, such as passion). Indian classical music, has only recently been Expression of the raga-rasa aspect is considered evaluated in evidence-based research into music the primary goal in ICM, and this expression is therapy. The need for systematic research in this intended to vary dynamic­ally during performance. area is underscored. The presentation of the raga in ICM therefore evolves over time, in various stages (alap, jhor-jala, gat, vilambit, dhrut) and dimensions. Variations are introduced not only in the melodic impro­visa­tion, An overview of Indian classical music but also in the composition, tempo and complex Music, like language, is a ubiquitous human trait. rhythmic cycle. Like any other art form, music has always been A study investigating the variations in emotional viewed from an aesthetic perspective and its experience during the different phases of raga healing power has been documented in various elaboration found that emotional variations within traditions of music across the world. Indian classi- certain ragas were often larger than between cal music (ICM) is perhaps one of the oldest forms ragas. Indian classical musicians have the ability of music. It dates back to the ancient scriptures of to strongly vary the expressivity associated with India, the Vedas (dated around 5000–2000 BC), a specific raga in their performances, but within and is said to have originated from one of the four the constraints of the raga framework (Hegde et al, Vedas, the Samaveda. The Vedas consist of verses 2012). in Sanskrit for chanting. The two present forms In an (EEG) study, 20 of ICM, known as north Indian classical music musically untrained individuals listened to NICM (or Hindustani classical music) (NICM) and south ragas; they showed increased overall alpha, delta Indian classical music (or Carnatic classical music) and theta power in comparison with an eyes-closed branched out from the same tradition around the rest condition. The observed changes during music 13th century AD. Ragas (from the Sanskrit phrase listening had previously been linked with highly ranjayiti iti ragaha), meaning ‘one which induces relaxed states, such as meditative states (Hegde et emotion in the mind’, and taal (a rhythmic struc- al, 2012). Listening to certain ragas, for example ture and cycle) form the core of ICM. The ragas ‘Desi-todi’, for 30 minutes every day for 20 days provide the framework for melodic elaboration has been shown to produce a significant decrease and are defined as a melodic basis for compositions in systolic and diastolic blood pressure, to reduce and improvisations (Jairazbhoy, 1995). There are stress, anxiety and depression, and to enhance hundreds of ragas in these two traditions. Each feelings of life satisfaction, experience of hope and raga has specific notes swar( ) for ascending and de- optimism. Changes in heart rate were much more scending, and a specific manner in which the notes evident in females than males (Gupta & Gupta,

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