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So-called earworms are very common – an estimated 98% of people have experienced this phenomenon of having a tune circling persistently through their minds at some time in their lives. But earworms can reach a clinical level of severity to be recurring, distressing, unwanted, and intrusive, and give rise to compulsive behavior, at which point they qualify for classification as musical obsessions (a.k.a. "stuck song syndrome").¹

Although the condition is rare and by various diagnostic procedures for obsessive compulsive disorder (OCD),² most patients with musical obsessions are ultimately diagnosed with OCD. Young adults in their mid-30s are most likely to be affected. Only about 100 cases have been reported worldwide.¹ The following report describes the diagnostic and treatment challenges of one such .³

The Case

A 32-year-old female psychology student presents to your office troubled by marked anxiety, distress, and a recent history of difficulty getting to sleep. She is troubled by hearing a series of songs that play repeatedly in her head, continuously throughout her waking hours. She explains that the constant loop of musical fragments she hears is interfering with her focus and concentration, to the extent that she cannot have a normal conversation or read without losing her train of thought.

She is single and lives with her mother, is a student, but otherwise has been unemployed for the past 3 years. Her symptoms are having a significant negative impact on her academic performance, and her apparent lack of attention is a detriment to her personal relationships at college and at home.

She is fully aware that the music is coming from inside her mind – although she knows some of the songs she is hearing and they are true to the original in melody and rhythm, the songs are not being triggered by music in her environment.

The stuck songs include songs she is fond of and songs she dislikes, choruses from television commercial jingles, and fragments of instrumental as well as vocal pieces. She notes that she first experienced this phenomenon 12 years ago; episodes were intermittent, lasting for a week or two and recurring monthly. Initially, the symptoms were mild, but they worsened gradually over the course of the following 6 years to become moderate to severe and to be associated with compulsive behaviors.

Her family has no history of mental health or neurological conditions. Her only mental health issue prior to this developed during adolescence, when she was affected by anorexia nervosa. This was resolved successfully with psychotherapy, an experience that may have actually inspired her to study psychology.

Her compulsive attempts to control these musical obsessions over the years have brought no lasting relief. She tried using headphones at high volume to listen to other music in an effort to distract herself from the songs looping in her head, and says that the resulting cacophony caused her intense anxiety and mental discomfort.

On the other hand, she found that matching her choice of music to the song in her head and listening at a very high volume offered some short-lived relief. Ultimately, her failure to control the musical obsessions left her feeling frustrated, defeated, sad, and powerless.

Case Challenge 1

Symptoms and Differential Diagnosis

As part of a clinical spectrum that ranges from normal to pathological, musical obsessions are distinct from "sticky tunes," or earworms.

These are manifestations of involuntary musical imagery in which music that has usually been recently heard repeats on an involuntary loop within the "mind's ear." This very common phenomenon may cause some distress, but does not reach the level of an obsession.⁴

When considering a patient reporting musical obsessions, common physiology may be distinguished from potential pathology by the extent of distress the stuck song causes in the patient, often signaled by a negative impact on sleep and daily functioning, active avoidance behaviors, and coexisting symptoms suggestive of OCD.⁵

Two key differential diagnoses include musical hallucinations and palinacousis. Musical hallucinations are a form of complex auditory hallucination in which individuals "hear" music they perceive as tunes or melodies coming from their surroundings, despite the absence of a corresponding external sound.⁶

Palinacousis is an illusory phenomenon thought to involve temporal lobe dysfunction, that involves persistent or recurrent echoing replication of music and/or environmental and vocal sounds after they have stopped.⁷

Assessments and Initial Treatment

A structured interview and evaluation reveals symptoms that meet the diagnostic criteria for OCD, as described in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

Assessment using the Spanish version of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) indicates that the patient has severe OCD, with scores of 17 for obsessions and 16 for compulsions, for a total of 33 out of a possible 40 (severe OCD).

Her score of 8 on the Beck Depression Inventory is negative for depression; however, she does have moderate to severe anxiety (Hamilton Anxiety Rating Scale score of 31). Results of laboratory tests are within normal limits, and no abnormalities are noted on brain magnetic resonance imaging and electroencephalogram.

When the patient's symptoms escalate to become severe about 7 years after onset, she is treated with fluvoxamine, a selective serotonin reuptake inhibitor (SSRI) medication. The dose is progressively escalated to 200 mg/day over 12 weeks. This decreases the frequency of her symptoms but not their intensity. A few years later, she receives treatment for sleep onset insomnia, which responds to eszopiclone 3 mg.

Case Challenge 2

Which medications would be appropriate to treat this patient's symptoms?

Case Follow-up and Outcome

The following year, she is treated with paroxetine controlled-release tablets 50 mg/day for persistent and severe symptoms (total Y-BOCS score=33). However, that SSRI is later discontinued due to causing intolerable drowsiness and dizziness.

A subsequent trial of fluoxetine 60 mg/day partially reduces the symptoms after 12 weeks of treatment. The dose of fluoxetine is increased to 80 mg/day, but she is unable to continue taking it due to headache.

However, her Y-BOCS score drops to 13 (10 for obsessions and 3 for compulsions -- i.e., mild OCD), a 60% reduction in symptoms from baseline. The Hamilton Anxiety Rating Scale yields a score of 16 (mild).

She refuses to start cognitive behavioral therapy (CBT) or other forms of psychotherapy as recommended. In particular, one form of CBT -- exposure and response prevention⁸ -- is effective in OCD and often combined with SSRI treatment.⁹

Medications in OCD

Although the effects of SSRI in adults with OCD appear to be of similar magnitude,⁹ they do have different pharmacodynamic properties. In contrast to paroxetine and fluvoxamine, fluoxetine not only inhibits serotonin reuptake, but also has norepinephrine reuptake inhibition and serotonin 2C (5HT2C) antagonist actions. Early research suggests that the 5HT2C receptor may have a role in OCD, which may help account for its effectiveness in this case.¹⁰

Importantly, musical obsessions may be misinterpreted as a psychotic symptom, which can result in erroneous use of antipsychotics such as chlorpromazine in these patients.²

The anesthetic ketamine is theorized to have a potential role in OCD -- likely by increasing glutamate levels -- and is currently in the treatment of OCD.

Discussion

Musical obsessions are largely accepted as a rare variant of OCD, given that the vast majority of these patients have met the diagnostic criteria. This case also presents an unusual form of compulsion that accompanied musical obsessions, in which the patient sought to complete the obsessive content by listening to real music.

Compulsive efforts to dispel obsession-related anxiety -- which can be described as a form of active harm avoidance -- have the paradoxical effect of intensifying anxiety over time. In fact, these compulsive behaviors have been proposed as a cause of OCD since they trigger further intrusive thoughts, in a vicious cycle. This avoidance behavioral trait has a neuroanatomical basis in the striatum, an area known to be involved in OCD and targeted by deep-brain stimulation therapies for OCD.¹¹

Conclusion

An often overlooked condition, musical obsessions can cause significant impairment of quality of life. This case was not complicated with comorbid illness, and the patient had a good level of self-awareness and understanding of her illness, and despite adverse effects, her symptoms proved to respond reasonably well to treatment. It is expected that psychotherapeutic measures would have further resolved her musical obsessions.

References

1. Taylor S, et al "Musical obsessions: A comprehensive review of neglected clinical phenomena" J Anxiety Disord 2014; 28: 580-589.

2. Saha A "Musical obsessions" Ind Psychiatry J 2012; 21: 64.

3. Orjuela-Rojas JM, Rodríguez ILL " The Stuck Song Syndrome: A Case of Musical Obsessions" Am J Case Rep 2018; 19: 1329-1333.

4. Williamson VJ, et al "Sticky tunes: How do people react to involuntary musical imagery?" PLoS One 2014; 9: e86170.

5. Euser AM, et al "Stuck song syndrome: musical obsessions – when to look for OCD" Br J Gen Pract 2016; 66: 90.

6. Golden EC, Josephs KA "Minds on replay: Musical hallucinations and their relationship to neurological disease" Brain 2015; 138: 3793-3802.

7. Patterson MC, et al "Palinacousis: A case report" Neurosurgery 1988; 22: 1088-1090.

8. Rafin ZY "A 19-year-old with intrusive loops of music in his mind" Psychiatric Annals 2016: 46: 12.

9. Skapinakis P, et al "Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: A systematic review and network meta-analysis" Lancet Psychiatry 2016; 3: 730-739.

10. Papakosta V-M et al "5-HT2C receptor involvement in the control of persistence in the reinforced spatial alternation animal model of obsessive – compulsive disorder" Behav Brain Res 2013; 243:176-183.

11. Hauser TU et al "Neural mechanisms of harm-avoidance learning: A model for obsessive-compulsive disorder?" JAMA Psychiatry 2016; 73(11): 1196-1197.

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