Mental Illness 2015; volume 7:6065

Musical hallucinations in reported having musical hallucinations.4 Notably the musical hallucinations tended to Correspondence: Robert G. Bota, UC Irvine schizophrenia be sudden in onset, familiar, and mixed instru- Health Neuropsychiatric Center, 101 The City mental and vocal, with most patients having a Drive South, Orange, CA 92868, USA. Jessica Galant-Swafford, Robert Bota soothing affective response to the music Tel.:+1.714.456.2056. Department of Psychiatry, University of (62%). Interestingly, when the musical halluci- E-mail: [email protected] California, Irvine, CA, USA nations had more religious content, the patients claimed to have less volitional control Received for publication: 8 June 2015. Accepted for publication: 8 June 2015. Musical hallucinations (MH) are complex over them. This suggests that the presence or phenomena that are associated with hearing absence of religious content in the musical This work is licensed under a Creative Commons loss, brain disease (glioma, epilepsy, cere- hallucination may be useful for differentiating Attribution NonCommercial 3.0 License (CC BY- brovascular disease, encephalitis), and psychi- between musical imagery and musical halluci- NC 3.0). atric disorders such as major depressive disor- nations. ©Copyright J. Galant-Swafford and R. Bota, 2015 der, bipolar disease, and schizophrenia. MH Baba and Hamada suggest that musical hal- lucinations in patients with schizophrenia are Licensee PAGEPress, Italy are also commonly seen in people without Mental Illness 2015; 7:6065 phenomena that originate as memory repre- otorhinolaryngological, neurological, or mental doi:10.4081/mi.2015.6065 illness pathology.1 sentations or pseudo-hallucinations akin to In his novel Musicophilia, Oliver Sacks evoked musical imagery, which transition into true hallucinations during the progression of writes that his patients with musical halluci- cal content that were obsessive-compulsive in the disease. They describe three stages of nations do not speak of themselves imagining nature in that they were intrusive, repetitive, every musical hallucination.4 The first stage the music, but of some strange, autonomous senseless, and distressful.5 The patient was a mechanism set off in the brain. They speak of occurs when the musical hallucination takes on an obsessive quality and is greatly distress- 35-year-old professional musician whose psy- tapes, circuits, radios, or recordings, in their chosis was well managed by olanzapine at a brains; one of [his] correspondents called it his ing in nature. The second stage is associated with the xenopathic experience in which words dose of 10 mg/day. The patient’s disease had intracranial jukebox. Additionally, Sacks recently taken on a more schizoaffective-like describes that although they have different or lyrics are added to the melody, and the music is understood as coming from outside course as the patient had developed multiple meanings to each individual, they also share episodes of major depressive disorder. certain features in their apparent exteriority, the self. The third stage is described as the Lamotrigine was subsequently added and their incessancy, their fragmentary and repeti- autochthonous experience, in which the musi- titrated to 300 mg/day. After the addition of tive character, [and] their involuntary and cal hallucination is accepted as part of the self lamotrigine, the patient complained of hearing intrusive nature.2 and is ego-syntonic. They found that the first music, mostly popular songs, which were Musical hallucinations have been most read- and third stages occur in 90% of musical hallu- indistinguishable from outside noise and that ily described in deaf patients. Saba describes cinations and that there were commonly shifts which he was unable to ignore. Functional three proposed mechanisms: i) neuronal irrita- between the first and third stage, from ego- magnetic resonance imaging (fMRI) was per- tion (an excitatory phenomenon); ii) perceptual dystonic to ego-syntonic. Lastly, they found formed during the patient’s musical hallucina- release (a release phenomenon); iii) the novel that the second stage was a rare transitional tion and the researchers found selective concept of parasitic memories, in which some period between musical and verbal hallucina- response of the right orbitofrontal cortex also memories (e.g. a song) are never unlearned and tions, when the musical hallucination sepa- thus maintain a fixed and autonomous pres- rates from the self and is completely out of voli- known as the right auditory association cortex. ence in the memory, and are therefore periodi- tional control. As suspected, the second stage A reduction of the dose of lamotrigine signifi- cally re-experienced.3 Musical hallucinations of musical hallucinations correlated clinically cantly lessened the intensity of the musical can be differentiated from musical imagery, in with the greatest disturbance of self and the hallucinations, and after the complete switch which there is the sensation of music in one’s most severe psychotic symptoms. Notably, first to valproate (up to 1000 mg/day), the musical mind, but individuals maintain volitional con- generation antipsychotics greatly reduced and hallucinations disappeared entirely. trol and are aware that the sound is not a true even in some cases eliminated the musical This study raises two interesting points. auditory stimulus in the environment. Musical hallucinations in the majority of these First, the fMRI demonstrates that this patient imagery is often experienced by trained musi- patients.7 was experiencing true hallucinations; the cians and is almost ubiquitous in the form of Baba and Hamada’s work would serve to increased signal in the right auditory cortex earworms or the sensation that a song is stuck suggest that the musical hallucinations as indicates that the brain was perceiving a real in one’s head. experienced by an individual with schizophre- auditory stimulus. Second, this study presents Auditory hallucinations are a common and nia may be different from those described by evidence that certain antipsychotics might con- defining feature of schizophrenia and a variety Dr. Sacks in his patients. The musical halluci- tribute to musical hallucinations or may change of types have been described (i.e. persecutory, nations are not singularly ego-dystonic and auditory hallucinations into those taking on a grandiose, command etc.). However, there is intrusive, but rather they may shift in quality, musical character. Particularly, the evidence sparse literature on patients with schizophre- character, and meaning corresponding to the that lamotrigine specifically caused this phe- nia whose hallucinations take on a musical severity of disease, particularly the degree to nomenon may hint at a deeper understanding quality. Musical hallucinations in schizophre- which they are understood as being part of or of lamotrigine’s mechanism of action. nia have often been described as having reli- outside of the self. Additionally, during the The relationship of music to schizophrenia gious content. The association between musi- course of disease, the musical hallucinations is not new. It has been suggested that individ- cal hallucinations and religious themes is may change in response to medications and uals with schizophrenia may have impair- expected as the delusions of a person with psychotherapy. ments in music perception called amusia, and schizophrenia often contain religious themes.3 In a more recent study, Bleich-Cohen et al. researchers have suggested that this may rep- In 1997, Saba and Keshavan surveyed 100 describe a patient with schizophrenia who resent a protolinguistic impairment critical to patients with schizophrenia and found that 16 developed auditory hallucinations with musi- the disease process.6 In addition, there have

[page 26] [Mental Illness 2015; 7:6065] Editorial been many reports that music therapy signifi- of improved and more individualized psy- phenomenology in schizophrenic inpa- cantly improves outcomes in patients with chotherapy and psychopharmacology. There tients. Psychopathology 1997;30:185-90. schizophrenia.7 However, this effect may be are many unanswered questions and as many 4. Baba A, Hamada H, Kocha H. Musical hallu- patient-specific. A recent study suggests that avenues for further research. It is evident that cinations in schizophrenia. 2. Relations music preferences can change after the onset musical hallucinations are a distinct phenom- with verbal hallucinations. Psychopathology of mental illness. One subgroup of patients, enon in individuals with schizophrenia and it 2003;36:104-10. even stop listening to music entirely.8 is important to inquire about them in the rou- 5. Bleich-Cohen M, Hendler T, Pashinian A, The researches concluded that for those tine course of a psychiatric assessment in et al. Obsessive musical hallucinations in whose preferences changed, music impaired order to provide more patient-centered care. a schizophrenia patient: psychopathologi- their mental state, while for those whose pref- cal and FMRI characteristics. CNS Spectr erences did not change, music was important 2011;16:153-6. for their emotional modulation.8 At UC Irvine 6. Kantrowitz JT, Scaramello N, Jakubovitz A, Health Center, a full time music therapist References et al. Amusia and protolanguage impair- leads group classes two days per week with ments in schizophrenia. Psychol Med inpatients on the psychiatric ward. However, 2014;44:2739-48. the efficacy of music therapy on patients with 1. Zabalza-Estevez RJ. [Musical hallucina- 7. Gold C, Heldal TO, Dahle T, Wigram T. musical hallucinations has yet to be studied tions: perpetual music]. Rev Neurol Music therapy for schizophrenia or schizo- and would be an important topic for further 2014;58:207-12. [Article in Spanish] phrenia-like illnesses. Cochrane Database research. 2. Sacks O. Tales of music and the brain. New Syst Rev 2005:CD004025. To conclude, there have been few studies on York: Vintage Books; 2008. 8. Gebhardt S, Von Georgi R. The change of musical hallucinations in the last five years to 3. Saba PR, Keshavan MS. Musical hallucina- music preferences following the onset of a build on the aforementioned literature in light tions and musical imagery: prevalence and mental disorder. Ment Illn 2015;7:5784.

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