Although musical phrases or songs may be heard along with voices or other noises, a great many people “hear” only music or musical phrases. Musical hallucinations may arise from a stroke, a tumor, an aneurysm, an infectious disease, a neurodegenerative process, or toxic or metabolic disturbances. Hallucinations in such situations usually disappear as soon as the provocative cause is treated or subsides.23
Sometimes it is difficult to pinpoint a particular cause for musical hallucinations, but in the predominantly geriatric population I work with, by far the commonest cause of musical hallucination is hearing loss or deafness—and here the hallucinations may be stubbornly persistent, even if the hearing is improved by hearing aids or cochlear implants. Diane G. wrote to me:
I have had tinnitus as far back as I can remember. It is present almost 24/7 and is very high pitched. It sounds exactly like how cicadas sound when they come in droves back on Long Island in the summer. Sometime in the last year [I also became aware of] the music playing in my head. I kept hearing Bing Crosby, friends and orchestra singing “White Christmas” over and over. I thought it was coming from a radio playing in another room until I eliminated all possibilities of outside input. It went on for days, and I quickly discovered that I could not turn it off or vary the volume. But I could vary the lyrics, speed and harmonies with practice. Since that time I get the music almost daily, usually toward evenings and at times so loud that it interferes with my hearing conversations. The music is always melodies that I am familiar with such as hymns, favorites from years of piano playing and songs from early memories. They always have the lyrics. . . .
To add to this cacophony, I now have started hearing a third level of sound at the same time that sounds like someone is listening to talk radio or TV in another room. I get a constant running of voices, male and female, complete with realistic pauses, inflections and increases and decreases in volume. I just can’t understand their words.
Diane has had progressive hearing loss since childhood, and she is unusual in that she has hallucinations of both music and conversation.24
There is a wide range in the quality of individual musical hallucinations—sometimes they are soft, sometimes disturbingly loud; sometimes simple, sometimes complex—but there are certain characteristics common to all of them. First and foremost, they are perceptual in quality and seem to emanate from an external source; in this way they are distinct from imagery (even “earworms,” the often annoying, repetitious musical imagery that most of us are prone to from time to time). People with musical hallucinations will often search for an external cause—a radio, a neighbor’s television, a band in the street—and only when they fail to find any such external source do they realize that the source must be in themselves. Thus they may liken it to a tape recorder or an iPod in the brain, something mechanical and autonomous, not a controllable, integral part of the self.
That there should be something like this in one’s head arouses bewilderment and, not infrequently, fear—fear that one is going mad or that the phantom music may be a sign of a tumor, a stroke, or a dementia. Such fears often inhibit people from acknowledging that they have hallucinations; perhaps for this reason musical hallucinations have long been considered rare—but it is now realized that this is far from the case.25
Musical hallucinations can intrude upon and even overwhelm perception; like tinnitus, they can be so loud as to make it impossible to hear someone speak (imagery almost never competes with perception in this way).
Musical hallucinations often appear suddenly, with no apparent trigger. Frequently, however, they follow a tinnitus or an external noise (like the drone of a plane engine or a lawn mower), the hearing of real music, or anything suggestive of a particular piece or style of music. Sometimes they are triggered by external associations, as with one patient of mine who, whenever she passed a French bakery, would hear the song “Alouette, gentille alouette.”
Some people have musical hallucinations virtually nonstop, while others have them only intermittently. The hallucinated music is usually familiar (though not always liked; thus one of my patients hallucinated Nazi marching songs from his youth, which terrified him). It may be vocal or instrumental, classical or popular, but it is most often music heard in the patient’s early years. Occasionally, patients may hear “meaningless phrases and patterns,” as one of my correspondents, a gifted musician, put it.
