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Musical hallucinations and the psychiatric approach 

22 Sep 2021

  • Researcher highlights need for comprehensive analysis of uncommon phenomena
By Ruwan Laknath Jayakody  Since certain patients present to psychiatric health services with both rare clinical phenomena and common clinical conditions, there is a need for psychiatric healthcare services to conduct a comprehensive assessment, liaise with other specialties when dealing with unusual presentations and be aware of the uncommon phenomenology associated with psychiatric disorders. This suggestion was made in the case of a local presentation of musical hallucinations, which is an extremely rare clinical phenomenon, which could only be definitively diagnosed upon the exclusion of common clinical conditions associated with auditory hallucinations.  This recommendation was made in a case report on “Musical hallucinations” by R. Weerasundera which was published in the Sri Lanka Journal of Psychiatry’s Fourth Volume’s First Issue in July 2013.  Background  Hallucinations are defined, per J.E.D. Esquirol’s “Des maladies mentales” as a thorough conviction about a perception of a sensation when no external object, suited to excite the said sensation, has impressed the senses. With regard to auditory hallucinations, G.R. Lowe noted in “The phenomenology of hallucinations as an aid to differential diagnosis” that while they are a common sensory modality, its diagnosis is determined for the most part through its content, the presence or absence of organic pathology and the level of insight. Auditory hallucinations are associated with a spectrum of acute and chronic organic disorders such as delirium, which is described as a state of mental disturbance characterised by confused thinking and disrupted attention usually accompanied by disordered speech and hallucinations; dementia, which is described as a group of symptoms severely affecting the memory, thinking and social abilities to the extent that it interferes with the patient’s daily life; cerebral infections, which are an invasion of the brain tissues by a pathogenic organism; focal brain/neurological lesions, which are problems with nerves, the spinal cord, or the brain function that affects a specific location; brain neoplasms, or tumours; intoxication; and withdrawal from substances (G.L. Fricchione, L. Carbone and W.I. Bennett’s “Psychotic disorder caused by a general medical condition, with delusions: Secondary ‘organic’ delusional syndromes”). That said, musical hallucinations composed of instrumental music or songs, and occurring in isolation, are, S. Evers and T. Ellger pointed out in “The clinical spectrum of musical hallucinations”, an extremely rare phenomenon.  Hence, Weerasundera narrated a case report of an elderly (84-year-old) female widow presenting with musical hallucinations; however, with no other demonstrable pathology related to the symptoms.  Case study  The woman in question presented with the complaint of hearing music and the singing of hymns similar to those sung at her wedding over a half a century ago, over the course of several weeks. Though the experience was pleasant to her, she had sought intervention since the persistence of the symptoms was distracting her from engaging in other tasks.  She had been a widow for over 20 years and had been living on her own since. She had three adult children, and as a mother, enjoyed good relationships with them. She had no past psychiatric history. Her medical co-morbidities included hypertension, where she had high blood pressure; hypothyroidism, where her thyroid gland was not producing sufficient thyroid hormone; and osteoporosis, where low bone mass and the deterioration of bone tissue leads to increased bone fragility. She was being medicated for all three conditions. Although a few weeks prior to her presentation, she had suffered an upper respiratory tract infection, her medical history immediately preceding her presentation was otherwise unremarkable.  On assessment, she was found to be pleasant. Her distress due to her symptoms was confined to being distracted from other tasks. Her speech was relevant and coherent, and she was euthymic, where she was in a state of living without mood disturbances. There were no other perceptual disturbances or other psychotic phenomena. She was well oriented with no evidence of cognitive impairment. She was aware that hearing musical sounds was unusual, was puzzled by this and was seeking an explanation, reassurance and intervention for her symptoms. Physical examination, including an ear examination revealed no abnormalities.  When investigation tests were conducted, the results were unremarkable except for a slightly elevated thyroid stimulating hormone level. A computerised tomography scan, which is a diagnostic imaging test used to create detailed images of internal organs, of the brain, revealed small vascular (relating to vessels) infarcts (obstruction of the blood supply to an organ or region of tissue, in turn causing the local death of the tissue) in the temporal region (a lobe which is close to the ear level within the skull which is largely responsible for creating and preserving both conscious and long term memory), which were unlikely to be of recent origin. It was established that there was no neurological or ear, nose and throat pathology that the symptoms could be attributed to. Psychiatric diagnoses such as delirium, dementia and late onset schizophrenia, which is a psychosis in which a person cannot tell what is real from what is imagined, were considered and excluded in the absence of their respective supporting clinical features. Even though the thyroxine dose was increased and her euthyroid (the state of having normal thyroid gland function) status was restored, the symptoms persisted.  The patient was commenced on an atypical antipsychotic medication, daily. The initial response was satisfactory with the hallucinations diminishing in frequency and intensity. However, they re-emerged after a few weeks. She was then commenced on a different atypical antipsychotic, daily, and has since remained symptom-free.  Musical hallucinations  According to G.E. Berrios’s “Musical hallucinations. A historical and clinical study”, auditory hallucinations characterised by songs, tunes, melodies and rhythms are deemed musical hallucinations.  Even though there is no accepted classification of musical hallucinations per Evers and Ellger, the condition is, as explained in J.D. Blom’s “A dictionary of hallucinations” described as the musical ear syndrome, musical hallucinosis, the Oliver Sacks (neurologist) syndrome and the auditory Charles Bonnet (writer) syndrome. Blom further notes that in the absence of other pathology, musical hallucinations as an isolated symptom are rare, with less than 150 reported cases.  Musical hallucinations are more commonly  associated with hearing impairment, epilepsy and psychosis as per M.S. Keshavan, A.S. Davis, S. Steingard and W.A. Lishman’s “Musical hallucinosis: A review and synthesis”. It is also noted by F. Pasquini and M.G. Cole in “Idiopathic (due to sudden or unknown cause) musical hallucinations in the elderly”, that in studies of patients presenting with musical hallucinations as an isolated symptom, females and the elderly tend to be over represented.  Also, in the majority of descriptions of musical hallucinations, it is revealed that the hallucinations carry a personal significance and are often related to a previous experience, according to O. Sacks’s “The man who mistook his wife for a hat”. Kesshavan et al. observe that musical hallucinations are conceptualised as being the result of a parasitic memory that originates from traces of memory retained from previous experiences which cannot be unlearned.  Furthermore, according to G.E. Berrios’s “Musical hallucinosis: A statistical analysis of 46 cases” and T.G. Bever and R.J. Chiarello’s “Cerebral dominance in musicians and non musicians”, musical hallucinations are associated more with a right (or non-dominant) hemispheric aetiology as the latter hemisphere is more dominant in terms of the perception of music. Meanwhile, brain imaging studies (K. Kasai, T. Asada, M. Yumotot, J. Takeya and H. Matsuda’s “Evidence for functional abnormality in the right auditory cortex during musical hallucinations”) have suggested an associated dysfunction of the temporal cortex while Berrios presented evidence of a more heterogeneous causation.  Treatment Weerasundera explained that owing to the unclear origin of the precise pathophysiology (disordered physiological processes associated with disease or injury) of musical hallucinations, it is only the symptoms of the condition that are treated with relief being provided in the form of antipsychotics and antidepressants (Evers and Ellger), anticonvulsants (S. Holroyd and S. Sabeen’s “Successful treatment of hallucinations associated with sensory impairment using gabapentin”) and medication used to treat Alzheimer’s disease, which is a progressive neurological disorder that causes the brain to shrink and brain cells to die (S. Ukai, M. Yamamoto, M. Tanaka, K. Shinosaki and M. Takeda’s “Donepezil in the treatment of musical hallucinations”), upon taking into account individual considerations and the potential side effects of medication.


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