Musical obsessions: a comprehensive review of neglected clinical phenomena

The modular mind and psychiatry: toward clinical integration with a focus on self-disorders

One of the foundational tenets of evolutionary psychology, the modular view of the mind, offers promising applications for clinical psychiatry. This perspective conceptualizes the mind as a collection of specialized information-processing modules, shaped by natural selection to address adaptive challenges faced by our ancestors. In this paper, we propose several points of integration between the modularity framework and clinical psychiatric practice. First, we argue that the descriptive psychopathology of self-disorders provides evidence supporting the modular view, demonstrating how a dysfunctional minimal self may expose the mind's modular architecture to conscious awareness. Next, we will explore how the modular perspective can illuminate the nature of intrapsychic conflicts. Finally, we will discuss how evidence from neuropsychiatric syndromes supports the modular view of the mind and, in turn, how this perspective can provide a basis for classifying mental disorders.

Earworms as 'mental habits': Involuntary musical imagery is associated with a wide range of habitual behaviors

Earworms have been associated with symptoms of obsessive-compulsive disorder (OCD), indicating a link to neurocognitive systems involved in the regulation of habitual behavior. The present study investigated whether earworms are associated with a range of habits and compulsions, and with a broader tendency to behave in habitual, routine ways in everyday life. Participants (N = 883) completed an online survey measuring frequency of earworms, other habits and compulsions, everyday habitual tendencies and anxiety. Habitual tendencies in everyday life positively predicted earworm frequency, control and disturbance, even when controlling for anxiety. Furthermore, earworms were strongly associated with 22 other habitual behaviors and compulsions, with the strongest associations being observed for repetitive motor behaviors such as foot tapping, and repetitive mental behaviors such as counting and spelling. These findings suggest that previously observed associations between earworms and OCD symptomatology might be due to a common basis in systems that produce and regulate habitual behavior.

Transcranial magnetic stimulation as a novel approach to effectively treat musical obsession (stuck song syndrome): a case series and a systematic review of case reports

This is the first case series that demonstrates the use of transcranial magnetic stimulation (TMS) for the treatment of musical obsessions or stuck song syndrome (SSS), following a systematic review that identified existing treatments. SSS can occur independently, but in literature it is commonly reported as an obsessive-compulsive disorder (OCD) or major depressive disorder (MDD) symptom. Most people are familiar with earworms, experienced by up to 98% of the western population. Earworms can become severe leading to the SSS diagnosis. SSS is a distressing repetition of involuntary tunes persisting in one's mind. According to literature, SSS has often been treated using antidepressants which are used to treat MDD and OCD. As TMS has shown a positive therapeutic effect for psychiatric disorders particularly MDD and OCD, we hypothesized that TMS could be an effective treatment that reduces symptoms of patients with SSS. We present two cases of TMS treatment contributing to a reduction in symptoms of SSS. We also aim to provide a systematic review of cases where SSS has been described and compare the pharmacological or psychotherapeutic treatments used with our novel TMS interventions for SSS. This report highlights some limitations, including patient's psychiatric comorbidities and treatment protocol changes, which affect the findings generalizability. Despite these limitations, TMS appears promising as a treatment for SSS due to the observed effectiveness in reducing SSS symptoms and minimal side effects especially in medication-resistant cases.

Late-Onset Musical Obsession: A Case Report of an Elderly Patient Treated in an Outpatient Psychiatry Clinic

Musical obsessions are a form of involuntary musical imagery that may occur in the context of obsessive-compulsive disorder and patients presenting with this symptom are usually in their early adulthood. This case highlights the unusual presentation of musical obsessions in an elderly patient and the subsequent evaluation and treatment given. It is important to recognize and distinguish this from other symptoms such as auditory hallucinations with musical content and palinacousis as this will affect the subsequent clinical assessment and management required.

Musical hallucination or musical obsession? A differential diagnosis between two cases

Musical hallucinations and musical obsessions are distinct phenomena. The first can be understood as a manifestation of the musical ear syndrome, which produces deafferentation auditory hallucinations, while the latter is an obsessive symptom of obsessive-compulsive disorders. Both symptoms are often poorly understood and mistaken for one another or for signs of psychotic disorders. We report two cases, one characterized by musical hallucinations and the other by musical obsessions, both with comorbid hearing impairment, which is the main confounding factor in their differential diagnosis. We critically compare the two cases and their key features, allowing diagnostic differentiation and a targeted therapeutic approach.

The aversiveness of intrusiveness: Evidence from involuntary musical imagery

OBJECTIVE

Intrusive thoughts are characterized by a sense of intrusiveness of foreign entry into cognition. While not always consisting of negative content, intrusive thoughts are almost solely investigated in that context. Involuntary Musical Imagery (INMI) offers a promising alternative, as it is a type of involuntary cognition that can be used to evaluate intrusiveness without negative content.

METHODS

In Study 1, 200 participants completed self-report questionnaires to assess several aspects of intrusiveness: meta-awareness, control, repetitiveness, frequency, and subjective experience of INMI. In Study 2, 203 participants completed self-report questionnaires to explore the clinical characteristics (depression, stress, anxiety, and rumination) which might mediate the connection between INMI frequency and INMI negative experience.

RESULTS

Study 1 revealed, through exploratory factor analysis, that intrusiveness shares variance with the negative experience of INMI but not with INMI frequency. In Study 2, ruminative thinking was found to mediate the relationship between frequent INMI and the negative experience of INMI.

CONCLUSION

These results suggest that INMI might be used to investigate intrusiveness in the lab without the potential confound of negative emotions. In addition, the results suggest that neither the content nor the frequency of intrusive thoughts can solely explain why these thoughts are aversive to some but not others. Ruminative style might be the missing link to explain how and why these intrusive thoughts become aversive and obsessive. In other words, we suggest that the cause for intrusiveness lies not in the thought or repetitiveness, but in the thinker.

Testing the Two-Factor Model of Musical Obsessions: Can They Be Predicted by the Interaction Between Frequency and Dysfunctional Interpretations of Common Earworms?

Musical obsessions can be conceptualized as a severe form of intrusive musical imagery (IMI). The two-factor model of musical obsessions proposes that musical obsessions result from the interaction of the frequency of IMI and dysfunctional interpretations of IMI. The aim of this study was to evaluate the predictions of the two-factor model. A total of 372 participants (291 without a known diagnosis of obsessive–compulsive disorder [OCD] and 81 with a lifetime diagnosis of OCD) completed online questionnaires about the frequency of IMI, their dysfunctional interpretations, and their severity. We specified a model with severity of IMI as outcome and interpretations and frequency as predictors and controlled for the type of sample. The interaction between frequency and dysfunctional interpretations predicted severity of IMI, however in another direction than suggested. Future studies should include experimental and longitudinal designs and pay particular attention to low-frequency IMI and their role in musical obsessions.

A Systematic Review of Scientific Studies and Case Reports on Music and Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a severe psychiatric disorder, which can be associated with music-related symptoms. Music may also be used as an adjunct treatment for OCD. Following the PRISMA guidelines, we performed a systematic literature review exploring the relationship between music and OCD by using three online databases: PubMed, the Web of Science, and PsycINFO. The search terms were "obsessive compulsive disorder", "OCD", "music", and "music therapy". A total of 27 articles were utilised (n = 650 patients/study participants) and grouped into three categories. The first category comprised case reports of patients with musical obsessions in patients with OCD. Most patients were treated with selective serotonin reuptake inhibitors (SSRIs) or a combination of an SSRI and another pharmacological or a non-pharmacological treatment, with variable success. Studies on the music perception of people with OCD or obsessive-compulsive personality traits represented the second category. People with OCD or obsessive-compulsive personality traits seem to be more sensitive to tense music and were found to have an increased desire for harmony in music. Three small studies on music therapy in people with OCD constituted the third category. These studies suggest that patients with OCD might benefit from music therapy, which includes listening to music.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Infective Messages: Definitions, Processes, and Implications for Trauma, Identities, Internal Conflicts, Psychotherapy, and Research

BACKGROUND

Throughout life, individuals are bombarded by countless emotion-generating messages. Certain of these messages, for example, some insults, admonitions, rejections, challenges, or insightful declarations, can be viewed as "infective." Infective messages shock, puncture, adhere, disturb, and generate discernable host responses that assimilate, accommodate, or repel the intruding messages. Messages originating in one's own mind can stimulate psychological equivalents of autoimmune responses. Sometimes, these messages produce enduring psychological changes. Infective messages may traumatize, organize, or therapize. The aims of this article are to consider how infective messages a) relate to their messengers (vectors), structural characteristics, and recipient (host) factors; b) might contribute to trauma, personal identity formation, psychological conflicts, and emotional self-regulatory and cognitive heuristics; c) might inform the conduct of psychotherapy; and d) suggest future research.

METHODS

Clinical observations were augmented with selective literature reviews. These sources contributed to perspectives regarding how certain messages might become infective; contribute to trauma, complex aspects of identity formation, and inner conflict; and inform the conduct of psychotherapy.

RESULTS

Infective messages are commonly characterized by short, cogent communications emanating from credible sources that fall on vulnerable recipients' receptive, dispositional feeling states. These infective stimuli trigger reactive and defensive emotions and associated behaviors reflecting responses to significant threats or benefits relative to the individual's deepest needs, motivations, and values. Defensive overreactions may occur in response to messages to which individuals have been previously sensitized. Infective message contents appear to assimilate into constantly evolving, dynamic autobiographical brain maps consisting of highly specific neuronal networks that range from the brainstem through limbic structures to multiple cortical areas. Autobiographical maps built from message-injected contents may transform, akin to the incorporation of retroviruses or prions, to encode personal identities as aspects of the self. Contrasting maps may exist semi-independently of one another, continuously evolving, interacting, combining, dividing, conflicting, and contending with one another for attention. Achieving attentional awareness, such maps help structure how individuals conceptualize and communicate about their encoded traumas, diverse identities, and the conflicts among them.

CONCLUSIONS AND IMPLICATIONS

During psychotherapy, aftereffects of traumatizing infective messages might be detoxified by deconstructing, desensitizing, and processing messages' precise words and emotional envelopes in relation to contexts in which they were delivered, and the individual's inner dispositions at moments of impact. Carefully crafted, timely interpretations can be therapeutically infective, generating enduring positive impacts. Future studies using an assortment of approaches can test these perspectives.

Major depression with musical obsession treated with vortioxetine: a case report

BACKGROUND

Musical obsession has been reported as the "stuck song syndrome" and can be accompanied by obsessive compulsive disorder (OCD). Musical obsession is the phenomenon where a particular set of known musical notes are perceived repeatedly. We present a case of major depression with musical obsession. In this case, vortioxetine improved both depressive symptoms and musical obsession.

CASE PRESENTATION

A female, 34-year-old, high school teacher presented with a depressed mood, anergia, difficulty in concentration, poor motivation, restlessness, anxiety, insomnia, and loss of appetite. She was diagnosed with major depression by her family physician and prescribed escitalopram (20 mg/day). Her depressive state partially responded to escitalopram. When she had been depressed, she also experienced musical obsessions as repetitive commercial tunes or instrumental notes inside her head that were not under conscious voluntary control and lasting several hours, causing a high level of distress in her daily life. After switching from escitalopram to vortioxetine (20 mg/day), her depressive symptoms and musical obsession symptoms were ameliorated.

CONCLUSIONS

This case report endorses the utility of vortioxetine for major depression with musical obsession, and further studies should be conducted to establish the optimal treatment.

Involuntary musical imagery as a component of ordinary music cognition: A review of empirical evidence

Involuntary musical imagery (INMI) refers to a conscious mental experience of music that occurs without deliberate efforts to initiate or sustain it. This experience often consists of the repetition of a short fragment of a melody, colloquially called an "earworm." Here, we present the first comprehensive, qualitative review of published empirical research on INMI to date. We performed an extensive literature search and discovered, in total, 47 studies from 33 peer-reviewed articles that met the inclusion criteria for the review. In analyzing the content of these studies, we identified four major research themes, which concern the phenomenology, dynamics, individual differences, and musical features of INMI. The findings answer many questions of scientific interest-for instance, what is typical in terms of INMI frequency, duration, and content; which factors influence INMI onset; and whether demographic and personality factors can explain individual differences in susceptibility and responses to INMI. This review showcases INMI as a well-established phenomenon in light of a substantial body of empirical studies that have accumulated consistent results. Although the populations under study show an unfavorable bias towards Western, educated participants, the evidence depicts INMI as a universal psychological phenomenon, the possible function of which we do not yet fully understand. The concluding section introduces several suggestions for future research to expand on the topic.

Stuck in my head: Musical obsessions and experiential avoidance

Earworms refer to catchy tunes that run repeatedly through a person's mind. Empirical literature regarding earworms is scant; however, some researchers have conceptualized the phenomenon as an unwanted intrusion in the context of obsessive-compulsive disorder. The current study expands upon past research by characterizing the experience of earworms and examining associations of earworm-related distress and interference with theoretical constructs of interest, including obsessive beliefs and experiential avoidance. Two hundred forty participants completed an online survey regarding the experience of musical obsessions (e.g., duration, frequency, distress) and related theoretical constructs (e.g., experiential avoidance) of interest. Descriptive results regarding the frequency, duration, and associated distress and interference of earworms are presented. Furthermore, results reveal that experiential avoidance is a unique predictor of earworm-related distress and interference. Results suggest that interference and distress due to earworms may be related to attempts to suppress them. Study conclusions, limitations, and directions for future research are discussed.

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the 'obsessive-compulsive and related disorders', a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive-behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.

The Stuck Song Syndrome: A Case of Musical Obsessions

Patient: Female, 32

Final Diagnosis: Obsessive compulsive disorder

Symptoms: Compulsive behavior • musical obsessions

Medication: —

Clinical Procedure: Treatment with serotonin selective reuptake inhibitors

Specialty: Psychiatry

An account of the Speech-to-Song Illusion using Node Structure Theory

In the Speech-to-Song Illusion, repetition of a spoken phrase results in it being perceived as if it were sung. Although a number of previous studies have examined which characteristics of the stimulus will produce the illusion, there is, until now, no description of the cognitive mechanism that underlies the illusion. We suggest that the processes found in Node Structure Theory that are used to explain normal language processing as well as other auditory illusions might also account for the Speech-to-Song Illusion. In six experiments we tested whether the satiation of lexical nodes, but continued priming of syllable nodes may lead to the Speech-to-Song Illusion. The results of these experiments provide evidence for the role of priming, activation, and satiation as described in Node Structure Theory as an explanation of the Speech-to-Song Illusion.

Involuntary and voluntary recall of musical memories: A comparison of temporal accuracy and emotional responses

Comparisons between involuntarily and voluntarily retrieved autobiographical memories have revealed similarities in encoding and maintenance, with differences in terms of specificity and emotional responses. Our study extended this research area into the domain of musical memory, which afforded a unique opportunity to compare the same memory as accessed both involuntarily and voluntarily. Specifically, we compared instances of involuntary musical imagery (INMI, or “earworms”)—the spontaneous mental recall and repetition of a tune—to deliberate recall of the same tune as voluntary musical imagery (VMI) in terms of recall accuracy and emotional responses. Twenty participants completed two 3-day tasks. In an INMI task, participants recorded information about INMI episodes as they occurred; in a VMI task, participants were prompted via text message to deliberately imagine each tune they had previously experienced as INMI. In both tasks, tempi of the imagined tunes were recorded by tapping to the musical beat while wearing an accelerometer and additional information (e.g., tune name, emotion ratings) was logged in a diary. Overall, INMI and VMI tempo measurements for the same tune were strongly correlated. Tempo recall for tunes that have definitive, recorded versions was relatively accurate, and tunes that were retrieved deliberately (VMI) were not recalled more accurately in terms of tempo than spontaneous and involuntary instances of imagined music (INMI). Some evidence that INMI elicited stronger emotional responses than VMI was also revealed. These results demonstrate several parallels to previous literature on involuntary memories and add new insights on the phenomenology of INMI.

"Radio Inside My Head": A Curious Case of Early Onset "Stuck Song Syndrome" or Obsessive-Compulsive Disorder with Predominant Musical Obsession

Musical obsessions also called "stuck song syndrome" is a topic of limited research. It is among the most poorly understood and rare phenomenology. There are only a few cases reported across the world which describes it. Subjects usually present with complaints of continuous play of a musical tune in the head which the subject is unable to remove. Because of its similarity in presentation with auditory musical hallucination, it presents a diagnostic dilemma to the clinician. Here, we present the case of a 25-year-old man who presented with this particular phenomenon, and the approach we took to manage it.

Persistent Interictal Musical Hallucination in a Patient With Mesial Temporal Sclerosis-Related Epilepsy: First Case Report and Etiopathological Hypothesis

Musical hallucination is a disorder of complex sound processing of instrumental music, songs, choirs, chants, etc. The underlying pathologies include moderate to severe acquired hearing loss (the auditory equivalent of Charles Bonnet syndrome), psychiatric illnesses (depression, schizophrenia), drug intoxication (benzodiazepines, salicylate, pentoxifylline, propranolol), traumatic lesions along the acoustic pathways, and epilepsy. The hallucinations are most likely to begin late in life; 70% of patients are women. Musical hallucination has no known specific therapy. Treating the underlying cause is the most effective approach; neuroleptic and antidepressant medications have only rarely succeeded.Musical hallucination in epilepsy typically presents as simple partial seizures originating in the lateral temporal cortex. To our knowledge, no formal report of musical hallucination in the interictal state has been published before. In contrast, other interictal psychotic features are a relatively common complication, especially in patients with long-standing drug-resistant epilepsy.We describe a 62-year-old woman with a long history of mesial temporal lobe epilepsy whose musical hallucination was solely interictal. We speculate on the possible link between temporal epilepsy and her hallucination. We hypothesize that, as a result of her epileptic activity-induced damage, an imbalance developed between the excitatory and inhibitory projections connecting the mesial temporal cortex to the other auditory structures. These structures may have generated hyperactivity in the lateral temporal cortex through a "release" mechanism that eventually resulted in musical hallucination.

Factorial validity of the death obsession scale in African University students

In this study the factor structure of the Death Obsession Scale (DOS) was examined using confirmatory factor analysis. Data used consisted of DOS reports of 328 Black African students. Confirmatory factor analysis revealed that two- and three-factor models obtained among female and male African students, respectively, provided the best fit to the data. The two factors in female African students were Death Rumination and Apprehension, and the three factors of their male counterparts were Death Ruminations, Apprehension, and Comprehensibility of Death. Factor intercorrelations did not resolve the dimensionality issue of the measure, leading to the conclusion that the factors must be investigated further.

Obsessive-compulsive disorder presenting with musical obsessions in otosclerosis: a case report

Introduction

Musical obsessions consist of intrusive recollections of music fragments that are experienced as unwanted. Otosclerosis is caused by an abnormal bone homeostasis of the otic capsule and represents a frequent cause of hearing impairment. Many conditions causing hearing loss have been associated with musical hallucinations, but the association between musical obsessions and hearing loss is frequently overlooked.

Case presentation

We present the case of a 51-year-old Caucasian woman with a history of obsessive-compulsive disorder who developed musical obsessions soon after being diagnosed with otosclerosis. She was referred to our obsessive-compulsive disorder outpatient unit by her general psychiatrist. At the time of our first evaluation, she had severe musical obsessions that interfered with her social functioning and made her unable to follow conversations. She was started on 40mg of paroxetine and 2.5mg of aripiprazole, which led to significant improvement of her symptoms and of her social and work functioning.

Conclusions

To the best of our knowledge, this is the first report of musical obsessions in a patient with hearing loss due to otosclerosis and a history of obsessive-compulsive disorder. This case suggests that a differential diagnosis of obsessive-compulsive disorder should be carefully considered in patients with hearing impairment who complain of involuntary musical imagery, especially in those patients who have a previous history of obsessive-compulsive disorder.