Posted by Lemon on June 5, 2001, at 11:59:21

_I've Got the Music in Me: A Look at Intrusive Music and OCD_ by Harold Pupko, M.D.



Musical Hallucinations (MH) are defined as the experience of music without any coexisting external stimulus. Not restricted to simple tunes or melodies, they can include the experience of rhythms, harmonics, or timbre depending on the musical appreciation level of the "hallucinator." This being the case, diagnosis may depend on the musical-appreciation talents of the diagnostician.

The medical literature describes the phenomenon of MH as rare, more commonly occurring among those with unilateral or bilateral deafness (transient or permanent), and those with brain disease. As the elderly are more prone to both conditions, MH is more commonly reported in this age group. As a clinician whose practice includes many patients with Obsessive-Compulsive Disorder (OCD), I am surprised that a diagnosis of intrusive music, a form of OCD, is rarely entertained by the psychiatrists and neurologists who write about MH in the scientific journals.



When I ask my OCD patients about intrusive music, I find that the phenomenon is quite common, with its expression ranging from mildly irritating to sometimes debilitating. More importantly, sufferers are relieved to finally have an opportunity to talk about these "unusual experiences" openly (as is the case with most OCD symptomatology). Because questions regarding intrusive music are not part of standard OCD inventories, such as the Y-BOCS symptom checklist, I hope that this article will stimulate my professional colleagues to start asking these questions so that OCD patients can be assured that they are not "loony tunes."

This article is based on a review of the scientific literature, my clinical experience, and letters I received in response to a letter published in this newsleter this past summer.



What is the experience like?

The experience of intrusive music covers a wide spectrum. A common analogy is that of a radio in one's head; the volume can be high or low, ranging from low-level background music to feeling as if a "boombox" is blasting in one's brain. The music may be clear, with rich detail, or jumbled. Some patients report that they can experience two or more songs playing simultaneously (e.g., ragtime on top of a rock and roll). The music may consist of a bar, a phrase, or even an entire piece, followed by other pieces, in what may seem like an endless musical procession. The intrusive tunes are commonly familiar ones (e.g., religious hymns), although new compositions may erupt spontaneously. Intrusive music is usually triggered by hearing music, from the bells of the local ice cream truck to popular music on the radio. Advertising jingles as well as television and radio signature tunes are notorious triggers. Once heard, the music repeats over and over, lasting anywhere from seconds to hours to days, and in extreme cases, months.

A key point to keep in mind is that OCD sufferers maintain insight into the source of the music, knowing that it emanates from their own minds, and cannot be heard by others (i.e., they are aware that they are not psychotic).

A common feature of this condition is that, like nature, musical OCD abhors a vacuum. Patients report that when they are highly focused on some outside task or conversation, the symptoms diminish, only to reappear when their minds are not actively engaged. However, when less focused, the music tends to compete, and often draws the attention away from the preferred target.

Intrusive music may also be triggered by feelings, thoughts, or words that can, in turn, trigger associations. This is not to be confused with synethesia, where one sensory modality is experienced as another (e.g., tasting colors), although there may be an overlap between the processes at work in the OCD sufferers and synesthetics. For example, the color blue may trigger the title "Blue Suede Shoes," which, in turn, may automatically trigger the experience of a random song from one's internal Elvis collection.

In some cases, intrusive music may "leak" out in the form of humming at inappropriate times. This may lead to embarrassment for the sufferers and/or people close to them, and the individual may not even be aware that this is occurring. This is not to say that humming or hearing music in one's head is abnormal in any way; but rather, that its inappropriateness to the situation makes it pathological. Intrusive music, like other forms of OCD, can truly detract from the quality of one's life, preventing even the enjoyment of the simplest of pleasures, such as a sunset savored in perfect silence. Even when the music stops, the resulting mood can linger on in a person's mind, often to the sufferer's detriment.

It is important to note that unilateral musical hallucinations which appear to emanate from one's ear may be a sign of neurological disease.



What triggers it?

Muscial OCD, like other forms of OCD, thrives under certain conditions. Stress, depression, or any other condition that deprives one of sleep, resulting in fatigue, certainly aggravates it. Intrusive music can also cause insomnia and poor sleep quality, thus perpetuating itself in a vicious cycle. Sufferers often note intrusive music to be their first experience upon wakening in the morning. There is one report in the literature of intrusive music resulting from a single head injury. I also received one letter reporting on such a case. Interestingly, both cases were well controlled by medication (Anafranil in the former, Paxil in the latter). OCD can be seen in some cases as the result of a susceptible brain being further compromised, with resultant symptomatology. For example, a case is described of a patient with "basal ganglia pathology" who developed repetitive musical intrusions secondary to having a low-blood calcium and phosphorus levels. Correction of this metabolic deficiency eliminated the intrusive music.

Prescription drugs, especially stimulant drugs, or the withdrawal of sedative drugs (with the resultant stimulation of the cortex) as well as those that lower blood pressure, can precipitate MH, especially in those already at risk (e.g., the deaf, etc.). For example, Anafranil was described in one case to trigger musical hallucinations.

It is interesting to note that there is some evidence that representation of musical information shifts with musical training from the non-dominant to the dominant hemisphere of the brain. As OCD is considered by some to be an information-processing problem, it may, for purposes of speculation only, be possible that a flawed transfer of musical information between the hemispheres of the brain contributes to the problem.



Treatment

So what's a sufferer to do? Avoidance of music in our daily lives is virtually impossible. Behavior therapy (BT), although potentially useful, is not that impressive, based on my clinical experience. Nevertheless, techniques such as visualizing the music as coming from a tape recorder and then hitting the pause button, or manipulating the volume control as a form of thought-stopping, should be considered. "Cranking the volume up" as exposure therapy has been suggested by some behavioral therapists as an effective technique, but I have yet to hear of a successful treatment with this approach, specifically for sufferers of intrusive music.

Once underlying conditions, as discussed above, are eliminated, medication should be seriously considered for those with significant impairment. This form of OCD can be responsive to the traditional medications for OCD (i.e., Anafranil, Prozac, Paxil, Zoloft, Luvox). There is no specific drug preferred for this condition, and finding the right one and correct dosage os still a matter of trial and error. The goal should be the elimination of symptoms, but realistically, sometimes all one can achieve is alleviation. If medication fails or severely aggravates the symptoms, one diagnosis that should not be overlooked is temporal lobe epilepsy, as it too can produce hallucinations. Consultation with a neurologist who is competent in this area should be considered.

In summary, intrusive music is common, can be debilitating, and is often overlooked in the management of OCD. I hope this brief review will stimulate discussion about this topic for the increased well-being of OCD sufferers everywhere. Comment on this article would be greatly appreciated. Please write to me at (author's address). I would like to thank all of the readers who took the time to share their experiences with me.



(From _OCD NEWSLETTER_ Volume 11, Number 2; April, 1997 -- by Harold Pupko, M.D.