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Reported herein is a case of obsessive–compulsive disorder with persistent and distressing musical obsessions along with other symptoms. Advanced source analysis of electroencephalographic data indicated high spectral power over the bifrontal region. The musical symptoms were resistant to pharmacotherapy but there was some reduction in frequency and duration of musical obsessions with thought-stopping technique.
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- CASE REPORT
The patient was a 21-year-old man who presented with complaints of repetitive thoughts of dirt and contamination, repeated washing and checking behavior, occurrence of distressing images, and the hearing of songs and tunes in his mind repeatedly for the past 5 years. Along with these symptoms, for the past 2 years he had developed low mood, suicidal ideas as well as disturbed sleep and appetite, which affected his academic performance. His father was diagnosed with paranoid schizophrenia and alcohol dependence and one elder sister had suffered an episode of major depressive disorder. Physical examination did not indicate any abnormality. On mental status he had anxious depressed affect, obsessions of dirt and contamination, doubts, and obsessive imagery of popular television programs along with depressive cognitions such as ideas of hopelessness and helplessness. There was no evidence of first-rank symptoms suggestive of schizophrenia. The most distressing symptom, however, was the hearing of songs along with background music in his mind. He used to hear parts of popular Hindi film songs, which the patient reported occurred in his mind, lasting from 2–3 min to a maximum period of 45 min at a stretch. It occurred 30–35 times in a day, nearly every day against his will. These tunes often appeared when he was alone and the patient was partially successful in getting rid of them by distraction such as engaging in some games or conversing with fellow patients; but they recurred after a few minutes. Occasionally when the patient heard any new song or tune, it replaced the older one in his mind. He was diagnosed with obsessive–compulsive disorder (OCD) with severe depression without psychotic symptoms. He was started on fluvoxamine, which was increased to 300 mg per day. Risperidone 2 mg per day was added later as an augmenting agent. The patient had shown improvement in depressive and obsessive–compulsive symptoms on this regimen except for the musical obsessions.
Thought-stopping technique5,6 was started for musical obsessions. The patient was asked to concentrate on the musical tunes and after a short period of time, the therapist emphatically said ‘stop’. After this procedure was repeated several times, the locus of control was shifted to the patient, that is, he would emit a subvocal ‘stop’ whenever the tunes appeared in his mind. After 6 weeks there was reduction in both the duration and frequency of musical obsessions, which occurred for 20–25 times for a maximum duration of 30 min.
A 32-channel quantitative electroencephalogram (EEG) recorded during acute phase of the illness with scalp electrodes using the international 10–20 system was obtained, which did not indicate any abnormality. Advanced source analysis using fast Fourier transformation (FFT) and multiple signal classification (MUSIC) was conducted over a 20-min EEG tracing in which multiple epochs were taken each of 0.256 s duration with overlapping by −1.000 s followed by averaging of the entire data. ASA version 2.5 (ANT, Enschede, The Netherlands) was used. There was high spectral power in low frequency (theta band) over the bifrontal region, which was further corroborated by MUSIC, which indicated high signal density over the bilateral frontal, particularly over the fronto-basal region for the same frequency band (Figs 1,2). Additionally there was high spectral power over the right prefrontal region in the beta frequency band. This implied that slow wave activity predominantly arose from the bilateral anterior hemisphere, which could indicate relative hyperfunctioning at the fronto-basal regions and fronto-temporal circuits in the brain, which has been implicated in patients with OCD.7
Figure 1. Fast Fourier transformation: (a) high spectral power over the bifrontal region in the theta band (3.5–7/5 Hz); (b) high spectral power over the right prefrontal region in the beta band (12.5–30.0 Hz).
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- CASE REPORT
The musical symptoms in the present patient were experienced as produced in his own mind and not imposed from outside. The music was experienced as repetitive, intrusive and inappropriate, which caused marked anxiety, distress and impairment of social–occupational functioning. It was not simply associated with excessive worries about life problems. The musical symptoms were accompanied by full insight into the senselessness and excessiveness of the symptoms, and the patient attempted to suppress the music or neutralize it with other thoughts. Thus, the musical symptoms observed in the present case are consistent with the psychopathological characteristics of obsessions.
In contrast, the experience of musical hallucinations has been described in previous studies as ‘music is coming from outside her head’ or ‘music is like a broken tape recorder repeatedly producing the same songs and music’ and so on.8–10 Hallucinations are actual false perceptions that are not perceptual distortions, but which arise as something new that occurs along with the real perceptions.11 They have the characteristics of sense perceptions, that is, they have concrete reality, appear in objective space, are full, fresh and clear, are constant and are independent of will. Hermesh et al. reported a high prevalence of musical hallucinations (30–41.4%) in OCD patients.12 One explanation for the phenomenon was advanced by Teunisse, 13 that the questionnaire used in that study could not differentiate hallucinations from obsessive imagery of music, which is common and a mild symptom of obsession. Nevertheless, when present, it dominates the clinical picture and may be relatively treatment resistant, as seen in the present case.
Another possibility is that these are musical pseudohallucinations14 rather than musical obsessions, because pseudohallucinations lack concrete reality, are heard in the subjective space, are a constant phenomena unlike images, are independent of will and the person retains insight into the phenomenon.11,15 While obsessions are also experienced as from the subjective space, Lewis has described three essential features for diagnosing obsessions: subjective compulsion, a resistance to it, and preservation of insight.16 On the Yale–Brown Obsessive Compulsive Scale symptom checklist there is a listing for ‘intrusive nonsense sounds, words or music’ under Miscellaneous Obsessions.17 Yet, internal hearing is another related phenomenon that is found in skilled musicians, which also needs to be differentiated from musical obsessions.18 The characteristics of hallucinations, pseudohallucinations and obsessions are summarized in Table 1.
Table 1. Characteristics of hallucinations, pseudohallucinations and obsessions
|Concrete, tangible, real||Figurative, subjective||Figurative, subjective|
|Objective space||Subjective space||Subjective space|
|No insight||Insight preserved||Insight preserved|
|Independent of will||Independent of will||Can change at will|
|No compulsion||No compulsion||Associated compulsion|
|No resistance||No resistance||Resistance present|
Musical obsession was first described by Kraepelin as a mild form of OCD.19 Subsequently there have been occasional case reports1,2,4 in which musical obsessions were documented. OCD patients with musical obsessions usually explain that the symptoms are irrational music or nonsense musical tunes (e.g. a commercial jingle) recurrently and persistently sounding in their mind, and they often attempt to suppress the obsessions by substituting other thoughts without any covert or mental compulsion.2 In the present case the patient had tunes and parts of songs in his musical obsessions, which the patient tried to suppress through distraction. Another phenomenon that was evident at times was that if the patient heard a musical tune or a song it replaced the previous one.
There is ample neurobiological evidence that supports the hypothesis that obsessions and compulsions arise due to deficits in fronto-cortico-basal–subcortical circuits. The neuroanatomical findings support two models: executive dysfunction, which implicates the dorsolateral prefrontal cortex, caudate nucleus, thalamus, and striatum; and modulatory control, which implicates the orbitofrontal and medial prefrontal cortex and the cingulate gyrus.20 Single photon emission computed tomography of two patients with musical obsessions indicated prominent decreases of blood flow in the temporal lobes as well as frontal perfusion defects.2 Electrophysiological studies have demonstrated gamma and beta frequency oscillations in response to auditory stimuli in patients with auditory hallucinations over the medial frontal lobe and inferior parietal lobule.21 Spectral analysis of EEG in the present case using FFT indicated high spectral power in the low-frequency band (3.5–7.5 Hz) over bilateral frontal and prefrontal regions, and subsequent source density analysis using MUSIC identified the source of activity as primarily over the fronto-basal regions, consistent with findings reported by Tot et al., who found predominantly left fronto-basal dysfunction in OCD patients poorly responsive to standard treatment.7 Source analysis of electrophysiological data in patients with schizophrenia with persistent auditory hallucination also indicated abnormal spectral power of theta band over the fronto-temporal regions.22 Inconclusive evidence also exists for patients with Tourette disorder.7 This is the first reported case of suspected musical obsession in which electrophysiological evidence supported the frontal lobe dysfunction hypothesis of OCD. This hypothesis, however, can be further substantiated using controlled experimental conditions in which source density analysis can be coupled with functional neuroimaging techniques to gain insight into the electrophysiological localization of this interesting phenomenon.
In previous reports OCD patients with musical obsessions have been reported to have pure obsessions,4 unlike in the present case, in which multiple other obsessions and compulsions were present. Nevertheless musical obsessions were the most prominent and distressing of all. They had persisted for almost 5 years in the present patient, consistent with the reports that musical obsessions are usually resistant to serotonin reuptake inhibitor pharmacotherapy, although there are reports of successful treatment of two patients using clomipramine.4 Carbamazepine, which helps in some cases of OCD, has been reported to be effective in two patients with musical hallucinations.23 The present patient had shown reduction of musical obsessions with thought-stopping technique. In another report Morita therapy was useful in a case of musical obsessions.3 Morita therapy, developed by Shoma Morita, aims to let patients reach a state of mind in which they can carry on with their work even while they exhibit symptoms.24 The defining therapeutic feature of Morita therapy is arugamama, the acceptance of reality as it is.
Obsessive musical symptoms have not been differentiated adequately from related psychopathologies, which will impede further research. These symptoms, although infrequent, require more attention from both clinicians and researchers because they tend to be distressing and persistent. Further studies are required that characterize musical obsessions on phenomenological grounds and which use functional imaging methods to identify the neurobiological substrate of these phenomena.