Musical Obsessions

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Accepted Manuscript

Title: Musical obsessions: A comprehensive review of

neglected clinical phenomena

Author: Steven Taylor Dean McKay Euripedes C. Miguel

Maria Alice De Mathis Chittaranjan Andrade Niraj AhujaDebbie Sookman Jun Soo Kwon Min Jung Huh Bradley C.

Riemann Jean Cottraux Kieron O’Connor Lisa R. Hale

Jonathan S. Abramowitz Leonardo F. Fontenelle Eric A.

Storch

PII: S0887-6185(14)00085-1

DOI: http://dx.doi.org/doi:10.1016/j.janxdis.2014.06.003

Reference: ANXDIS 1613

To appear in: Journal of Anxiety Disorders

Received date: 14-11-2013

Revised date: 9-5-2014

Accepted date: 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., O’Connor, K., Hale, L. R., Abramowitz, J. S., Fontenelle, L. F., and Storch,

E A M sical obsessions: A comprehensi e re ie of neglected clinical phenomena

http://dx.doi.org/doi:10.1016/j.janxdis.2014.06.003http://dx.doi.org/doi:10.1016/j.janxdis.2014.06.003


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E A Musical obsessions: A comprehensive review of neglected clinical phenomena

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Highlights:

This is the first comprehensive review of musical obsessions.

It was based on the largest sample of published and unpublished cases ever

assembled.

Phenomenology, differential diagnosis, comorbidity, and treatments are reviewed.

Musical obsessions differ from other obsessions in phenomenology and treatment.

Etiological hypotheses and important directions for future research are presented.

*Highlights (for review)


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Running head: Musical Obsessions

Musical Obsessions: A Comprehensive Review of Neglected Clinical Phenomena

Steven Taylora*, Dean McKay

b, Euripedes C. Miguel

c, Maria Alice De Mathis

c,

Chittaranjan Andrade d, Niraj Ahuja e, Debbie Sookman f , Jun Soo Kwon g, Min Jung

Huhg, Bradley C. Riemann

h, Jean Cottraux

i, Kieron O‘Connor

j, Lisa R. Hale

k ,

Jonathan S. Abramowitzl, Leonardo F. Fontenelle

m, & Eric A. Storch

h, n

aUniversity of British Columbia, BC, Canada

b

Fordham University, NY, USAcUniversity of São Paulo Medical School, Brazil

d National Institute of Mental Health and Neurosciences, India

e Northumberland, Tyne and Wear NHS Foundation Trust, UK

fMcGill University, PQ, Canada

g

Seoul National University, Republic of Koreah

Rogers Memorial Hospital, WI, USA

iUniversity Lyon 1, France

*Manuscript

Click here to view linked References

http://ees.elsevier.com/anxdis/viewRCResults.aspx?pdf=1&docID=3168&rev=1&fileID=50228&msid={08B6C796-D1CD-461C-AB89-5AE8076E0C6B}http://ees.elsevier.com/anxdis/viewRCResults.aspx?pdf=1&docID=3168&rev=1&fileID=50228&msid={08B6C796-D1CD-461C-AB89-5AE8076E0C6B}


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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

merit investigation in their own right and, more generally, research into these phenomena

may broaden our understanding of obsessive-compulsive disorder (OCD), which is

phenomenologically and etiologically heterogeneous. We present the first comprehensive

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

IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential

diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical

obsessions may be under-diagnosed because they are not adequately assessed by current

measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena,

which has led to ineffective treatment. Accurate diagnosis is important for appropriate

treatment. Musical obsessions may respond to treatments that are not recommended for

prototypic OCD symptoms.


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Keywords: Obsessive-compulsive disorder, intrusive musical imagery, involuntary

musical imagery, earworms, orhwurms, musical obsessions.

Highlights:

This is the first comprehensive review of musical obsessions.

It was based on the largest sample of published and unpublished cases ever

assembled.

Phenomenology, differential diagnosis, comorbidity, and treatments are reviewed.

Musical obsessions differ in several ways from other obsessions regarding

phenomenology and treatment.

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

urges. Compulsions are repetitive behaviors or cognitive rituals that the person feels

compelled to perform, often in response to obsessions (American Psychiatric Association

[APA], 2013). Although intrusive mental imagery has long been recognized as a salient

feature of OCD (de Silva, 1986), clinical descriptions and research have focused almost

exclusively on visual imagery. Phenomena involving intrusive musical imagery (IMI),

consisting of intrusive recollections of fragments of music (i.e., music running through

one‘s mind), have been neglected by contemporary OCD researchers. This is surprising

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

to be studied by contemporary musicologists and neurologists (Liikkanen, 2012b; Sacks,

2007). IMI is almost universally experienced (Liikkanen, 2012b). Underscoring the

importance of IMI, the neurologist Oliver Sacks (2007) observed that it is ―the clearest


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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.

Although there have been few studies of musical obsessions compared to studies

of other OC phenomena, this is not necessarily an indication of the clinical insignificance

of musical obsessions. Historically, clinical investigators have tended to underestimate

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

recognized as a ―hidden epidemic‖ (Jenike, 1989). Similarly, the prevalence and

significance of excessive hoarding — an OC-related phenomenon — was not fully

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

merit publication (Greenberg, 1987).

To our knowledge, the present paper is the first comprehensive review of musical

obsessions, based on the largest ever assembled set of case descriptions ( N = 96,


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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,

ohrwurms, or involuntary musical imagery, IMI is a form of intrusive, auditory imagery

occurring in the absence of neurological pathology or ear disease. In a survey of over

5,000 participants, Stafford (2012) found that IMI usually — but not invariably — consists

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

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;

Beaman & Williams, 2010; Liikkanen, 2012b,c). Repetitions of IMI may last from

minutes to hours (Halpern & Bartlett, 2011), but most often consist of recurrent,

intermittent episodes rather than a continuous musical soundtrack (Hyman et al., 2013).


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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

a funeral might become a source of later IMI.

Surveys indicate that more than 85% of people in the general population

experience involuntary musical imagery at least weekly (Bailes, 2007; Bennett, 2002;

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

importance of music (Beaman & Williams, 2010; Bennett, 2002; Floridou, Williamson,

& Müllensiefen, 2012; Liikkanen, 2012b).

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

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

illustrate, Williamson and Müllensiefen (2012) administered measures of IMI and OC


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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.

3. Musical Obsessions: Descriptive Psychopathology

3.1. Diagnostic Criteria

Musical obsessions are not mentioned in the most recent version of the Diagnostic

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;

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

with an obsessional fear of becoming a lesbian, for example, might fear and avoid songs

with homoerotic lyrics, such as Katy Perry‘s I Kissed a Girl and I Liked it. This is not a

musical obsession as the term is used. Similarly, the definition of musical obsessions


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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

veridical (Sedman, 1966). Musical hallucinations are rare (Berrios, 1990). They have

been described in patients with acquired hearing loss, epilepsy, structural brain lesions,

psychosis, delirium, drug induced states, and hypnagogic states (Evers & Ellger, 2004).

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

suffer from hearing disorders or neurological pathology.

3.2.2. Pseudohallucinations. The concept of pseudohallucinations is problematic

because of the lack of consensus regarding its definition and distinction from true

hallucinations (Sanati, 2012). However, it is generally agreed that pseudohallucinations

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

resemble musical obsessions. The two differ in that pseudohallucinations need not be


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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

believe that it comes from an external source (Sanati, 2012).

3.2.3. Palinacousis. This is a neurological symptom consisting of episodes of

paroxysmal auditory hallucination, in which perseveration (echoing) of an external

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

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

neuroimaging abnormalities, with structural brain pathology (e.g., cortical atrophy,

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),

although it may also be a post-ictal or a migrainous phenomenon (Di Dio et al., 2007;


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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

wild cards). Articles in all languages were considered. References in the identified

articles were examined for additional relevant material. Researchers who had previously

published on musical obsessions were also contacted for published and unpublished

cases. A total of 17 publications were identified (Ahuja, 2001; Akhtar, Wig, Varma,

Pershad, & Verma, 1975; Andrade & Rao, 1997; Berg, 1953; Cameron & Wasielewski,

1990; Fontenelle, 2008; Gomibuchi, Gomibuchi, Akiyama, Tsuda, & Hayakawa, 2000;

Hemming & Altenmüller, 2012; Maršanić, Aukst-Margetić, Grgić, & Kušmić, 2011;

Matsui et al., 2003; Mendhekar & Andrade, 2009; Nath, Bhattacharya, Hazarika, Roy, &

Praharaj, 2013; Pfizer & Andrade, 1999; Praharaj et al., 2009; Rapoport, 1980; Saha,

2012; Zungu-Dirwayi et al., 1999). The five cases reported by Hemming and Altenmüller

(2012) were excluded because most suffered from tinnitus.

Berg (1953) summarized findings from 10 cases, Gomibuchi et al. (2000)


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3.3.2. Additional cases. To supplement the published case studies, the authors of

the present paper — clinicians with expertise in OCD — reviewed their own clinical case

files for previously unpublished cases of musical obsessions. All cases had been

evaluated with Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al.,

1989). The patients had been evaluated in a variety of settings, ranging from private

practices focusing on the treatment of anxiety and related problems to large-scale hospital

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

clinical records. We obtained information on 63 unpublished cases. Thus, we had

information on a total of 96 previously published and new cases of musical obsessions.

To the best of our knowledge, this is by far the largest set of cases of musical obsessions

ever assembled.

The representativeness of the published and unpublished cases cannot be

determined on the basis of the available information; that would require epidemiologic

research, which has yet to be conducted. Nevertheless the published and new cases


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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

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

obsessions of two patients were initially misdiagnosed as symptoms of schizophrenia.

However, neither they nor any of the other cases had psychotic features such as formal

thought disorder or verbal auditory hallucinations. Neurological factors (brain

inflammation or injury) might have contributed to three cases of musical obsessions,

discussed below, but even these cases had unremarkable findings on neurological

evaluations (e.g., EEG, neuroimaging).

3.3.4. Content of obsessions. Musical obsessions were either the sole presenting

problem or occurred in the context of other psychopathology. Musical obsessions were

either primary or secondary to other presenting problems in terms of severity. Musical

obsessions consisted of either a single song or a series of songs that changed over time, as


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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

common for people with OCD, regardless of the type of symptoms, to attempt to cope

with their obsessions by engaging in avoidance behaviors or some form of compensatory

ritual (Abramowitz et al., 2011). For example, someone with visual obsessional imagery

of harming their child might avoid kitchen knives, seek reassurance from others about the

child‘s well-being, and attempt to suppress or eliminate the unwanted violent images. We

found evidence of analogous behaviors in the cases of musical obsessions.

In some cases of musical obsessions, patients developed fear and avoidance of

stimuli that triggered musical obsessions, including avoidance of stimuli or situations

associated with music, such as avoiding listening to music or avoiding public places

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

silent (vibrate) mode, urged others to do the same, and avoided places where he might


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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

of ring tones.

The onset and exacerbation of musical obsessions in other cases appeared to be

stress related. In several cases, musical obsessions developed in students who were

studying for exams. In another case, musical obsessions consisted of funeral dirges,

which develo ped shortly after the death of the patient‘s wife. In yet another case the

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

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

cases, however, onset might have been triggered by a neurological insult. In one case


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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

presentation resembled the class of pediatric autoimmune neuropsychiatric disorders

associated with streptococcal infection (PANDAS). PANDAS-related OCD is said to

arise from infection-related inflammation of the basal ganglia and associated structures.

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

confirm its existence and whether it is a post-streptococcal autoimmune disorder‖

(Knupp, de Oliveira, & Pelajo, 2010, p. 103). Pfizer and Andrade (1999) concluded that

the association between infection and the onset of musical obsessions was probably

coincidental.

In a third case (Zungu-Dirwayi et al., 1999, Case 2), musical obsessions

developed six months after a closed head injury. The patient was unconscious for four

days and had a month of retrograde amnesia. A CT scan was normal although there was


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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,

intrusive recollections of verses of spoken poetry. Comorbidity of musical obsessions

with many other types of OC symptoms is consistent with OCD in general, in which such

comorbidity is common (APA, 2013).

Several patients were described as having features of obsessive-compulsive

personality disorder (i.e., extreme perfectionism or preoccupation with orderliness). One

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

floor tiles). Another patient exhibited misophonia, which is characterized by intolerance

and distress in response to minor everyday sounds such as the sound of other people

eating (Møller, 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

evidence of psychotic features in the 96 cases. In summary, for most cases the pattern of


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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

―intrusive nonsense sounds, words, or music‖, with the example given as ―words, songs,

or music in your mind that you can‘t stop.‖ This item fails to distinguish musical

obsessions from other intrusive auditory imagery.

4. Musical Obsessions Compared to Obsessions

Characterized by Intrusive Visual Imagery

To further clarify the nature of musical obsessions, it is useful to consider how

they are similar to, and different from, other types of obsessional imagery. Most

obsessional imagery is visual (de Silva, 1986; Speckens et al., 2007). Obsessions

characterized by spoken words, olfactory, gustatory, or tactile imagery are rare (Chauhan,

Shah, & Grover, 2010; de Silva, 1986; Speckens et al., 2007). Unwanted visual images

are typically inherently aversive or violate the person‘s values or beliefs. Common

examples include images of violently attacking one‘s child or elderly parents,


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ego-dystonic material such as unwanted images that violate the person‘s 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

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

actually heard or composed. In comparison, visual obsessional imagery typically consists

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

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

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,

and ordering compulsions. Our case series indicates that it is not uncommon for musical


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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

IMI but relatively few develop musical obsessions.

5. Etiological Considerations

5.1. Contemporary Cognitive-Behavioral Models of OC Symptoms

Although there is no definitive etiological model of obsessions and compulsions,

contemporary cognitive-behavioral models are among the leading approaches (Frost &

Steketee, 2002; Salkovskis, 1996). These models, which share basic postulates, propose

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

inter-correlated types of beliefs have been theoretically and empirically linked to OC

symptoms: (a) perfectionism (P) and intolerance of uncertainty (C; collectively referred

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

Cognitions Working Group, 2005). PC involves beliefs that mistakes and imperfection


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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

distress or impairment due to the unwanted image. In comparison, if a person interpreted

the intrusion as an indication that he or she is at risk for losing control and inflicting

harm, then the person would become distressed, attempt to vigorously suppress such

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).

Consistent with this formulation, research shows that the frequency or severity of

obsessions in general is predicted by the strength of a person‘s beliefs about the

significance of one‘s unwanted thoughts (e.g., ―Violent thoughts lead to dangerous

deeds‖), and by beliefs about the importance of controlling such thoughts (e.g., ―If I don‘t

drive the violent thoughts out of my mind, I will lose control and inflict harm on others‖)

(Taylor, Abramowitz, McKay, & Cuttler, 2012).

5.2. Toward a Model of Musical Obsessions


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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

persistent IMI is insufficient by itself to account for musical obsessions. If a person

interprets highly persistent IMI as an innocuous background soundtrack to daily life then

IMI would not become a source of distress or lead to impairing avoidance behaviors or

compulsions. Negative beliefs and appraisals seem important for transforming inherently

innocuous IMI into musical obsessions.

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

can‘t 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

I can‘t concentrate, then I might fail at school‖). Threat-related misinterpretations may

lead to maladaptive coping responses that in turn increase the frequency of IMI. This

pattern of maladaptive coping is suggested in the cases of musical obsessions reported by


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(Gomibuchi et al., 2000, p. 206)

This account is similar to cognitive-behavioral accounts of OCD in general,

concerning the paradoxical, self-defeating effects of attempting to suppress obsessional

thoughts (Salkovskis, 1996).

5.3. What Causes Individual Differences in IMI?

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.

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

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

imagery, it is likely that the interconnecting circuitry is complex. To better understand


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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,

Cabral‖; Fontenelle, 2008). In two other cases the person experienced intrusions

consisting of lines of spoken poetry (Andrade & Rao, 1997; Saha, 2012). Further research

is required to investigate whether musical obsessions are part of a general hyper-retrieval

of auditory memories.

6. Treatment

The available database of cases provides leads as to how musical obsessions

might be effectively treated, and provides a basis for developing treatment protocols that

could be empirically evaluated in future research. Details of the treatments for the cases

appear in the Appendix. The following is a summary of the salient points arising from the

cases and the relevant literature.

6.1. Assessment for Treatment Planning

In assessing musical obsessions the clinician cannot rely solely on the Y-BOCS


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(Maršanić et al., 2011). In our case series, two patients were misdiagnosed as having a

psychotic disorder (Maršanić et al., 2011; Nath et al., 2013). In neither case did the

patient benefit from antipsychotics; in fact, there was evidence of symptom worsening.

When musical obsessions were correctly diagnosed, treatment was changed to

medications known to be efficacious for OCD (e.g., clomipramine, fluvoxamine) and the

patients began to clinically improve. Accordingly, an accurate assessment of musical

obsessions is important for planning appropriate treatment.

6.2. Pharmacotherapy

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

antipsychotic medications (e.g., risperidone, clozapine, haloperidol). Such drugs may be

effective in treating musical hallucinations (Evers & Ellger, 2004) and verbal auditory

hallucinations associated with schizophrenia (Martinez, Marangell, & Martinez (2008).

The case material also suggests that patients with musical obsessions are more likely to

benefit from medications that are efficacious for OCD in general, such as selective


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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 & Müllensiefen, 2012). Reappraisal and acceptance strategies show promise

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

head; there is no need to dwell on it or fight it because it will eventually pass‖.

6.4. Distraction

Distraction-based treatments are not recommended for prototypic OC symptoms

(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.,

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,

Hyman et al. (2013) found that normal IMI was disrupted when the person engaged in


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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

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

associations with other sources. This is based on the assumption that the musical

obsession has a singular association (song = aversive experience). With additional

experiences of the melody under new conditions, the obsession has an expanded base of

associations (song = aversive experience; song = clinical practice in patient and

clinician‘s voice; song = other emotional experience). This expanded base is assumed to

lead to greater flexibility in associations, derived from a relational frame theory (Dymond

& Roche, 2013).

6.5. Exposure and Response Prevention (ERP)

The successful use of distraction or competing tasks in some cases of musical

obsessions is quite different from treatments for other types of OC symptoms.


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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.

6.6. Summary

There are several promising approaches to treating musical obsessions that merit

further investigation in randomized, controlled studies. Musical obsessions may respond

to medications and to cognitive-behavioral protocols used to treat OCD in general.

However, some cases of musical obsessions have responded to treatments involving

distraction or stimulus substitution. ERP, cognitive interventions, SSRIs, and

clomipramine are first-line treatments for OCD in general, so it is reasonable to

implement these interventions singly or in combination in the treatment of musical

obsessions. If these interventions are unsuccessful then we recommend that the clinician

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

diagnosis is musical obsessions, then distraction-based interventions could be considered.


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(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).

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,

we were able to readily identify a large number of unpublished cases, obtained from

clinicians with expertise with OCD. It may be that musical obsessions are more common

than previously recognized.

3. Musical obsessions may be under-diagnosed and under-treated because

contemporary assessment methods do not sufficiently probe for such phenomena, and

clinicians may be unfamiliar with musical obsessions. Musical obsessions are sometimes

misdiagnosed as psychotic phenomena, which has led to inappropriate treatment (i.e.,

antipsychotic medication). An accurate diagnosis is important for planning appropriate

treatment.

4. Musical obsessions differ from visual obsessions in that the content of the


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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

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

persistence or frequency of IMI may play a role but may be insufficient because

persistent, frequent IMI is not always distressing. Consistent with contemporary cognitive

models of OCD (Frost & Steketee, 2002), we propose that the person‘s beliefs and

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

the workplace because ringtones might be heard, or failure to fulfill household

responsibilities because of avoidance of supermarkets, in which background music is

often played).


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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

obsessional imagery. In terms of weaknesses, the cases in our review were almost

entirely clinical (treatment-seeking) individuals, and so it is unclear whether the findings

generalize to people who suffer from musical obsessions but do not seek treatment. A

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

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

the best available clinical description of musical obsessions, along with testable

hypotheses about etiology and treatment.

7.3. Future Directions


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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

studies, including the distraction-based interventions, which are quite different from

exposure-based empirically supported treatments for other types of obsessive-compulsive

phenomena.


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Appendix


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Appendix of Supplementary Materials for:

Musical Obsessions: A Comprehensive Review of Neglected Clinical Phenomena

Correspondence: Steven Taylor, Ph.D., Department of Psychiatry, 2255 Wesbrook Mall,

University of British Columbia, Vancouver, BC, Canada, V6T 2A1. Email:

[email protected], Tel: 011-1-604-785-7558, Fax: 011-1-604-822-7756.

p

mailto:[email protected]:[email protected]:[email protected]


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Table A1. Previously published case studies of musical obsessions.

Case Country Age Sex Occupation Musical

Obsession(s)

Duration of

Musical Obsession(s)

Notes, Including a Description of Other

Clinical Features (Current or Past)

1.

Ahuja (2001) India 24 F Trainee physician

Tunes from Hindisongs.

Two episodes; mostrecent was 8 months

No other OC symptoms. OCPD traits. Onsetwhile studying for exams.

2. Ahuja (2001) India 33 F Homemaker Lyrics and tunes

from Hindi songs.

18 months Washing, sexual obsessions. OC personality

traits. Marked impairment in daily life.

3. Akhtar et al.

(1975)

India 23 F Student A tune popular at

the time.

-- --

4. Andrade &

Rao (1997)

India 30 M Musician Some musical

passages were more

troubling that others,

particularly Ravel’s

Bolero, a Chopin

nocturne, an operatic piece by Verdi, andsome of the person’s

own compositions.

Over 5 years Recognized the musical imagery as his own

thoughts but regarded them as abnormal. Tried

to resist with little success, although

sometimes he was successful by concentrating

on other melodies. Also reported intrusive

verses of poetry, and checking and orderingcompulsions. OCPD traits. No evidence ofneurological problems.

5. Berg (1953):

Summary

of 10 cases

USA Adult 40%F 70%

employed,

30%

students

Popular songs from

the 1920s-1950s.

-- All patients were in counseling for various

stress-related problems unrelated to musical

obsessions (e.g., distress regarding financial

problems).

6. Cameron &

Wasielewski

(1990)

USA 24 M Student Any music he had

recently heard.

2 years No other psychopathology. Musical

obsessions started 1 month after he received a

blow to the head, but a comprehensive

evaluation, including EEG, revealed no

neurological abnormalities.7. Fontenelle

(2008)

Brazil 38 F Homemaker Various popular

songs.

-- Distressing pareidolias (illusory images seen

out of shapes; e.g., seeing gorillas in the floor

tiles). Auditory and visual images of a dead

friend (auditory imagery of his name and

visual imagery of the imagined funeral).

Aggressive obsessions, washing, ordering, and

hoarding rituals. Depression,

depersonalization and derealization. Normal

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EEG.

8. Gomibuchi et

al. (2000)

– Case 1

Japan 19 M Student Various melodies he

had recently heard.

Several

months

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 tryinghard to concentrate while studying. OCPD

traits (highly perfectionistic). Misophonia

(low tolerance for sounds; minor sounds

evoked distress).

9. Gomibuchi et

al. (2000)

– Case 2

Japan 18 M Student Music he had heard

to the previous day.

Several

months

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.

10. Maršanić et al.

(2011)

Croatia 17 F Student Popular songs and

jingles.

One month

(approx.)

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.

11.

Matsui et al.

(2003)

– Case 1

Japan 20 M Student Popular songs,

jingles, and other

well-known

melodies.

2 years 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

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obsessions consisted of covert compulsions

(suppression, neutralization). OCPD traits

(perfectionistic), anxious, and depressed

(dysthymic disorder). The more he worried

about, and tried to suppress, the musicalimagery, the more persistent it became.

Avoided classes and social activities due to

musical obsessions. Experienced

depersonalization. Initially misdiagnosed as

having schizophrenia. Neurological exam

including EEG was normal. ENT normal.

12. Matsui et al.

(2003)

– Case 2

Japan 28 M Retail sales Current and old

popular songs.

2 years Premorbid “tender and obedient” character.

Onset after he quit his job due to interpersonal

conflict (stress-related). He often attempted to

suppress the symptoms by thinking about

another melody (i.e., suppress, neutralize),

although he usually was unable to do so.Obsessions worsened when he started living

alone. Neurological exam normal, including

normal EEG. Comorbid major depressive

disorder.

13. Mendhekar &

Andrade

(2009)

India 22 M Student Various cell phone

ring tones, occurring

6-8 hrs/day.

4 months Feared and avoided exposure to ring tones. He

wore earplugs, used distraction by thinking of

other tunes, kept his phone in silent mode, and

asked others to do the same, avoided places he

might hear the ringing of cell phones. Prior to

onset of musical obsession he had enjoyed

downloading and changing ring tones on his

phone. He would devote 2-3 hrs every 2-3

days to this activity (i.e., had been spending a

lot of time listening to ringtones). History of

counting, checking, and washing. At the time

of presentation he had mild comorbid

checking. Musical obsessions interfered with

his ability to study and became depressed as a

result.

14. Nath et al. India 22 M -- Recently heard 3 years Attempted to resist the musical imagery but

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(2013) tunes. was unsuccessful. Vocal tics, washing,

harming obsessions, ordering, hoarding,

sexual obsessional images. Initially

misdiagnosed as having schizophrenia. No

history of neurological problems.15. Pfizer &

Andrade

(1999)

India 25 F Homemaker A single Tamil film

song running

through her head for

8 hrs/day

Arose suddenly 4 days

prior to seeking

treatment, along with a

sore throat and fever,

but did not abate when

the infection was

successfully treated

with erythromycin.

Her attempts at controlling the intrusion were

unsuccessful. No past history of

psychopathology. Musical obsessions

persisted despite no evidence of a general

medical condition. Reported feeling

depersonalized because of the obsession.

16. Praharaj et al.

(2009)

India 21 M -- Sections of music

from various

popular Hindi films,

lasting from 2-45min per episode,

occurring 30-35

times/day, nearly

every day.

Occasionally a new

song he heard

replaced an older

one.

5 years Tunes commonly intruded when he was alone.

He was partially successful in temporarily

banishing them by distraction such as

engaging in games or conversations, but theintrusions returned. Washing, checking,

doubting, intrusive visual obsessions, severe

depression. Normal physical examination.

Normal EEG.

17. Rapoport

(1980)

USA 16 M Student Popular music,

movie scores.

7 years Past history of checking, counting, washing,

and superstitious rituals (only even numbers

were acceptable). Was in therapy for 4 years

for anxiety and adjustment problems but never

disclosed his musical obsessions. Efforts at

suppressing imagery was unsuccessful.

Musical obsessions greatly interfered with

everyday functioning. Normal CT.

18. Rapoport

(1980)

USA 60 M Farmer Six or more notes of

a fiddle tune (“a dull

short jig”).

31 years Kept the musical obsession secret from others.

His spouse observed that he looked

preoccupied while he was experiencing the

obsessions. No evidence of neurological or

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audiologic problems, and no evidence of

psychosis. Experienced the tune as a constant

unpleasantness, bore, and irritation. Described

it as “living my life through the noise.”

19.

Saha (2012) India 30 M -- Music that he orothers had

composed,

associated with

intrusive images of

him humming the

tunes.

4 years Attempted to resist with little success.Distraction with other melodies was

successful, at least in the short term. Intrusive

verses of poetry, along with checking,

ordering symptoms.

20. Zungu-

Dirwayi et al.

(1999) – Case

1

South

Africa

59 F -- Various tunes. 20 years. Developed in

the context of major

depression following

her husband’s death 20

years previously.

Obsessions persistedafter depression abated.

Tried to get rid of the musical obsessions by

substituting them with other thoughts or tunes.

Normal EEG.

21. Zungu-

Dirwayi et al.

(1999) – Case

2

South

Africa

29 F -- Unspecified tune. Intrusive tune

developed 5 months

after a closed head

injury. Intrusion had

persisted for a month at

the time of assessment.

Unconscious for 4 days due to head injury.

One month of retrograde amnesia. Post-injury

personality changes (increased aggressiveness

and apathy) with little insight as to the

changes. CT scan was normal. Unsuccessful

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.

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Table A2. Unpublished cases of musical obsessions from the authors’ clinical files.

Case Country Age Sex Occupation Musical

Obsession(s)

Duration of

Musical

Obsession(s)

Notes, Including Details of Other Clinical

Features (Current or Past)

1. BCR – Case 1

USA 21 M Student Songs on hisiPod, which

were mostly

popular songs.

If someone

was to sing a

song in

passing, and

he knew the

song, it would

also become a

musicalobsession.

-- Would hear a song involuntarily playing in hishead and then need to play it out or listen to it in

full before moving on – otherwise it would be

“stuck” all day. Washing, hoarding, doubting,

obsessions (somatic, aggressive, sexual).

Anorexia nervosa, mood disorder NOS, GAD.

2. BCR –

Case 2

USA 59 M Unemployed

(former

cleric)

Numerous

types of songs

(e.g., jingles,

Christmas

songs,

hymnals,

popular music

on the radio).

Intermittently

since teens.

Fear that a song will get stuck in his head and

then he will be unable to function. No other OC

symptoms. Recurrent, moderate major depressive

disorder.

3. CA India 23 M Unemployed Not reported. Intermittently,

sometimes

lasting a day

or more.

Child-onset OCD and comorbid bipolar disorder,

for which the patient was in a depressive phase at

the time of assessment and treatment. OC

symptoms included musical and visual

obsessions. The latter consisted of sexual and

violent obsessions.

4. DM –

Case 1

USA 9 M Student A pop song

that was

heavily played

on the radio.

2 months Avoided exposure to music for fear of developing

new intrusive song. Sexual and aggressive

obsessions, along with compulsions to confess

unwanted thoughts. Past history of separation

anxiety and mild attention difficulties.

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5. DM –

Case 2

USA 37 F Lawyer Heavy metal

songs

4 months Washing, checking. Past history of abuse of a

prescribed anxiolytic.

6. DM –

Case 3

USA 49 M Lawyer Popular songs

and TV

themes.

Intermittently

for 2 years

Violent imagery and harming obsessions. Past

history of depression.

7. DS –

Case 1

Canada 25 M Student Bach, various

piano music.

-- OCPD traits (perfectionistic). Symmetry,

ordering, and counting.

8. DS –

Case 2

Canada 67 M Retired

businessman

Choral music. -- Checking and religious obsessions.

9. DS –

Case 3

Canada 43 F Homemaker Lullabies. -- Washing.

10. DS –

Case 4

Canada 83 M Retired

lawyer

Funeral dirges. 3 months.

Musical

obsession

started after

the death of

his wife.

Depression, ordering.

11.

DS –

Case 5

Canada 32 F Retail sales Any song she

recently heard.

-- Musical obsessions exacerbated by stress. OCPD

traits (perfectionistic). Ordering rituals.

12. ECM&

ADM –

Case 1

Brazil 22 F Student Not reported. 8 years Washing, ordering, hoarding, and obsessions

(aggressive, sexual, religious).

13. ECM&

ADM –

Case 2

Brazil 25 M Factory

worker

Not reported. 10 years Washing, ordering, hoarding, and obsessions


14. ECM&

ADM –

Case 3

Brazil 28 F Office

supervisor

Not reported. 14 years Washing, ordering, hoarding.

15. ECM&

ADM –

Case 4

Brazil 31 F Office

assistant

Not reported. 16 years Washing, ordering, hoarding, and obsessions


16. ECM&

ADM –

Case 5

Brazil 21 M Computer

industry

Not reported. 4 years Hoarding, ordering, and obsessions (aggressive,

sexual, religious).

17. ECM&

ADM –

Case 6

Brazil 31 F Architect Not reported. 6 years Washing, ordering, and obsessions (aggressive,

sexual, religious).

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18. ECM&

ADM –

Case 7

Brazil 37 F Business

consultant

Not reported. 19 years Washing, ordering, and obsessions (aggressive,

sexual, religious).

19. ECM&

ADM – Case 8

Brazil 45 F Researcher Not reported. 20 years Washing and ordering.

20. ECM&

ADM –

Case 9

Brazil 34 F Advertising Not reported. 23 years Washing, hoarding, ordering, and obsessions


21. ECM&

ADM –

Case 10

Brazil 22 F Telemarketer Not reported. 1 year Washing, ordering, and aggressive obsessions.

22. ECM&

ADM –

Case 11

Brazil 60 F Homemaker Not reported. 53 years Washing, ordering, and obsessions (aggressive,

sexual, religious).

23. ECM&

ADM –

Case 12

Brazil 25 F Lawyer Not reported. 13 years Washing, hoarding, ordering, and obsessions


24. ECM&

ADM –

Case 13

Brazil 58 F Retired Not reported. 18 years Washing, ordering, and obsessions (aggressive,

sexual, religious).

25. ECM&

ADM –

Case 14

Brazil 42 F Independentlywealthy*

Not reported. 24 years Washing, hoarding, ordering, and obsessions

(sexual and religious)

26. ECM&

ADM –

Case 15

Brazil 46 F Office

worker

Not reported. 20 years Washing, ordering, and aggressive obsessions.

27. ECM&

ADM –

Case 16

Brazil 54 F Homemaker Not reported. 24 years Washing, hoarding, ordering, and obsessions

(aggressive, sexual, and religious)

28. ECM&

ADM –

Case 17

Brazil 43 F Homemaker Not reported. 23 years Washing, ordering, and obsessions (aggressive,

sexual, and religious)

29. ECM&

ADM –

Case 18

Brazil 32 F Secretary Not reported. 20 years Washing, hoarding, ordering, and aggressive

obsessions.

30. ECM& Brazil 60 F Office Not reported. 45 years Washing, hoarding, ordering, and obsessions

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ADM –

Case 19

worker (aggressive, sexual, and religious)

31. ECM&

ADM –

Case 20

Brazil 53 F Homemaker Not reported. 33 years Washing, hoarding, ordering, and obsessions


32. ECM&

ADM –

Case 21

Brazil 27 F Marketing Not reported. 22 years Symmetry

33. ECM&

ADM –

Case 22

Brazil 25 F Lawyer Not reported. 14 years Washing, hoarding, symmetry

34. ECM&

ADM –

Case 23

Brazil 60 M Retired Not reported. 10 years Symmetry

35. ECM&

ADM –

Case 24

Brazil 33 M Lawyer Not reported. 26 years Washing, hoarding, symmetry, and obsessions


36.

ECM&

ADM –

Case 25

Brazil 22 F Student Not reported. 3 years Washing, symmetry, and obsessions (aggressive,


37. ECM&

ADM –

Case 26

Brazil 25 F Admin. Not reported. 10 years Washing, symmetry

38. ECM&

ADM –

Case 27

Brazil 68 M Admin. Not reported. 53 years Washing, symmetry, and obsessions (aggressive,


39. ECM&

ADM –

Case 28

Brazil 18 M Student Not reported. 10 years Washing, symmetry

40.

ECM&

ADM –

Case 29

Brazil 26 M Admin. Not reported. 6 years Symmetry

41. ECM&

ADM –

Case 30

Brazil 29 F Hair stylist Not reported. 14 years Washing, hoarding, symmetry, and obsessions


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42. ECM&

ADM –

Case 31

Brazil 48 M Teacher Not reported. 1 year Symmetry, and obsessions (aggressive, sexual,

and religious)

43. ECM&

ADM – Case 32

Brazil 21 M Student Not reported. 6 years Symmetry, and obsessions (sexual and religious)

44. ECM&

ADM –

Case 33

Brazil 42 F Diplomat Not reported. 25 years Symmetry and violent obsessions

45. ECM&

ADM –

Case 34

Brazil 27 M Communi-

cations

Not reported. 17 years Washing, symmetry

46. ECM&

ADM –

Case 35

Brazil 20 F Teacher Not reported. 8 years Washing, hoarding, symmetry, and obsessions


47. ECM&

ADM –

Case 36

Brazil 38 F Homemaker Not reported. 23 years Washing

48. ECM&

ADM –

Case 37

Brazil 36 M Dentist Not reported. 22 years Washing, hoarding, symmetry, and obsessions


49. ECM&

ADM –

Case 38

Brazil 27 F Admin. Not reported. 17 years Symmetry, and obsessions (aggressive, sexual,

and religious)

50. ECM&

ADM –

Case 39

Brazil 33 M Railway

worker

Not reported. 2 years Washing, hoarding, symmetry, and obsessions


51. ECM&

ADM –

Case 40

Brazil 30 F Saleswoman Not reported. 1 year Washing, hoarding, symmetry

52. ECM&

ADM –

Case 41

Brazil 29 M Technical

support

Not reported. 7 years Washing, hoarding, symmetry, and obsessions


53. ECM&

ADM –

Case 42

Brazil 24 F Actress Not reported. 9 years Symmetry and violent obsessions

54. JSK& Republic 24 M Student Korean pop 4 years Musical obsessions were accompanied by mild

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MJH –

Case 1

of Korea song. depression. Symptoms were aggravated while

studying for exams. Patient also had aggressive,

sexual obsessions and related checking as

concurrent symptoms.

55.

JSK&MJH –

Case 2

Republicof Korea 21 M Student Korean popsong. 3 years Musical obsessions started after conflicts withfriends at school. Patient also had aggressive

obsessions without compulsion, somatic

obsessions, pathological doubt and idea of

reference as concurrent symptoms.

56. JSK&

MJH –

Case 3

Republic

of Korea

30 M Unemployed Korean pop

song.

9 months After listening to music, the melody of music

continued for an hour. Due to the somatic

obsessions and related idea of reference he had

cosmetic surgery on his nose. Comorbid major

depressive disorder and social anxiety disorder

57. JSK&

MJH –

Case 4

Republic

of Korea

20 M Student Korean pop

song.

4 years When he experienced musical obsessions, he also

had to perform his activities according to the

rhythm of them. Patient also had repeating,

checking, contamination, cleaning, perfectionism

and impulsivity as concurrent symptoms.

Comorbid bipolar disorder NOS.

58. JSK&

MJH –

Case 5

Republic

of Korea

18 M Student Korean pop

song.

6 years Korean pops which he usually listens to replayed

in his head for several hours. These musical

obsessions did not disturb his concentration or

activities of daily life. Patient also had

pathological doubt, checking, aggressive and

sexual obsessions as concurrent symptoms.

59. JSK&

MJH –

Case 6

Republic

of Korea

31 F Office

worker

Korean pop

song.

9 years Musical obsessions started after job-related stress.

The melody of the music that she heard in the

morning replayed all day long. She began binge-

eating to avoid the stress due to the musical

obsessions. Recently musical obsessions were

aggravated by the conflict with a colleague at

work and she couldn’t concentrate on her work.

Patient also had checking and hoarding

compulsions. Comorbid bulimia nervosa, alcohol

abuse and depression.

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60. KO Canada 33 M Unemployed Sad songs

replaying in

his head. He

feared that

they would provoke bad

events in

reality

-- Duration of up to 12 hrs/day. Onset frequently

associated with sad memories. Sometimes the

intrusive musical imagery was so intense that he

difficulty following conversations. He consulted a

psychiatrist for fears that he might haveschizophrenia. Comorbid symmetry and

superstitious rituals, and body focused repetitive

behaviors (skin picking and nail biting).

61. KO Canada 32 M Student &

teacher

Parts of

various songs

intrude

randomly

-- Songs can repeat in a loop up to 4hrs per day

every day, interferes with work and writing,

incapable of concentrating. No particular trigger

but only occur when stressed.Comorbid harming

obsessions.

62. LF Brazil 29 F Student Any recently

heard song

“with chorus”

10 years History of obsessions with aggressive content at

age 9, which disappeared soon afterwards. At age

14, she had her first panic attack and developed,

since then, chronic panic disorder with

agoraphobia. OCD, including sexual/religious and

aggressive obsessions reappeared acutely at age

19, together with the onset of musical obsessions.

For quite awhile, musical obsessions remained

her most significant symptom. They were worse

when she was either relaxed or very stressed. Of

note, she did not endorse any type of overt or

covert compulsions. At her worse, her Y-BOCS

obsessions score was 14 and BDI 26. She had her

first depressive episode at age 19, 2 months

before the onset of OCD. In addition, she

developed chronic and persistent

depersonalization disorder (not ascribed to OCD

or panic attacks) since age 23.

63. LH USA 24 F Admin.

assistant and

graduate

student.

Any recently

heard song.

Intermittent

episodes since

adolescence.

Musical obsession was a negative side effect o f a

coping strategy of singing to herself to distract

from other obsessions. Began hearing songs

whenever not engaged in focused conversation.

Musical obsession caused significant interference,

especially at night, contributing to insomnia.

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Visual obsessions (violent and horrific images),

washing, checking, hoarding, specific phobias of

spiders and blood. Past history of anorexia

nervosa and bulimia nervosa.

Initials of cases refer to the authors of the present article. All cases were assessed with the Y-BOCS. *Classified as employed because the person has an income.

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Table A3. Summary of treatments for previously published case studies of musical obsessions.

Case Treatment and Outcome

1. Ahuja (2001) Distraction and fluoxetine (40 mg/day).

2.

Ahuja (2001) Fluvoxamine (200 mg/day), buspirone (40 mg/day).3. Andrade & Rao

(1997)

Patient was offered pharmacotherapy but declined. Preferred to try to control the obsessions on his own.

4. Cameron &

Wasielewski

(1990)

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.

5. Fontenelle

(2008)

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 i s most likely that her musical obsession abated with treatment a lthough this is not

explicitly stated by the author.

6. Gomibuchi et al.

(2000) – Case 1

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.

7. Gomibuchi et al.

(2000) – Case 2

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 h

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Musical Obsessions

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