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http://dx.doi.org/doi:10.1016/j.janxdis.2014.06.003
ANXDIS 1613
To appear in:
Received date:
Revised date:
Accepted date:
14-11-2013
9-5-2014
6-6-2014
Please cite this article as: Taylor, S., McKay, D., Miguel, E. C., Mathis, M. A. D.,
Andrade, C., Ahuja, N., Sookman, D., Kwon, J. S., Huh, M. J., Riemann, B. C.,
Cottraux, J., OConnor, K., Hale, L. R., Abramowitz, J. S., Fontenelle, L. F., and Storch,
E. A.,Musical obsessions: A comprehensive review of neglected clinical phenomena,
Journal of Anxiety Disorders (2014), http://dx.doi.org/10.1016/j.janxdis.2014.06.003
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Highlights:
It was based on the largest sample of published and unpublished cases ever
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Etiological hypotheses and important directions for future research are presented.
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Running head: Musical Obsessions
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Chittaranjan Andrade d, Niraj Ahuja e, Debbie Sookman f, Jun Soo Kwon g, Min Jung
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Abstract
Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping
fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that
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merit investigation in their own right and, more generally, research into these phenomena
may broaden our understanding of obsessive-compulsive disorder (OCD), which is
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review of musical obsessions, based on the largest set of case descriptions ever assembled
(N = 96). Characteristics of musical obsessions are described and compared with normal
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obsessions may be under-diagnosed because they are not adequately assessed by current
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which has led to ineffective treatment. Accurate diagnosis is important for appropriate
treatment. Musical obsessions may respond to treatments that are not recommended for
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Keywords: Obsessive-compulsive disorder, intrusive musical imagery, involuntary
Highlights:
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It was based on the largest sample of published and unpublished cases ever
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assembled.
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Etiological hypotheses and important directions for future research are presented.
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1. Introduction
Obsessions and compulsions are the cardinal features of obsessive-compulsive
disorder (OCD). Obsessions are unwanted, intrusive, and distressing thoughts, images, or
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urges. Compulsions are repetitive behaviors or cognitive rituals that the person feels
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[APA], 2013). Although intrusive mental imagery has long been recognized as a salient
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feature of OCD (de Silva, 1986), clinical descriptions and research have focused almost
exclusively on visual imagery. Phenomena involving intrusive musical imagery (IMI),
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because descriptions of IMI appeared in the psychological and psychiatric literature for
over a century (e.g., Ebbinghaus, 1885; Janet, 1903; Kraepelin, 1915), and IMI continues
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importance of IMI, the neurologist Oliver Sacks (2007) observed that it is the clearest
sign of the overwhelming, and at times helpless, sensitivity of our brains to music (p.
49). Musical obsessions are distressing, persistent, and disruptive forms of IMI.
OCD is etiologically heterogeneous, shaped by etiologic factors (genetic and
environmental) that are specific to a given class of symptom (e.g., etiologic factors
specific to washing compulsions) and by broader etiologic factors influencing many
different types of obsessive-compulsive (OC) symptoms and other forms of
psychopathology (Miguel et al., 2005; Taylor, 2011). Given the heterogeneity and
complexity of OCD, it is insufficient to study only the most common types of symptoms,
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such as washing or checking compulsions. A comprehensive understanding requires that
even the less common symptoms be investigated in order to gain a better understanding
of OCD.
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Although there have been few studies of musical obsessions compared to studies
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the prevalence and importance of OC-related phenomena. OCD was once considered
rare. It was not until the epidemiologic surveys were conducted that OCD came to be
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appreciated until recently (Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009).
Even as late as 1987, descriptive case studies of hoarding were sufficiently rare as to
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To our knowledge, the present paper is the first comprehensive review of musical
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obsessions, based on the largest ever assembled set of case descriptions (N = 96,
consisting of 33 previously published cases and our 63 new cases). In this paper we will
review the characteristics of IMI in general, and then consider musical obsessions in
particular, including an examination of clinical features, differential diagnosis,
comparisons with visual obsessional imagery, etiologic considerations, assessment, and
treatment. We also highlight important gaps in the empirical literature and suggest
avenues for further investigation. The present paper aims to provide the groundwork for
subsequent research, by synthesizing and describing what is currently known, based on
published and unpublished research.
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2. Intrusive Musical Imagery
IMI is characterized by a tune that repeatedly comes to mind without the person
consciously trying to recall it (Williamson et al., 2011). Also known as earworms,
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5,000 participants, Stafford (2012) found that IMI usuallybut not invariablyconsists
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of simple repetitive song fragments, such as a particular verse or hook that has an
ineffable catchy quality. IMI need not be limited to simple or rhythmically repetitive
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songs; almost any song can be a source of IMI (Hyman et al., 2013). IMI involves a
fragment of music that the person has previously heard, such as a chorus or line of music,
equal to or less than the capacity of auditory short-term memory. That is, repetitions of
15-30 second segments of music, persisting like a looping soundtrack (Bailes, 2007;
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Beaman & Williams, 2010; Liikkanen, 2012b,c). Repetitions of IMI may last from
minutes to hours (Halpern & Bartlett, 2011), but most often consist of recurrent,
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intermittent episodes rather than a continuous musical soundtrack (Hyman et al., 2013).
IMI typically shifts over time; imagery of one particular tune might persist for a day or
two and then, days or weeks later, some other tune might become the new source of IMI
(Beaman & Williams, 2010; Hyman et al., 2013).
Episodes of IMI can be triggered by exposure to music, including repeated
exposure to a given song or jingle. To illustrate, Halpern and Bartlett (2011) found that
Christmas carols were most likely to become a source of IMI during the festive season,
when such music is most likely to be heard. IMI can also be triggered by stimuli
associated with particular pieces of music, such as by reading written lyrics or exposure
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to people or places associated with a particular piece of music (Halpern & Bartlett, 2011;
Hyman et al., 2013; Liikkanen, 2012a; Williamson et al., 2011). IMI can also be triggered
by personally important events (Janata, 2009; Reik, 1953). For example, music played at
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Surveys indicate that more than 85% of people in the general population
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experience involuntary musical imagery at least weekly (Bailes, 2007; Bennett, 2002;
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Liikkanen, 2012b). The frequency of IMI is positively correlated with the amount of
music involvement (e.g., amount of practice or listening to music), and the perceived
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importance of music (Beaman & Williams, 2010; Bennett, 2002; Floridou, Williamson,
For most people, IMI is not aversive (Beaman & Williams, 2010; Halpern &
Bartlett, 2011; Hyman et al., 2013). In fact, some songs and advertising jingles become
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popular precisely because they induce IMI. People who find IMI to be aversive are more
likely to have prototypic OC symptoms, such as washing or checking rituals. To
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were caused by a third variable, such as a vulnerability factor for OC symptoms (see
below for etiologic considerations). Nevertheless, the findings show that prototypic OC
symptoms and IMI-related distress are correlated with one another.
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Musical obsessions are not mentioned in the most recent version of the Diagnostic
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and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). Musical obsessions are
described in the clinical literature as episodes of IMI that meet criteria for OC symptoms;
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that is, the obsessional imagery is recurrent, persistent, intrusive, unintentional, time
consuming (i.e., more than an hour per day), and causes distress or functional
impairment. Note that this definition refers to persistent, involuntary musical imagery. It
does not refer to obsessional preoccupations about particular pieces of music. A woman
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with an obsessional fear of becoming a lesbian, for example, might fear and avoid songs
with homoerotic lyrics, such as Katy Perrys I Kissed a Girl and I Liked it. This is not a
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musical obsession as the term is used. Similarly, the definition of musical obsessions
excludes cases in which the person feels compelled to repeatedly listen to, or recall a
piece of music until some perfectionistic just right sense of completeness has been
attained. Musical obsessions are also distinct from sought-out musical recollections,
which have been described by composers who are absorbed in thinking about and writing
music, and by some music enthusiasts. A person who ardently collects and repeatedly
listens, with enjoyment and without impairment, to the many different versions of
Beatles songs can be considered to have a musical preoccupation, not a musical
obsession as the term is defined.
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3.2. Differential Diagnosis
3.2.1. Musical hallucinations. Hallucinations are perceptions lacking an adequate
input stimulus, which are perceived to arise from an external source and are interpreted as
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veridical (Sedman, 1966). Musical hallucinations are rare (Berrios, 1990). They have
been described in patients with acquired hearing loss, epilepsy, structural brain lesions,
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psychosis, delirium, drug induced states, and hypnagogic states (Evers & Ellger, 2004).
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In contrast to musical hallucinations, musical obsessions are a form of imagery that the
person recognizes as originating from his or her mind, and occur in people who do not
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because of the lack of consensus regarding its definition and distinction from true
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are forms of imagery that occur in inner (subjective) space and are recognized by the
person as not veridical perceptions. To this extent, musical pseudohallucinations
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resemble musical obsessions. The two differ in that pseudohallucinations need not be
perceived as aversive and are not associated with compulsions (Oyebode, 2001). Unlike
musical obsessions, which are not due to drug intoxication or deafness,
pseudohallucinations can occur exclusively during hallucinogen intoxication and can
arise as a result of severe hearing loss (El-Mallakh & Walker, 2010).
Pseudohallucinations can occur in psychotic disorders such as schizophrenia, and in
various non-psychotic disorders such as dissociative disorders and borderline personality
disorder (Oyebode, 2001; Sanati, 2012). Musical obsessions and pseudohallucinations
also differ in terms of insight. By definition, insight is always present in musical
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obsessions; that is, the person always recognizes that the musical imagery is a product of
his or her mind. In comparison, insight can fluctuate in musical pseudohallucinations; at
times the person might believe that the source of the music is internal, but at times may
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auditory stimulus occurs after cessation of the stimulus. The person recognizes the
hallucinatory nature of the experience, which is often described as hearing a fragment
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of music, a noise, or portions of speech (Jacobs, Feldman, Diamond, & Bender, 1973;
Mohamed, Ahuja, & Shah, 2012). Palinacousis is rare and musical palinacousis is even
rarer (Mohamed et al., 2012; Podoll, 2010). Palinacousis is associated with EEG and
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primary tumors, and metastases), typically in the temporal or parietal lobes (Mohamed et
al., 2012). Palinacousis is usually a manifestation of seizure activity (e.g., an aura),
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although it may also be a post-ictal or a migrainous phenomenon (Di Dio et al., 2007;
Mohamed et al., 2012; Podoll, 2010). Palinacousis is associated with marked
neurological deficits (e.g., aphasia; Di Dio et al., 2007), whereas musical obsessions are
not associated with such pathology. Unlike musical obsessions, which occur in ones
mind with no auditory localization to a given ear, the sounds in palinacousis often occur
only in one ear (Mohamed et al., 2012). Musical obsessions also differ from palinacousis
in that the former are limited to repetitions of fragments of music the person has heard in
the past, rather than being simply recollections of the last thing the person heard.
3.3. Characteristics of Musical Obsessions: Findings from 96 Cases
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3.3.1. Acquisition of published case material. A literature search of the following
databases was conducted up to May 1, 2014: PsychInfo, MEDLINE, EMBASE, and
Google Scholar. The keywords were obsess* and music* (the asterisks denote the use of
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wild cards). Articles in all languages were considered. References in the identified
articles were examined for additional relevant material. Researchers who had previously
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published on musical obsessions were also contacted for published and unpublished
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cases. A total of 17 publications were identified (Ahuja, 2001; Akhtar, Wig, Varma,
Pershad, & Verma, 1975; Andrade & Rao, 1997; Berg, 1953; Cameron & Wasielewski,
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1990; Fontenelle, 2008; Gomibuchi, Gomibuchi, Akiyama, Tsuda, & Hayakawa, 2000;
Hemming & Altenmller, 2012; Marani, Aukst-Margeti, Grgi, & Kumi, 2011;
Matsui et al., 2003; Mendhekar & Andrade, 2009; Nath, Bhattacharya, Hazarika, Roy, &
Praharaj, 2013; Pfizer & Andrade, 1999; Praharaj et al., 2009; Rapoport, 1980; Saha,
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2012; Zungu-Dirwayi et al., 1999). The five cases reported by Hemming and Altenmller
(2012) were excluded because most suffered from tinnitus.
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presented illustrative information on two of their five cases, four other studies each
presented two cases (Ahuja, 2001; Matsui et al., 2003; Rapoport, 1980; Zungu-Dirwayi et
al., 1999), and the remaining articles each described a single case. Thus, we were able to
locate published reports of 33 cases of musical obsessions. We also identified a study
comparing diagnostic groups in terms of the prevalence of musical obsessions (Hermesh
et al., 2004). Those authors equated musical hallucinations with musical obsessions. That
study was not included in our count of cases of musical obsessions because of Hermesh
et al.s questionable decision to equate musical hallucinations with musical obsessions.
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3.3.2. Additional cases. To supplement the published case studies, the authors of
the present paperclinicians with expertise in OCDreviewed their own clinical case
files for previously unpublished cases of musical obsessions. All cases had been
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practices focusing on the treatment of anxiety and related problems to large-scale hospital
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or research clinics specializing in OCD and related problems. The number of patient files
that were examined ranged from a few dozen to databases consisting of over a thousand
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To the best of our knowledge, this is by far the largest set of cases of musical obsessions
ever assembled.
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research, which has yet to be conducted. Nevertheless the published and new cases
provide the most comprehensive collection of clinical reports to date and, in aggregate,
provide a preliminary portrait of the nature and treatment of musical obsessions. Details
of the cases appear in the Appendix. The following sections summarize the main
findings.
3.3.2. Demographic features. The 96 cases were obtained from throughout the
world: Brazil, Canada, India, Japan, Republic of Korea, South Africa, and the U.S. The
mean age was 33 years (range 9-83 years) and 50% were female. About half (53%) were
employed, with the remainder being students (29%), homemakers (10%), retired (4%), or
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unemployed (4%).
3.3.3. Diagnostic features. With the exception of Berg (1953), for which
diagnostic status was unclear, all cases were diagnosed with OCD. There was no
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evidence that any of these individuals suffered from palinacousis (e.g., none had a history
of seizures) and none appeared to be suffering from tinnitus or deafness. Musical
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However, neither they nor any of the other cases had psychotic features such as formal
thought disorder or verbal auditory hallucinations. Neurological factors (brain
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discussed below, but even these cases had unremarkable findings on neurological
3.3.4. Content of obsessions. Musical obsessions were either the sole presenting
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obsessions consisted of either a single song or a series of songs that changed over time, as
in the case with IMI in general. All musical obsessions were songs or melodies that the
person had heard recently or in the past, and were often popular songs. In some cases,
however, the songs were more specific, sometimes with a special meaning to the
individual. For one person, a professional musician, the musical obsessions consisted of
classical music he had played (e.g., Ravels Bolro) or music he had recently composed.
In other cases, the obsessions consisted of advertising jingles or pieces of film scores. In
one case the obsession consisted of cellular phone ringtones. The duration of musical
obsessions generally ranged from months to years. In some cases the obsessions occurred
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intermittently and in other cases were reported as occurring almost continuously during
waking hours.
3.3.5. Fear, avoidance, and compulsions related to musical obsessions. It is
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common for people with OCD, regardless of the type of symptoms, to attempt to cope
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ritual (Abramowitz et al., 2011). For example, someone with visual obsessional imagery
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of harming their child might avoid kitchen knives, seek reassurance from others about the
childs well-being, and attempt to suppress or eliminate the unwanted violent images. We
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associated with music, such as avoiding listening to music or avoiding public places
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where music is commonly played. To illustrate, a patient with ring tone obsessions went
to great lengths to avoid exposure to ring tones. He wore earplugs, kept his phone on
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silent (vibrate) mode, urged others to do the same, and avoided places where he might
hear the ringing of cellular phones (Mendhekar & Andrade, 2009). In other cases,
patients worried about, and made unsuccessful attempts to suppress, the unwanted
musical imagery (Matsui et al., 2003). Thought suppression involved attempts to replace
the unwanted IMI with other, distracting stimuli (i.e., cognitive rituals). In at least one
case, the mere thought that one might hear unwanted music was sufficient to trigger the
IMI, leading the person to engage in efforts at avoidance or thought suppression.
3.3.6. Circumstances of onset. Onset in a number of cases occurred after the
person had been spending a lot of time listening to music. For example, prior to onset of
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ring tone obsessions the patient had enjoyed downloading, previewing, and changing ring
tones on his cellular phone, devoting up to 2-3 hours/day to this activity. He discontinued
the activity as he became increasingly troubled by recurrent unwanted intrusive imagery
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of ring tones.
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stress related. In several cases, musical obsessions developed in students who were
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studying for exams. In another case, musical obsessions consisted of funeral dirges,
which developed shortly after the death of the patients wife. In yet another case the
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obsessions began after the patient resigned from his job due to interpersonal conflicts. In
one case the musical obsession appeared to be the result of an attempt by the patient to
distract herself from other obsessions. She developed the strategy of singing to herself to
avoid or neutralize her other, non-musical obsessions, but then began experiencing
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unwanted, distressing musical imagery of the songs she had used as distraction.
There was no evidence of neurological abnormalities in almost all cases. In three
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cases, however, onset might have been triggered by a neurological insult. In one case
(Cameron & Wasielewski, 1990), musical obsessions began a month after the patient
received a blow to the head. However, a comprehensive evaluation revealed no evidence
of neurological abnormalities or non-musical auditory echoing or seizures. The patient
was successfully treated with clomipramine. Although one should be cautious about
drawing conclusions about etiology based on treatment response, the patients response to
clomipramine was consistent with what is typically reported for OCD in general. There is
no evidence that a neurological condition such as palinacousis would respond to
clomipramine.
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In a second case (Pfizer & Andrade, 1999), musical obsessions arose suddenly, in
conjunction with an infection causing sore throat and fever. The infection was
successfully treated with erythromycin but the musical obsessions persisted. The clinical
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arise from infection-related inflammation of the basal ganglia and associated structures.
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The validity of the concept of PANDAS is contentious (Murphy, Kurlan, & Leckman,
2010); Despite more than a decade of studying PANDAS, it is still not possible to
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the association between infection and the onset of musical obsessions was probably
coincidental.
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days and had a month of retrograde amnesia. A CT scan was normal although there was
evidence of personality changes, in which the patient became apathetic with intermittent
aggressive outbursts. Zungu-Dirwayi et al. (1999) regarded the case as one of acquired
OCD.
were most extensively investigated in the unpublished cases, where patients completed
the Y-BOCS symptom checklist. The published cases, however, also provided some
information on comorbidity. Most patients suffering from musical obsessions had past or
current comorbid OC symptoms, including washing, checking, or ordering compulsions,
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and aggressive, horrific, sexual, or religious obsessions. Some of the comorbid
obsessions consisted of distressing visual imagery. Some patients had comorbid
obsessions that were similar in form to musical obsessions; for example, unwanted,
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with many other types of OC symptoms is consistent with OCD in general, in which such
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patient was described as suffering from distressing pareidolias, that is, illusory images
that were perceived while looking at shapes (e.g., seeing gorillas in the mosaic pattern of
and distress in response to minor everyday sounds such as the sound of other people
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eating (Mller, 2011). Disorders that are commonly comorbid with OCD in general were
also described, such as other anxiety disorders, mood disorders, and tics. There was no
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evidence of psychotic features in the 96 cases. In summary, for most cases the pattern of
comorbidity was broadly similar to that of OCD in general.
3.3.8. Prevalence. There have been no epidemiologic studies that assessed
musical obsessions. It is widely assumed that musical obsessions are rare (Nath et al.,
2013; Rapoport, 1980; Saha, 2012). Prevalence may have been underestimated because
of a lack of clinical attention to the phenomena (i.e., clinicians failing to inquire about the
phenomena), because of limitations in our assessment methods, and patients often fail to
disclose the full range of their obsessions and compulsions unless they are specifically
asked about particular types of symptoms (Andrade & Rao, 1997; Marani et al., 2011).
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Current measures of OC symptoms and OCD fail to adequately assess musical
obsessions, which makes it difficult to estimate their prevalence. Only one item of the
symptom checklist of the Y-BOCS assesses whether the respondent has suffered from
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intrusive nonsense sounds, words, or music, with the example given as words, songs,
or music in your mind that you cant stop. This item fails to distinguish musical
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obsessional imagery is visual (de Silva, 1986; Speckens et al., 2007). Obsessions
characterized by spoken words, olfactory, gustatory, or tactile imagery are rare (Chauhan,
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Shah, & Grover, 2010; de Silva, 1986; Speckens et al., 2007). Unwanted visual images
are typically inherently aversive or violate the persons values or beliefs. Common
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ego-dystonic material such as unwanted images that violate the persons religious, sexual,
or moral values. The intrusive music is usually not something that the person associates
with some unpleasant event, although there are some exceptions (e.g., the funeral dirge
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case). Musical and visual obsessional imagery also differ in that the former involves
music that is typically familiar to the person; that is, something that the person has
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of imagined scenarios. Musical and visual obsessional imagery also differ to some extent
in their treatment. Imaginal (and situational) exposure and response prevention is an
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empirically supported treatment for OCD in general, including the treatment of visual
obsessional imagery (Abramowitz, Deacon, & Whiteside, 2011).These methods have
been used to treat musical obsessions, but distraction has also been successfully used in
case studies (see below). Distraction is not an empirically supported treatment for visual
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obsessions, as discussed below. Musical and visual obsessional imagery are similar in
that both are commonly comorbid with other OC symptoms, such as washing, checking,
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and ordering compulsions. Our case series indicates that it is not uncommon for musical
obsessions to be comorbid with visual obsessions. The comorbidity and
phenomenological similarities and differences between musical and visual obsessional
imagery raise the question of whether there are similarities and differences in their
etiologic mechanisms. This remains to be investigated.
Obsessions involving visual imagery can be explained in terms of contemporary
cognitive-behavioral models of OCD (see below). Given that musical obsessions differ
from visual obsessional imagery in important ways, as discussed above, it seems likely
that current cognitive-behavioral models would require modification if they are to be
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extended to account for musical obsessions. In the following section we summarize these
models and discuss how they might be modified to explain why most people experience
5. Etiological Considerations
5.1. Contemporary Cognitive-Behavioral Models of OC Symptoms
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contemporary cognitive-behavioral models are among the leading approaches (Frost &
Steketee, 2002; Salkovskis, 1996). These models, which share basic postulates, propose
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that OC symptoms arise from specific types of dysfunctional beliefs, where the content
and strength of belief influences the development and severity of OC symptoms. Three
symptoms: (a) perfectionism (P) and intolerance of uncertainty (C; collectively referred
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to as PC), (b) over-importance of thoughts and the need to control thoughts (ICT), and (c)
inflated responsibility and the overestimation of threat (RT) (Obsessive Compulsive
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Cognitions Working Group, 2005). PC involves beliefs that mistakes and imperfection
are intolerable, along with beliefs that it is necessary and possible to be completely
certain that aversive events will not occur. ICT entails beliefs that the mere presence of
unwanted thoughts indicates that such thoughts are important or portentous (e.g., the
belief that bad thoughts, even unwanted ones, lead to bad deeds), along with beliefs
that complete control over ones thoughts is necessary and possible. RT includes beliefs
that aversive events are quite likely to occur and that one has a duty to prevent such
events.
The presence of strongly held dysfunctional beliefs are said to play a role in
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transforming ordinary intrusions into obsessions. To illustrate, consider the unwanted
intrusive image of stabbing a loved one. If the person interprets the intrusion as having no
significance (i.e., regarded it as mental detritus) then he or she would experience little
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harm, then the person would become distressed, attempt to vigorously suppress such
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imagery, avoid triggering stimuli (e.g., kitchen knives), and repeatedly seek reassurance
that loved ones have not been harmed (Abramowitz et al., 2011; Frost & Steketee, 2002).
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Consistent with this formulation, research shows that the frequency or severity of
obsessions in general is predicted by the strength of a persons beliefs about the
deeds), and by beliefs about the importance of controlling such thoughts (e.g., If I dont
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drive the violent thoughts out of my mind, I will lose control and inflict harm on others)
(Taylor, Abramowitz, McKay, & Cuttler, 2012).
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consequences of their unwanted, uncontrollable musical imagery. Therefore, individual
differences in the frequency and duration of IMI seem likely to play some role in
influencing the development of musical obsessions. However, even highly frequent and
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interprets highly persistent IMI as an innocuous background soundtrack to daily life then
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IMI would not become a source of distress or lead to impairing avoidance behaviors or
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compulsions. Negative beliefs and appraisals seem important for transforming inherently
innocuous IMI into musical obsessions.
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Negative appraisals of IMI can arise from beliefs that IMI is abnormal (e.g., a
harbinger of mental deterioration), a sign that one lacks sufficient self-control (e.g., If I
cant control my mind, then I might lose control of my behaviors), or a sign of some
other aversive outcome (e.g., The music in my head interferes with my concentration; if
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They tried hard to get rid of the music that, they felt, was abnormal. Their attempt,
therefore, focused more attention on the symptom [the intrusive music]. The more
they tried to get rid of it, the more they focused attention on it. This is the vicious
cycle ... Their efforts not to hear it, paradoxically, made it occur more frequently
and more intensively. Through this process, musical obsession was formed.
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(Gomibuchi et al., 2000, p. 206)
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Very little is known about the factors influencing individual differences in the
frequency or persistence of IMI. This is an important gap in the research literature.
an
Neural imaging and other forms of research suggest that auditory imagery involves the
same brain areas as those involved in auditory perception (Hubbard, 2010; Zatorre &
Halpern, 2005). These include the superior temporal gyrus, frontal and parietal lobes, and
supplementary motor cortex (Hubbard, 2010; Janata, 2009). Levitin (2006) speculated
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that repetitive IMI occurs because the neural circuits representing the song get stuck in
playback mode (p. 155). Given the multitude of structures involved in auditory
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Page 24 of 60
24
recurrent intrusions of verbal auditory imagery. There was suggestive evidence of this in
our case series. One patient had musical obsessions along with auditory verbal intrusions
consisting of the name of a dead friend that echoed in her mind (Cabral, Cabral,
ip
t
Cabral; Fontenelle, 2008). In two other cases the person experienced intrusions
consisting of lines of spoken poetry (Andrade & Rao, 1997; Saha, 2012). Further research
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6. Treatment
us
of auditory memories.
an
could be empirically evaluated in future research. Details of the treatments for the cases
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appear in the Appendix. The following is a summary of the salient points arising from the
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In assessing musical obsessions the clinician cannot rely solely on the Y-BOCS
because it does not specifically assess musical obsessions. The clinician needs to
specifically inquire about whether the patient suffers from musical obsessions and should
rule out differential diagnoses (see above). If cognitive-behavioral treatments are
planned, then it would be useful to assess the patients beliefs and appraisals of unwanted
musical imagery, to determine whether the person is making catastrophic
misinterpretations (e.g., The uncontrollable music in my head means that I have
something seriously wrong with my brain).
Unusual OCD symptoms can lead to misdiagnosis and inappropriate treatment
Page 25 of 60
25
(Marani et al., 2011). In our case series, two patients were misdiagnosed as having a
psychotic disorder (Marani et al., 2011; Nath et al., 2013). In neither case did the
patient benefit from antipsychotics; in fact, there was evidence of symptom worsening.
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medications known to be efficacious for OCD (e.g., clomipramine, fluvoxamine) and the
us
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6.2. Pharmacotherapy
an
For musical obsessions in general, including those that were correctly diagnosed
at the outset, our case studies suggest that patients tended not to benefit from
effective in treating musical hallucinations (Evers & Ellger, 2004) and verbal auditory
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benefit from medications that are efficacious for OCD in general, such as selective
serotonin reuptake inhibitors (SSRIs) and clomipramine.
6.3. Cognitive-Behavioral Interventions
Cognitive restructuring may be useful to address threat-related beliefs about the
Page 26 of 60
26
without trying to suppress it. As had been reported for other obsessions, the effort the
person puts into trying to suppress IMI is correlated with the frequency of IMI
(Williamson & Mllensiefen, 2012). Reappraisal and acceptance strategies show promise
ip
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for reducing distress and reduce maladaptive efforts at suppressing musical obsessions
(Gomibuchi et al., 2000). A helpful coping statement might be: This is just music in my
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6.4. Distraction
an
(Abramowitz et al., 2011). However, there are several lines of evidence suggesting that
they can be useful in treating musical obsessions. Studies of normal IMI suggest that
distraction can be useful. Retrospective surveys and prospective diary research indicates
that people most commonly use distraction to terminate episodes of normal IMI (e.g.,
te
keeping busy with whatever task is at hand, or listening to a competing piece of music;
Beaman & Williams, 2010). In an experimental analogue study of normal volunteers,
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Hyman et al. (2013) found that normal IMI was disrupted when the person engaged in
tasks producing a moderately high load on working memory (i.e., completing easy
anagrams or Sudoku puzzles).
Distraction can take the form of competing stimuli (such as competing sounds)
that are incompatible with forming melodies or incompatible with the specific intrusive
melody (such as other dissimilar songs). One of the authors (DM) successfully used a
distraction method in which the patient was asked to sing songs other than those
characterizing the musical obsession (see Appendix). The patient was also asked to sing
the target obsessional song aloud but incorrectly. In this approach musical obsessions
Page 27 of 60
27
were conceptualized as similar to depressive ruminations, which can be successfully
treated with distraction strategies (Teismann, Michalak, Willutzki, & Schulte, 2012). The
additional component involving participants singing aloud the target song, with the
ip
t
clinician, may weaken the specificity of the IMI. That is, rather than only experiencing
the obsession of the song as heard in its original form, the same melody now has
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associations with other sources. This is based on the assumption that the musical
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an
lead to greater flexibility in associations, derived from a relational frame theory (Dymond
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Page 28 of 60
28
suggest that ERP can be effective. Case reports are useful in that they suggest areas for
further investigation. Future studies could directly compare distraction versus ERP as
treatments for musical obsessions, and to investigate whether there are any variables.
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6.6. Summary
There are several promising approaches to treating musical obsessions that merit
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us
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obsessions. If these interventions are unsuccessful then we recommend that the clinician
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reevaluate the diagnosis to determine whether the patient has musical obsessions or some
other clinical condition such as a psychotic or neurological disorder. If the most likely
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7.1. Conclusions
The present paper is, to our knowledge, the first comprehensive review of musical
obsessions, based on the largest set of case studies ever assembled. We sought to
integrate the findings with research on normal IMI and compare musical obsessions with
other obsessive-compulsive phenomena. The following are our main conclusions:
1. There are several reasons for regarding musical obsessions as true obsessions:
(a) forms of IMI can be identified that meet all DSM-5 diagnostic criteria for obsessions;
Page 29 of 60
29
(b) musical obsessions lead to avoidance and compulsions in the same way that occurs
for prototypic obsessions; and (c) musical obsessions are commonly comorbid with other
types of OC symptoms, as is typically the case for OCD in general (APA, 2013).
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t
2. The previous literature has been limited mainly to a scattering of isolated case
reports, which has been taken as suggesting that musical obsessions are rare. However,
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we were able to readily identify a large number of unpublished cases, obtained from
us
clinicians with expertise with OCD. It may be that musical obsessions are more common
than previously recognized.
an
clinicians may be unfamiliar with musical obsessions. Musical obsessions are sometimes
treatment.
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4. Musical obsessions differ from visual obsessions in that the content of the
obsession (i.e., the intrusive music) is not inherently aversive and does not violate the
persons system of beliefs or values. The content of visual obsessions is typically either
inherently aversive (e.g., horrific images of mutilated corpses), or violates the persons
values (e.g., blasphemous images). This raises the question of whether musical
obsessions and visual obsessions differ, at least to some extent, in their etiological
mechanisms. This conjecture, which awaits further investigation, is consistent with
research showing that OCD is etiologically heterogeneous (Taylor, 2011). That is, the
various symptoms of OCD (e.g., washing, checking, ordering) are shaped distinctive
Page 30 of 60
30
etiologic factors (environment and genetic) but also are shaped by factors that influence
all OC symptoms (Taylor, 2011).
5. IMI is common and yet musical obsessions are comparatively rare. Building on
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t
previous theorizing on OCD (e.g., Frost & Steketee, 2002), we propose a set of testable
hypotheses about the etiology of musical obsessions. Factors that influence the
cr
persistence or frequency of IMI may play a role but may be insufficient because
us
persistent, frequent IMI is not always distressing. Consistent with contemporary cognitive
models of OCD (Frost & Steketee, 2002), we propose that the persons beliefs and
an
appraisals of IMI play an important role in the etiology and maintenance of musical
obsessions. If a person appraises the IMI as threatening (e.g., as an indication of a life
threatening neurological problem), then he or she will become preoccupied and distressed
with the musical imagery. This may lead to functional impairment (e.g., failure to go to
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often played).
treatments for prototypic OC symptoms (e.g., ERP, SSRIs), there is evidence to suggest
that musical obsessions can be successfully treated with distraction-based interventions,
which are not among the recommended treatment of non-musical obsessions, such as
doubting/rumination and visual obsessions (Abramowitz et al., 2011).
7.2. Strengths and Limitations
There are various strengths and limitations to our review. In terms of strengths,
the present article is, to our knowledge, the first comprehensive review of musical
Page 31 of 60
31
obsessions, based on the largest set of case descriptions ever assembled. Our review is
comprehensive in that we sought to cover all the relevant literature, including, for
comparison with musical obsessions, the literatures on IMI in general and on visual
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obsessional imagery. In terms of weaknesses, the cases in our review were almost
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generalize to people who suffer from musical obsessions but do not seek treatment. A
us
further limitation is that there have been few studies comparing patients with musical
obsessions to other patient groups, and treatments have not been evaluated by means of
an
randomized controlled trials. A further limitation is that there have been few large-scale
empirical studies of IMI, and no empirical studies of the etiology of musical obsessions.
These limitations are unavoidable, given the lack of empirical attention to the neglected
clinical phenomena of musical obsessions. Despite these limitations, our review presents
te
the best available clinical description of musical obsessions, along with testable
hypotheses about etiology and treatment.
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Page 32 of 60
32
obsessions. Further research is also needed to investigate the cognitive-behavioral and
neurobiological bases of normal IMI in general, and musical obsessions in particular.
Research is also needed to investigate the promising treatments identified in the case
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studies, including the distraction-based interventions, which are quite different from
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phenomena.
Page 33 of 60
33
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Page 42 of 60
Appendix
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Page 43 of 60
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Sex
Occupation
Musical
Obsession(s)
Tunes from Hindi
songs.
1. Ahuja (2001)
India
24
Trainee
physician
2. Ahuja (2001)
India
33
Homemaker
3. Akhtar et al.
(1975)
4. Andrade &
Rao (1997)
India
23
Student
India
30
Musician
5. Berg (1953):
Summary
of 10 cases
USA
6. Cameron &
Wasielewski
(1990)
USA
Duration of
Musical Obsession(s)
Two episodes; most
recent was 8 months
M
an
us
Country
18 months
2 years
Various popular
songs.
--
--
ce
pt
40%F
24
70%
employed,
30%
students
Student
Homemaker
Ac
7. Fontenelle
(2008)
Adult
Brazil
38
Over 5 years
--
ed
Case
Page 44 of 60
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t
19
Student
9. Gomibuchi et
al. (2000)
Case 2
Japan
18
Student
Croatia
17
Several
months
Japan
20
M
an
ed
Several
months
Student
One month
(approx.)
Student
Popular songs,
jingles, and other
well-known
melodies.
2 years
ce
pt
Ac
Various melodies he
had recently heard.
cr
Japan
us
8. Gomibuchi et
al. (2000)
Case 1
EEG.
Stress-related onset (studying for exams).
Tried to suppress the musical imagery, with
little success. Musical intrusions were most
frequent and distressing when he was trying
hard to concentrate while studying. OCPD
traits (highly perfectionistic). Misophonia
(low tolerance for sounds; minor sounds
evoked distress).
Stress-related onset (studying for exams).
Used to listen to music while studying because
it helped block out extraneous noises. Then
tried to study without listening to music but
began experiencing musical obsessions.
Musical intrusions were most frequent and
distressing when he was trying hard to
concentrate while studying. OCPD traits
(highly perfectionistic), mild checking
compulsions.
Grades at school dropped significantly due to
musical obsessions. She often attempted to
suppress the symptoms but was unable to do
so. Intense anxiety, insomnia,
depersonalization, derealization, along with
harming and sexual obsessions. Neurological
examination, including EEG, was normal.
Initially misdiagnosed as being acutely
psychotic.
Intrusions were particularly troublesome when
he was studying for exams. He described the
symptoms as a broken tape recorder
repeatedly producing the same songs and
music all day long. It was monotonous and
interfered with his normal routine, academic
functioning, and usual social activities or
relationships. Exacerbated by stress (studying
for exams). Coping responses to musical
Page 45 of 60
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t
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13. Mendhekar &
Andrade
(2009)
India
28
Retail sales
M
an
Japan
2 years
ce
pt
ed
Student
4 months
--
Recently heard
3 years
Ac
22
India
22
Page 46 of 60
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tunes.
India
25
Homemaker
India
21
--
17. Rapoport
(1980)
USA
M
an
us
(2013)
ce
pt
ed
Sections of music
from various
popular Hindi films,
lasting from 2-45
min per episode,
occurring 30-35
times/day, nearly
every day.
Occasionally a new
song he heard
replaced an older
one.
Popular music,
movie scores.
Student
Farmer
7 years
Ac
16
18. Rapoport
(1980)
USA
60
31 years
Page 47 of 60
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t
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30
--
South
Africa
59
--
us
India
Music that he or
others had
composed,
associated with
intrusive images of
him humming the
tunes.
Various tunes.
4 years
M
an
Ac
ce
pt
ed
20 years. Developed in
Tried to get rid of the musical obsessions by
the context of major
substituting them with other thoughts or tunes.
depression following
Normal EEG.
her husbands death 20
years previously.
Obsessions persisted
after depression abated.
South
29
F
-Unspecified tune.
Intrusive tune
Unconscious for 4 days due to head injury.
21. ZunguDirwayi et al.
Africa
developed 5 months
One month of retrograde amnesia. Post-injury
(1999) Case
after a closed head
personality changes (increased aggressiveness
2
injury. Intrusion had
and apathy) with little insight as to the
persisted for a month at
changes. CT scan was normal. Unsuccessful
the time of assessment.
attempts at thought suppression.
-- = Not reported. Gomibuchi et al. (2000) presented, for illustrative purposes, 2 of 5 of their cases of musical obsessions (4 M, 1 F, ages 18-22). References to all
cited articles appear in the reference list of the main article.
Page 48 of 60
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Sex
Occupation
Musical
Obsession(s)
1. BCR
Case 1
USA
21
Student
2. BCR
Case 2
USA
59
Unemployed
(former
cleric)
3. CA
India
23
Songs on his
iPod, which
were mostly
popular songs.
If someone
was to sing a
song in
passing, and
he knew the
song, it would
also become a
musical
obsession.
Numerous
types of songs
(e.g., jingles,
Christmas
songs,
hymnals,
popular music
on the radio).
Not reported.
4. DM
Case 1
USA
Duration of
Musical
Obsession(s)
--
ed
ce
pt
M
Unemployed
Student
A pop song
that was
heavily played
on the radio.
us
Age
M
an
Country
Ac
Case
cr
Table A2. Unpublished cases of musical obsessions from the authors clinical files.
Intermittently
since teens.
Intermittently,
sometimes
lasting a day
or more.
2 months
Page 49 of 60
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5. DM
Case 2
6. DM
Case 3
USA
37
Lawyer
USA
49
Lawyer
7. DS
Case 1
8. DS
Case 2
9. DS
Case 3
10. DS
Case 4
Canada
25
Student
Canada
67
Canada
43
Retired
businessman
Homemaker
Canada
83
Retired
lawyer
11. DS
Case 5
12. ECM&
ADM
Case 1
13. ECM&
ADM
Case 2
14. ECM&
ADM
Case 3
15. ECM&
ADM
Case 4
16. ECM&
ADM
Case 5
17. ECM&
ADM
Case 6
Canada
32
Retail sales
Brazil
22
Student
Brazil
25
Factory
worker
Not reported.
10 years
Brazil
28
Office
supervisor
Not reported.
14 years
4 months
--
Lullabies.
--
Washing.
Funeral dirges.
3 months.
Musical
obsession
started after
the death of
his wife.
--
Depression, ordering.
us
Intermittently
for 2 years
M
an
ed
ce
pt
Ac
Heavy metal
songs
Popular songs
and TV
themes.
Bach, various
piano music.
Choral music.
--
8 years
Brazil
31
Office
assistant
Not reported.
16 years
Brazil
21
Computer
industry
Not reported.
4 years
Brazil
31
Architect
Not reported.
6 years
Page 50 of 60
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37
Business
consultant
Not reported.
19 years
Brazil
45
Researcher
Not reported.
20 years
Brazil
34
Advertising
Not reported.
23 years
Brazil
22
Telemarketer
Not reported.
1 year
Brazil
60
Homemaker
Not reported.
53 years
Brazil
25
Lawyer
Not reported.
13 years
Brazil
58
Retired
Not reported.
18 years
Brazil
42
Independently
wealthy*
Not reported.
24 years
Brazil
46
Office
worker
Not reported.
20 years
Brazil
54
Homemaker
Not reported.
24 years
Brazil
43
Homemaker
Not reported.
23 years
Brazil
32
Secretary
Not reported.
20 years
Brazil
60
Office
Not reported.
45 years
M
an
ed
ce
pt
us
Brazil
Ac
18. ECM&
ADM
Case 7
19. ECM&
ADM
Case 8
20. ECM&
ADM
Case 9
21. ECM&
ADM
Case 10
22. ECM&
ADM
Case 11
23. ECM&
ADM
Case 12
24. ECM&
ADM
Case 13
25. ECM&
ADM
Case 14
26. ECM&
ADM
Case 15
27. ECM&
ADM
Case 16
28. ECM&
ADM
Case 17
29. ECM&
ADM
Case 18
30. ECM&
Page 51 of 60
36.
37.
38.
39.
40.
41.
cr
ip
t
35.
Homemaker
Not reported.
33 years
Brazil
27
Marketing
Not reported.
22 years
Brazil
25
Lawyer
Not reported.
14 years
Brazil
60
Retired
Not reported.
10 years
Symmetry
Brazil
33
Lawyer
Not reported.
26 years
Brazil
22
Student
Not reported.
3 years
Brazil
25
Admin.
Not reported.
10 years
Washing, symmetry
Brazil
68
Admin.
Not reported.
53 years
Brazil
18
Student
Not reported.
10 years
Washing, symmetry
us
M
an
34.
53
ed
33.
Brazil
ce
pt
32.
worker
Ac
31.
ADM
Case 19
ECM&
ADM
Case 20
ECM&
ADM
Case 21
ECM&
ADM
Case 22
ECM&
ADM
Case 23
ECM&
ADM
Case 24
ECM&
ADM
Case 25
ECM&
ADM
Case 26
ECM&
ADM
Case 27
ECM&
ADM
Case 28
ECM&
ADM
Case 29
ECM&
ADM
Case 30
10
Symmetry
Brazil
26
Admin.
Not reported.
6 years
Symmetry
Brazil
29
Hair stylist
Not reported.
14 years
Page 52 of 60
ip
t
cr
48
Teacher
Not reported.
1 year
Brazil
21
Student
Not reported.
6 years
Brazil
42
Diplomat
Not reported.
25 years
Brazil
27
Communications
Not reported.
17 years
Washing, symmetry
Brazil
20
Teacher
Not reported.
8 years
Brazil
38
Homemaker
Not reported.
23 years
Washing
Brazil
36
Dentist
Not reported.
22 years
Brazil
27
Admin.
Not reported.
17 years
Brazil
33
Railway
worker
Not reported.
2 years
Brazil
30
Saleswoman
Not reported.
1 year
Brazil
29
Technical
support
Not reported.
7 years
Brazil
24
Actress
Not reported.
9 years
Republic
24
Student
Korean pop
4 years
M
an
ed
ce
pt
us
Brazil
Ac
42. ECM&
ADM
Case 31
43. ECM&
ADM
Case 32
44. ECM&
ADM
Case 33
45. ECM&
ADM
Case 34
46. ECM&
ADM
Case 35
47. ECM&
ADM
Case 36
48. ECM&
ADM
Case 37
49. ECM&
ADM
Case 38
50. ECM&
ADM
Case 39
51. ECM&
ADM
Case 40
52. ECM&
ADM
Case 41
53. ECM&
ADM
Case 42
54. JSK&
11
Page 53 of 60
ip
t
cr
MJH
Case 1
of Korea
55. JSK&
MJH
Case 2
Republic
of Korea
21
Student
Korean pop
song.
56. JSK&
MJH
Case 3
Republic
of Korea
30
Unemployed
Korean pop
song.
9 months
57. JSK&
MJH
Case 4
Republic
of Korea
20
Student
Korean pop
song.
4 years
58. JSK&
MJH
Case 5
Republic
of Korea
18
Student
Korean pop
song.
6 years
59. JSK&
MJH
Case 6
Republic
of Korea
31
Office
worker
Korean pop
song.
9 years
M
an
3 years
ed
ce
pt
us
song.
Ac
12
Page 54 of 60
ip
t
Unemployed
61. KO
Canada
32
Student &
teacher
62. LF
Brazil
29
Student
63. LH
USA
cr
Sad songs
replaying in
his head. He
feared that
they would
provoke bad
events in
reality
Parts of
various songs
intrude
randomly
--
Any recently
heard song
with chorus
10 years
Any recently
heard song.
Intermittent
episodes since
adolescence.
--
ce
pt
Ac
24
Admin.
assistant and
graduate
student.
us
33
M
an
Canada
ed
60. KO
13
Page 55 of 60
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t
cr
14
Ac
ce
pt
ed
M
an
us
Page 56 of 60
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15
Table A3. Summary of treatments for previously published case studies of musical obsessions.
6. Gomibuchi et al.
(2000) Case 1
7. Gomibuchi et al.
(2000) Case 2
us
Clomipramine up to 100 mg/day for 12 weeks. OCD was rated as very much improved according to both the CGI (score=1) and
YBOCS (score=5). Given the very low scores it is most likely that her musical obsession abated with treatment although this is not
explicitly stated by the author.
Diazepam (6mg/day) along with advice not to study too hard and not to attempt to suppress musical imagery. Five sessions in all.
Reported being symptom free at 5-year followup.
Bromazepam (6mg/day) along with advice not to study too hard and not to attempt to suppress musical imagery. Three sessions in all.
Musical obsession diminished within a week. Relapsed at 5-year followup but then improved after he re-implemented the strategy of
not trying to suppress musical imagery.
Failed to respond to, or worsened, on antipsychotics (risperidone, clozapine, ziprasidone, haloperidol, flufenazine). Musical obsessions
remitted entirely after 2 months of fluvoxamine (200 mg/day). Dose increased to 300 mg/day. Symptom free at 6-month followup.
No response to haloperidol or risperidone. Responded to clomipramine, up to 150 mg/day for 6 weeks. Rated as much improved on the
CGI.
No response to haloperidol (6 mg/day for 2 months). Then received 8 weeks of clomipramine (up to 150 mg/day), after which he was
rated as much improved on the CGI.
Treated with a combination of fluvoxamine (200 mg/day) and clomipramine (75 mg/day), after which the patient reported a 90%
improvement. No residual functional impairment at 3-month followup.
Symptoms worsened when treated with olanzapine (10 mg/day). Was then treated with clomipramine (up to 150 mg/day) augmented
with flupenthixol (1 mg/day). This markedly improved tics and all OC symptoms except for musical obsessions, for which treatment
had no effect. Patient reported a 20% improvement in musical obsessions after treatment with a combination of thought-stopping, ERP,
and Morita therapy.
Clomipramine (75 mg/day) and alprazolam (.75 mg/day), along with antibiotic and antipyretic medication for sore throat and fever.
The sore throat and fever remitted within a week but the musical obsessions remained unchanged. Discontinued psychotropic
medications due to side effects. Dropped out of treatment. The patient wanted to try to control the obsessions on her own.
Musical obsession was resistant to pharmacotherapy (fluvoxamine 300mg/day augmented with respiridone 2mg/day). However, the
other OC symptoms and depression responded to the fluvoxamine/respiridone combination. There was some reduction in frequency
and duration of musical obsessions by applying thought-stopping. After 6 weeks of practicing thought-stopping, musical obsessions
reduced from up to 45 min per episode to no more than 30 min per episode. Frequency reduced from 30-35 times/day to 20-25
Ac
8. Marani et al.
(2011)
9. Matsui et al.
(2003) Case 1
10. Matsui et al.
(2003) Case 2
11. Mendhekar &
Andrade (2009)
12. Nath et al. (2013)
M
an
5.
Clomipramine up to 250 mg/day for 14 weeks. Statistical and clinically significant improvement. Patient was able to return to school.
Prior to receiving clomipramine the patient had failed to respond to other, unspecified medications.
ed
4.
ce
pt
1.
2.
3.
Case
Ahuja (2001)
Ahuja (2001)
Andrade & Rao
(1997)
Cameron &
Wasielewski
(1990)
Fontenelle
(2008)
Page 57 of 60
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Ac
ce
pt
ed
17. Zungu-Dirwayi
et al. (1999)
Case 1
18. Zungu-Dirwayi
et al. (1999)
Case 2
us
times/day.
Clomipramine plus L-tryptophan. Despite a 31 year history of musical obsessions, the patient was symptom free after 3 months of
treatment.
Combined fluvoxamine (200 mg/day) and fluoxetine (60 mg/day), augmented with lithium (900 mg/day). Also received
psychotherapy, ERP, and systematic desensitization. Clinically significant response after 8 weeks of treatment and was almost
completely remitted at 6 month followup.
Failed to respond to trials of various medications including SRIs (fluoxetine, paroxetine, citalopram, and clomipramine). She also
failed to respond to augmentation of SRIs with risperidone or gabapentin, and was unable to tolerate therapeutic doses of
carbamazepine or valproic acid.
The patient was offered pharmacotherapy but declined.
M
an
16
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4. DM
Case 1
5. DM
Case 2
6. DM
Case 3
7. DS
Case 1
8. DS
Case 2
9. DS
Case 3
10. DS
Case 4
11. DS
Case 5
12. JSK
--
us
M
an
Psychoeducation about intrusive thoughts, ERP consisting of refraining from playing the song in his head to
completion. That in turn, evolved into a compulsion; when a song began to play he felt compelled to stop playing the
song or interrupt it. Treatment then shifted toward acceptance of intrusive musical imagery. That is, he was encouraged
to accept that songs played in his head and to not try to resist the intrusive imagery.
Exposure to catchy songs and jingles, with continued activity (no avoidance of other tasks if/when song gets
stuck). Acceptance when song gets stuck.
Treatment focused on OCD and comorbid depression. When the patient presented to CA, a range of treatments tried.
OC symptoms improved with a combination of clomipramine (150 mg/day), clozapine (300 mg/day), and valproate
(1,500 mg/day). However, depressive symptoms persisted. Depression improved with a course of ECT. Patient also
appeared to respond to intranasal ketamine (0.5 mg/kg/day). Musical obsessions persisted in an attenuated form despite
improvements in other OCD and mood symptoms.
2 sessions of rapid competing music sing-alongs (with clinician) and singing target obsession song incorrectly
ed
2. BCR
Case 2
3. CA
ce
pt
1. BCR
Case 1
Pretreatment
global
severity
(CGI-S)
5
Outcome
(CGI-I)
3
--
2
1
4 sessions of rapid competing music sing-alongs (with clinician) and singing target obsession song incorrectly. Patient
also had treatment sessions for other OC symptoms. Responded rapidly to treatment, with reductions in all symptoms.
8 sessions of rapid competing music sing-alongs (with clinician) and singing and humming target obsession songs
incorrectly. Patient also had treatment sessions for other OC symptoms. Client struggled to fully conquer musical
obsessions and other obsessions.
6 months of weekly CBT (including ERP).
1
3
8 months of weekly CT largely related to mourning the death of his wife, and also CT and ERP for ordering symptoms
at home that worsened after the death of his wife. Musical obsessions were not directly treated but they abated as a
result of the CT related to mourning.
6 months of weekly CBT (including ERP).
Escitalopram (60mg/day).
7
5
Ac
Case
17
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Aripiprazole (30mg/day).
Aripiprazole (10mg/day), venlafaxine (75mg/day), lamotrigine (50mg/day), valproic acid (325mg/day). Medications
were administered simultaneously to treat OCD comorbid with bipolar disorder NOS.
Aripiprazole (10mg/day), sertraline (200mg/day).
us
M
an
Case 1
13. JSK
Case 2
14. JSK
Case 3
15. JSK
Case 4
16. JSK
Case 5
17. JSK
Case 6
18. KO
19. LF
18
CBT. Over the course of therapy, Y-BOCS scores dropped from 35 to 21.
-All OC symptoms including musical obsessions improved significantly with clomipramine, 150 mg/day (post-treatment Y-BOCS=5).
20. LH
6
ERP for main targets (exposure to and altering songs), then distraction and label as OCD and move on strategies for
1
any target aspects with SUDS ratings 3 or below.
21. NA
4
Described in Table A3. The ratings were obtained as supplementary unpublished information.
1
22. NA
5
Described in Table A3. The ratings were obtained as supplementary unpublished information.
1
Clinical Global Impression (CGI) scales: CGI-S (pretreatment severity for all pretreatment psychopathology): 1, normal, not at all ill; 2, borderline mentally ill;
3, mildly ill; 4, moderately ill; 5, markedly ill; 6, severely ill; or 7, extremely ill. CGI-I (treatment-related improvement for musical obsessions): 1, very much
improved; 2, much improved; 3, minimally improved; 4, no change; 5, minimally worse; 6, much worse; or 7, very much worse. -- = Not reported.
Ac
ce
pt
ed
6
--
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