Musical hallucinations (also known as auditory hallucinations, auditory Charles Bonnet Syndrome, and Oliver Sacks' syndrome) describes a neurological disorder in which the patient will hallucinate songs, tunes, instruments and melodies. The source of these hallucinations are derived from underlying psychotic illness or hearing impairment. These hallucinations are often rare and are followed by mental decline. Majority of patients who have symptoms of musical hallucinations are older and have onset conditions predisposing them to the disease. While there is no set form of treatment, research has discovered medications and alternative therapies to be successful in alleviating the hallucinations.
Description
In 73 individual cases reviewed by Evers and Ellger, 57 patients heard tunes that were familiar, while 5 heard unfamiliar tunes. These tunes ranged from religious pieces to childhood favorites, and also included popular songs from the radio. Vocal and instrumental forms of classical music were also identified in most patients. Keshavan found that the consistent feature of musical hallucinations was that it represented a personal memory trace. Memory traces refer to anything that may seem familiar to the patient, which indicate why certain childhood or familiar songs were heard.
For the case of an 84 year old widow who complained of hearing sounds, she described her symptoms as pleasant, but also sought for treatment because she felt distracted. The music that played over her head was similar to the hymns and songs sung at her own wedding. Moreover, had been widowed for a while and had no signs of psychiatric disorders. However, she did have
hypertension
Hypertension (HTN or HT), also known as high blood pressure (HBP), is a long-term medical condition in which the blood pressure in the arteries is persistently elevated. High blood pressure usually does not cause symptoms. Long-term high bl ...
,
hyperthyroidism
Hyperthyroidism is the condition that occurs due to excessive production of thyroid hormones by the thyroid gland. Thyrotoxicosis is the condition that occurs due to excessive thyroid hormone of any cause and therefore includes hyperthyroidism ...
, and
osteoporosis
Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to bone fragility, and consequent increase in fracture risk. It is the most common reason for a broken bone ...
. From these diagnosis it was theorized that the distress from the illnesses manifested the hallucinations. Through further analysis, researchers found that due the unexpected origin of the
hallucination
A hallucination is a perception in the absence of an external stimulus that has the qualities of a real perception. Hallucinations are vivid, substantial, and are perceived to be located in external objective space. Hallucination is a combinatio ...
s, there is no clear diagnosis or treatments to carry out.
Another case, which studies a 74-year-old woman, described her symptoms as music that would play in short verses of patriotic and children's songs. These symptoms would occur when the patient was alone and much more frequently when driving. Researchers suspected her hearing loss as a factor for developing the hallucinations. Moreover, through further analysis the patient had a medical history of hypertension, hyperlipidemia, and atrial fibrillations.
Oftentimes, cases are commonly found in the elderly, but a 29-year-old female reported hearing music for one week. Prior to her hallucinations, the patient had undergone surgery for intraventricular and intracranial hemorrhages. Following her recovery, she mentioned the onset of hallucinations followed by headaches. Through scans, doctors found no neurological impairments, but prescribed her with medication. For her, the symptoms only lasted a year due to the treatment of quetiapine, which she responded well to.
Causes
Musical hallucinations can occur in people who are physically and mentally healthy, and for them, there is no known cause.
[
] Most people find their musical hallucinations obtrusive, and wish to be rid of them, while others welcome them. In addition, investigators have pointed to factors that are associated with musical hallucinations. Evers and Ellgers compiled a significant portion of musical hallucination articles, case studies etc. and were able to categorize five major etiologies:
*
Hypoacusis
Hearing loss is a partial or total inability to hear. Hearing loss may be present at birth or acquired at any time afterwards. Hearing loss may occur in one or both ears. In children, hearing problems can affect the ability to acquire spoken l ...
*
Psychiatric disorders
A mental disorder, also referred to as a mental illness or psychiatric disorder, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. Such features may be persistent, relapsing and remitti ...
*
Focal brain lesion
*
Epilepsy
Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical ...
*
Intoxication
Intoxication — or poisoning, especially by an alcoholic or narcotic substance — may refer to:
* Substance intoxication:
** Alcohol intoxication
** LSD intoxication
** Toxidrome
** Tobacco intoxication
** Cannabis intoxication
** Cocaine i ...
Hypoacusis
Hypoacusis is defined as impairment in hearing or deafness. Hypoacusis is one of five etiologies of musical hallucinations, and is the most common in the case studies reviewed by Evers and Ellgers.
According to Sanchez et al. 2011, there have been suggestions that pontine lesions could alter the central auditory system's function causing hypoacusis and musical hallucinations.
Psychiatric disorders
A case study by Janakiraman et al. 2006, revealed a 93‑year‑old woman with
major depressive disorder
Major depressive disorder (MDD), also known as clinical depression, is a mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities. Introdu ...
who experienced musical hallucinations while treated with
electroconvulsive therapy
Electroconvulsive therapy (ECT) is a psychiatry, psychiatric treatment where a generalized seizure (without muscular convulsions) is electrically induced to manage refractory mental disorders.Rudorfer, MV, Henry, ME, Sackeim, HA (2003)"Electroco ...
(ECT). Investigators found that the patient's depression symptoms were inversely related to her hallucinations and primarily stemmed from the ECT treatment. The patient had no known abnormalities in hearing, suggesting that musical hallucinations could arise from a variety of sources including psychiatric illnesses. After a complete course of ECT, her hallucinations dissipated, also suggesting that they can be acute.
According to Evers and Ellgers, some other major psychiatric disorders that contribute to musical hallucinations include
schizophrenia
Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social withdra ...
and depression. Some patients who have schizophrenia experience musical hallucinations due to their ongoing psychosis, but there are some cases that do so without psychosis. There are also a very small percentage of musical hallucination cases due to
obsessive-compulsive disorder (OCD).
Several different types of psychiatric disorders can be precursors for Musical Hallucinations. according to Blom and Coebergh, Bipolar Disorder and personality disorders can increase the chances of musical hallucinations. Likewise, cocaine dependence can elevate the symptoms.
Focal brain lesions
Among the handful of cases that Evers and Ellgers studied, major lesion sites included the temporal cortex; however, the specific location and laterality (left vs. right temporal cortex) was variable. Many cases of focal brain lesions had comorbidity with hearing impairment (see hypoacusis), epileptic activity and intoxication.
There have also been several findings of acute musical hallucinations in patients with dorsal
pons
The pons (from Latin , "bridge") is part of the brainstem that in humans and other bipeds lies inferior to the midbrain, superior to the medulla oblongata and anterior to the cerebellum.
The pons is also called the pons Varolii ("bridge of Va ...
lesions post-stroke and
encephalitis
Encephalitis is inflammation of the brain. The severity can be variable with symptoms including reduction or alteration in consciousness, headache, fever, confusion, a stiff neck, and vomiting. Complications may include seizures, hallucinations, ...
potentially due to disruption of connections between the
sensory cortex The sensory cortex can refer informally to the primary somatosensory cortex, or it can be used as a term for the primary and secondary cortices of the different senses (two cortices each, on left and right hemisphere): the visual cortex on the occi ...
and
reticular formation
The reticular formation is a set of interconnected nuclei that are located throughout the brainstem. It is not anatomically well defined, because it includes neurons located in different parts of the brain. The neurons of the reticular formation ...
.
Also, any kind of traumatic lesion imposed on the brain can be a risk factor for Musical Hallucinations.
Epilepsy
Epileptic brain activity in musical hallucinations originates in the left or right temporal lobe.
In a specific case studied by Williams et al. 2008, a patient who received a left temporal lobectomy in order to treat epilepsy was diagnosed with musical hallucinations post-surgery. The patient also had multiple additional risk factors that could have accounted for the hallucinations including mild neuropsychiatric dysfunction and
tinnitus
Tinnitus is the perception of sound when no corresponding external sound is present. Nearly everyone experiences a faint "normal tinnitus" in a completely quiet room; but it is of concern only if it is bothersome, interferes with normal hearin ...
.
The causation of hallucination through epilepsy is linked to seizure episodes. Through experiments, researchers have found that patients with epilepsy and hallucinations will respond to antiepileptics and surgery
Intoxication
Intoxication accounts for a small percentage of musical hallucination cases. Intoxication leads to either withdrawal or inflammatory encephalopathy, which are major contributors to musical hallucinations. Some of the drugs that have been found to relate to musical hallucinations include salicylates, benzodiazepines, pentoxifylline, propranolol, clomipramine, amphetamine, quinine, imipramine, a phenothiazine, carbamazepine, marijuana, paracetamol, phenytoin, procaine, and alcohol. General anesthesia has also been associated with musical hallucinations.
In a case study by Gondim et al. 2010, a seventy–seven-year-old woman with
Parkinson's disease
Parkinson's disease (PD), or simply Parkinson's, is a long-term degenerative disorder of the central nervous system that mainly affects the motor system. The symptoms usually emerge slowly, and as the disease worsens, non-motor symptoms becom ...
(PD) was administered
amantadine
Amantadine, sold under the brand name Gocovri among others, is a medication used to treat dyskinesia associated with parkinsonism and influenza caused by type A influenzavirus, though its use for the latter is no longer recommended due to wid ...
after a year of various other antiparkinsonian treatments. Two days into her treatment, she started to experience musical hallucinations, which consisted of four musical pieces. The music persisted until three days after cessation of the drug. Although the patient was taking other medications at the same time, the timing of onset and offset suggested that amantadine either had a synergistic effect with the other drugs or simply caused the hallucinations. Although the case wasn't specific to intoxication, it leads to the idea that persons with PD who are treated with certain drugs can experience musical hallucinations.
Other risk factors
In summary, musical hallucinations can be separated into five categories according to their cause: hypoacusis, psychiatric disorders, brain lesions, epilepsy, and substance use. However, certain factors can trigger hallucinations, these factors include, old age, social isolation and even gender. Many cases highlight female patients who have the disease. Overall, psychiatric disorders and neurological disease lead to hallucinations, but certain factors, such as age and gender play a role in heightening the causation.
Imaging
Positron emission tomography
Positron emission tomography (PET) is a functional imaging technique that uses radioactive substances known as radiotracers to visualize and measure changes in Metabolism, metabolic processes, and in other physiological activities including bl ...
(PET) and
functional magnetic resonance imaging
Functional magnetic resonance imaging or functional MRI (fMRI) measures brain activity by detecting changes associated with blood flow. This technique relies on the fact that cerebral blood flow and neuronal activation are coupled. When an area o ...
(fMRI) show that musical hallucinations activate a wide variety of areas in the brain including the following: auditory areas,
motor cortex
The motor cortex is the region of the cerebral cortex believed to be involved in the planning, control, and execution of voluntary movements.
The motor cortex is an area of the frontal lobe located in the posterior precentral gyrus immediately a ...
, visual areas,
basal ganglia
The basal ganglia (BG), or basal nuclei, are a group of subcortical nuclei, of varied origin, in the brains of vertebrates. In humans, and some primates, there are some differences, mainly in the division of the globus pallidus into an extern ...
,
brainstem
The brainstem (or brain stem) is the posterior stalk-like part of the brain that connects the cerebrum with the spinal cord. In the human brain the brainstem is composed of the midbrain, the pons, and the medulla oblongata. The midbrain is cont ...
,
pons
The pons (from Latin , "bridge") is part of the brainstem that in humans and other bipeds lies inferior to the midbrain, superior to the medulla oblongata and anterior to the cerebellum.
The pons is also called the pons Varolii ("bridge of Va ...
,
tegmentum
The tegmentum (from Latin for "covering") is a general area within the brainstem. The tegmentum is the ventral part of the midbrain and the tectum is the dorsal part of the midbrain. It is located between the ventricular system and distinctive b ...
,
cerebellum
The cerebellum (Latin for "little brain") is a major feature of the hindbrain of all vertebrates. Although usually smaller than the cerebrum, in some animals such as the mormyrid fishes it may be as large as or even larger. In humans, the cerebel ...
,
hippocampi,
amygdala
The amygdala (; plural: amygdalae or amygdalas; also '; Latin from Greek, , ', 'almond', 'tonsil') is one of two almond-shaped clusters of nuclei located deep and medially within the temporal lobes of the brain's cerebrum in complex verteb ...
, and peripheral auditory system.
Treatment
To date, there is no successful method of treatment that "cures" musical hallucinations. There have been successful therapies in single cases that have ameliorated the hallucinations. Some of these successes include drugs such as neuroleptics, antidepressants, and certain anticonvulsive drugs. A musical hallucination was alleviated, for example, by antidepressant medications given to patients with depression.
Sanchez reported that some authors have suggested that the use of hearing aids may improve musical hallucination symptoms.
They believed that the external environment influences the auditory hallucinations, showing worsening of symptoms in quieter environments than in noisier ones.
Oliver Sacks' patient, Mrs. O'C, reported being in an "ocean of sound" despite being in a quiet room due to a small thrombosis or infarction in her right temporal lobe. After treatment, Mrs. O'C was relinquished of her musical experience but said that, "I do miss the old songs. Now, with lots of them, I can't even recall them. It was like being given back a forgotten bit of my childhood again." Sacks also reported another elderly woman, Mrs. O'M, who had a mild case of deafness and reported hearing musical pieces. When she was treated with anticonvulsive medications, her musical hallucinations ceased but when asked if she missed them, she said "Not on your life."
Researchers found that patients with musical hallucinations respond well to the drug
Donepezil
Donepezil, sold under the brand name Aricept among others, is a medication used to treat dementia of the Alzheimer's disease, Alzheimer's type. It appears to result in a small benefit in mental function and ability to function. Use, however, ha ...
, making it another potential treatment for the condition. Donepezil, which belongs to a class of medication called
acetylcholinesterase inhibitors
Acetylcholinesterase inhibitors (AChEIs) also often called cholinesterase inhibitors, inhibit the enzyme acetylcholinesterase from breaking down the neurotransmitter acetylcholine into choline and acetate, thereby increasing both the level and ...
, is most commonly used to treat dementia in patients with Alzheimer's disease. Although it cannot cure Alzheimer's, it can provide patients with a better quality of life by inhibiting the loss of function and improving the ability to think. For patients with musical hallucinations, the medication keeps them more aware and stimulated to control the onset symptoms of hallucinations. Overall, with few adverse effects, research has found that donepezil is an effective and safe choice of treatment.
History
According to
Oliver Sacks
Oliver Wolf Sacks, (9 July 1933 – 30 August 2015) was a British neurologist, naturalist, historian of science, and writer. Born in Britain, Sacks received his medical degree in 1958 from The Queen's College, Oxford, before moving to the Uni ...
' ''
Hallucinations
A hallucination is a perception in the absence of an external stimulus that has the qualities of a real perception. Hallucinations are vivid, substantial, and are perceived to be located in external objective space. Hallucination is a combinatio ...
'', the first known medical report of musical hallucinations was published in 1846, by French alienist Jules Baillarger.
However, the first scientific description of the disorder was reported in the early 1900s. In the last three decades, Berrios has reported case studies in 1990 and 1991 along with Keshavan et al. in 1992. Berrios concluded that confirmed diagnoses of deafness, ear disease, brain disease, advanced age and drug use are all important factors in the development of musical hallucinations. After analyzing 46 cases, Berrios found a female predominance of 80% in women over the age of 60. The study concluded that musical hallucinations were more likely to be seen in elderly women affected by deafness or brain disease than in individuals with no psychiatric illness at all.
Keshevan and Berrios were the first authors to identify classes of musical hallucinations. These classes consisted of hearing loss, coarse brain disease (i.e. tumors),
epileptic disorder,
stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
, and psychiatric disorder. Although no statistical analyses were performed, the authors stated that deafness was the most strongly related factor in musical hallucinations and that there was a female predominance, which could entail a genetic component.
References
{{Music psychology
Hallucinations
Auditory illusions
Rare diseases
Central nervous system disorders
Music psychology
Symptoms and signs of mental disorders