Review
Musical obsessions: A comprehensive review of neglected clinical phenomena

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Highlights

  • This is the first comprehensive review of musical obsessions.

  • It was based on the largest sample of published and unpublished cases ever assembled.

  • Phenomenology, differential diagnosis, comorbidity, and treatments are reviewed.

  • Musical obsessions differ in several ways from other obsessions regarding phenomenology and treatment.

  • Etiological hypotheses and important directions for future research are presented.

Abstract

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N = 96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Introduction

Obsessions and compulsions are the cardinal features of obsessive-compulsive disorder (OCD). Obsessions are unwanted, intrusive, and distressing thoughts, images, or urges. Compulsions are repetitive behaviors or cognitive rituals that the person feels compelled to perform, often in response to obsessions (American Psychiatric Association [APA], 2013). Although intrusive mental imagery has long been recognized as a salient feature of OCD (de Silva, 1986), clinical descriptions and research have focused almost exclusively on visual imagery. Phenomena involving intrusive musical imagery (IMI), consisting of intrusive recollections of fragments of music (i.e., music running through one's mind), have been neglected by contemporary OCD researchers. This is surprising because descriptions of IMI appeared in the psychological and psychiatric literature for over a century (e.g., Ebbinghaus, 1885, Janet, 1903, Kraepelin, 1915), and IMI continues to be studied by contemporary musicologists and neurologists (Liikkanen, 2012b, Sacks, 2007). IMI is almost universally experienced (Liikkanen, 2012b). Underscoring the importance of IMI, the neurologist Oliver Sacks (2007) observed that it is “the clearest sign of the overwhelming, and at times helpless, sensitivity of our brains to music” (p. 49). Musical obsessions are distressing, persistent, and disruptive forms of IMI.

OCD is etiologically heterogeneous, shaped by etiologic factors (genetic and environmental) that are specific to a given class of symptom (e.g., etiologic factors specific to washing compulsions) and by broader etiologic factors influencing many different types of obsessive-compulsive (OC) symptoms and other forms of psychopathology (Miguel et al., 2005, Taylor, 2011). Given the heterogeneity and complexity of OCD, it is insufficient to study only the most common types of symptoms, such as washing or checking compulsions. A comprehensive understanding requires that even the less common symptoms be investigated in order to gain a better understanding of OCD.

Although there have been few studies of musical obsessions compared to studies of other OC phenomena, this is not necessarily an indication of the clinical insignificance of musical obsessions. Historically, clinical investigators have tended to underestimate the prevalence and importance of OC-related phenomena. OCD was once considered rare. It was not until the epidemiologic surveys were conducted that OCD came to be recognized as a “hidden epidemic” (Jenike, 1989). Similarly, the prevalence and significance of excessive hoarding—an OC-related phenomenon—was not fully appreciated until recently (Mueller, Mitchell, Crosby, Glaesmer, & de Zwaan, 2009). Even as late as 1987, descriptive case studies of hoarding were sufficiently rare as to merit publication (Greenberg, 1987).

To our knowledge, the present paper is the first comprehensive review of musical obsessions, based on the largest ever assembled set of case descriptions (N = 96, consisting of 33 previously published cases and our 63 new cases). In this paper we will review the characteristics of IMI in general, and then consider musical obsessions in particular, including an examination of clinical features, differential diagnosis, comparisons with visual obsessional imagery, etiologic considerations, assessment, and treatment. We also highlight important gaps in the empirical literature and suggest avenues for further investigation. The present paper aims to provide the groundwork for subsequent research, by synthesizing and describing what is currently known, based on published and unpublished research.

Section snippets

Intrusive musical imagery

IMI is characterized by a tune that repeatedly comes to mind without the person consciously trying to recall it (Williamson et al., 2011). Also known as earworms, ohrwurms, or involuntary musical imagery, IMI is a form of intrusive, auditory imagery occurring in the absence of neurological pathology or ear disease. In a survey of over 5000 participants, Stafford (2012) found that IMI usually—but not invariably—consists of simple repetitive song fragments, such as a particular verse or “hook”

Diagnostic criteria

Musical obsessions are not mentioned in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013). Musical obsessions are described in the clinical literature as episodes of IMI that meet criteria for OC symptoms; that is, the obsessional imagery is recurrent, persistent, intrusive, unintentional, time consuming (i.e., more than an hour per day), and causes distress or functional impairment. Note that this definition refers to persistent,

Characterized by intrusive visual imagery

To further clarify the nature of musical obsessions, it is useful to consider how they are similar to, and different from, other types of obsessional imagery. Most obsessional imagery is visual (de Silva, 1986, Speckens et al., 2007). Obsessions characterized by spoken words, olfactory, gustatory, or tactile imagery are rare (Chauhan et al., 2010, de Silva, 1986, Speckens et al., 2007). Unwanted visual images are typically inherently aversive or violate the person's values or beliefs. Common

Contemporary cognitive-behavioral models of OC symptoms

Although there is no definitive etiological model of obsessions and compulsions, contemporary cognitive-behavioral models are among the leading approaches (Frost and Steketee, 2002, Salkovskis, 1996). These models, which share basic postulates, propose that OC symptoms arise from specific types of dysfunctional beliefs, where the content and strength of belief influences the development and severity of OC symptoms. Three inter-correlated types of beliefs have been theoretically and empirically

Treatment

The available database of cases provides leads as to how musical obsessions might be effectively treated, and provides a basis for developing treatment protocols that could be empirically evaluated in future research. Details of the treatments for the cases appear in Appendix. The following is a summary of the salient points arising from the cases and the relevant literature.

Conclusions

The present paper is, to our knowledge, the first comprehensive review of musical obsessions, based on the largest set of case studies ever assembled. We sought to integrate the findings with research on normal IMI and compare musical obsessions with other obsessive-compulsive phenomena. The following are our main conclusions:

  • (1)

    There are several reasons for regarding musical obsessions as true obsessions: (a) forms of IMI can be identified that meet all DSM-5 diagnostic criteria for obsessions;

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