Musical hallucinations in normal children and adult non-psychiatric population

Abstract

A descriptive account of musical hallucinations of a series of 19 people is presented. Five people reported the onset of hallucination before adulthood. In this paper we demonstrate that musical hallucinations are not necessarily pathological and can occur as a normal experience in people (children and adults) who have no contact with mental health services and no concurrent mental disorder. This is also the first paper to recognise that children can experience musical hallucinations. Also, we show that musical hallucinations are more common than previously thought, but people do not report their occurrence. It seems plausible that in musical hallucinations there is an insult to the ear or brain that produces a change in quality of these images, converting them to a psychotic experience. Musical hallucinations should be regarded as a continuum with normal experiences and clinical syndromes.

BACKGROUND

Musical hallucinations are experiences of hearing music with all the qualities of hearing real music but without any sound being made. Musical hallucinations are complex auditory hallucinations.¹ This article is a descriptive account of musical hallucinations of a series of 19 people; five people reported the onset of hallucination before adulthood. They contacted us following the publication of our paper in 2005² and gave permission for their accounts to be written up. As far as we know none of them had a diagnosis of psychiatric disorder or contact with mental health services. Also, we have little information about the demographics of these individuals apart from what they wrote to us about.

In this paper our aim is to demonstrate that musical hallucinations are not necessarily pathological and can occur as a normal experience in people (children and adults) who have no contact with mental health services and no concurrent mental disorder. This is also the first report to recognise that children can experience musical hallucinations.

CASE PRESENTATION

Children and young adults

We have no idea how common musical hallucination is in children or young people, and we would like to document some of our findings in this important group of people. Five young men presented with a history of musical hallucination since the age of 10 years, with an average age of first presentation of 10–18 years old.

In the first two cases, they heard songs and music mixed together and playing incessantly like an in-mind, never ending iPod.

In the third case the musical hallucinations consisted entirely of fully orchestrated classical music. These experiences usually, but not always, occurred when he was a passenger in a car, train or airplane. The experiences were quite pleasant and he enjoyed them greatly. He was exposed to classical piano music in his family for as long as he can remember. From when he was about 10 year old, he went with his family to symphony orchestra performances regularly. He had classes in school on classical music appreciation and composition. None of the music that he heard while hallucinating was familiar to him, although it very much resembled Beethoven, Brahms, Schubert or Schumann.

The fourth case experienced what might be called “auditory dreams”. While falling asleep, he would hear orchestral music which would stop as soon as he became consciously aware of it–that is, as soon as he woke up.

In the fifth case the musical hallucinations presented at time of emotional distress. He had a radio constantly playing in his head. He attributed the experience to the difficult emotional problems he was going through with his family. He felt that these personal issues were causing this musical anomaly along with some psychophysical troubles, chief among them depression and insomnia. He was stuck in a vicious cycle where each problem would contribute to the worsening of the others. In other words, he would be depressed so he could not sleep and the lack of sleep would cause (he believed) music to play in his head which would only cause him to stay awake longer; this, in turn, would deprive him of energy, taking his depression deeper and deeper. To describe his experience with musical hallucinations during that time, he would lay in the quiet of his bed trying to relax, trying to sleep, and he would hear sometimes just a rhythm, most times a string of popular familiar songs. Lying there and listening to this music, he would inevitably hear a song he enjoyed. He would get lost in the beat or the lyrics and would bop his head or maybe hum along–this could go on for hours. Then he would realise the trance he was in and look over at the radio and the realisation would hit him that it was off and it was all in his head. He found psychological support and worked his way to becoming a well adjusted and productive man. While he cannot say that he has been cured of the hallucinations, he does not experience them to the degree that he did 10 years ago.

Adults

14 cases of normal people with no previous psychiatric histories presented with the phenomenon–eight men and six women, with an average age of 40 years.

Case 1–A 58-year-old man who has had heard music in his head for as long as he can remember, and who described his experience as follows: “I have music playing all the time–literally all the time. At any point in the day I can ‘tune in’ to what’s playing and usually name the tune, although sometimes the songs I’m hearing are ones I’m sure I’ve never heard before. Some seem to be new compositions. I can play them and re-play them and vary them at will. Then days later I’ll hear these new compositions again, as though they had entered my musical repertoire. Often throughout the day, my wife will ask me ‘What’s playing?’ and I will give her the name of the tune. She notices me tapping my feet or hands regularly, and I explain that I’m keeping time with the music in my head. When I wake up in the night, I hear music playing, too. I was happy to read the article about your work because I’ve never known anyone else who hears music constantly like I do. Truthfully, I’ve lived with it for so long that it doesn’t bother me. I’m used to the music and sometimes enjoy just hearing it play. So for me it’s not so much an ailment or neurological condition as it is a gift–sometimes annoying, yes, but other times welcome.”

Case 2–“I had for a great part of my life (age 15–40) experienced what might be called ‘auditory dreams’ and which might be connected to the musical hallucinations which you have studied. While falling asleep, I would hear orchestral music which would stop as soon as I became consciously aware of it, that is, as soon as I woke up.”

Case 3–A man stated that he has had a soundtrack playing in his head for his whole life.

Case 4–A women started hearing music after wax was removed from her ears the previous year (2006). The music is very distinct, some of the music she hasn’t actually heard for awhile; however, it is all familiar to her. She has a notebook to write down the names of the music and about how long it “plays”, sometimes the same music “plays” for hours.

Case 5–Another woman started hearing musical hallucination following an episode of shingles and treatment with paracetamol and codeine. The songs in her head often mean nothing to her–they hold no special significance and she doesn’t like them. She has tried playing a CD of a tune she does like in a bid to replace something unpleasant with a more restful tune. Unfortunately if the new tune does stick, it is often sung in a distorted and distressing voice.

Case 6–A 31-year-old woman started hearing musical hallucination following a bad case of pneumonia. Her fever rose to 105°F and during this period of high fever, the hallucinations began and were continuous over a period of about 36 h. At first, they were exceedingly pleasurable. The music was orchestral, classical. The experience was like being in a concert hall. But as time went on (and she did not sleep while the hallucinations went on), they degenerated. At the end, she was being treated to reruns of the distinctly non-musical congregation at her childhood church singing hymns. She was completely lucid during this time; she knew she was hallucinating. Reality was merely accompanied by music. She was still hearing the music when she was in the office of the doctor who finally diagnosed double pneumonia. These were like actual experiences of hearing live or stereophonic music, quite distinct from recalling music in an ordinary way. Antibiotics chased out the hallucinations in a few hours, and she has never experienced them again. Somehow her fever was causing brain cells with stored memory to fire. These were not familiar memories they were something not ordinarily accessible to her. But it seemed likely to her that at some point she had actually heard all of the music, either in live performance or in high quality recordings, since it was so complete–every orchestral instrument in its place, for example, in a symphony–and so full, as if filling a room. She likes music and played instruments and sang while in school.

Case 7–For another woman the experience of musical hallucinations can be really awful, and is directly related to sleep loss. If she is heavily sleep deprived, the music comes at night as she tries to fall asleep, and it keeps her awake, making the problem worse. As she catches up on sleep, it disappears. Her experience of musical hallucinations has also been closely tied with a revulsion against real music. For a while she could not listen to music of any kind at any volume. The mental discomfort was so intense that it became physical. She would grit her teeth, all her muscles would tense up, and she could hardly breathe. The revulsion for real music and the musical hallucinations have gone hand in hand, and as the hallucinations have improved with more sleep, the problem with real music has also eased, though it has not disappeared.

Case 8–For another man the musical hallucinations begin to play whenever he is in an environment where all noise has been drowned out but some overriding sound. For example, he will hear music when he is sitting near the wing of a plane and the roar of the engines removes all other ambient sounds; also when he is standing under a showerhead whose water flow is large enough to run past both ears and the sound is a low roar causing a backdrop to induce musical hallucinations. Similar sensory (especially sound) deprivation situations (quiet dark rooms, sitting next to a strong fan, etc) will bring back the music in his head.

Case 9–A man who has been very aware of music running through his head for a very long time says it doesn’t bother him as long as there are other things on which to focus. It just plays in the background like the soundtrack playing in the background of an ongoing movie. Sometimes the music stops, and it makes him feel out of place and time, like something’s wrong. He also doesn’t like quiet. When it is too quiet, he has to talk or turn on the radio or something, otherwise the song playing in his head at the time will just keep repeating. The songs aren’t always complete. His brain picks out songs appropriate to the situation. Perhaps it is the lyrics, or maybe the beat, or perhaps even the tone, but the song always matches the circumstances. When a new song pops into his head, he analyses the song and his situation and search for the connection. He doesn’t know inherently what the connection is, but he always figures it out. Generally, the answer is somewhere in the lyrics.

Case 10–A man experienced musical hallucinations with almost any tune that he chooses (among those he knows). Without the white noise background, he can’t imagine the tune in his head, but this imagining is not accompanied by a bona fide perception of sound. With the white noise, his mind can somehow pick out of the white noise whatever tune he has decided to hear, and pretty much ignore the rest of the white noise, so that in this case he is really hearing that tune as sound. It sounds much like when someone “plays” a tune by not quite whistling, but just inhaling and exhaling to produce the right notes (unlike whistling, this has almost no timbre whatsoever). He has been a music lover all his life, and he has an unusually good memory for tunes.

Case 11–A woman who was living alone heard musical hallucination of Yiddish music that her mother always sang to her when she was a child. She would sing all the words to it. The interesting fact was that she was living in a Christian facility–she wondered why they played Yiddish music so frequently, but didn’t question the fact any further than that. She was not agitated by the music, just perplexed that no one else heard it.

Case 12–Another woman lady with musical hallucinations hears accurate representations of songs she has previously heard, although they are not necessarily songs she likes (much to her dismay, at times). She has experienced this for many years now, but doesn’t recall if this was present in her childhood. She has never considered this a hallucination because it’s not the same as hearing a song that’s actually playing. The best description she can give is that it’s as though she has a radio in her head. It doesn’t sound like it’s coming from the environment; it’s more like hearing in her mind a song she wants to recall, except that it’s “recalled” constantly and entirely without intent or effort. The songs she hears may be instrumentals, vocals and melody, or a Capella vocal, and may have many voices singing simultaneously. In general, she recalls songs accurately as they are recorded, instantaneously, and with ease. At times, this has been somewhat intrusive and many times while she was trying desperately to concentrate on her work, she found it very difficult to focus due to the song that kept going on and on, sort of in the background of her mind. It takes a very determined effort on her part to process the words in her work and “drown out” the song. She is coping by reading aloud, and focusing on each and every word one at a time and mentally stating that word, but the song does not go away, only recedes more or less. When she has a song going that she doesn’t like, she tries to change it by thinking of a song she does like, but this requires conscious effort to recall and focus on the replacement song’s words and melody and does not always work. The song that she is trying to replace will sort of muscle its way back into dominance. Another approach she has tried (when she is alone) is to sing or whistle the song aloud in an effort to sort of satisfy her mind’s desire to hear the song, but this doesn’t seem to work very well. Sometimes she can change the song by playing a recording of a song she likes, but this doesn’t work instantly; it requires an extended listening of the new songs to “purge” the other song from her mind. Sometimes she tries to mentally speed up the song to get through it faster, but it “insists” on going at the original tempo, and it requires effort to change to a different part of the song than the one that is supposed to follow in its natural form. She has a 20 year history of migraine, which has transformed into chronic daily headache, tension headache, and chronic migraine with aura. She has been on preventive medical therapy for around 12 years and has tried many different medications, none of which have affected this mental music.

Case 13–A man can play any songs he wishes from his memory, and rearrange them to his liking, using the instrumental and vocal sounds. However, he can turn this on and off, as he is completely conscious. For him, it is a source of enjoyment for a music lover.

Case 14–Another man described his experience as follows: “This sounds the same as listening to radio, TV, or a show. Both forms can be altered (to change tunes or stop altogether) with me as the Disk Jockey (DJ). I am often the DJ in the stream of music that I am experiencing. I decide to change the song and end the broken record by thinking of another song. At other times, analysis of why I am hearing a song can change my mood or let me continue to hear it because of what it means to me! I have been listening to music, and participating in music through my whole life. These types of music are not randomly memorised, but are part of my history. As a result, they often evoke a certain time or feeling from that time and are converted to output as the need arises”.

DISCUSSION

Many people have a tune running through their head, especially at times of quiet or during undemanding activity. Although these melodies can contain all the variations in tone and dynamics of a full symphony orchestra, or contain the unique characteristic of a particular singer’s performance, they are recognised as images and that the experience arises within the mind with a certain degree of mental control. With musical hallucinations the perception has all the same qualities as listening to a live singer, a concert, the radio or an iPod. Musical hallucinations are complex auditory hallucinations with the qualities of true hallucinations–that is, it arises in the absence of any external stimulus, perceived as being located in the external world, not subject to conscious manipulation and perceived as having the same qualities as normal perceptions. It is important to differentiate between a normal percept, imagery and hallucination. Sense perception is experienced as being real and therefore to be acted on; imagery is created voluntarily by oneself and is not real in the sense of external perception. In everyday life we tend to mix fantasy and fact.³ Saba and Keshavan⁴ postulated that the lack of volitional control over the experience of musical hallucinations implied that the phenomenon was more likely hallucinatory than the product of musical imagery. They found that religious content and unfamiliarity may help to indicate true hallucinations, while musical imagery appears to be more associated with non-religious music and familiar tunes. Another point in helping the differentiation between imagery and hallucination is that musical hallucinations can be very loud and interfere with perception or conversation in a manner that never occurs with normal musical imagery.⁵

Our sample population has presented the difference between musical memories, imagery and hallucination in a beautiful way. In some people musical memory occurs to make some sense of and provide comfort and distraction from extreme stress and/or loneliness. Musical memory and imagery can be part of a continuum with memory and thought. Together they act like a multitude of radio stations continuously being tuned in and out. If the music continues after the first set it is usually due to a similar tune or pitch or wording in the next memory file. This appears to be related to several possible reasons: it is the last song in the file, it is a favourite tune, it is a default tune (one which you come back to if you can’t think of another tune), you are trying to memorise the tune, or you have errors in how you are remembering the words or tune and need to perfect it until it is as correct as you can make it (often you end up with it being almost correct by substituting some similar words or ideas). At other times, previous experience and musical backgrounds play an important part in its production and it can form the past and present basis for the input for musical memory. These types of music can be randomly memorised, or can be a part of the individual history and, as a result, they often evoke a certain time or feeling from that time and are converted to output as the need arises. Johns et al⁶ interviewed 5196 ethnic minority and 2867 white respondents to examine the prevalence of hallucinations using the Psychosis Screening Questionnaire in the community sample. Four per cent of the white sample endorsed a hallucination question. Hallucinations were 2.5-fold higher in the Caribbean sample and half as common in the South Asian sample. Of those who reported hallucinatory experiences, only 25% met the criteria for psychosis. Evidence indicates that psychotic hallucinations lie on a continuum with normal experiences, and many more people experience hallucinations than meet criteria for clinical psychosis.⁷

Historically there have been reports of hallucinations of music as religious experiences attributed to the singing of angels. Hallucinations of music have been also reported as part of a bereavement reaction in the same way that other hallucinations of the recently deceased can occur, and in states of physical exhaustion.⁸ Musical hallucinations have been associated with hearing loss, advanced age, female sex, lack of response to treatment and general lack of associated psychopathology.⁹ Musical hallucinations have been also associated with epilepsy, vascular, cerebral tumours, dementia, alcohol withdrawal states, depression¹⁰ and psychoses.¹¹ In our sample population musical hallucination has also been associated with ear wax, shingles, pneumonia, sleep and sensory deprivation and emotional distress. Some people tried different things to cope with the experience such as reading aloud, and focusing on each and every word one at a time and mentally stating that word; thinking of another song or melody using conscious efforts; to sing or whistle the song aloud; playing a recording/CD of a song they like; trying to mentally speed up the songs to get through it faster; and even trying medications. In most people none of these have affected the mental music experience much.

CONCLUSION

This paper is limited in its scope because of sample bias. Self referral cases following media publicity present an exceptional group of subjects. However, this is the first time that a paper has been written which records that musical hallucinations occur in the general healthy population, and that they can occur in children and adolescents. While some people present to psychiatrists with musical hallucinations, there are others who accept their symptoms and do not present to doctors with a problem. For some it is distressing but for others it is an enjoyable experience and hence do not report it. The type of music heard is very varied. Sometimes musical hallucinations presented secondary to medical problems but also it occurred with no precipitating factors. We believe that the neural network involved in music listening interacts with perception and memory to produce musical experiences, whether imagery, memory or hallucination. This is coloured by the characteristic of the individual personality and background in a dynamic way. It seems plausible that in musical hallucinations there is an insult to the ear or brain that produces a change in quality of these images converting them to a psychotic experience. Musical hallucinations should be regarded as a continuum with normal experiences and clinical syndromes. We hope that future research will involve normal people as well as musical disordered individuals.

LEARNING POINTS

• This paper is limited in its scope because of sample bias. Self referral cases following media publicity present an exceptional group of subjects. However this is the first time that a paper has been written which records that musical hallucinations occur in the general healthy population, and that they can occur in children and adolescents.

• While some people present to psychiatrists with musical hallucinations, there are others who accept their symptoms and do not present to doctors with a problem. For some it is distressing but for others it is an enjoyable experience and hence don’t report it.

• The type of music heard is very varied. Sometimes musical hallucinations presented secondary to medical problems but also it occurred with no precipitating factors.

• We believe that the neural network involved in music listening interacts with perception and memory to produce musical experiences whether imagery, memory or hallucination. This is coloured by the characteristic of the individual personality and background in a dynamic way. It seems plausible that in musical hallucinations there is an insult to the ear or brain that produces a change in quality of these images converting them to a psychotic experience.

• Musical hallucinations should be regarded as a continuum with normal experiences and clinical syndromes. We hope that future research will involve normal people as well as musical disordered individuals.