INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2006; 21: 394–397.

Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/gps.1463

RESEARCH LETTER

Musical hallucinations in psychiatric patients

Sandra M. M. Schakenraad1, Robert J. Teunisse2 and Marcel G. M. Olde Rikkert1*
1
University Medical Centre Nijmegen, The Netherlands
2
Department of Old Age Psychiatry, Adhesie GGZ Midden-Overijssel, The Netherlands

INTRODUCTION of age of a social psychiatric institute (RIAGG

Little research has been done to determine the
prevalence of musical hallucinations in psychiatric
patients. Fukunishi et al. (1998) found a prevalence
of only 0.16%. In contrast, 27% of the 190 patients
studied by Hermesh et al. (2004) were suffering from
musical hallucinations.
In several case studies, musical hallucinations were
associated with female gender, old age, progressive
deafness, tinnitus, depression (Eizenberg et al.,
1987; Wengel et al., 1989; Berrios, 1990, 1991;
Keshavan et al., 1992; Pasquini et al., 1997;
Fukunishi et al., 1998; Johns et al., 2002) and
psychiatric illness (Eizenberg et al., 1987; Wengel
et al., 1989; Keshavan et al., 1992; Pasquini et al.,
1997; Saba et al., 1997).
Because of the scarcity of reliable data on this
topic, this study was conducted to determine the pre-
valence of musical hallucinations in psychiatric
patients and to analyse possible associations of such
hallucinations with tinnitus, gender, age or hearing
impairment.
PATIENTS AND METHODS
Inclusion and exclusion criteria
Inpatients over 18 years of age of three departments of
a psychiatric hospital with mostly elderly patients
(Adhesie GGZ Midden-Overijssel, The Netherlands)
and consecutively referred outpatients over 60 years
Ijsselland, The Netherlands) were selected.
Patients with insufficient comprehension of the
Dutch language and/or severe cognitive disorders that
made interviews unreliably were excluded.
A total of 180 patients were asked to participate:
143 inpatients [department of general hospital psy-
chiatry (19); department for the elderly (18) and long
stay department (106)] and 37 outpatients (social psy-
chiatric institute).
Screening instrument
All patients were screened with a structured question-
naire (see Appendix 1) by the same interviewer (S.
S.), who also asked informed consent. The question-
naire comprised of 14 questions regarding tinnitus,
auditory hallucinations in general and musical hallu-
cinations in particular. Hallucinations were carefully
discriminated from illusions and imagery (details
available on request from authors).
Determining hearing impairment
The interviewer used a five-point scale to determine
hearing impairment, starting from absence of any
hearing impairment (0) up to only being able to com-
municate by writing (5). In patients with no obvious
hearing impairment a whispered voice test was per-
formed (Pirozzo et al., 2003).

*Correspondence to: Prof. M. GM Olde Rikkert, Department of Psychiatric diagnoses

Geriatric Medicine, University Medical Centre Nijmegen, code
931, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Tel: þ31
Psychiatric diagnoses, classified according to DSM-
24 3616772. Fax: þ 31 24-3617408. IV-TR criteria, were extracted from the patients’ psy-
E-mail: M.Olde-Rikkert@ger.umcn.nl chiatric files.
Received 18 April 2005
Copyright # 2006 John Wiley & Sons, Ltd. Accepted 31 August 2005
 musical hallucinations in psychiatric patients
Statistical analysis
The data were analysed with SPSS for Windows ver-
sion 11.0. Subgroups were compared using a t-test for
continuous variables and a chi-square test for catego-
rical variables. A p-value of less than 0.05 was taken
to indicate statistical significance.
RESULTS
Of the subjects that were invited to participate, 53 did
not want to participate in the interview and seven had
to be excluded. The included and excluded group
were not significantly different in age (p ¼ 0.65) or
gender ( p ¼ 0.90).
Seventy-eight women (60.9%) and 50 men (39.1%)
were included. Mean age was 62 years (range 21–89
years). The most common psychiatric diagnoses were
schizophrenia (21%), major depressive disorder
(18%) and bipolar disorder (8%). Other diagnoses
were psychosis (NOS 5%, with depression 3%), rela-
tional problems (6%), panic (4%) or anxiety (2%) dis-
orders, dementia (3%) and other axis I diagnoses
(23%). 7% did not have a DSM IV axis I disorder
and in total there were 149 axis I disorders in 128
patients.
14.8% (19 patients) had a serious hearing impair-
ment (communication score of 2, 3 or 4). Thirty-five
patients (27.3%) had a slight hearing loss (communi-
cation score of 0 or 1 with a disturbed whispered
voice test), 74 patients (57.9%) had no hearing loss.
Prevalence of tinnitus and hallucinations
25% of the patients (32 out of 128) had suffered from
tinnitus during the past 4 weeks. The prevalence of
complex auditory hallucinations in general was
18.8% (24 patients, CI95 12.0–25.5%). Schizophrenic
patients experienced complex auditory hallucinations
significantly more often than patients without schizo-
phrenia (p ¼ 0.01).
Musical hallucinations were found in five patients
(3.9%, CI95 0.5–7.3%) of whom three were aged over
60 years. The characteristics of these are described in
Table 1.
Table 1. Characteristics of patients (n ¼ 5) with musical hallucinations
Sex Age Diagnosis
Female 89 Psychosis NOS
Female 65 Adaptation impairment
Female 42 Borderline personality disorder
Female 64 Phase of life problem
Male 24 ADHD, personality disorder NOS
Copyright # 2006 John Wiley & Sons, Ltd.
395
No significant associations were found between
musical hallucinations and age, gender, hearing
impairment or depression (p-values of resp. 1.00,
0.65, 0.56 and 0.33).
DISCUSSION
The prevalence of musical hallucinations in this study
is rather high compared to the prevalence found by
Fukunishi et al. (1998) but lower than the prevalence
described by Hermesh et al. (2004). The low preva-
lence in Fukunishi’s study may be an underestimation
due to the fact that this was a retrospective study of
medical files. Because musical hallucinations will
rarely be a reason for hospitalisation, patients may
not mention their musical hallucinations themselves
and doctors will usually not ask about these kind of
hallucinations. The prevalence of 27% presented by
Hermesh et al. (2004) is very high. Probably, inclu-
sion of imagery has inflated the prevalence in the lat-
ter study, as the questionnaire that was used did not
distinguish between musical hallucinations and
obsessive musical imagery. The present study sug-
gests that musical hallucinations are not rare in
elderly psychiatric patients, but, lacking a control
group, does not prove these hallucinations are asso-
ciated with their psychiatric disorder. Musical halluci-
nations were not significantly associated with hearing
impairment, tinnitus, advanced age, female sex or
depression, but the number of cases was too small
to yield sufficient power to exclude these associations.
In this study, participants were recruited from three
different psychiatric settings which promotes group het-
erogeneity. Initially only elderly patients were selected.
Later during the study, it was decided to include
younger patients as well, to study age related differ-
ences. However, because of the small number of sub-
jects with musical hallucinations, this analysis could
not be made.
CONCLUSION
Psychiatrists should ask more routinely about musical
hallucinations, as these remain generally undetected.
Tinnitus Hearing-impairment Contents of hallucinations
No Yes Children’s songs national anthem
No No St. Nicholas songs
Yes No Music of father’s funeral
Yes No Piano music
Yes No Classical music
Int J Geriatr Psychiatry 2006; 21: 394–397.
396 s. m. m. schakenraad ET AL.

In this study, only one of the five patients with musical
hallucinations was known to have them. Musical and
other auditory hallucinations can be distressing if peo-
ple can not control them. In order to gain more reliable
information on the prevalence and determinants of
musical hallucinations it will be necessary to study lar-
ger psychiatric and also non-psychiatric populations.
REFERENCES
Berrios GE. 1990. Musical hallucinations. A historical and clinical
study. Br J Psychiatry 156: 188–194.
Berrios GE. 1991. Musical hallucinations: a statistical analysis of
46 cases. Psychopathol 24: 356–360.
Eizenberg D, Modai I, Roitman M, et al. 1987. Musical hallucina-
tions, depression and old age. Psychopathol 20: 220–223.
Fukunishi I, Horikawa N, Onai H. 1998. Prevalence rate of musical
hallucinations in a general hospital setting. Psychosomat 39: 175.
Hermesh H, Konas S, Shiloh R, et al. 2004. Musical hallucinations:
prevalence in psychotic and non-psychotic outpatients. J Clin
Psychiatry 65(2): 191–197.
Johns LC, Hemsley D, Kuipers E. 2002. A comparison of auditory
hallucinations in a psychiatric and non-psychiatric group. Br J
Clin Psychol 41: 81–86.
Keshavan MS, David AS, Steingard S, et al. 1992. Musical halluci-
nations: a review and synthesis. Neuropsychiatry neuropsychol
Behav Neurol 5(3): 211–223.
Pasquini F, Cole MG. 1997. Idiopathic musical hallucinations in the
elderly. J Geriatr Psychiatry Neurol 10(1): 11–14.
Pirozzo S, Papinczak T, Glasziou P. 2003. Whispered voice test for
screening for hearing impairment in adults and children: sys-
tematic review. BMJ 327(7421): 967.
Saba PR, Keshavan MS. 1997. Musical hallucinations and musical
imaginary: prevalence and phenomenology in schizophrenic
inpatients. Psychopathol 30(4): 185–190.
Wengel SP, Burke WJ, Holemon D. 1989. Musical halluc-
inations. The sounds of silence? J Am Geriatr Soc 37:
163–166.

Available on request from authors:

APPENDIX 1: Questionnaire 1
Screening form ‘Spontaneous auditory phenomena in psychiatric patients’
Name: Date:
Birth date: Location:
Gender: M/F Research number:

Hearing impairment
0 ¼ no subjective hearing impairment
Whispered voice test ¼
1 ¼ subjective hearing impairment, no notable influence on the conversation
Whispered voice test ¼
2 ¼ researcher has to speak more loudly than normal
Hearing aid? Yes–No
3 ¼ disturbs the interview substantially
Hearing aid? Yes–No
4 ¼ questions have to be presented in writing
Hearing aid? Yes–No
Which ear hears best: LR
Questionnaire
1. Have you ever heard sounds different from normal? Yes–No
(e.g. with an echo, booming or with a strange pitch)
2. Do you experience tinnitus, peeping or buzzing? Yes–No
If yes, did you experience that during the past 4 weeks? Yes–No
Can you describe the sound?
3. Have you ever heard something wrong, i.e. that you thought you Yes–No
heard something, but it turned out to be something else?
If yes: did that happen during the past 4 weeks? Yes–No
Can you give an example?
4. Have you heard sounds no-one else could hear? Yes–No
5. Have you heard songs or other sorts of music while Yes–No
nothing or nobody was making/playing that music?
6. Have you heard voices speak while nobody was with you? Yes–No
7. Have you heard sounds, voices or music that arose from Yes–No
inside your head?

Copyright # 2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2006; 21: 394–397.
 musical hallucinations in psychiatric patients 397

8. Have you experienced other special things related to hearing? Yes–No

If yes, can you describe your experience?
9. Is the patient a possible case? Yes–No
If no, end the interview; if yes: continue questionnaire
10. Can you describe what you have heard?
Are those sounds complex auditory phenomena? Yes–No
11. Did these sounds appear as real as actual sounds? Yes–No
(or more like hearing in thoughts)
12. Could it have been a different sound that you heard wrong? Yes–No
13. When did you hear that sound for the last time?
14. (For the interviewer) Are there complex auditory phenomena? Yes–No

Copyright # 2006 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2006; 21: 394–397.