doi:10.1093/brain/awv286
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Minds on replay: musical hallucinations and
their relationship to neurological disease
Erin C. Golden and Keith A. Josephs
The phenomenon of musical hallucinations, in which individuals perceive music in the absence of an external auditory stimulus,
has been described sparingly in the literature through small case reports and series. Musical hallucinations have been linked to
multiple associated conditions, including psychiatric and neurologic disease, brain lesions, drug effect, and hearing impairment.
This study aimed to review the demographics of subjects with musical hallucinations and to determine the prevalence of neurological disorders, particularly neurodegenerative disease. Through the Mayo medical record, 393 subjects with musical hallucinations were identified and divided into five categories based on comorbid conditions that have been associated with musical
hallucinations: neurological, psychiatric, structural, drug effect and not otherwise classifiable. Variables, including hearing impairment and the presence of visual and other auditory hallucinations, were evaluated independently in all five groups. The mean age
at onset of the hallucinations was 56 years, ranging from 18 to 98 years, and 65.4% of the subjects were female. Neurological
disease and focal brain lesions were found in 25% and 9% of the total subjects, respectively. Sixty-five subjects were identified with
a neurodegenerative disorder, with the Lewy body disorders being the most common. Visual hallucinations were more common in
the group with neurological disease compared to the psychiatric, structural, and not otherwise classifiable groups (P 5 0.001),
whereas auditory hallucinations were more common in the psychiatric group compared to all other groups (P 5 0.001). Structural
lesions associated with musical hallucinations involved both hemispheres with a preference towards the left, and all but two
included the temporal lobe. Hearing impairment was common, particularly in the not otherwise classifiable category where
67.2% had documented hearing impairment, more than in any other group (P 5 0.001). Those with an underlying neurodegenerative disorder or isolated hearing impairment tended to hear more persistent music, which was often religious and patriotic
compared to those with a structural lesion, where more modern music was heard, and those with psychiatric disorders where music
was mood-congruent. This case series shows that musical hallucinations can occur in association with a wide variety of conditions,
of which neurological disease and brain lesions represent a substantial proportion, and that Lewy body disorders are the most
commonly associated neurodegenerative diseases. A future prospective study would be helpful to further delineate an association
between musical hallucinations and neurodegenerative disease.
Department of Neurology, Division of Behavioural Neurology, Mayo Clinic, Rochester, Minnesota, USA
Correspondence to: Keith A. Josephs, MD, MST, MSc
Professor of Neurology
Mayo Clinic
200 1st Street S.W.
Rochester, MN, 55905, USA
E-mail: Josephs.keith@mayo.edu
Keywords: music; psychosis; dementia; depression; Lewy body disease
Abbreviation: NOC = not otherwise classifiable
Received May 14, 2015. Revised July 27, 2015. Accepted August 9, 2015. Advance Access publication October 7, 2015
ß The Author (2015). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
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Introduction
‘Music, when soft voices die; Vibrates in the memory’
mused English poet Percy Bysshe Shelley (Shelley, 1901).
The relationship between music and memory is particularly
highlighted by the curious phenomenon of musical hallucinations (Wieser, 2003; Sacks, 2006).
An auditory hallucination, or the perception of sound in
the absence of an acoustic stimulus, is not an uncommon
phenomenon. Auditory hallucinations usually consist of unformed sounds, such as those heard in tinnitus; however,
formed or complex hallucinations are experienced less
frequently. Musical hallucinations represent a subset of
complex auditory hallucinations in which individuals perceive music in the form of tunes or melodies, which can be
continuous or intermittent, in the absence of a corresponding external stimulus. Sometimes, singing voices may
accompany the music (Berrios, 1990; Warner and Aziz,
2005). The hallucinations can be transient or long-lasting.
Often occurring in cognitively and psychiatrically normal
individuals, they are likely under-reported due to concern
for being perceived as ‘crazy’. In addition, it may be that
the music is not bothersome or disruptive to daily functioning and so does not prompt a discussion with a medical
provider. Often, the tunes are familiar to the person perceiving them, but there are reports of novel or unfamiliar
tunes (Berrios, 1990; Warner and Aziz, 2005). Even when
the melody is unrecognizable to the subject, it may represent a familiar melody that is no longer consciously remembered by the subject (Vitorovic and Biller, 2013), a
phenomenon that has prompted important questions as to
whether our memory for music is distinct from other
memories.
Musical hallucinations are an uncommon phenomenon.
In one series of general psychiatric admissions, the prevalence rate was 0.16% (Fukunishi et al., 1998). In another
series of elderly subjects at an audiology clinic, approximately one-third experienced auditory hallucinations, but
of these only one subject (or a total of 0.8%) experienced
musical hallucinations (Cole et al., 2002).
More detailed reports of musical hallucinations have
been published, albeit sparingly. Berrios (1990) published
the first series of subjects with musical hallucinations and
identified that they were more often seen in females compared to males, and positively correlated with advancing
age, deafness, and brain disease. Since the Berrios (1990)
study, literature reviews compiling case reports and small
case series have been published (Keshavan et al., 1992;
Evers and Ellger, 2004); however, no large single centre
case series has been published to date.
The most commonly accepted predisposing condition for
the development of musical hallucinations has been shown
to be hearing impairment, however, most people who have
significant hearing impairment never develop musical hallucinations. Therefore, hearing impairment represents one
variable in what likely represents a complex and
E. C. Golden and K. A. Josephs
multifactorial pathophysiological process (Evers and
Ellger, 2004). Lesions anywhere along the auditory pathway, from the ear to the auditory association cortex, can
lead to musical hallucinations (Cope and Baguley, 2009). In
keeping with Berrios’ reported association between brain
disease and musical hallucinations, case reports detailed
musical hallucinations occurring in the setting of cerebral
ischaemia (Calabro et al., 2012; Dinges et al., 2013; Woo
et al., 2014), encephalitis (Douen and Bourque, 1997),
tumour (Scott, 1979; Nagaratnam et al., 1996), postsurgery (Keshavan et al., 1988; Isolan et al., 2010), multiple sclerosis (Husain et al., 2014) and epilepsy (Roberts
et al., 2001; Gentile et al., 2007; Ozsarac et al., 2012).
Given the strong association between hearing impairment
and musical hallucinations, some have suggested that musical hallucinations represent a release phenomenon.
According to one proposal, sensory deprivation eliminates
the afferent input to the auditory sensory processing system
allowing spontaneous activity to occur in a network
(Griffiths, 2000), analogous to the Charles Bonnet syndrome, in which visual impairment precipitates the development of visual hallucinations (Burke, 2002). A significant
proportion of patients with the Charles Bonnet syndrome
eventually develop dementia with Lewy bodies (Lapid
et al., 2013). However, the prevalence of neurodegenerative
disorders among those who experience musical hallucinations, and how these subjects compare to those with musical hallucinations in the setting of other disorders has not
been addressed in the literature to date. Musical hallucinations are often noted to occur in cognitively normal
people; however, anecdotally musical hallucinations have
been described to occur in the presence of dementia
(Mori et al., 2006; Berger, 2015).
In this study, we sought to address this knowledge gap
by characterizing the conditions associated with musical
hallucinations through a large case series. We further
aimed to further explore the prevalences and characteristics
of neurological diseases, particularly neurodegenerative, in
those experiencing musical hallucinations compared to
groups without an associated neurological disease. Given
the previous literature, we hypothesized that structural
lesions would have a significant preference towards the
right hemisphere. We further predicted an association
between musical hallucinations and neurodegenerative disorders, specifically Lewy body disorders, given their known
correlation with hallucinations.
Materials and methods
Subjects
The research project was approved by the Mayo Institutional
Review Board. The Mayo Clinic Medical Records Linkage
System was used to identify all subjects who underwent evaluation at this institution and had musical hallucinations from 1
January 1996 to 31 December 2013. The system was queried
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Musical hallucinations and associated neurological conditions
to capture all medical records in which the terms ‘musical
hallucinations’, ‘music AND hallucinations’, and ‘hear music’
including all tenses of ‘hear’ appeared. The medical records of
all subjects identified were then reviewed to determine whether
they met criteria for musical hallucinations defined as the perception of music not perceived by others present. Subjects were
only included if they were at least 18 years old and the symptom of musical hallucinations was documented in a clinical
encounter with a Mayo Clinic provider including physician,
nurse practitioner, or psychologist. Subjects who only experienced isolated hypnagogic or hypnopompic hallucinations
were excluded. Clinical data were abstracted in all subjects
that met the inclusion criteria, including age at onset of
musical hallucinations, the presence of visual or other auditory
hallucinations, available imaging, documentation of hearing
impairment, and audiometry. Subjects were divided into five
categories according to the condition felt to be most strongly
associated with musical hallucinations, recognizing that often
multiple factors may have contributed. The five categories
included neurologic, psychiatric, structural, drug toxicity or
withdrawal and not otherwise classifiable (NOC) for those
not fitting into the other four groups. Subjects with musical
hallucinations were grouped in the neurologic category if the
hallucinations developed in the setting of a neurological disorder. Within the neurologic category, those with a neurodegenerative disease were further subclassified to assess for
associations. All subjects were subclassified based on the diagnosis rendered by the evaluating neurologist. Subjects were
subclassified as having a Lewy body disorder (Parkinson’s disease, Parkinson’s disease dementia, dementia with Lewy
bodies), Alzheimer’s dementia or frontotemporal dementia
based on accepted diagnostic criteria. Others were diagnosed
with dementia without a more specific diagnosis (dementia not
otherwise specified or dementia NOS.) Sometimes those with a
neurologic diagnosis had concomitant psychiatric disease,
often as a neuropsychiatric symptom related to the neurological disease, and these subjects remained in the neurologic
group given the main aim of our study. Subjects were placed in
the structural category if they clearly developed musical hallucinations in the context of a focal brain lesion, with imaging
done in close temporal relationship to the hallucinatory experience. Subjects who experienced seizures related to focal lesions
were included in the structural category. Subjects placed in the
psychiatric category experienced musical hallucinations that
were clearly associated with worsening of psychiatric symptoms. For subjects in the drug category, there was a clear
temporal relationship between the initiation of a drug or the
withdrawal state and the musical hallucinations, which was
noted by either patient and/or care provider. Co-morbid psychiatric conditions were collected for subjects in all groups.
Statistical analyses
Statistical analyses were performed using JMP statistical software (JMP, version 10.0.0; SAS Institute Inc, Cary, North
Carolina), with statistical significance set at P 5 0.05. Sex
ratios and binary variables collected (presence or absence of
hearing impairment, visual or other auditory hallucinations)
were compared across groups and subgroups using the 2
test. Age at musical hallucination onset was compared across
groups and subgroups using the analysis of variance test.
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If significance was found, the Tukey-Kramer post hoc test
was then used to compare all pairs of groups.
We did not adjust for multiple comparisons in our study
given that we had an a priori hypothesis for testing for these
associations. In addition, adjusting for multiple comparisons
would have increased the likelihood of type II errors for associations that were not null. Not adjusting for multiple comparisons has been advocated since it will result in fewer errors
in interpretation when the data are not random numbers but
actual observations in nature (Rothman, 1990). Therefore,
adjusting our data could have resulted in missing important
findings.
Results
A total of 636 subjects were identified by the Mayo
Medical Records Linkage System. Of these, 393 met inclusion criteria. The mean age at onset of the hallucinations
was 56 years (range 18–98). Two hundred and fifty-seven
(65.4%) of these subjects were female. One hundred and
five (26.7%) subjects had documented hearing impairment,
77 of whom had audiometry confirming hearing impairment. While most subjects underwent head CT imaging,
207 (52.8%) had head MRI performed. Generalized atrophy, leukoaraiosis, and lacunar infarcts were common
findings.
After division into groups (Fig. 1), psychiatric disorders
predominated (39%) with neurological disorders (25%) the
next most common. Drug toxicity or withdrawal, structural
lesions, and NOC made up a smaller proportion of the
total subjects. Co-existing auditory and visual hallucinations were relatively common, as detailed in Table 1.
Examples of specific songs or music genres for each of
the five categories are shown in Table 2. Musical hallucinations were sometimes transient particularly when associated with a reversible neurological condition, structural
lesion or drug effect. Often however, particularly in the
neurodegenerative and NOC groups, the hallucinations
were persistent, lasting for months to years at a time.
Descriptions of these experiences are provided in
Supplementary Box 1.
Neurologic group
A total of 98 patients had a primary neurologic diagnosis
associated with the hallucinations. The mean age in this
category was 64 years (range 18–98), which was significantly different than the mean age of all other groups
and second oldest to the mean age of the NOC group,
and 71.4% were female. Of these subjects, 32.7% had
documented hearing loss, and 71.8% of subjects with hearing loss had supporting audiometry. By far, the most
common neurological diagnosis seen was a neurodegenerative disorder (67.3%), followed by seizures (16.3%), and
encephalitis (9.2%) (Table 3). The most common of the
neurodegenerative diseases was Lewy body disease
(34.8%) (Table 3). Of the Lewy body disorders, dementia
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E. C. Golden and K. A. Josephs
mood, and at least two were associated with a deceased
person. Auditory hallucinations were significantly more
common in those in the psychiatric group than in all
other groups. The frequency of hearing impairment was
significantly less than for all other groups excluding structural, for which it was similar.
Structural group
Figure 1 The proportions of musical hallucinations
attributed to different associated conditions. Psychiatric disease represented the most commonly associated condition; however, neurological disease and focal brain lesions together accounted
for over a third of the patients.
with Lewy bodies was the most common (60.9%), followed
by Parkinson’s disease and Parkinson’s disease dementia.
Often, those with neurodegenerative disorders did not
have the insight that their hallucinations represented false
perceptions and were convinced that the neighbours were
playing music too loudly. One subject was described to go
around ‘knocking on neighbours doors and at times harassing them as a result of this symptom’. Songs were often
religious or patriotic, and reminiscent of childhood. Visual
hallucinations were significantly more common in those in
the neurologic group relative to those in the psychiatric,
structural, and NOC groups. Thirty-four per cent of
those in the neurologic group had a comorbid psychiatric
diagnosis: depressive disorders (n = 23), anxiety disorders
(n = 6), psychotic disorders (n = 2), and bipolar disorder
(n = 2). With the exception of bipolar disorder, many of
these diagnoses were neuropsychiatric symptoms secondary
to the neurological disease.
Psychiatric group
The mean age in the psychiatric category was 48.1 years
(range 8–90), and 70.3% were female. Of these, 11.6%
had documented hearing loss, and 72.2% of subjects with
hearing loss had supporting audiometry. Depression and
bipolar disorder accounted for the majority of diagnoses
and there tended to be waxing and waning of the hallucinations with depressive and manic symptoms (Table 4).
Psychotic disorders represented a smaller proportion
(17.4%) with schizoaffective disorder being the most
predominant of those. Only one person had obsessivecompulsive disorder. Songs tended to be affected by
Thirty-seven subjects (9%) had structural lesions associated
with the musical hallucinations. Of the 37, all had MRI
completed except for two who had a head CT and one
who did not have imaging available for review but had a
history of a right temporal astrocytoma resection several
years earlier, after which he developed seizures manifesting
as musical hallucinations attributed to the lesion. The mean
age was 43.5 years (range 18–87), and 48.9% were female.
Hearing loss was documented in 13.5%, and 80% of these
subjects had supporting audiometry. As shown in Table 5,
the most common structural lesion noted was tumour
(n = 14 subjects), with a lesser frequency of post-surgical
lesions (comprised of resections of tumours, vascular
anomalies, and a non-structural epileptic focus), mesial
temporal
sclerosis
and
undifferentiated
lesions.
Interestingly, only two subjects experienced musical hallucinations following an infarct documented by imaging.
Tumours tended to be low grade (meningioma, oligodendroglioma, low-grade glioma, pilocytic astrocytoma)
(n = 9 subjects) compared to high-grade glioma (n = 5 subjects). Temporal lobe involvement was noted with all the
structural lesions with the exception of two, a tumour
located in the pons with extension into the midbrain and
cerebellum and a right parietal infarct. Both the right and
left hemispheres were involved. More lesions were noted in
the left hemisphere (57%) compared to the right hemisphere, however to an insignificant degree. Examples of
lesions resulting in musical hallucinations are shown in
Fig. 2. Songs heard were often more modern, including
genres like country and rock. Twenty-seven per cent of
those in the structural group had a co-morbid psychiatric
diagnosis: depressive disorders (n = 6), anxiety disorders
(n = 2), psychotic disorders (n = 2).
Drug toxicity or withdrawal group
Forty-five subjects experienced the onset of musical hallucinations in close temporal relationship to drug initiation or
in the setting of withdrawal. The mean age in this group
was 54 years (range 19–91), and 51.1% were female. Of
these subjects, 24.4% had documented hearing loss, 63.5%
of which had supporting audiometry. The most commonly
associated subgroups were alcohol withdrawal and steroids. Table 6 is a complete list of drugs. Alcohol abuse
was a common confounder in the psychiatric population,
often accompanying depression. All cases of stimulants
were in association with polysubstance abuse. In 48.9%
of subjects, the hallucinations resolved completely upon
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Table 2 Description of music heard across groups
Psych = psychiatric; LBD = Lewy body disease; AD = Alzheimer’s disease; FTD = frontotemporal dementia; NOS = not otherwise specified.
Post hoc P-values were considered significant if 50.05.
*All of the results except for the gender association would have survived Bonferroni correction.
a
Neuro versus Psych; bNeuro versus Structural; cNeuro versus Drug; dNeuro versus NOC; ePsych versus Structural; fPsych versus Drug; gPsych versus NOC; hStructural versus Drug; iStructural versus NOC; jDrug versus NOC.
50.0001a,b,c,d,g,i,j
50.0173b,c,e,f
50.0001a,b,d,f,g,i,j
50.0001a,e,f,g
50.0001a,b,d,e,h
58
73 (12.9)
39 (67.2%)
39 (67.2%)
17 (29.3%)
7 (12.1%)
37
44 (19.2)
18 (48.9%)
5 (13.5%)
10 (27.0%)
1 (2.7%)
45
54 (19.0)
23 (51.1%)
11 (24.4%)
7 (15.6%)
12 (26.7%)
n
Age at onset
Frequency of
Frequency of
Frequency of
Frequency of
(SD)
female gender
hearing impairment
other auditory hallucinations
visual hallucinations
98
64
70
32
25
38
(19.6)
(71.4%)
(32.7%)
(25.5%)
(38.8%)
23
72 (9.9)
12 (52.2%)
11 (47.8%)
4 (17.4%)
17 (73.9%)
18
78 (8.5)
14 (77.8%)
8 (44.4%)
7 (38.9%)
7 (38.9%)
65
74
46
27
19
32
(11.1)
(70.8%)
(41.5%)
(29.2%)
(49.2%)
22
73 (12.7)
19 (86.4%)
8 (36.4%)
7 (31.8%)
7 (31.8%)
2
59 (3)
2 (100%)
1 (50%)
1 (50%)
0 (0%)
155
48 (15.5)
109 (70.3%)
18 (11.6%)
74 (47.8%)
33 (21.3%)
Structural NOC
Drugs
Dementia NOS All Neurodegenerative Psych
FTD
AD
All neurologic LBD
Neurodegenerative
Neurological
Table 1 Demographic features across all five categories groups
P-values*
Musical hallucinations and associated neurological conditions
Category
Neurologic
Description
Neurodegenerative ‘church choral music’
Structural
Psychiatric
Drug
Not otherwise
classifiable
‘echo of last music he heard’
‘big band’ (n = 2 subjects)
‘single tune with the words “where were
you when the Lord was crucified” or
“where were you when your Lord was
placed in the grave, 24 hours a day”
‘church hymns’
‘rock music’
‘old video game’
‘Fraggle rock’
‘country music’ (n = 2 subjects)
‘Queen’
‘hearing a record playing over and over
again which appeared to skip at times’
‘believes it was someone who had
passed away’
‘fun and snappy but scary’
‘radio playing in another room’
‘favorite songs of late husband’
‘like funeral music when depressed’
‘music from Beauty and the Beast’
‘hard rock’
‘elevator music’
‘Yankee Doodle Dandy’
‘Bram’s type music’
‘Christmas carols’ (n = 2 subjects)
‘string instruments’
‘radio through vent’
‘school songs and hymns’
‘Glory, Glory, Alleluia’
‘Silent Night, O Holy Night, Edelweiss,
The Battle Hymn of the Republic’
‘America the Beautiful sung as by a choir
with an orchestra which lasted four to
five months. . .[which] changed to a
hymn, then a Christmas song, then to
presently single notes.’
‘How much is that doggy in the window,
The Star Spangled Banner and Swing
Low-Sweet Chariot’
‘Japanese’
‘Polish’
‘Marine call, Silent Night, Little Drummer
Boy, isolated trumpet or bugle calls or
clarinet or flute music’
‘almost constantly, I Walk the Line and
This Land Is Your Land’
‘National anthem’
‘Star-Spangled banner’
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E. C. Golden and K. A. Josephs
Table 3 All neurological diagnoses associated with
musical hallucinations
Table 4 All psychiatric disorders associated with musical hallucinations
Neurological diagnosis
n
Psychiatric diagnosis
n
Neurodegenerative
Lewy body disorders
Dementia with Lewy bodies
Parkinson’s disease
Parkinson’s disease dementia
Dementia NOS
Alzheimer’s dementia
Frontotemporal dementia
Seizure
Encephalitis
Post-concussive syndrome
Amyloid beta related angiitis
Migraine
Posterior reversible encephalopathy syndrome
Traumatic brain injury
Leukoencephalopathy
Multiple system atrophy
65
23
14
5
4
22
18
2
16
9
2
1
1
1
1
1
1
Depression
Bipolar disorder
Schizoaffective disorder
Anxiety
Delirium
Psychotic disorder NOS
Schizophrenia
Spell
Post-traumatic stress disorder
Obsessive compulsive disorder
Chronic fatigue syndrome
Dysthymia
Adjustment disorder
Mood disorder NOS
62
29
12
13
10
9
6
6
3
1
1
1
1
1
cessation of the offending drug or withdrawal syndrome. In
two subjects (4.4%), the hallucinations improved, and in
another two subjects, no improvement was noted. In the
remainder of subjects, follow-up information was not available. A high proportion (64%) of subjects in this group had
a comorbid psychiatric diagnosis: depressive disorders
(n = 17), anxiety disorders (n = 8), bipolar disorder
(n = 3), and psychotic disorders (n = 1).
Not otherwise classifiable group
For those not otherwise classifiable (NOC), the average age
was 73 years (range 36–94), which was significantly greater
than the mean age of all other groups, and 67.2% were
female. Of these subjects, 67.2% had hearing impairment,
74.4% of which had supporting audiometry. There were
no unifying underlying co-morbidities; however, interestingly two subjects developed musical hallucinations after
cochlear implants. As in the neurologic category, many of
these subjects heard songs familiar to them from childhood,
particularly religious or patriotic songs. Twenty-six per cent
of subjects in this group had a co-morbid psychiatric diagnosis: depressive disorders (n = 9), anxiety disorders (n = 5),
and psychotic disorders (n = 1).
Discussion
This study represents the largest series of musical hallucinations to date, from which several important points can be
highlighted. Similar to previous studies (Berrios, 1990;
Keshavan et al., 1992; Evers and Ellger, 2004) most of
the individuals experiencing musical hallucinations were
female (with the exception of those related to structural
lesions and drugs where the genders were fairly equally
divided). It remains unclear why there would be a female
predominance amongst those with musical hallucinations in
these groups, and likely the cause is multifactorial and complex, possibly related to underlying structural or metabolic
differences between genders. Data evaluating gender differences in hallucinations associated with psychiatric and
neurological disease is sparse; however, there is some literature to suggest that hallucinations are more common in
females in psychiatric disease (Rector et al., 1992) and
dementia (Xing et al., 2012).
The average ages at which the individuals in the neurologic and NOC groups experienced musical hallucinations
were significantly higher than other groups, and that of the
neurodegenerative disorders group was quite similar to that
of the NOC group, namely 74 and 73 years, respectively.
Neurological disease and structural lesions were associated
with musical hallucinations in a significant proportion of
subjects—a total of 135. Several of the subjects included in
the psychiatric group presented with new-onset psychosis at
an older age but did not have a neurological evaluation or
cognitive screening. For some of these subjects, follow-up
in the institution was lacking, raising the question as to
whether some may have had underlying neurodegenerative
disease.
Hearing impairment was common across groups, particularly in the relatively small proportion of NOC subjects.
The prevalence of documented hearing impairment was significantly higher in the NOC group than the other groups
and audiometry was not available for those who denied
hearing impairment or for whom it was unknown in this
group, which may suggest the prevalence was even higher.
As the history and exam had not identified co-morbidities
or toxicity in the NOC group, which might otherwise have
been associated with the hallucinations, the high incidence
of hearing impairment instead supports the established
theory that isolated peripheral auditory dysfunction alone
can lead to musical hallucinations (Gordon, 1997).
However, deafness with normal central functioning does
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Musical hallucinations and associated neurological conditions
Table 5 All structural lesions associated with musical
hallucinations
Structural
Location
n
Tumour
Left temporal
Left frontotemporal
Left temporoparietal
Right parietotemporal
Right pons, midbrain,
cerebellum
Total = 14
8
3
1
1
1
Total = 7
4
1
1
1
Total = 4
2
2
Total = 3
1
1
1
Total = 2
1
1
Total = 4
1
Post-surgical lesion
Right temporal
Right frontotemporal
left temporoparietal
Left temporal
Mesial temporal sclerosis
Right
Left
Undifferentiated lesion
Left frontotemporal
Right temporal
Left temporal
Infarct
Left temporal
Right parietal
Encephalomalacia
Arteriovenous malformation
Arachnoid cyst
Subdural fluid
Bilateral parietal, right
temporal, occipital, and
cerebellum
Right frontotemporal
Left frontotemporal
Left temporal
Right temporal
Right temporal
Right hemisphere
1
1
1
1
1
1
not account for the fact that most people with hearing
impairment never develop musical hallucinations and thus
an element of abnormal central processing must be implicated even in this group (Stewart et al., 2006). Hearing
impairment was also relatively common in the neurologic
and drug group (32.7 and 24.4%, respectively), which
likely signifies that peripheral pathology can predispose a
brain already made vulnerable from central dysfunction to
musical hallucinations. Additionally, in the series, 11 of our
subjects with musical hallucinations had normal audiometry, but had other associated psychiatric or neurological
diagnoses, directly contesting the idea that hearing impairment is a requisite to the development of musical hallucinations (Gordon, 1997).
The exact mechanism behind which hearing impairment
can predispose an individual to musical hallucinations is
unclear but has been hypothesized to be related to disinhibition of the areas involved in musical imagery through
the reduction of external auditory input. Neural activation
during musical imagery is remarkably similar to that in the
actual perception of music (Zatorre et al., 1996; Halpern
and Zatorre, 1999; Kumar et al., 2014). However, while
activity in the auditory association cortex is seen in both
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musical imagery and perception, the primary auditory
cortex is not necessarily activated in musical imagery
(Cope and Baguley, 2009). In a model proposed by
Griffiths (2000), hearing impairment decreases auditory
input to the primary auditory cortex, releasing basal inhibition on the auditory association cortex allowing for spontaneous activity and potentially augmenting connections
with areas that encode and recognize patterned sounds
such as music. It is suggested that the threshold for spontaneous activity varies between people and may be lowered
by disease or toxicity affecting the auditory pathway
(Griffiths, 2000; Kumar et al., 2014). This study characterizes a variety of conditions associated with musical hallucinations that may act to lower the threshold for
spontaneous activity of the auditory pathway.
Notably, the structural lesions we found associated with
musical hallucinations involved both hemispheres with an
insignificant preference to the left as opposed to previous
studies, which have shown a marginal preference toward
the right (Berrios, 1990; Keshavan et al., 1992). All lesions
involved the temporal lobe with the exception of one subject who had a brainstem tumour with a separate lesion in
the cerebellum and another in whom musical hallucinations
developed after a right parietal stroke. This case series provides novel support for bilateral brain representation in the
localization of musical hallucinations. Our series was able
to capture all those who had addressed musical hallucinations with a care provider, even if not their major complaint, and thus provided greater sensitivity for assessing
the hemispheric predominance in focal brain lesions associated with musical hallucinations. One subject had a history of central pontine myelinolysis and developed alcohol
withdrawal-induced musical hallucinations, and perhaps
pre-existing pontine pathology predisposed him to this particular drug effect. These findings match previous studies,
which have found lesions located along the auditory pathway and particularly the pons and temporal lobes resulting
in musical hallucinations (Douen and Bourque, 1997;
Roberts et al., 2001; Isolan et al., 2010; Calabro et al.,
2012; Ozsarac et al., 2012; Serby et al., 2013; Woo
et al., 2014).
It may be that deposition from neurodegenerative pathology can also act to disturb connections within the auditory pathway and lower the threshold for spontaneous
activity of the auditory association cortex. In one case of
musical hallucinations in a subject with Alzheimer’s disease,
regional cerebral blood flow was increased in the left temporal region and left angular gyrus (Mori et al., 2006). In
this series, Lewy body disorders accounted for the majority
of neurodegenerative disorders, and dementia with Lewy
bodies predominated amongst these. The prevalence of
visual hallucinations in this series in Alzheimer’s dementia
(38.9%) is higher than that reported by McKeith et al.
(1992) and possibly some subjects with Alzheimer’s dementia had co-existing dementia with Lewy bodies.
Additionally, in the subjects who had an undifferentiated
dementia, the high prevalence of visual hallucinations
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E. C. Golden and K. A. Josephs
Figure 2 Imaging in subjects with musical hallucinations related to structural lesions. (A) Coronal T2 FLAIR head MRI scan of a 33year-old female with focal epilepsy involving a musical aura with a right superior temporal pilocytic astrocytoma. (B) Coronal T1 gadoliniumenhanced head MRI scan of an 87-year-old female with left temporal lobe radiation necrosis. (C) Axial T2 head MRI scan of a 69-year-old male with
high grade astrocytoma in the pons with extension into the midbrain. (D) Axial T1 gadolinium-enhanced head MRI scan of a 77-year-old female
with a right temporal arteriovenous malformation. (E) Axial T2 FLAIR head MRI scan of a 74-year-old male with a recent left insular infarction. (F)
Coronal T2 FLAIR head MRI of a 47-year-old female after resection of right mesiotemporal meningioma.
Table 6 All drugs associated with musical hallucinations, either in toxicity or withdrawal
Drug
n
Alcohol withdrawal
Steroids
Stimulants
Opiates
Antidepressants
Alcohol
Opiate withdrawal
Benzodiazepine withdrawal
Lisinopril
Pramipexole
Ramelteon
Carbidopa/levodopa
Clarithromycin
Polysubstance abuse
10
9
5
4
4
2
2
2
2
1
1
1
1
1
(31.8%) suggests that many may have underlying Lewy
body disease. Lewy body deposition in the temporal lobe,
particularly in the amygdala and parahippocampus,
strongly correlates with the development of visual hallucinations (Harding et al., 2002); however, the pathological
correlation of auditory hallucinations in Lewy body disease
has not been demonstrated. The neurochemistry of psychosis in dementia likely involves dysregulation of multiple
neurotransmitters (Lanari et al., 2006; Zahodne and
Fernandez, 2008); however, a cholinergic deficit in the temporal neocortex has been shown to be associated with hallucinations in both Lewy body and Alzheimer’s disease
(Perry et al., 1999; Ballard et al., 2005; Zahodne and
Fernandez, 2008; Pinto et al., 2011). Indeed, preferential
damage to the nucleus basalis of Meynert, from which a
significant proportion of the cholinergic neurons originate,
is greater in the Lewy body disorders compared to
Alzheimer’s disease where dysfunction appears to be related
to cholinergic axonal input to the neocortex, and the
cumulative cholinergic deficit is greater in Lewy body disease (Perry et al., 1993). Further supporting a role for
acetylcholine in the development of psychosis, acetylcholinesterase inhibitors are effective in both Lewy body and
Alzheimer’s psychosis (Cummings, 2005; Zahodne, 2008).
Musical hallucinations have been effectively treated using
donepezil in at least one subject in the literature (Ukai
et al., 2007) suggesting a contribution of the cholinergic
deficit to the development of musical hallucinations similar
to other hallucinations. We would propose that our finding
that Lewy body disorders may be more associated with
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Musical hallucinations and associated neurological conditions
musical hallucinations than other neurodegenerative disorders is due to a greater cholinergic deficit and possibly
due to early brainstem involvement, affecting the proximal
auditory pathways.
Subjects who had musical hallucinations in association
with a neurodegenerative disease or with isolated hearing
impairment tended to hear music, which was more persistent
over a longer time period. Several of these individuals experienced an interesting phenomenon where the music disintegrated over time into increasingly shorter melodies and tunes
and sometimes terminating in repetitive single notes well
described by one subject who reported that she ‘noted a
change in the phenomena. . .such as hearing a certain
phrase or line of a song being repeated “back and forth”
rather than hearing a full song in its entirety’. This was
described in the original series by Berrios (1990) and has
later been referred to by Sacks (2007). Sacks made the comparison to telescoping, an analogous phenomenon in phantom limb sensation (another proposed release phenomenon)
where sensation of the distal part of the phantom retracts
over time (Nikolajsen and Jensen, 2001).
Interestingly, qualitative differences emerged between
songs heard by subject groups. For those in the neurodegenerative and NOC groups, which also had the highest
rates of hearing impairment, songs tended to date back to
childhood and also represented likely overlearned material
given that they were commonly religious, patriotic, or cultural songs. Those who experienced musical hallucinations
secondary to structural lesions, often in the context of a
musical aura, heard more modern music, such as country
or rock, likely not learned in childhood, whereas in psychiatric causes, songs tended to be mood-congruent, either sad
or ‘scary’ music, and sometimes represented a reminder of
a close acquaintance or family member who had died
(Table 2). This difference may in part be related to musical
preferences with age, with older individuals favouring religious or traditional songs. However, the traditional songs
heard by the neurodegenerative and NOC groups are distinguished by their relatively high frequency throughout a
lifetime and relationship to emotionally-charged situations.
Thus, they may be more vulnerable to manifesting as
hallucinations in the presence of hearing impairment or
neurodegenerative disease.
There were a number of limitations associated with this
retrospective study. As previously noted by Keshavan and
colleagues (1992), dividing subjects creates boundaries for
a phenomenon that is likely multifactorial. However, we
believe that the groupings are generally instructive when
viewed with an understanding that multiple variables
likely play a role in the development of musical hallucinations. Subjects were divided into categories according to
conditions associated with musical hallucinations; however,
psychiatric disorders were a common comorbidity in all
categories as detailed. There was an ascertainment bias present in the study given that data collected were based on
chart review. Subjects were restricted to those who had
addressed their musical hallucinations with a medical care
BRAIN 2015: 138; 3793–3802
| 3801
provider, sometimes unsolicited and sometimes as part of
screening in neurologic or psychiatric review of symptoms,
which may have slightly shifted the population. Certainly,
there were patients seen at Mayo Clinic during the study
time period outside of neurology and psychiatry practices
who were not screened for hallucinations. Detail concerning hallucination characteristics and temporal profile was
often lacking. Hearing impairment was not always screened
for or documented so its prevalence in this population was
certainly falsely low.
This study reviewed cases seen at Mayo Clinic across
specialties, including primary care, neurology, psychiatry,
otorhinolaryngology, and audiology, a design which
offered a favourably large case series from which we
were able to analyse the demographics of musical hallucinations and their association to comorbid conditions. In the
future, a cross-sectional population-based study would be
informative to eliminate the bias associated with a single
centre series. Additionally, a prospective study following
those who have musical hallucinations compared to
age-matched controls with a standardized assessment of
hearing and neurological exam including formal cognitive
testing, would be helpful to better understand the relationship between musical hallucinations and neurological
disease.
Conclusion
Musical hallucinations can occur in a wide variety of disease
states, of which neurological disorders and brain lesions represent a substantial proportion. Neurodegenerative diseases represent a large subset of neurological disease which can be
associated with musical hallucinations and of these, the Lewy
body disorders tend to be seen commonly. Hearing impairment
likely represents a variable predisposing to the phenomenon,
and those groups with the highest rates of hearing loss hear
songs (neurodegenerative and NOC) that tend to be derived
from childhood compared to other groups. A future prospective study would be helpful to further delineate an association
between musical hallucinations and neurological disease.
Funding
The study was funded by the Mayo Clinic Department of
Neurology.
Supplementary material
Supplementary material is available at Brain online.
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