Complex musical hallucinosis in a professional musician with a left subcortical haemorrhage

Musical hallucinations: review of treatment effects

BACKGROUND

Despite an increased scientific interest in musical hallucinations over the past 25 years, treatment protocols are still lacking. This may well be due to the fact that musical hallucinations have multiple causes, and that published cases are relatively rare.

OBJECTIVE

To review the effects of published treatment methods for musical hallucinations.

METHODS

A literature search yielded 175 articles discussing a total number of 516 cases, of which 147 articles discussed treatment in 276 individuals. We analyzed the treatment results in relation to the etiological factor considered responsible for the mediation of the musical hallucinations, i.e., idiopathic/hypoacusis, psychiatric disorder, brain lesion, and other pathology, epilepsy or intoxication/pharmacology.

RESULTS

Musical hallucinations can disappear without intervention. When hallucinations are bearable, patients can be reassured without any other treatment. However, in other patients musical hallucinations are so disturbing that treatment is indicated. Distinct etiological groups appear to respond differently to treatment. In the hypoacusis group, treating the hearing impairment can yield significant improvement and coping strategies (e.g., more acoustic stimulation) are frequently helpful. Pharmacological treatment methods can also be successful, with antidepressants being possibly more helpful than antiepileptics (which are still better than antipsychotics). The limited use of acetylcholinesterase inhibitors has looked promising. Musical hallucinations occurring as part of a psychiatric disorder tend to respond well to psychopharmacological treatments targeting the underlying disorder. Musical hallucinations experienced in the context of brain injuries and epilepsy tend to respond well to antiepileptics, but their natural course is often benign, irrespective of any pharmacological treatment. When intoxication/pharmacology is the main etiological factor, it is important to stop or switch the causative substance or medication.

CONCLUSION

Treatments for musical hallucinations tend to yield favorable results when they target the main etiological factor of these phenomena. There is a need to establish the natural course of musical hallucinations, their response to non-pharmacological treatments, and their effects on the patient's quality of life. There is also a need to standardize the assessment of treatment responses, and document long-term follow up.

Monoaural musical hallucinations caused by a thalamocortical auditory radiation infarct: a case report

INTRODUCTION

Musical hallucinations are complex auditory perceptions in the absence of an external acoustic stimulus and are often consistent with previous listening experience. Their causation can be classified as associated with either psychiatric disorders, such as schizophrenia, or organic disorders, such as epilepsy or sensorineural deafness. Non-epileptic musical hallucinosis due to lesions of the central auditory pathway, especially of the thalamocortical auditory radiation, is rare.

CASE PRESENTATION

We describe the case of an 85-year old ethnic Chinese woman with a history of transient ischemic attacks and chronic bilateral hearing impairment, who experienced an acute onset of left unilateral musical hallucinations. Our patient did not experience any psychiatric symptoms and there was no other neurological deficit. Pure tone audiometry revealed bilateral hypacusis and magnetic resonance imaging revealed a right non-dominant hemisphere sublenticular lacunar infarct of the thalamocortical auditory radiation. Our patient was managed expectantly and after three months her symptoms subsided spontaneously.

CONCLUSION

We propose that all patients with monoaural musical hallucinations have brain imaging to rule out a central organic cause, especially within the non-dominant hemisphere, regardless of the presence of a hearing impairment.

Musical hallucination following whiplash injury: case report and literature review

INTRODUCTION

A musical hallucination is defined as a form of auditory hallucination characterised by the perception of music in the absence of external acoustic stimuli. It is infrequently cited in the literature, although population studies suggest a greater prevalence. The aetiology of this unusual disorder remains unclear.

CASE REPORT

A 70-year-old man with acquired hearing loss suffered a whiplash injury in a low-speed road traffic accident, and subsequently presented with bilateral 'tinnitus.' On closer questioning, he described hearing orchestral music. There was no evidence of psychosis, delirium or intoxication, and the patient was managed expectantly.

CONCLUSION

This patient represents the first published case of musical hallucination precipitated by whiplash injury. We explore the possible pathophysiological underpinnings of musical hallucination and highlight the need for a greater awareness of this disorder. A management strategy is suggested.

Musical hallucination associated with hearing loss

In spite of the fact that musical hallucination have a significant impact on patients' lives, they have received very little attention of experts. Some researchers agree on a combination of peripheral and central dysfunctions as the mechanism that causes hallucination. The most accepted physiopathology of musical hallucination associated to hearing loss (caused by cochlear lesion, cochlear nerve lesion or by interruption of mesencephalon or pontine auditory information) is the disinhibition of auditory memory circuits due to sensory deprivation. Concerning the cortical area involved in musical hallucination, there is evidence that the excitatory mechanism of the superior temporal gyrus, as in epilepsies, is responsible for musical hallucination. In musical release hallucination there is also activation of the auditory association cortex. Finally, considering the laterality, functional studies with musical perception and imagery in normal individuals showed that songs with words cause bilateral temporal activation and melodies activate only the right lobe. The effect of hearing aids on the improvement of musical hallucination as a result of the hearing loss improvement is well documented. It happens because auditory hallucination may be influenced by the external acoustical environment. Neuroleptics, antidepressants and anticonvulsants have been used in the treatment of musical hallucination. Cases of improvement with the administration of carbamazepine, meclobemide and donepezil were reported, but the results obtained were not consistent.

Is musical hallucination an otological phenomenon? a review of the literature

BACKGROUND

Musical hallucination is the subjective experience of hearing music, or aspects of music, when none is being played, and as such is a disorder of the processing of complex sounds.

OBJECTIVE OF REVIEW

To determine the extent to which the otological system is responsible for musical hallucination, and to evaluate approaches to clinical management.

TYPE OF REVIEW

A review of all studies and literature reviews pertaining to musical hallucination, supplemented by inclusion of informative case reports.

SEARCH STRATEGY

A systematic search of multiple databases carried out on 22nd March 2009 was complemented by referral to the reference lists of included manuscripts.

RESULTS

Although not always troublesome in itself, musical hallucination can be a marker of underlying pathology in the ear or brain, or indicate obsessive-compulsive traits or social isolation, and is likely to be clinically underreported. Associations have been reported with hearing loss, female gender, social isolation and being over 60 years of age, although it is rare even in this group, and these may well not be independent risk factors. Robust comparative analysis of these factors with controls has yet to be undertaken. Underlying causes include neurovascular pathology, psychiatric disorders and opioid medications, however these are absent in the majority of cases.

CONCLUSIONS

This review supports the proposal that the otological system plays a role in the pathogenesis of musical hallucination. Hearing impairment may act as an initiating factor, and the primary dysfunction is overactivity of auditory association cortex, although an impairment of higher-level inhibition does also seem necessary. Once underlying sinister causes have been excluded, first line treatment should be explanation of the condition and optimisation of hearing. Medications have a role only in selected patient groups.

Musical hallucinations and Parkinson disease

INTRODUCTION

Musical hallucinations are complex auditory hallucinations. The term covers the clinical phenomenon of hearing tunes and melodies that are uncontrollable and not related to external stimuli. Musical hallucinations may be experienced in a variety of conditions including diseases of the ear and neurologic, psychiatric, infectious, and toxic states. When the underlying pathology resolves, musical hallucinations tend to disappear.

CASE REPORT

We present an elderly man with musical hallucinations and without any conditions known to be related with its occurrence, except for Parkinson disease.

CONCLUSION

Musical hallucinations in the elderly occur predominantly in women with a hearing impairment. Parkinson disease is usually accompanied by visual hallucinations. Auditory hallucinations are rare in Parkinson disease and most of them are accompanied by visual hallucinations. Isolated auditory hallucinations are rarer in Parkinson disease and mostly consist of human voices.

Musical hallucinosis: case reports and possible neurobiological models

OBJECTIVE

The perception of music without a stimulus, or musical hallucination, is reported in both organic and psychiatric disorders. It is most frequently described in the elderly with associated hearing loss and accompanied by some degree of insight. In this setting it is often referred to as 'musical hallucinosis'. The aim of the authors was to present examples of this syndrome and review the current understanding of its neurobiological basis.

METHOD

We describe three cases of persons experiencing musical hallucinosis in the context of hearing deficits with varying degrees of associated central nervous system abnormalities.

RESULTS

Putative neurobiological mechanisms, in particular those involving de-afferentation of a complex auditory recognition system by complete or partial deafness, are discussed in the light of current information from the literature.

CONCLUSION

Musical hallucinosis can be experienced in those patients with hearing impairment and is phenomenologically distinct for hallucinations described in psychiatric disorders.

Abnormal musical pacemaker in a patient with musical hallucinations

Music creation requires a highly orchestrated temporal pattern. The study of a patient with repetitive musical hallucinations enabled us to examine temporal pacemakers in music production. Here, we show that the pattern of faster silent production of a chosen tune compared with its production aloud was reversed when the patient produced the hallucinatory tune. This observation might suggest the utilization of a pacemaker(s), which functions differentially during the disease.

Music and the brain: disorders of musical listening

The study of the brain bases for normal musical listening has advanced greatly in the last 30 years. The evidence from basic and clinical neuroscience suggests that listening to music involves many cognitive components with distinct brain substrates. Using patient cases reported in the literature, we develop an approach for understanding disordered musical listening that is based on the systematic assessment of the perceptual and cognitive analysis of music and its emotional effect. This approach can be applied both to acquired and congenital deficits of musical listening, and to aberrant listening in patients with musical hallucinations. Both the bases for normal musical listening and the clinical assessment of disorders now have a solid grounding in systems neuroscience.

The clinical spectrum of musical hallucinations

Musical hallucinations are a well known although rare phenomenon in neurological and psychiatric patients. Many case reports have been published to date. However, an accepted common theory on the classification and on the pathophysiology of musical hallucinations is still missing. We analysed all cases published to date, including two own cases, with respect to their demographic and clinical features and to the possible pathomechanisms underlying the hallucinations. In total, 132 cases could be analysed statistically and separated into five groups according to their aetiology (hypacusis; psychiatric disorder; focal brain lesion; epilepsy; intoxication). There was a female preponderance of 70% and a mean age of 61.5 years. Patients with focal brain lesions were significantly younger than the other groups, the hemisphere of the lesion did not play a major role. No systematic studies on treatment are available. However, anticonvulsant and antidepressive substances were reported to be effective most consistently. The pathophysiology of musical hallucinations is discussed considering the theories of deafferentiation including the concept of auditory Charles-Bonnet syndrome, of sensory auditory deprivation, of parasitic memory, and of spontaneous activity in a cognitive network module. In conclusion, musical hallucinations are a phenomenon with heterogeneous clinical and pathophysiological backgrounds.

Musical and auditory hallucinations: A spectrum

Musical hallucinosis is a rare and poorly understood clinical phenomenon. While an association appears to exist between this phenomenon and organic brain pathology, aging and sensory impairment the precise association remains unclear. The authors present two cases of musical hallucinosis, both in elderly patients with mild-moderate cognitive impairment and mild-moderate hearing loss, who subsequently developed auditory hallucinations and in one case command hallucinations. The literature in reference to musical hallucinosis will be reviewed and a theory relating to the development of musical hallucinations will be proposed.