Limbic Music: The Band Plays On

Introduction

First appearing in 1987 in an internally published collection of essays celebrating the 50th anniversary of the Massachusetts General Hospital Department of Psychiatry, George Murray's “Limbic Music” is a rare example of the medical literature producing actual literature . Its synthesis of neuroscience, philosophy, clinical wisdom, and engaging writing was, like Dr. Murray himself, unique. Subsequent versions of that essay in the journal Psychsomatics , and in every edition of this Handbook , inspired many psychiatrists' career paths and practice patterns.

Dr. Murray retired a year after the last edition of this book was published, and he died 2 years later. Those of us left with the daunting task of carrying on his tradition of “Limbic Music” urge (or even toothlessly command) the reader to track down and read one of its past incarnations. What follows here is less an update, sequel, or remix of the preceding “Music” than a song heavily inspired by earlier work. One does not discard a Miles Davis record when another trumpeter tests out his chops on a new album. The former makes the latter possible and perhaps even part of something bigger than it otherwise would or could be on its own. As justification for his 1990 publication of “Limbic Music” in Psychosomatics , Dr. Murray reproduced a letter of encouragement from his mentor, Dr. Thomas Hackett. We, in turn, offer up Figure 6-1 as proof of permission and pedigree for this effort.

This chapter inherits a few core iterative themes from that pedigree. First, the limbic system concept is advanced here in a way that bucks against an intellectual bias that privileges “higher” (read: “cortical”) cognitive functions over “lower” (read: “primitive”) emotional, conditioned, and instinctive functions in routine and aspirational human life. Second, important parts of our individual and shared existences go on outside of conscious awareness; it is important for psychiatrists to understand some of the anatomic, philosophical, and psychological ideas that expand this truth beyond more prosaic teaching about the “unconscious.” Third, to the alert, this knowledge presents opportunities to access the limbic domain, and an imperative to respect it.

Why Limbic Music?

Why introduce, let alone carry forward, “Limbic Music” in this text? One cannot justify attention to the limbic system with a trite, “because it's there,” since for more than four decades there has been debate over whether or not it is —but more on that to come. Instead, the limbic system and the Limbic Music concept provide a site where philosophy, psychology, and biology can co-mingle in ways that are clinically practical. Make no mistake, though; while the limbic system is fertile scientific ground, its clinical usage in this chapter does not always reflect 100% established brain–behavior relationships.

Dr. Murray made no bones about his paper being “primarily heuristic.” Some aspects of Limbic Music stray into the realm of metapsychology. Describing an emotionally detached, hyper-rationalized person as an “overgrown neocort” or a mercurial, shallow thinker as a “thin-layer neocort” exemplifies the descriptive utility of indulging in neuroanatomic metaphor. However, couching meta-psychology in the jargon of neuroscience does not make it ipso facto real. It is easy to find “skeptics and enthusiasts in neuropsychiatry.” Hyman notes the prematurity of claims sometimes staked by those willing to extrapolate from current neuroscience a complete lack of free will in those who suffer from addictions, and Uttal arguably puts the lie to a neuroscience of “love” being ready for pedagogic prime time in psychiatry training. On the other hand, skepticism is mobilized by some in the ironic service of defending their own non-biologically referent meta-psychologies (e.g., psychodynamics).

Limbic Music favors neuroanatomically referenced explanations, does not shy away from potential accusations of “dualism,” but also recognizes that brain-based explanations are meaningless unless attached to the outside world as understood through psychology and philosophy. Stretching the music metaphor, Limbic Music treats these sometimes adversarial ways-of-understanding like the treble and bass clefs. A holist might see them (correctly) as artificially dividing up the unity of musical notes. But it does not take a dualist to see that some instruments, not to mention our bodies, are constructed such that composition, performance, and appreciation demand that the clefs sometimes be cleft. The same goes for mind–body, bio-psycho-social, and other ways of thinking about, interacting with, and treating our patients.

So why privilege the brain, let alone the limbic system? Because it is the target organ of our specialty, because the explanation of disease through biological theory is the distinguishing trait of the Western medical tradition of which psychiatry is part, and because cognitive neuroscience is marching inexorably toward validating a materialist, brain-based understanding of psychological phenomena. Some would argue that, for clinicians, this understanding can be achieved without using the brain as an intermediary. Those arguing otherwise need to be wary of pushing their luck further than contemporary neuroscience can support. However, even (misguidedly) putting aside the neglected need for greater neuropsychiatric competency among psychiatrists, an everyday, pragmatic biological model of unconscious processes, which is the essence of Limbic Music, does not get much air time.

Most other models of mind that incorporate unconscious elements (e.g., ego psychology, object relations theory, self-psychology) are taught with reference to their respective psychotherapies. Infrequent exceptions do exist, and, interestingly, tend to appear in the psychosomatic literature. Limbic Music fills a void that even these approaches to personality/coping categorization and life narratives cannot. That is, Limbic Music, like any music, need not serve a preconceived function. It may, as with other approaches, lead to a formulation or an intervention, but it is playing, and can be played, from the very start of a clinical interaction. Dr. Murray enjoyed using “limbic probes” ( Table 6-1 ), which can be used to elicit “squelched” affect, test hunches, convey understanding, hold an emotional mirror up to the patient, demonstrate what cannot be tolerated if spoken aloud, comfort, or even strategically antagonize a patient. Mental health professionals often speak of using themselves as instruments; Limbic Music augments this idea by making the model itself an instrument. Not just that, it embraces the uncertainty principle by which that instrument simultaneously takes the measure of and influences (or, some would say, manipulates) the patient.

What Is Limbic Music?

As we will later see about the limbic system itself, Dr. Murray's definition of limbic music was simultaneously fuzzy edged and potent. “ Limbic music is a term that denotes the existential, clinical raw feel emanating from the patient. It is a truer rendering of the patient's clinical state than is articulate speech.” It arises from processes that subserve, among other things, survival-related functions, and exert their effects via neuroanatomic structures and pathways that bypass downstream association cortex. This definition partially recalls Paul MacLean's initial proposals of the “visceral brain,” for which he later coined the term, “limbic system” (note: earlier usage of the term “limbic,” by Willis and Broca referred to the “border,” or limbus, formed by the cingulate and parahippocampal gyri around the corpus callosum and rostral brainstem). MacLean entertained the possibility that the limbic system is “not at all unconscious … but rather eludes the grasp of the intellect because its animalistic and primitive structure makes it impossible to communicate in verbal terms.” He connected the intellect with “the word brain.”

While agreeing in principle about a language-limbic disconnect, Dr. Murray bristled (or worse) at the depiction of the limbic system as “animalistic and primitive.” He had disdain for an “Olympian” view of humans as ideally and uniquely rational creatures who are at their best when suppressing their limbic urges. The lofty viewpoint finds some loose correspondence between MacLean's “triune brain,” with its reptilian complex, paleomammalian complex (corresponding to his concept of the limbic system), and neomammalian complex, and Plato's tripartite soul with its appetitive, spirited, and rational parts (and perhaps even Freud's id, ego, and superego).

Evolution and Western philosophy thus seem to grade our humanity and morality based on our respective rational:emotive ratios. However, this view comes under fire not only from 30 years of “Limbic Music,” but also from figures in contemporary philosophy, psychology, and neuroscience. Plato himself saw his tripartite soul as optimally operating in harmony with itself, not necessarily as a constant top-down hierarchy. Lakoff and Johnson, in their book, Philosophy in the Flesh , make a compelling case against a Western philosophical tradition that views conscious reason as the defining feature of humanity and the measuring stick of virtue. They note that “abstract reason builds on and makes use of forms of perceptual and motor inference present in ‘lower’ animals.” Meanwhile, “we think of our ‘higher’ (moral and rational) selfstruggling to get control over our ‘lower’ (irrational and amoral) self.” Yet these ideas, and that of “thought-as-language” are really metaphors for a brain that is largely operating outside of our own awareness.

The “psychological unconscious” as a major influencer of human behavior takes several forms, many, if not most, of which are subsumed under the functions of the limbic system. Khilstrom identifies many of these, bringing to light that the psychological unconscious can even include some highly complex cognitive processes. These bleed into the realm of emotion in cases of prosopagnosia, where patients with downstream visual association cortex lesions or disconnection syndromes can still feel affective responses to faces they do not consciously recognize, likely due to preserved connections between (relatively) upstream visual association cortex and limbic and paralimbic areas. In “desynchrony,” behavioral or physiological correlates of emotion are expressed without the agent being consciously aware of what is occurring.

Moving from psychology to metapsychology, the prosopagnosia situation described above is not too far afield from transference reactions. We can easily view the latter as “limbic” responses, through one or more of the consciousness-bypassing routes cited below, to incomplete information with enough valence to activate the bypass connections. Desynchrony is seen every day in what is often casually brushed aside by psychiatrists and patients as a “nervous laugh” (both parties conveniently not registering that these quick chuckles sometimes sound more sadistic than nervous). Most often bubbling up from the limbic depths when the conversation edges towards anger or fear (begging for speculation on the role of the amygdala), these laughs demand that the interviewer make quick decisions about whether or not to bring them to light and/or continue the line of inquiry that elicited them. “Higher”-level cortex may be your friend or enemy here, playing dumb or clamping down on a limbic system that has shown too much of its hand (a state, when persistent, referred to by Dr. Murray as “ineluctable bepissment” and signaling a smoldering, long-suffering state), surrendering to the gratification and peril of opening the floodgates of rage, or being guided to a state of Platonic harmony where true feelings and “cortical squelch” can co-exist in a state of well-modulated honesty.

Habib Davanloo's Intensive Short Term Dynamic Psychotherapy indirectly exemplifies many of the points just raised. Davanloo's approach touches upon neurophysiology, including involuntary motor responses and autonomic nervous system activity, in listening for Limbic Music (though he does not use the term), and making decisions about what to do with it. In his “central dynamic sequence,” the patient's laughter might be met with light pressure (“You just laughed while telling me how difficult your husband is. Did you notice that?”) that is incrementally increased (“You just did it again. Do you always laugh when you are starting to talk about something uncomfortable?” “And there it is again. Why are you putting up this wall?”), or decreased depending on responses that range from modulated but honest emotion, to hyper-rationalization, to autonomic dyscontrol (e.g., how many times have you had an emotionally intense consultation interrupted by borborygmi and the patient's departure to the bathroom?). In Davanloo's work, we see a model that, removed from its formal psychotherapeutic context and translated via the concept of Limbic Music, can be used in a multitude of ways in the interactions and assessments of routine consultation psychiatry. The same could be done with many other psychotherapeutic approaches.