|Year : 2019 | Volume
| Issue : 2 | Page : 176-177
Musical obsessions: Successful treatment with low dose of escitalopram
Aneesh Alexander, Parthasarathy Ramamurthy, Pradeep Thilakan
Department of Psychiatry, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||09-Apr-2019|
|Date of Decision||04-Jun-2019|
|Date of Acceptance||06-Jun-2019|
|Date of Web Publication||18-Dec-2019|
Dr. Aneesh Alexander
Department of Psychiatry, Pondicherry Institute of Medical Sciences (A Unit of Madras Medical Mission), Kalathumettupathai, Ganapathichettikulam, Village No. 20, Kalapet, Puducherry - 605 014
Source of Support: None, Conflict of Interest: None
Musical obsessions include repeated intrusive musical tunes, lyrics, or songs. In this report, two patients who presented with isolated musical obsessions and responded well to low dose of escitalopram (10 mg/day) are described. Musical obsessions have to be differentiated from musical hallucinations and palinacousis. Attention to psychopathology and associated clinical features are important in differentiating these conditions. Our case studies add to the limited knowledge of this uncommon condition.
Keywords: Escitalopram, musical obsessions, obsessive–compulsive disorder
|How to cite this article:|
Alexander A, Ramamurthy P, Thilakan P. Musical obsessions: Successful treatment with low dose of escitalopram. Ann Indian Psychiatry 2019;3:176-7
|How to cite this URL:|
Alexander A, Ramamurthy P, Thilakan P. Musical obsessions: Successful treatment with low dose of escitalopram. Ann Indian Psychiatry [serial online] 2019 [cited 2020 Jul 13];3:176-7. Available from: http://www.anip.co.in/text.asp?2019/3/2/176/262245
| Introduction|| |
The most common obsessions described in patients with obsessive–compulsive disorder (OCD) are fear of causing harm to someone else or self, and fear of contamination. Infrequently, repeated intrusive thoughts of musical tunes, lyrics, or even songs occur, and this has been termed as “musical obsession.” The treatment of musical obsessions using antiobsessive doses of selective serotonin reuptake inhibitors (SSRIs),, and clomipramine  has been well described. Distraction and exposure and response prevention were the psychotherapeutic interventions found to be useful in the treatment of musical obsessions. In this article, we describe two patients with isolated musical obsessions who responded well to low dose of escitalopram.
| Case Reports|| |
An 18-year-old female student presented with a 3-year history of “hearing music when in class and inability to concentrate on the lessons.” On clarification, she reported having tunes of songs of the previous generation running in her mind over and over again. She said that the songs along with music would keep playing inside her mind spanning several minutes to hours. These would come to her at inopportune moments such as when she tried to concentrate in her class or when she was spending time with her friends. She found it difficult to “forget” the particular song once it started despite enormous efforts on her part. She found that these songs would stop running in her mind once she actually listened to the song once or when she downloaded the poster of the movie in which the song was originally played. The same process would be repeated with a different song after some time. She was able to differentiate these repetitive unwanted songs from other contemporary songs which she liked to listen and would download onto her mobile phone out of her own interest. There was no other classical obsession or compulsion in this patient. She did not have any mood symptoms, psychotic symptoms, substance use, or medical illness that could explain these symptoms. A diagnosis of OCD was made according to the International Classification of Diseases (ICD)-10 criteria. She was started on escitalopram at 5 mg which was titrated to 10 mg/day. There was complete resolution of symptoms within 1 month of initiating the treatment. No psychotherapy was initiated.
A 35-year-old married man who was staying away from his family due to work-related reasons presented to us with “lyrics of songs running in his mind and sleep disturbance.” He reported that lyrics of songs without any accompanying music or tune would come to mind over and over again in an unpleasant manner during the day. These were particularly prominent in the night when he tried to sleep. He started developing insomnia as he would have these lyrics running in his mind when in bed, thereby disturbing his sleep. He had the habit of listening to songs every day for long hours while commuting. He stopped listening to songs completely in an attempt to stop the lyrics from bothering him. This effort ended in vain as there was no reduction in the severity of musical obsessions. This patient did not have any other classical obsession or compulsion. No substance abuse or medical/neurological illness was found on evaluation. A diagnosis of obsessive OCD was made according to ICD-10 criteria. He responded well to escitalopram 10 mg/day and was asymptomatic within a month of initiating treatment. No psychotherapy was initiated.
| Discussion|| |
Both the patients reported the fragments of music as recurrent, persistent, intrusive, unintentional, time consuming, and causing distress or functional impairment – this description was in line with previously described cases.
Differentiating them from musical hallucinations, pseudohallucinations, and palinacousis was also straightforward in our cases when close attention was paid to the phenomenology. Unlike musical hallucinations, the repetitive songs were perceived as originating in the patients' own mind and not interpreted as veridical. They were not pseudohallucinations as these experiences were aversive to the patients and not associated with severe hearing loss or hallucinogen intoxication. Moreover, there was no fluctuation in the insight in both our patients. Palinacousis was ruled out because our patients did not describe “hearing” the fragments of music and did not have associated neurological deficits. Furthermore, they did not describe auditory localization to one ear and were limited to repetitions of fragments of music which the patient heard in the past.
The striking feature in our cases was the complete resolution of musical obsessions to a relatively low dose of escitalopram. Saha  described a patient with musical obsession who was treated with fluvoxamine 200 mg, fluoxetine 60 mg, and lithium 900 mg along with exposure prevention therapy and systematic desensitization. Aneja et al. reported successful treatment of musical obsessions with escitalopram 10–15 mg/day and behavior therapy. However, in their patient, an exacerbation during a stressful period of examination necessitated a dose increase to 30 mg/day. Praharaj et al. reported a patient whose musical obsessions did not respond to fluvoxamine 300 mg and risperidone 2 mg/day. Later, this patient was reported to have responded to thought stopping technique. Matsui et al. reported two cases who responded well to clomipramine 150 mg/day. Islam et al. reported good improvement in a patient with musical obsessions with paroxetine 40 mg and aripiprazole 2.5 mg/day. It can be clearly seen that high-dose SSRIs and clomipramine with or without augmentation were found to be effective in treatment of musical obsessions.
A recent meta-analysis concluded that the greater efficacy of higher doses of SSRIs in OCD is counterbalanced by a greater side-effect burden. In this context, the efficacy of low-dose escitalopram in musical obsessions assumes significance as the side-effect burden in these patients can be mitigated.
| Conclusion|| |
Low-dose escitalopram was found to be efficacious in both our patients with isolated musical obsessions. Although other case studies have reported the use of higher doses of SSRI medications, it would be judicious to wait on a lower dose of SSRI as seen in our case studies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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