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Case Report | WVMJ OA

Musical Hallucinations Treated with Atypical Antipsychotics in

a Geriatric Population – A Case Series
Adam Schindzielorz, MD The presented cases add of typical inhibitory pathways
D. Scott Murphy, MD to the paucity of literature in auditory association cortices
regarding utilization of atypical leading to erroneous feedback
Suzanne Holroyd, MD
All of Marshall University Joan C. Edwards School antipsychotics for treatment that is ultimately perceived as
of Medicine, Marshall Psychiatry. of musical hallucinations and external sound.8 This hypothesis
demonstrate efficacy to this effect. however, does not address the
Corresponding Author: Adam Schindzielorz, MD. This study lends further validity to emergence of these symptoms in
Marshall Psychiatry, 1115 20th Street, Suite 205, 20th
Street Professional Building, Huntington, WV 25703. the use of psychopharmacologic individuals with intact hearing or in
Email: agents for novel purposes that those with underlying medical or
have yet to be fully explored. psychiatric comorbidity. Ergo, it is
Abstract likely that the presenting features
Musical hallucinations have been Introduction represent a common outcome of
likened to the auditory equivalent Musical hallucinations have been a more heterogeneous group of
of Charles Bonnet Syndrome, likened to the auditory equivalent pathophysiologic mechanisms.
which involves complex visual of Charles Bonnet Syndrome, In regards to treatment, there is a
hallucinations, most often in the which involves complex visual wide array of modalities that exist.
context of visual impairment. Musical hallucinations, most often in the Acetylcholinesterase inhibitors such
hallucination frequently take the context of severe visual impairment.1 as donepezil and antidepressants
form of hymns, carols, and show- Musical hallucinations involve the appear to be the most efficacious
tunes and are strongly associated development of musical auditory pharmacologic agents in the current
with hearing loss, with some phenomena, often repetitive and literature, with some more mild
studies suggesting a prevalence of with a strong nostalgic quality, in the cases even appearing to be able
2.5–3.6% in the hearing impaired. absence of an external source.2,3 to be treated through reassurance
Musical hallucinations are typically Like Charles Bonnet Syndrome, the and lifestyle modification alone.9,10,11
treated with anticonvulsant and phenomena are strongly associated However, one more recent study by
anticholinesterase medications, with primary sensory loss, in this Coehberg et al attempted to explore
with some studies having evaluated case hearing, carrying a prevalence whether or not certain medications
the efficacy of sedative hypnotics, of 2.5-3.6% in the hearing impaired may be more efficacious when used
antipsychotics and antidepressants with higher prevalence in geriatric in differing clinical sub-populations
in various psychiatric and medical versus general populations.3,4 based on their primary presenting
subpopulations suggesting a Severity may differ from mild disease, be it medical or psychiatric.
heterogeneous spectrum of and well-tolerable to severely Their findings showed that while
causes for this disorder. disabling, leading to impaired the two previously mentioned
We present two cases of musical quality of life, significant distress classes of medications do have
hallucinations in both a 70-year- and comorbid psychiatric illness. higher efficacy than most, other
old African American female with Despite the common connection classes such as antipsychotics
past psychiatric history of major with auditory impairment, musical may be more beneficial in patients
depressive disorder who developed hallucinations are also seen in other exhibiting acute psychotic
hymnal auditory hallucinations settings including epilepsy, focal symptoms.12 Our study builds on
during an acute medical and brain lesions, intoxication and acute the current literature by presenting
psychiatric admission and an medical or psychiatric illness.5,6,7 two complex patients who were
86-year-old Caucasian female, Though they also occur in states successfully treated with aripiprazole
who complained of hearing of acute metabolic derangement and quetiapine for this reason.
gospel music with eventual onset and delirium, they more often are
of visual hallucinations after a seen in patients with intact reality Case I
fall at age 80. Our patients were testing and cognitive function.3 The Our first case involved a
successfully treated in both the current prevailing theory regarding 69-year-old African-American
inpatient and outpatient settings their etiology relates to hearing female with past medical and
with atypical antipsychotics. impairment causing a release psychiatric histories significant for

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Case Report | WVMJ OA

chronic kidney disease requiring ideation with plans to refuse family physician with sertraline and
hemodialysis three times per hemodialysis or nutrition. Refusal alprazolam, but did not have a prior
week, type II diabetes mellitus, of oral intake soon followed. history of psychosis or dementia
hypertension, mild left-sided However, with regular visits and and during her course was never
hearing impairment and major encouragement from the patient’s under suspicion for suffering from
depressive disorder, severe, daughter she began to accept delirium. It must also be noted
recurrent with melancholic features. food and medications with more that she did carry a history of mild
Though psychotic symptoms had regularity. Paranoia and auditory bilateral hearing impairment that was
been noted over the course of disturbance however remained at never reported to be of significant
her psychiatric history, they had roughly the same intensity with her clinical consequence. This patient
been limited to paranoid ideation musical hallucinations staying at was noted to have developed
regarding hemodialysis staff a constant volume and frequency. musical hallucinations after suffering
wanting to harm the patient with Venlafaxine was increased from a fall, with report indicating that
no previous occurrence of frank 225mg daily to 300mg and oral she had been walking her dog in
perceptual disturbances. Prior to aripiprazole was started at 2.5mg an area with a significant drop-off,
hospitalization the patient was stable for further control of her paranoia and ultimately slipped and fell. She
on venlafaxine 225mg daily and and auditory phenomena. Despite had significant injuries, developing
mirtazepine 30mg nightly with full increases in her medications, cutaneous necrosis requiring
remission of symptoms since 2013. depressive symptoms persisted and a plastic surgery intervention.
According to medical records in a final effort to provide relief she Head imaging at the time did not
the patient had discontinued her was started on Methylphenidate demonstrate significant hemorrhage
medications in the weeks before her 5mg twice daily. Following or other structural damage. She
admission leading to her having an initiation of Methylphenidate developed headaches in the
episode of acute decompensated the patient demonstrated a immediate aftermath of the injury,
depression. Thereafter, she suffered significant improvement within but did not immediately develop
profound despondency, decreased 72hrs, experiencing notable psychiatric symptoms. Around one
oral intake, suicidal ideation, with reduction in core presenting year after the fall, she started to hear
a plan to end her life through symptoms – suicidality, paranoia gospel music when there was none
refusal of hemodialysis and vague and social withdrawal. Oral playing. This phenomenon was not
paranoid ideation involving harm intake continued to improve, as problematic for the patient. In fact,
by an unknown person. She was did medical compliance with oral she described it as comforting.
thereby transported to a local medication and hemodialysis. About one year subsequent to
area hospital and admitted to the However, despite overall the initial musical hallucinations,
medical floor with psychiatry being affective improvement her musical she developed paranoia and
consulted for further assessment. hallucinations remained. Aripiprazole delusions. She developed auditory
Admission lab data and imaging was thusly increased over the hallucinations of multiple voices,
were found to be unremarkable. remainder of her hospitalization with negative comments and threats
On initial psychiatric interview to a total of 10mg daily. Roughly of sexual and physical violence.
the patient appeared withdrawn seven days after the final titration She had delusions that people
and voiced complaints consistent her musical hallucinations began were living under her home and
with the aforementioned symptoms, to improve, becoming quieter and she began using the toilet in the
however additionally noted that subjectively more distant until they dark to prevent them from seeing
within the days leading to her being finally resolved roughly one and her. She also had the phone lines
hospitalized she had begun to hear a half weeks post final titration. removed to keep people from
music. The music was described Ultimately she was discharged listening to her and developed
to be a hymn from her childhood, after nearly a 1-month stay on visual hallucinations of people. The
constant and external in nature. the unit with complete resolution patient’s daughter had complained
She was noted to initially attribute of presenting symptomatology that the patient would get agitated
the music to someone playing that has since been maintained and talk to the voices. She made
outside of the room but due to its in the outpatient setting. claims that they were trying to take
constancy had insight enough to belongings from her home and
realize that she was the source. Case II making threats to harm the dog.
On admission to the psychiatric Our second case involved an Initial notes from just after the
unit the patient became increasingly 81-year-old female who carried a time of the fall indicated extensive
despondent and isolative and history of depression and anxiety, physical injuries but no neurological
continued to experience suicidal treated for many years by her or psychotic sequelae. Notes from

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the next two years indicate anxiety and paranoia was increased. The input, thereby the mechanism by
as an ongoing problem, but do psychiatrist restarted lithium at 150 which antipsychotics would provide
not reference any of the psychotic mg daily. Her mood was re‑stabilized relief still remains unknown in this
symptoms. A note from the patient’s with the resumption of lithium. context. One author has suggested
daughter included in the chart from Quetiapine was gradually titrated that it may be possible that
around two years after the accident up to 200 mg as patient was noted antipsychotics restore an underlying
references hearing voices, not to improve significantly in terms aberrant process to baseline function
sleeping, acting paranoid and fearful. of paranoia and hallucinations. at the neurotransmission level,
The family physician at that point There was a brief trial of increasing resulting in remission of symptoms.13
started the patient on lithium 150 mg sertraline, but patient seemed to do In other studies these auditory
daily. She had some improvement in worse on the higher dose, and so the phenomena typically demonstrate
mood stability but the confusion and psychiatrist tapered off of sertraline. rapid resolution in response to
auditory hallucinations persisted. The At this point, the patient was on antipsychotic initiation as was seen
patient’s PCP had also uncovered lithium 150 mg daily, alprazolam in our first case. Our second case
and treated a UTI, which seemed 0.25 mg in afternoon and 0.5 mg however demonstrated a much
to be exacerbating the symptoms. at bedtime, and quetiapine 200 slower and incomplete resolution,
The family physician had been mg at bedtime. She has remained similar to what has been seen in
gradually decreasing the patient’s relatively stable on this regimen a report by Peritogiannis et al.13
sertraline dose, and around four in terms of mood stability. Mild The difference in symptomatic
years after the accident, sertraline auditory hallucinations of both resolution may suggest differences
was at 50 mg. She was still on music and derogatory voices in either the underlying etiology of
alprazolam 0.5 mg three times continue intermittently, but the the disorder or perhaps the sub-
daily and lithium 150 mg daily. patient is no longer troubled by the class of the medication used.
She had an abnormal neurological symptoms. Patient has had mild Though the outcomes in our
exam at that point and was sent renal impairment, with estimated cases were largely positive and
to the hospital for evaluation for GFR at 46 mL/min. Lithium the chronology of drug initiation
possible stroke. Records from the remained steady at 0.4 meq/L. to symptomatic improvement
emergency room indicate patient suggestive of atypical antipsychotics
had a head CT that showed Discussion being efficacious in this regard,
chronic ischemic changes of mild Musical hallucinations have several arguments must be noted.
to moderate severity. There was no been reported since 1846, yet a For example, though our first patient
indication of stroke, and the patient paucity of strong clinical data exists had demonstrated resolution of
was diagnosed with Bell’s palsy. regarding treatment regimens and symptoms nearest to the final
A few months after the Bell’s their efficacy.11 Recent studies increase in her aripiprazole, it
palsy, the patient had a trial of have evaluated several classes cannot be ruled out that her other
going off of lithium. She became of medications and their uses in medications may have had a role.
more confused, wasn’t sleeping, various clinical populations. As It has been shown previously that
and seemed more depressed. previously mentioned, the study antidepressants are quite efficacious
Lithium was restarted and patient performed by Coebergh et al in treating musical hallucinations in
was started on quetiapine 50 stratified subgroups of patients those suffering from a depressive
mg at bedtime. Alprazolam had based on medical and psychiatric disorder.11 Thereby, the time
continued at same dose throughout. illness and postulated that in the from the increase in the patient’s
Hallucinations of voices were psychiatric groups it appeared that venlafaxine to her abatement of
still noted to persist. At this time, the type of disorder was the most symptoms makes the attribution
she was referred to psychiatry important guide as to the choice of clinical success solely to her
for evaluation and treatment. of treatment.12 In our cases the antipsychotic regimen unclear. In our
At the initial visit, the psychiatrist most closely associated symptom second case however the increase
titrated quetiapine up to 100 mg was psychosis, thereby the choice in quetiapine appears to be more
at bedtime and stopped lithium to utilize atypical antipsychotics clearly associated with the resolution
“due to lack of effect.” Subsequent was made for this reason. of the patient’s symptoms, providing
phone note indicates that off of Being largely associated with stronger evidence that the increase
lithium the patient again developed deafferentiation phenomena, in dose of her atypical antipsychotic
mood instability, this time including it is hypothesized that musical was central to her improvement.
agitation. She once again did not hallucinations are evoked through Additionally, given the underlying
sleep for several nights in a row the absence of normal auditory medical pathology in both patients,

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it cannot be ruled out that the hallucination manifestation in two 2. Hammeke TA, McQuillen MP, Cohen BA.
Musical hallucinations associated with
resolution of their symptoms was very different scenarios in which acquired deafness. Journal of Neurology,
not merely due to the natural course multiple psychiatric and medical Neurosurgery and Psychiatry, 1983; 46(6):
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challenge for psychiatric therapeutical
argued that our patient’s known as in the first case or direct head management. Journal of Medicine and Life,
hearing impairment may have been trauma as in the second. These 2015; 8: 533-535
4. Teunisse RJ, Olde Rikkert MG: Prevalence of
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of their perceptual disturbances. differentiating the patients’ musical audiometric testing. Am J Geriatr Psychiatry
phenomena from their primary 2012; 20: 1075–1077
However, given the long-standing 5. Janakirama R, Wildgoose K, Seelam K. ECT
nature of these findings without underlying psychiatric illness. While associated musical hallucinations in an elderly
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considered to be significant of symptoms with initiation Musical hallucinations associated with pontine
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contributing factors in these cases. of antipsychotic medications and Clinical Neurosciences, 2013; 25:153-156
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9. Blom J, Coebergh J, Lauw R, Sommer I.
given negative imaging and intact to the paucity of literature Musical hallucinations treated with
cognitive function in both cases this regarding utilization of atypical acetylcholinesterase inhibitors. Frontiers in
Psychiatry, 2015; 6:46
was also felt to be noncontributory. antipsychotics for treatment 10. Ukai S, Yamamoto M, Tanaka M, Shinosaki K,
Therefore, given the chronicity of the of musical hallucinations and Takeda M. Donepezil in the treatment of
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development of symptoms to serious demonstrate efficacy to this effect. Neurosciences, 2007; 61: 190-192
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hallucinations: a particular pathology
absence of previous perceptual the use of psychopharmacologic impacting on patients’ quality of life. European
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or metabolic pathology. 1. Maricle R, Turner D, Lehman K. The charles antipsychotics for the treatment of musical
bonnet syndrome: a brief review and case hallucinations in an elderly patient without a
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