Case of musical hallucinosis

The theme of the article is a 68-year old patient whose case was diagnosed as organic brain disease complicated by musical hallucinosis. The patient was admitted to a mental hospital, several times, as suffering from psychic disturbances of the auditory hallucinosis type whose dominant symptom are musical hallucinations. The most significant in the disease pathogenesis of the described case turned out to be the recognition of severe brain injury.     

Musical hallucinations: report of two unusual cases.

Two elderly patients with musical hallucinations are described. In the first case, the musical hallucinations were precipitated by the administration of benzodiazepines. The symptoms in the second case resembled those described in cases of visual hallucinosis (Charles Bonnet syndrome) in the elderly. Issues related to the presentation and course of musical hallucinations are discussed.     

Isolated hallucinosis in Alzheimer's disease is associated with African-American race

OBJECTIVES: The aim of this investigation was to study the relationship between isolated hallucinosis and race in Alzheimer's disease. METHODS: This was a cross-sectional, case control study carried out at the Neuropsychiatry Service, outpatient clinic at the Johns Hopkins School of Medicine, USA. The participants were 237 community-residing patients with probable Alzheimer's disease according to NINCDS/ADRDA criteria were included in the study. 9 patients with isolated hallucinosis were compared to a control group of 228 patients who had neither delusions nor hallucinations. Patients with only delusions or both delusions and hallucinations were excluded based on prior research. Patients were assessed clinically for the presence of hallucinations using the DSM-IV glossary definitions. They were also rated on standardized measures of cognitive impairment, depression, functional impairment, and general health. RESULTS: There was a significant association between hallucinations and race in patients with Alzheimer's disease. Before adjustment for other variables, the African-American race conferred a 5.5-fold (95% CI = 1.4-21.6; p = 0.02) increased risk for isolated hallucinosis. After adjustment for multiple other variables, this risk increased further to 27.2-fold (95% CI = 1.6-457.3; p = 0.02). CONCLUSIONS: African-American patients with Alzheimer's disease are more likely to have isolated hallucinations than Caucasian patients even after statistical adjustment for multiple confounding variables, which might distort this association. This finding has implications for our understanding of the etio-pathogenesis of hallucinations in Alzheimer's disease and for meeting health service needs of African-American patients.     

Musical hallucinations, depression and old age

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.     

Auditory hallucinosis in brainstem lesions and musical hallucination in deafness. Analogies and differences

Auditory hallucinations are found at the cross-roads of otological, neurological and psychiatric practice. They are generally considered to be the manifestation of psychosis, delirium tremens and chronic alcoholism, toxic states, hemispheric (predominantly temporal lobe) involvement, brainstem disorders or acquired peripheral (acoustic nerve, cochlea or middle-ear) deafness. Auditory hallucinosis in one case of brainstem lesion and musical hallucinations in two cases associated with acquired peripheral deafness are presented. Analogies and differences, pathophysiology and review of the literature are discussed.     

Auditory hallucinations in lesions of the brain stem

Since the publication by Jean Lhermitte in 1922 of his paper on hallucinosis, the peduncular type has been described as a purely visual phenomenon. However, limited brain stem lesions can give rise to analogous manifestations in the auditory field. Five cases of auditory hallucinosis are reviewed, the first four resulting from a lesion of tegmentum of pons responsible for contralateral hemi-anesthesia and homolateral facial palsy with paralysis of laterality. Central type hypoacusis and a severe disorder of localization of sounds revealed a lesion of trapezoid body. The fifth case resulted from a peduncular lesion in region supplied by superior cerebellar artery, the auditory deficit being related to a lesion of inferior corpus quadrigeminum. In one patient, the auditory hallucinosis was followed by a period of visual hallucinations and oneiric delusions. Both auditory and visual hallucinosis can be related to hypnagogic hallucinations. Dream mechanisms (the geniculo-occipital spikes system) escape from normal inhibitory control exerted by the raphe nuclei. Auditory deafferentation could predispose to auditory hallucinosis.     

Desynchronization in the right auditory cortex during musical hallucinations: A MEG study

Desynchronization in the right auditory cortices, including the transverse gyrus of Heschl, planum temporale and supramarginal cortex, occurred during musical hallucinations in a 78‐year‐old woman with hearing impairment and depression. This phenomenon was assessed using a novel, spatially filtered magnetoencephalography (MEG) analysis, termed synthetic aperture magnetometry (SAM). In general, the affected areas are consistent with neuroimaging studies of normal musical perception and imagery, suggesting that musical hallucinations involve abnormal spontaneous activity in the neural substrate dedicated to musical perception and imagery in which false imagery occurs.     

Persistent hallucinosis in borderline personality disorder

A case series of 10 patients with a diagnosis of borderline personality disorder (BPD) presenting with auditory hallucinosis is examined. In this series, the hallucinations were persistent, longstanding, and a significant source of distress and disability. Extrapolating from this series to our sample of 171 patients with BPD suggests that a form of auditory hallucinosis may occur in almost 30% of this population. The failure to emphasize this phenomenon in current systems of classification risks misdiagnosis or inappropriate treatment. Use of terms such as pseudohallucination or quasi hallucination dismisses the phenomenon as unimportant or as "not real." There is an emerging literature on the frequency of hallucinosis among nonpatients. A basis for understanding different forms of hallucination is discussed with reference to the concept of "normativity." We propose a nomenclature for hallucinosis that is expressed in positive terms, reflecting the clinical significance of the phenomenon in different contexts: (1) normative hallucinosis, (2) traumatic-intrusive hallucinosis (as in our series), (3) psychotic hallucinosis, and (4) organic hallucinosis.     

Musical hallucinations induced by bromocriptine

A case of bromocriptine‐induced musical hallucinations in a 67‐year‐old patient with probable Lewy body dementia is reported. The patient was given bromocriptine for the treatment of parkinsonism. At a bromocriptine dosage of 7.5 mg, the patient complained, ‘I hear karaoke songs in the inner part of my head.’ The musical hallucinations gradually decreased after administration of the drug was discontinued. Bromocriptine is known to cause hallucinations, but not musical hallucinations. The dopaminergic effect of bromocriptine and the patient's cognitive impairment might have acted together to generate the musical hallucinations.     

Musical hallucinosis following infarction of the right middle cerebral artery

A 44-year-old woman demonstrated a musical hallucinosis four months after a massive infarction in the territory of the right middle cerebral artery. This musical hallucinosis consisting of familiar tunes, was continuous and perceived by both ears. Magnetic Resonance Imaging, middle and late auditory evoked potentials suggested that right Heschl's gyrus and associative areas were imparied. Audiometry demonstrated a low right transmission deafness. The hallucinosis was persistent for seven months and stopped just after hemorrhage of the right ear. This case gives the opportunity to review the different mechanisms responsible for musical hallucinosis.     

Successful treatment of hallucinations associated with sensory impairment using gabapentin

Sensory impairment hallucinations, such as visual hallucinations with visual loss, may not respond to traditional treatments such as antipsychotics. In this case series, the authors describe four patients with either visual or musical hallucinations associated with sensory impairment who were successfully treated with gabapentin.     

The clinical spectrum of musical hallucinations

Musical hallucinations are a well known although rare phenomenon in neurological and psychiatric patients. Many case reports have been published to date. However, an accepted common theory on the classification and on the pathophysiology of musical hallucinations is still missing. We analysed all cases published to date, including two own cases, with respect to their demographic and clinical features and to the possible pathomechanisms underlying the hallucinations. In total, 132 cases could be analysed statistically and separated into five groups according to their aetiology (hypacusis; psychiatric disorder; focal brain lesion; epilepsy; intoxication). There was a female preponderance of 70% and a mean age of 61.5 years. Patients with focal brain lesions were significantly younger than the other groups, the hemisphere of the lesion did not play a major role. No systematic studies on treatment are available. However, anticonvulsant and antidepressive substances were reported to be effective most consistently. The pathophysiology of musical hallucinations is discussed considering the theories of deafferentiation including the concept of auditory Charles-Bonnet syndrome, of sensory auditory deprivation, of parasitic memory, and of spontaneous activity in a cognitive network module. In conclusion, musical hallucinations are a phenomenon with heterogeneous clinical and pathophysiological backgrounds.     

Peduncular hallucinosis associated with isolated infarction of the substantia nigra pars reticulata

We report the clinicopathological study of an 83-year-old man who abruptly developed complex visual hallucinations, disordered sleep, and mild cognitive impairment that persisted until his death 6 months later. Postmortem neuropathological examination including serial sections through the diencephalon, midbrain, and pons disclosed isolated bilateral infarcts confined to the medial substantia nigra pars reticulata. The findings suggest that destruction of the pars reticulata may be the essential feature to the development of peduncular hallucinosis.     

When a Parkinson's disease patient starts to hallucinate

Visual hallucinations are a typical feature of Lewy body parkinsonism and occur in some 40% of patients with Parkinson's disease. Age and cognitive decline are the most important intrinsic risk factors, but hallucinosis is often triggered by comorbid conditions such as infection and dehydration. The single most important trigger, however, is exposure to CNS drugs, in particular antiparkinsonian agents. While hallucinosis and psychosis can be triggered by amantadine and anticholinergics, they are more commonly experienced after changes in dopaminergic medication. Dopamine agonists have greater potential to induce hallucinosis compared with L-dopa. Attempting to reduce antiparkinsonian drugs is an important part in the management of these patients, but atypical neuroleptics like clozapine or quetiapine are frequently necessary. Visual hallucinations in Parkinson's disease patients with dementia can also be improved by treatment with the cholinesterase inhibitor rivastigmine.     

Musical hallucinations associated with abruptly developed bilateral loss of hearing

OBJECTIVE: To present a depressive patient who developed abrupt hearing loss with musical hallucinations. METHOD: This study is a case report. The patient was evaluated by cranial CT, EEG. audiometry, brain SPECT. MMPI and the Hamilton Depression Scale. RESULTS: A patient with depression developed abrupt hearing loss with musical hallucinations following an intramuscular injection of gentamycin. Audiometry showed mild sensorineural hearing loss in both ears. The Hamilton Depression Scale disclosed moderate depression. Her symptoms disappeared with the initiation of antidepressive medication. CONCLUSION: Musical hallucinations are the hearing of tunes, melodies, harmonics, rhythms and timbres. They have been reported to be in association with healing loss in several published cases. The uniqueness of our patient was that she was younger than previously reported cases of musical hallucinations, who were elderly people, and her symptoms of depression disappeared gradually after the initiation of moclobemide.     

PET and SPECT findings in alcohol hallucinosis: case report and super-brief review of the pathophysiology of this syndrome.

Alcohol hallucinosis is a rare complication of chronic alcoholism with schizophreniform symptomatology. The pathophysiology is basically unclear. We report the case of a 48-year-old, never-medicated, long-term alcoholic suffering from alcohol hallucinosis with pure acoustic hallucinations for at least six months. Current FDG PET data suggest a hypofrontality and possibly a thalamic hypofunction in alcohol hallucinosis, findings similar to those reported in unmedicated schizophrenics. Current IBZM SPECT data do not support a dopamine receptor dysfunction in alcohol hallucinosis but TRODAT SPECT showed reduced dopamine transporter binding. Possible implications of these findings are discussed.     

Pathogenesis and symptomatology of hallucinations (delusions) of organic brain disorder and schizophrenia

In this review article, in order to explore the mechanisms underlying the hallucinations/delusions of schizophrenia, we discuss the contribution of the following four questions: (i) can an understanding of dreams contribute to our understanding of the genesis of halluciations and/or delusions; (ii) are the mechanisms underlying psychotropic drug‐induced psychoses the same as those underlying the hallucinations and/or delusions in schizophrenia; (iii) does disturbed consciousness contribute to the manifestation of psychotic features; and (iv) are the psychoses caused by organic brain disorders any different to the hallucinations and/or delusions seen in schizophrenia? We conclude that there is a strong association between drug‐induced hallucinations or hallucinations associated with organic brain disorders and simple hallucinosis or fluctuations in arousal level. Because intermediate configurations and/or cross‐staining phenomena exist for hallucinations and delusions, especially in schizophrenic disorders, it is difficult to isolate the hallucinations and to recognize them as being abnormal experiences.     

Peduncular hallucinosis after debulking of a third ventricular pilocytic astrocytoma: Case report and review of the literature

Peduncular hallucinosis is a rare clinical syndrome manifesting as complex visual hallucinations and sleep-wake dysregulation after injury to deep neural structures, most commonly the midbrain and diencephalon. Initially reported after ischaemic and haemorrhagic stroke, an increasing range of pathologies and procedures have been described as causative of peduncular hallucinosis. We present a novel case of peduncular hallucinosis following debulking of a third ventricular pilocytic astrocytoma as well as a review of the existing literature.