Brief: Patient Presentation and Self-Constructed Causal Model

#!/usr/bin/env python3
"""Build the MES/MdDS causal model evidence review document for neurology consultation."""

from docx import Document
from docx.shared import Pt, Inches, RGBColor
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.enum.table import WD_TABLE_ALIGNMENT
from docx.oxml.ns import qn
from docx.oxml import OxmlElement

GREEN = RGBColor(0x1E, 0x7D, 0x32)
AMBER = RGBColor(0xB8, 0x86, 0x00)
RED = RGBColor(0xB0, 0x2A, 0x2A)
GRAY = RGBColor(0x59, 0x59, 0x59)
NAVY = RGBColor(0x1F, 0x33, 0x55)

def shade_cell(cell, hex_color):
    tcPr = cell._tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), hex_color)
    tcPr.append(shd)

def set_col_widths(table, widths):
    for row in table.rows:
        for idx, w in enumerate(widths):
            row.cells[idx].width = w

def add_rating_cell(cell, text, color):
    cell.text = ""
    p = cell.paragraphs[0]
    p.alignment = WD_ALIGN_PARAGRAPH.CENTER
    run = p.add_run(text)
    run.bold = True
    run.font.color.rgb = color
    run.font.size = Pt(9.5)

def add_body_cell(cell, text, bold=False, size=9.5):
    cell.text = ""
    p = cell.paragraphs[0]
    run = p.add_run(text)
    run.font.size = Pt(size)
    run.bold = bold

def header_row(table, headers, widths):
    hdr = table.rows[0]
    for i, h in enumerate(headers):
        hdr.cells[i].text = ""
        p = hdr.cells[i].paragraphs[0]
        run = p.add_run(h)
        run.bold = True
        run.font.size = Pt(9.5)
        run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
        shade_cell(hdr.cells[i], "1F3355")
    set_col_widths(table, widths)

doc = Document()

style = doc.styles["Normal"]
style.font.name = "Calibri"
style.font.size = Pt(11)

sections = doc.sections
for s in sections:
    s.top_margin = Inches(0.6)
    s.bottom_margin = Inches(0.6)
    s.left_margin = Inches(0.7)
    s.right_margin = Inches(0.7)

# ---------- Title block ----------
title = doc.add_paragraph()
title.alignment = WD_ALIGN_PARAGRAPH.CENTER
r = title.add_run("Evidence Review: MES / MdDS Causal Model")
r.bold = True
r.font.size = Pt(20)
r.font.color.rgb = NAVY

sub = doc.add_paragraph()
sub.alignment = WD_ALIGN_PARAGRAPH.CENTER
r = sub.add_run("Established vs. Speculative Claims — Prepared for Neurology Consultation")
r.italic = True
r.font.size = Pt(12.5)
r.font.color.rgb = GRAY

meta = doc.add_paragraph()
meta.alignment = WD_ALIGN_PARAGRAPH.CENTER
r = meta.add_run("Companion review of 'MES Recovery v4' and 'MES Clinical Reference — Neurologist' documents  |  August 2026")
r.font.size = Pt(9.5)
r.font.color.rgb = GRAY

doc.add_paragraph()

# ---------- Purpose ----------
h = doc.add_heading("Purpose of This Document", level=1)
h.runs[0].font.color.rgb = NAVY
p = doc.add_paragraph(
    "The patient has developed a detailed, internally consistent mechanistic model explaining the onset, "
    "maintenance, and proposed treatment of his Musical Ear Syndrome (MES) and Mal de Débarquement Syndrome "
    "(MdDS), documented across two prior reference files. This summary separates the model into components "
    "that are supported by established neuroscience/pharmacology literature versus components that are the "
    "patient's own extrapolation, inference, or unverified causal reasoning. It is intended to help focus the "
    "consultation on decisions that matter clinically, rather than adjudicating every mechanistic detail."
)
p.runs[0].font.size = Pt(10.5)

# ---------- Legend ----------
h = doc.add_heading("Rating Legend", level=2)
h.runs[0].font.color.rgb = NAVY
legend_table = doc.add_table(rows=1, cols=3)
legend_table.style = "Table Grid"
hdr = legend_table.rows[0]
labels = [("ESTABLISHED", GREEN, "Consistent with textbook / peer-reviewed sources"),
          ("PARTIALLY SUPPORTED", AMBER, "Real hypothesis in the literature, but contested or not validated for this specific case"),
          ("SPECULATIVE / UNVERIFIED", RED, "Patient-generated extrapolation with no direct literature support")]
for i, (lab, color, desc) in enumerate(labels):
    cell = hdr.cells[i]
    cell.text = ""
    p1 = cell.paragraphs[0]
    run = p1.add_run(lab)
    run.bold = True
    run.font.color.rgb = color
    run.font.size = Pt(9.5)
    p2 = cell.add_paragraph()
    run2 = p2.add_run(desc)
    run2.font.size = Pt(8.5)
    run2.font.color.rgb = GRAY

doc.add_paragraph()

# ---------- Patient Summary ----------
h = doc.add_heading("1. Patient Summary", level=1)
h.runs[0].font.color.rgb = NAVY

summary_items = [
    ("Chief complaint", "Complex auditory hallucinations ('Musical Ear Syndrome') — 16-17 months, evolved from "
     "instrumental music to complex chorus singing in an unknown language."),
    ("Timeline", "Clonazepam cessation Dec 13, 2024 → MES onset ~March 2025 (month 3 post-cessation). "
     "Currently 50+ days into a self-directed magnesium-glycinate-lysinate taper (~78% removed)."),
    ("Comorbidities", "Mal de Débarquement Syndrome (MdDS, recurrent since childhood, re-triggered 2024/2025); "
     "moderate sensorineural hearing loss; hyperacusis."),
    ("Drug sensitivity history", "Carbamazepine (linked by patient to a 2.5-month MdDS episode); lamotrigine "
     "11mg (linked to 2 weeks of MES spikes); magnesium L-threonate (linked to a persistent right-ear tone); "
     "quetiapine declined by patient."),
    ("Requests for this visit", "Neurologist input on a proposed levetiracetam trial, taper safety, lamotrigine "
     "as second-line, continued mirtazapine use, and perampanel as a potential adjunct."),
]
for label, text in summary_items:
    p = doc.add_paragraph(style="List Bullet")
    r1 = p.add_run(f"{label}: ")
    r1.bold = True
    r1.font.size = Pt(10.5)
    r2 = p.add_run(text)
    r2.font.size = Pt(10.5)

doc.add_paragraph()

# ---------- Established ----------
h = doc.add_heading("2. Established Mechanisms (Textbook / Peer-Reviewed Support)", level=1)
h.runs[0].font.color.rgb = NAVY

established = [
    ("Glycine is an obligatory NMDA receptor co-agonist alongside glutamate; without glycine binding, channel "
     "opening does not occur.",
     "Goodman & Gilman's Pharmacological Basis of Therapeutics, p.448; Miller's Anesthesia, 10e"),
    ("Benzodiazepines are positive allosteric modulators of GABA-A receptors; chronic use produces "
     "neuroadaptation (GABA-A downregulation, compensatory glutamatergic upregulation) that is unmasked on "
     "dose reduction/cessation — the accepted mechanism of benzodiazepine withdrawal syndrome.",
     "The Maudsley Deprescribing Guidelines, 'Pathophysiology of Benzodiazepine Withdrawal Syndrome', p.553"),
    ("Chronic benzodiazepine exposure directly increases NMDA receptor activity in preclinical models "
     "(supports a withdrawal-related glutamatergic rebound).",
     "Chapman et al., Neuropharmacology 2025 (PMID 40754183)"),
    ("NR2B-containing NMDA receptors have distinct pharmacological properties (higher glycine affinity, "
     "longer channel open times) versus NR2A-dominant receptors — general receptor pharmacology, not case-specific.",
     "Standard NMDA receptor subunit pharmacology (anesthesia/pharmacology texts)"),
    ("Mirtazapine's receptor profile (5-HT2A antagonism, H1 antagonism) and its effect on slow-wave sleep "
     "restoration are accurately described.",
     "Standard psychopharmacology references"),
    ("Sodium-channel blockers can show inactivated-state/use-dependent selectivity, preferentially affecting "
     "pathologically hyperactive (rapidly firing) circuits over normal circuits — a real pharmacological property.",
     "Standard anticonvulsant pharmacology"),
    ("MdDS core model: maladaptation of the vestibulo-ocular reflex and central 'velocity storage' mechanism "
     "after motion exposure, with symptom relief during re-exposure to movement.",
     "Cummings Otolaryngology–Head & Neck Surgery; K.J. Lee's Essential Otolaryngology; Mucci et al. 2020 "
     "(PMC7683778)"),
    ("Quetiapine/antipsychotics are frequently ineffective for MES because it is a non-psychotic, "
     "non-dopaminergic phenomenon — declining antipsychotic treatment on this basis is a defensible position.",
     "PMC review, 'Frequently Seen But Rarely Diagnosed: Musical Ear Syndrome' (PMC5353248)"),
]

t = doc.add_table(rows=1, cols=2)
t.style = "Table Grid"
header_row(t, ["Claim", "Source / Basis"], [Inches(4.3), Inches(2.5)])
for claim, src in established:
    row = t.add_row()
    add_body_cell(row.cells[0], claim)
    add_body_cell(row.cells[1], src, size=8.5)
    for c in row.cells:
        shade_cell(c, "EAF5EA")

doc.add_paragraph()

# ---------- Partially supported ----------
h = doc.add_heading("3. Partially Supported / Contested Hypotheses", level=1)
h.runs[0].font.color.rgb = NAVY
p = doc.add_paragraph("These are real, actively-studied ideas in the literature, but they are not validated "
                       "specifically for benzodiazepine-withdrawal MES, or remain debated even in their original "
                       "context.")
p.runs[0].font.size = Pt(10)
p.runs[0].italic = True

partial = [
    ("Thalamocortical dysrhythmia (TCD) as the mechanism underlying phantom sound perception (tinnitus) and "
     "chronic neuropathic pain.",
     "Real, ongoing research hypothesis (Kaplan & Sadock's Comprehensive Textbook of Psychiatry; PMID 40945543, "
     "40503593, 39505139, 34608267 — 2024-2025). Not yet an established, validated mechanism specifically for "
     "musical/complex auditory hallucinations in benzodiazepine withdrawal — this is an analogical extension by "
     "the patient, not a documented finding."),
    ("A GABA-deficit contribution to MdDS pathophysiology, layered onto the velocity-storage model.",
     "A GABA/CGRP theory has been proposed (Mucci et al. 2018) but is one hypothesis among several, not the "
     "consensus mechanism."),
    ("Framing MES and MdDS as sharing a single underlying vulnerability (thalamocortical dysrhythmia from "
     "combined GABA deficit + NMDA upregulation) that differs only by circuit.",
     "No literature source directly links these two conditions through a shared TCD/NMDA mechanism — this is "
     "the patient's own synthesis of two separately-studied hypotheses."),
]
t = doc.add_table(rows=1, cols=2)
t.style = "Table Grid"
header_row(t, ["Claim", "Status"], [Inches(3.6), Inches(3.2)])
for claim, src in partial:
    row = t.add_row()
    add_body_cell(row.cells[0], claim)
    add_body_cell(row.cells[1], src, size=8.5)
    for c in row.cells:
        shade_cell(c, "FCF3DA")

doc.add_paragraph()

# ---------- Speculative ----------
h = doc.add_heading("4. Speculative / Unverified Claims", level=1)
h.runs[0].font.color.rgb = NAVY
p = doc.add_paragraph("These claims carry a false sense of precision (specific percentages, ratios, timing "
                       "windows) that is not derivable from symptom history or supplement records, and are not "
                       "found in any textbook or peer-reviewed source reviewed.")
p.runs[0].font.size = Pt(10)
p.runs[0].italic = True

speculative = [
    "Mainstream literature attributes MES primarily to auditory deafferentation/sensory deprivation from "
    "hearing loss, and explicitly states the precise mechanism is unknown (Cleveland Clinic; PMC5353248). The "
    "patient's benzodiazepine-withdrawal/glycine-threshold narrative is a personal causal model layered on top "
    "of — and not equivalent to — the mainstream explanation.",
    "Magnesium glycinate identified as the specific 'threshold-crossing' agent that generated the MES network, "
    "including a stated glycine:magnesium molecular ratio (6.18:1) used to support the causal claim.",
    "Quantified NR2B receptor 'dominance' and receptor density estimates attributed to this patient's own "
    "nervous system.",
    "A specific 15-month timeline for Hebbian consolidation 'migrating' MES maintenance from NMDA-dependent to "
    "AMPA-dominant.",
    "Precise dose-timing pharmacokinetic claims (e.g., glycine peak at 7:15-7:30 PM, dissipation before sleep "
    "onset) presented as an established basis for retiming supplement dosing.",
    "Carbamazepine's HCN-channel activity specifically causing the patient's 2.5-month MdDS episode.",
    "Magnesium L-threonate causing a 'right ear tone' via acute CNS-specific magnesium elevation misinterpreted "
    "by the nervous system as reduced NMDA activity.",
    "Taper-related sensitivity attributed to three named mechanisms (unmasking, reduced Mg2+ channel block, "
    "reduced GABAergic support) presented as a corrected/proven model rather than a working hypothesis.",
    "Levetiracetam and perampanel proposed as targeted treatments for 'AMPA-consolidated' MES — there is no "
    "clinical evidence base for either agent in musical/complex auditory hallucinations; this is an extrapolated "
    "trial proposal from general AMPA/glutamate pharmacology, not a documented indication.",
]
for s in speculative:
    p = doc.add_paragraph(style="List Bullet")
    run = p.add_run(s)
    run.font.size = Pt(10)

doc.add_paragraph()

# ---------- Overall assessment ----------
h = doc.add_heading("5. Overall Evidence Assessment", level=1)
h.runs[0].font.color.rgb = NAVY

p = doc.add_paragraph()
r = p.add_run("Approximate composite: ")
r.bold = True
r.font.size = Pt(11)
r2 = p.add_run("~30-40% of the causal model rests on established, verifiable neuroscience/pharmacology. The "
               "remaining ~60-70% is plausible-sounding but clinically unverified extrapolation, presented with "
               "a level of quantitative precision that exceeds what can be known from symptom history and "
               "supplement records alone.")
r2.font.size = Pt(10.5)

p = doc.add_paragraph()
r = p.add_run("Note: ")
r.bold = True
r.italic = True
r.font.size = Pt(10)
r2 = p.add_run("This percentage is a qualitative synthesis for discussion purposes, not a validated metric. The "
               "individual building-block facts (receptor pharmacology, withdrawal physiology, MdDS "
               "vestibular model) are accurate; it is primarily the disease-specific causal chain connecting "
               "them to this patient's case that is unverified.")
r2.font.size = Pt(9.5)
r2.font.color.rgb = GRAY

doc.add_paragraph()

# ---------- Discussion points ----------
h = doc.add_heading("6. Suggested Discussion Points for This Visit", level=1)
h.runs[0].font.color.rgb = NAVY

discussion = [
    "Ask the neurologist to independently characterize the likely mechanism of MES in this case, rather than "
    "confirming or refuting the patient's pre-built model point-by-point.",
    "Clarify whether thalamocortical dysrhythmia is being invoked as an established diagnosis or as one "
    "plausible framework among several for documentation/prescribing purposes.",
    "Review taper safety and pace independent of the specific 'unmasking vs. upregulation' framing.",
    "Discuss levetiracetam/lamotrigine/perampanel based on their approved indications and general risk profile, "
    "rather than the patient's AMPA/NMDA staging model.",
    "Consider flagging, supportively, the degree of granular self-generated mechanistic detail (exact "
    "percentages, ratios, minute-level timing) as worth exploring in its own right — independent of the "
    "auditory symptoms — given it may be shaping treatment decisions more than the clinical picture warrants.",
]
for d in discussion:
    p = doc.add_paragraph(style="List Number")
    run = p.add_run(d)
    run.font.size = Pt(10.5)

doc.add_paragraph()
footer = doc.add_paragraph()
footer.alignment = WD_ALIGN_PARAGRAPH.CENTER
r = footer.add_run("Prepared as a supporting reference for clinical discussion — not a substitute for independent neurological assessment.")
r.italic = True
r.font.size = Pt(8.5)
r.font.color.rgb = GRAY

doc.save("/tmp/workspace/mes-neurology-summary/output/MES_MdDS_Evidence_Review.docx")
print("Saved.")