LETTERS

Musical Hallucinations: CaseReport and Review of theLiterature

Musical hallucinations (MH) area rare subtype of complex auditoryhallucinations, linked to a disorder ofthe processing of complex sounds.The abnormal perception is formedby music, instrumental sounds orsongs.1 Typically there is someinsight for the nature of thehallucination.2

Case reportThe patient was a 75-year-oldwoman with medical history of mildhypertension and hypercholesterol-emia, medicated with sinvastatine,carvedilol, omeprazole, triflusal andbetahistine dihydrochloride. Therewas an otorhinolaryngology consul-tation in 2008 for hypoacusis, tinitusand dizziness without rotatory ver-tigo, with years of evolution.Oriented for psychiatric

observation in 2010, for suspectedanxious symptomatology.Complained of hearing Portuguesepopular music bilaterally, since theprevious month. Could identify thelyrics and sing the songs heard.Allocated the sounds out of her head,although having doubts about theirreality. Absence of other auditory orvisual hallucinations. No cognitiveimpairment.Audiogram showed sensorineural

hearing loss, bilateral, moderate andasymmetrical (medium loss of 26,5dB at the right and 40dB at the left).Tympanogram was type A1.Electrocochleography revealedendolymphatic hidropsis on the left.MRI of the internal auditory canalswas normal. Anti-68 Kd antibody

were positive but there was no re-sponse to glucocorticoid therapy.Otoscopic examination was normal.Rinne test was positive bilaterally.Weber test without lateralization.Psycho active were proposed butrefused.

DiscussionChronic auditory impairmentseems to be the main aetiologicalfactor of MH, but other causes likepsychiatric disorders (depression,schizophrenia, obsessive-compulsivedisorder), social isolation, epilepsy,focal brain lesions (vascular, infec-tious, tumors, etc.) and the use ofsome drugs and substances have alsobeen described as important factorsin the generation and persistence ofMH.3, 4 The relative importance ofeach factor remains unclear.4

It affects mainly female gender andolder people.2 Patients whosehallucinations are caused by focalbrain lesion are usually significantlyyounger than those suffering fromhypoacusis.2

The sound heard is frequentlyfamiliar to the patient and theperception bilateral.2 Reaction ofpatients to the sounds and theexistence of insight is variable. Whenthey are totally aware of nonrealnature of the perception it should beconsidered an hallucinosis.Some authors defend that MH

may be an auditory form of theCharles Bonnet Syndrome (sensorydeprivation leads to releasephenomenon).1, 2, 5

Treatment of MH is not completelyagreed-upon. When an underlyingcause is identified, it should betreated. In other cases, reassurancethat hallucinations are due to hearingloss might be enough.3 Medicationmanagement can also be considered.

Depending on the cause,antipsychotics, antidepressants,benzodiazepines, and anticonvulsivedrugs might be successful.3, 5 A singlecase of MH where donepezil waseffective has been reported.5 In somecases, MH disappear after theunderlying hearing defect is cured.2

ConclusionThe case presented supports thefindings in literature. However, thereare still many doubts about classi-fication and pathophysiology ofmusical hallucinations, so morestudies are needed.Altough MH are a rare

phenomenon, psychiatrists shouldtry to evaluate its existence moreoften, as patients are frequently tooembarrassed to refer to them freely.Snia SimesJoana MesquitaNuno MaralMaria SantosBraga, Portugal

References

1. Evers S, Ellger T, Ringelstein EB, et al: Ishemispheric language dominance relevantin musical hallucinations? Two case reports.Eur Arch Psychiatry Clin Neurosci 2002;252:299302

2. Evers S, Ellger T: The clinical spectrum ofmusical hallucinations. J Neurol Sci 2004;227:5565

3. Holroyd S, Sabeen S: Successful treatmentof hallucinations associated with sensoryimpairment using gabapentin.J Neuropsychiatry Clin Neurosci2008; 20:364366

4. E Fischer C, Marchie A, Norris M:Musical and auditory hallucinations:A spectrum. Psychiatry Clin Neurosci2004; 58:9698

5. Ukai S, Yamamoto M, Tanaka M, et al:Donepezil in the treatment of musicalhallucinations. Psychiatry Clin Neurosci2007; 61:190192

E8 http://neuro.psychiatryonline.org J Neuropsychiatry Clin Neurosci 24:2, Spring 2012