Clinical Geriatrics

In general, auditory hallucinations can be “unformed,” with the perception of ringing, chirping, buzzing, roaring, clicking, whooshing, blowing, etc; or “formed,” with the perception of word sentences and musical tones. Auditory musical hallucinations (AMHs) occur in psychiatric disease,^1,2 ictal states of complex partial seizures,^3-5 abnormalities in the auditory cortex,⁶ thalamic infarcts, subarachnoid hemorrhage,⁷ tumors of the brain stem,⁸ intoxications,⁹ and progressive deafness.¹⁰

Nonpsychotic AMHs, as a type of “formed tinnitus,” occur in people with age-related bilateral sensorineural hearing loss. Most people who are deaf do not develop AMHs, but AMHs in deafness are more common than is generally appreciated.¹⁰ There are many descriptive reports of deaf elderly individuals with AMHs.^11-17 These subjective experiences consist of hearing singing voices, hymns, steady musical tones, words of songs that the patient learned previously, instrumental music, or the combination of instrumental music and singing voices.

The question is raised as to whether AMHs should be defined as auditory illusions instead of hallucinations, since hallucinations are defined as the perception of sensory input where there is none, and illusions are distortion or misperceptions of a sensory input. However, with any type of tinnitus, there is no impingement of sound waves on the eardrum. The signal is generated within the auditory system itself. Therefore, this type of musical tinnitus in people who are deaf can be considered a hallucinatory phenomenon.

Evers and Ellger⁹ statistically analyzed 132 cases with musical hallucinations and separated them according to etiology in cases of hypoacusis, psychiatric disorders, focal brain lesions, epilepsy, and intoxications. They noted a female preponderance of 70%, and a mean age of 61.5 years. Patients with focal brain lesions were significantly younger than the mean age. The hemisphere in which the lesion was located did not seem to play a major role in whether the patient had AMHs. The authors did not find any systematic studies about treatment of AMHs, although they did note that, of the treatments reported, anticonvulsants and antidepressants were the most effective.

Weiser¹⁸ noted that the theme “music and the brain” is usually conceptualized at three levels: acoustic, cognitive, and aesthetic. At the acoustic level, one should consider the spatiotemporal pattern of sound waves, the specific excitation of sensory cells, the acoustic pathway and its connections, and the acoustic cortex. At the cognitive level, there are centers of interest such as the acoustic memory and the analysis of sound, tones, pitch, timber, and rhythm. At the aesthetic level, one takes into account the sociocultural aspect of music and our musical preferences. Hermesh et a^l2 examined the lifetime experience of musical hallucinations with a specially designed structural interview in 190 consecutive outpatients diagnosed with anxiety, affective, and schizophrenic disorders. They found that musical hallucinations occur in more than one-fifth of all diagnoses, and the prevalence was highest in subjects with a diagnosis of obsessive-compulsive disorder. Obsessive-compulsive disorder comorbidity with other psychiatric disorders increased the frequency of musical hallucinations.²

Most patients with nonpsychotic AMHs are elderly individuals with tinnitus and severe high-frequency sensorineural hearing loss. They have a constant, clear perception of music pieces, such as marches, country music, and hymns. Some patients identify one musical instrument that predominates over others in the production of the hallucinatory musical tinnitus. The musical tones have a vibrating quality similar to the sound produced by blowing air through a paper-covered comb.