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Musical Hallucinations, Depression and Old Age

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An essay in the Psychopathology 20:220-223 (1987)

 

D. Eizenberg, I. Modai, M. Roitman, E. Mendelson, H. Wijsenbeek


Abstract. The association between musical hallucinations, depression and acquired hearing loss is described in two elderly patients. Following the presentation of this underdiagnosed clinical phenomenon we propose that musical hallucinations should be addressed as a final outcome of several factors including both mental and physical components. This conceptual framework enhances our understanding and treatment of such phenomena.

 


Introduction

 

 

Acquired hearing loss is increasingly encountered among the elderly. Musical hallucinations associated with acquired deafness and depression is an entity rarely described in the medical literature, and is considered an underdiagnosed phenomenon [1]. An association between hearing deficits and mental disorders in old age has generally been assumed but has been poorly substantiated in the psychiatric literature [2].

 

The contributory role of depression in the occurrence of musical hallucinations was described in two patients while in a state of nonpsychotic depression [3]. A recent survey showed evidence of an association between hearting loss and dysphoric states [2], thus elderly depressed patients are more susceptible for developing musical hallucinations.

 

Surprisingly, there are possibly only two other case reports of such an association in the medical literature [4, 5]. We present two case histories of elderly depressed patients with musical hallucinations.

 


Case reports

Case No. 1

 


B. A., a 70-year-old patient, married and mother of a son, was referred to our clinic in an acute psychotic depression. She suffered from four recurrent depressive episodes in the last 30 years. At the time of admission to the hospital, B.A. complained about anxiety, depressive mood and voices speaking to and about her. In addition, she spoke about musical hallucinations, which appeared during the last 4 months concomitantly with the last depressive episode.

 

The musical hallucinations were of childhood songs, monotonous and extremely disturbing by their persistence and exacerbation during silent ambiance and at night. During the 4 months they progressed into hallucinations of two voices singing, a man sang love songs, which she remembered from her childhood in Hungary.

 

She was treated with haloperidol, 3mg/day, which affected a disappearance of the critical libretto. Central and peripheral brain atrophy was demonstrated by computerized tomography.

 


Case No. 2

 


A.M., a 65-year-old woman, married and mother of 2 children, was referred to the psychiatric outpatient clinic in a depressive state. She manifested depressive affect, inability to work, insomnia, decreased appetite, constipation and anaclitic anxiety. She had suffered 3 similar kinds of depressive episodes 4 years ago, and also attempted suicide by swallowing 20 capsules of Amytal Sodium 300 mg. At that time musical hallucinations first appeared in the form of melodies from radio programs. The songs disappeared concomitantly with remission and for 3 years she felt well. When the depression reappeared, the songs emerged again and she was able to vocalize them. She gained insight into this phenomenon by the reality feedback of her husband.

 

The course out of improvement of the depressive episode was inconsistent due to noncompliance problems. There were three remissions and exacerbations due to cessation of medication and therapeutic contact. Every exacerbation was accompanied by the reappearance of musical hallucinations.

 

The drug treatment included first amitriptyline, 150 mg/day, then a trial of chlomipramine. 150 mg/day, followed by doxepin, 100 mg/day. When dosage was reduced after 2 months to 75 mg/day of doxepin, there was a resultant clinical decline and concomitant reappearance of musical hallucinations and depression. This time the music was a combination of religious melodies from the radio. And a 'noise of woods'. The music and the noise increased when less external stimuli were available.

 

Recurrent electroencephalograms performed during her evaluation and treatment showed no epileptic activity. Computerized tomography illustrated slight atrophy in the parietal lobes. Audiometry revealed a borderline sensory neural decline of hearing in both ears.

 


Discussion

 

 

Hallucinations occur in all sense modalities with auditory hallucination by far the most common [6]. Hallucination, among other perceptual disturbances, may be very hard to evaluate for there are few objective signs associated with them. This is one of the reasons why hallucinations are rarely of pathognomonic significance. The presence of other associated signs and symptoms is usually required to establish a specific diagnosis.

 

Common clinical practice suggests that the less formed the hallucinations the more likely they are due to biochemical of neurological causes, while the more formed, describable and prolonged hallucinations probably denote a functional psychiatric disorder [7].

 

Although hallucinations usually indicate a severe disruption in reality testing, auditory hallucinations may also occur in normal populations. Parish [cited in ref. 8] reported that approximately 12% of the normal population has experienced a hallucination in the waking state. Mott et al. [9] found in a control group of admissions to a medical ward 16 of 50 patients who reported experiencing an auditory hallucination at some time in their life [9].

 

In the medical literature there are a few case reports of patients identified by the clinical association of musical (formed complex) hallucinations and acquired hearing loss [1, 10, 11]. The hallmark of this group is the lack of psychopathology and advanced age.

 

The perceptual release theory of West [citied in ref. 3] hypothesized a disruption of the usual level of external sensory input necessary to inhibit the emergency of percepts of memory traces within the brain. Thus, previously recorded perceptions may by released into awareness and create hallucinations. One may conceptualize musical hallucinations as a net outcome measure of several components, which affect the normal 'balance' of sensory stimuli.

 

Regional brain atrophy disclosed by Computerized Tomography and a degree of hearing loss were found in both patients. These two findings are more prevalent among the elderly population and probably represent irreversible vulnerability of other components affecting perceptual processes to produce musical hallucination.

 

A significant relationship between hearing impairment and dysphoria was reported among an elderly population [2, 23]/ we recently described two patients with musical hallucinations while in a state of nonpsychotic depression [3]. One of them suffered from acquired deafness. But no such pathology was found in the other. Cessation of musical hallucinations occurred concomitantly in both patients with improvement of the affective state. The clinical course presented here by both patients supports the contributory role ascribed to depression.

 

Musical hallucinations are not unique to depression and/or acquired hearing loss. The effect exerted by drugs should always be considered.

 

A salicylate-induced musical hallucination in an elderly lady with otosclerosis [13] is a recent example of the clinical constellation of hearing loss and drug effect in an elderly patient. Our second patient described an increased intensity of her hallucinations during the first week of her second therapeutic trial with clomipramine. This could be attributed to the affective state of depression yet unimproved; on the other hand, the clinical phenomenon might represent transitory side effects of clomipramine.

 

It seems reasonable to address musical hallucinations as a final clinical outcome of several factors, some of which are organic (e.g. regional brain atrophy, drugs) and some of them functional (depression). A frequent diagnostic error arises if the physician seeks to make a diagnosis of organic or functional disease when in fact - both are present.

 

It has been suggested that formal musical hallucinations associated with deafness and/or depression are more common than generally appreciated [3]. One of the reasons given is that affected patients are reluctant to discuss their false perceptions lest people think them crazy [2]. We believe the phenomenon might exist among psychiatric patients as well who view their false perception as egodystonic.

 

Another reason might be the doctor's awareness. Our recognition of an additional two patients within the periods of 1 year attests to this fact. There is a tendency to ascribe all clinical manifestations to one or the other 'disorders' rather than to confront both simultaneously. Identification of contributory components, both mental and physical, will enhance our understanding and treatment of such phenomena.

 

 

References:

 

 

1. Ross, E.D.; Joaman, P.D.; Bell, B.; Sabin, T.; Geschwind, N.; Musical hallucinations in deafness. J. Am, med, Ass. 231: 620-622 (1975).

2. Eastwood, M.R.; Corbin, S.L.; Reed, M.; Nobbs, H.; Kedward, H.B.: Acquired hearing loss and psychiatric illness: an estimate of prevalence and co-morbidity in a geriatric setting. Br. J. Psychiat. 147:552-5556 (1985).

3. Aizenberg, D,; Schwarts, B.; Modai, I.: musical hallucinations, acquired deafness and depression. J. nerv. ment. Dis. 174:309-311 (1986).

4. Clovis, W.I.: They hear music (letter) Am. J. psychiat. 133: 1096 (1976).

5. Ross, E.D.: musical hallucinations in deafness revisited (letter). J. AM. Med. Ass 240:716- (1978).

6. American psychiatric Association: Diagnostic and statistical manual of mental disorders; 3rd ed. (American Psychiatric association, Washington, 1980).

7. Ludwig, A.M.: The perceptual sphere in principles of clinical psychiatry (Free press, New York 1980).

8. Junginger, J.; Frame, C.L.: Self report of the frequency and phenomenology of verbal hallucinations .J. Nerv. Ment. Dis. 173:149-155 (1985).

9. Mott, R.; Small, I.; Anderson, J.: Comparative study of hallucinations. Archs gen. Psychiat. 12:595-601 (1065).

10. Hammeke, T.A.; McQuillen, M.P.; Cohen, B.A.: musical hallucinations associated with acquired deafness. J. Neurol. Neurosurg. Psychiat. 46:570-572 (1983).

11. Miller, T.C.; Crosby, T.W: musical hallucinations in a deaf elderly patient, Neurol. 5:301-302 (1979).

12. Gilhome-Herbst, K.: Jumphry, C.: Hearing impairment and mental state in the elderly living at home. Br. Med, J. 281:903-905 (1980).

13. Allen, J.R.: Salicylate-induced musical perceptions (letter). New Engl. J. Med. 313: 642-643 (1095). D. Aizenberg, MD Geha Psychiatric Hospital Beilinson Medical Center Petah Tiqva 49100 (Israel)

 

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