Brain (2000), 123, 2065–2076
Musical hallucinosis in acquired deafness
Phenomenology and brain substrate
T. D. Griffiths
Department of Neurology, Newcastle University,
Newcastle-upon-Tyne and Wellcome Department of
Cognitive Neurology, Institute of Neurology, London, UK
Summary
Six subjects with musical hallucinations following
acquired deafness are described. The subjects all
experienced the condition in the absence of any other
features to suggest epilepsy or psychosis. I propose a
neuropsychological model for the condition consistent
with detailed observation of the subjects’
phenomenology. The model is based on spontaneous
activity within a cognitive module for the analysis of
temporal pattern in segmented sound. Functional
imaging was carried out to test the hypothesis that
musical hallucinosis is due to activity within such a
module, for which the neural substrate is a distributed
Keywords: music hallucination; deafness; functional imaging; PET
Abbreviations: HG ⫽ Heschl’s gyrus; PT ⫽ planum temporale
Introduction
Musical hallucinosis is a disorder of complex sound
processing. Subjects perceive complex sound in the form of
music in the absence of an acoustic stimulus. As such, the
phenomenon might be regarded as an example of mental
imagery, defined as ‘mental acts in which we seem to re-
enact the experience of perceiving an object when the object
is no longer available’ (Halpern and Zatorre, 1999). Mental
imagery is, however, usually less vivid than actual perception,
and is never attributed to an external process. Musical
hallucinosis may be associated with structural brain lesions,
epilepsy or psychosis (for reviews, see Berrios, 1990;
Keshavan et al., 1992). However, it is most commonly seen
in subjects with moderate or severe acquired deafness, and
as such it may represent an auditory form of the Charles
Bonnet syndrome. This term is more commonly used to
describe formed visual percepts in the absence of visual
stimulation in subjects with peripheral visual loss (ffytche
et al., 1998). This study addresses the basis for musical
hallucinosis in six subjects with acquired deafness.
Musical hallucinosis is a disorder of the processing of the
high-level pattern in sound. Music comprises discrete sounds
© Oxford University Press 2000
Correspondence to: Dr T. D. Griffiths, Department of
Physiological Sciences, Newcastle University Medical
School, Newcastle-upon-Tyne NE2 4HH, UK
E-mail: t.d.griffiths@ncl.ac.uk
network distinct from the primary auditory cortex.
PET was carried out on the six subjects to identify
areas where brain activity increased as a function of
the severity of the hallucination. In a group analysis,
no effect was demonstrated in the primary auditory
cortices. Clusters of correlated activity were
demonstrated in the posterior temporal lobes, the right
basal ganglia, the cerebellum and the inferior frontal
cortices. This network is similar to that previously
demonstrated during the normal perception and imagery
of patterned–segmented sound, and is consistent with
the proposed neuropsychological and neural mechanism.
that are characterized by fundamental properties such as pitch
and onset time. These sounds are built into a high-level
pattern at the temporal level of hundreds of milliseconds.
Musical hallucinosis requires a mental representation of such
a high-level pattern. The mental representation might be
based on the same neural mechanism as that active during
normal musical perception, although distinct mechanisms for
musical perception and imagery are also possible. I use the
term ‘high-level’ to refer to structure over and above that in
the individual units; in this sense the term might equally be
used to refer to tonal or atonal Western music or African or
Eastern music.
Previous studies suggest that the processing of discrete
sounds depends on a neural substrate different from that used
for the processing of high-level patterns formed by these
sounds. Several studies suggest that the processing of pitch
is related to the function of the human primary auditory
cortex in Heschl’s gyrus (Zatorre, 1988; Pantev et al., 1989;
Griffiths et al., 1998), whilst the onset time of auditory
transients is accurately represented in the primary auditory
cortex of animals (Phillips and Hall, 1990). Stimulation of
2066 T. D. Griffiths
the primary auditory cortex at operation is associated with
the perception of simple noises or tones (Penfield and Perot,
1963). In contrast, the processing of musical patterns formed
by individual sounds is related to a network of cortical areas
distinct from the primary auditory cortex. Melody is a pattern
of sound pitches, whilst rhythm is a pattern of the onset
times and durations of sounds. Studies of melody perception
demonstrate a predominantly right-sided network that
includes the planum temporale and frontal cortex (Zatorre
et al., 1994), whilst the involvement of the cerebellum and
basal ganglia has been emphasized in studies of rhythmic
processing (Penhune et al., 1998). Stimulation of the superior
temporal gyrus outside Heschl’s gyrus at operation can be
associated with the perception of music (Penfield and Perot,
1963). A study using atonal sequences without conventional
rhythm (Griffiths et al., 1999a) suggests the possibility of a
general role for superior temporal networks in the analysis
of patterns in segmented sound, rather than a specific role in
the analysis of music.
This study is a test of the hypothesis that musical
hallucinosis in subjects with acquired deafness is related to
activity within the neural network for the perception of high-
level pattern in sound. The hypothesis makes predictions
about the phenomenology of, and the brain substrate for,
musical hallucinosis. In terms of phenomenology, the
hypothesis predicts that subjects with musical hallucinosis
due to acquired deafness will experience normal high-level
sound patterns because of activation of the normal central
perceptual mechanism. In terms of brain substrate, the
hypothesis predicts that musical hallucinosis will be
associated with activity in distributed networks, distinct from
the primary auditory cortex, including the posterior superior
temporal cortex, frontal cortex and cerebellum. I was
particularly interested to examine whether the planum
temporale is active during musical hallucinosis. Several
studies suggest a general role for this area in the perception
of patterned–segmented sound (Binder et al., 1996; Mummery
et al., 1999).
Patients and methods
Table 1 gives the clinical details for the subjects, all of whom
were initially referred to neurologists with the exception of
Subject 5, who was initially referred for a psychiatric opinion.
All subjects gave informed consent to take part in this study,
which was conducted with the approval of the ethical
committee of the National Hospital for Neurology and
Neurosurgery (London).
ENT symptoms/audiometry
All subjects had moderate or severe bilateral deafness, as
assessed by pure-tone audiometry (Fig. 1). All subjects
suffered progressive hearing loss. No subject had a family
history of deafness. In Subject 2 the symptomatic onset
occurred when the subject was working as a tank crew
member, whilst in Subject 5 there were two episodes of acute
lateralized hearing loss following head injuries. The duration
of symptomatic hearing loss varied between 5 and 40 years.
Subjects 4 and 5 experienced accompanying tinnitus whilst
Subjects 2 and 4 had experienced rotatory vertigo (related to
head movement in Subject 2, and in only the early history
in Subject 4). No subject experienced a syndrome to suggest
Menière’s disease (fluctuating deafness, fluctuating tinnitus,
fluctuating vertigo or aural fullness).
Case histories
The subjects perceived music in the absence of any musical
stimulus. Several of the subjects had initially thought that
actual music was playing, but all subjects subsequently
attributed the experience to a problem with the brain or the
ears (the nature of the percept did not change). Apart from
low mood accompanying the experiences, which all of
the subjects found distressing, no subject described any
accompanying delusion. There was no description of
experiential features (Gloor, 1990) or generalized convulsions
in any subject. The abnormal auditory experiences were
restricted to the musical domain in all of the subjects except
Subject 6, who also experienced auditory hallucinations in
the form of speech and environmental sounds. All of the
subjects described an experience of continuous or near-
continuous musical hallucinations and described variation in
the severity of their symptoms over the course of the day
(which was an inclusion criterion for the study). There was
no historical suggestion in any of the subjects of any
accompanying difficulty with the perception of music, speech
or environmental sound over and above that due to the
deafness; I did not feel that any of the subjects had an
apperceptive auditory agnosia (Griffiths et al., 1999b). One
of the subjects (Subject 1) had noticed a small decrease in
symptoms with the consistent use of a hearing aid. None of
the other subjects, all of whom had used amplification
devices, felt that these had any effect on the severity of the
experience.
Subject 1
This subject, with 5 years of symptomatic hearing loss, has
been reported previously as a single case (Griffiths et al.,
1997). He had a history of ⬍1 year of continuous musical
hallucinations in the form of multiple singers singing familiar
melodies with indistinguishable lyrics. The onset was abrupt
and not related to any other symptoms. The songs included
hymns and rugby songs, and recent popular music.
Subject 2
This subject, with approximately 40 years of symptomatic
hearing loss, had a history of 3 years of continuous musical
hallucinations. The onset was abrupt and was not
accompanied by other neurological symptoms. The songs
 Musical hallucinosis 2067

Table 1 Subject details

Subject Age Sex Hand* Musical† Index Vascular Symptomatic Measured Tinnitus Vertigo Lateralizing Structural EEG
event disease deafness deafness‡ neurological imaging
(dB ISO) signs

1 73 M 6/6 R No No Stable ⬍5 yr bilateral 51 No No No MRI normal Normal

angina
2 71 M 6/6 R No No HT Noise damage 1950s 53 No Occasional No MRI signal
(tank crew) then with head change in
progressive bilateral movement white matter
loss cerebral
hemispheres
3 78 F 6/6 R No No HT Progressive 95 No No No MRI normal Normal
bilateral loss
⬎40 yr
4 58 F 6/6 R No No No risk 23 yr progressive 82 Yes Yes during No MRI normal No specific
bilateral loss early abnormality
deafness
5 65 M 6/6 R No Head injuries No risk L deafness after after 105 Yes No No MRI signal Minor
aged 15, 57 factors head injury at age 15 yr change in slowing
63 yr R deafness after head hemispheric
injury aged 57 yr, then white matter/
bilateral progression pons
6 82 F 6/6 R No Posterior Single stroke Progressive bilateral, 69 No No No R occipital Normal
circulation without risk 15 yr lobe cyst on
stroke aged factors CT
79 yr

*Handedness on six-point Annett scale (Annett, 1970); †defined as passing a grade examination in any musical instrument; ‡mean hearing level (dB ISO) for the two ears
measured at intervals of 1 octave from 250 Hz to 8 kHz. HT, hypertension.

included light operatic pieces, and popular songs by artists Subject 5

including Shirley Bassey and Boyzone.
Subject 3
This subject, with 40 years of symptomatic hearing loss,
had a history of 9 years of almost continuous musical
hallucinations. The onset was abrupt and not accompanied
by other symptoms. The experience would usually take the
form of organ or piano music, which might be accompanied
by singers. If accompanied by singers, the lyrics would be
distinguishable. The songs included hymns, nursery rhymes
and old popular songs.
This subject, with more than 40 years of progressive deafness,
had a history of 2 years of continual musical hallucinations
in the form of three or four male singers singing familiar
songs with accompanying musical instruments. The onset
followed shortly after a head injury, and was accompanied
by hearing a localized noise behind his head and experiencing
a hot feeling that rose up the back of his head on two
occasions only. There were no accompanying experiential
features or depression of his conscious level. The songs
usually dated from before the 1970s, when the patient lost
interest in listening to music. He finds the sound of actual
music distorted.

Subject 4
This subject, with 23 years of symptomatic hearing loss, had
a history of more than 10 years of almost continuous musical
hallucinosis. The onset of the hallucinations was not abrupt.
The experience was different from that of the other subjects
in that she did not hear instruments or singers but experienced
musical hallucinations in which the individual notes had
the quality of a buzzy pitch. In psychoacoustic terms her
experience would be equivalent to hearing notes with pitch,
where the individual pitches were associated with band-pass
noise with different passbands. Her experience had evolved
from almost continuous tinnitus with similar characteristics
to the buzzy pitches experienced as music. She currently
chooses not to listen to actual music because it is so distorted
at the level she needs to listen.
Subject 6
This subject, with 15 years of progressive deafness, had a
history of less than 3 years of continual musical hallucinations.
The onset of the events was coincident with an episode when
she developed loss of vision, disorientation, perplexion,
slurring of her speech and unsteadiness of body; this is likely
to have been a posterior circulation vascular event. She would
hear one or more singers and accompanying music in the
form of a piano or band. Unlike the five other subjects, she
also experienced environmental sound hallucinations and
verbal hallucinations. The environmental sound hallucinations
included wartime planes and sirens, and the sound of dogs
barking and children crying. The verbal hallucinations
included hearing indistinguishable sounds similar to the
2068 T. D. Griffiths
Fig. 1 Pure-tone audiograms.
murmuring of a crowd and the sound of her sisters talking
to each other. The voices never talked about her or to her.
She also experienced palinacousis; she described several
prolonged hallucinations in the form of hymns triggered by
listening to the television programme ‘Songs of Praise’.
Structural imaging
All subjects underwent structural imaging using MRI
(Subjects 1–5) or CT (Subject 6). No subject demonstrated
loss of grey or white matter volume. MRI of Subjects 2 and
4 demonstrated multiple areas of signal change in the deep
white matter of the cerebral hemispheres consistent with
small vessel disease (Subject 2, Fig. 2). Subject 6 had a large
arachnoid cyst in the right occipital lobe (Fig. 2).
Functional imaging
Functional imaging was carried out using PET to measure
regional cerebral blood flow as a measure of local cerebral
activity. A parametric design was used to demonstrate areas
of the brain where activity varied as a function of the reported
severity of the hallucinosis (Silbersweig et al., 1995; Griffiths
et al., 1997). For each subject, 12 PET scans were performed
on a Siemens scanner with 3D acquisition using the
intravenous oxygen 15 water bolus technique to estimate
regional cerebral blood flow. Twelve acquisitions were
performed in two separate blocks of six that were 12 h apart.
This was in order to maximize the differences in symptom
severity corresponding to the scans. Before the onset of each
scan, the subjects were told that a scan was about to be
carried out and asked to close their eyes. At the end of each
scan they were told that the scan had finished and asked to

Fig. 2 Structural imaging of Subjects 2 and 6. MRI of Subject 2 (left) shows multiple vascular lesions
in the hemispheric deep white matter. CT scan of Subject 6 (right) shows a large arachnoid cyst in the
right occipital lobe.
give a rating, between 1 and 7, of the severity of musical
symptoms during the scan. A rating of 1 corresponded to no
perception of music and 7 to the most severe experience
ever. Subjects also reported the features of the experience
after each scan in response to structured questions, as shown
in Table 2. There was no output task during the scan.
PET image processing and statistical analysis were carried
out using statistical parametric mapping software (SPM99b,
http//:www.fil.ion.ucl.ac.uk/spm). Scans were realigned and
spatially normalized (Friston et al., 1995) to the standard
stereotaxic space of Talairach and Tournoux (Talairach and
Tournoux, 1988). The data were smoothed with a Gaussian
filter (filter width at half maximum, 16 mm). Analysis of
covariance was used to correct for differences in global blood
flow between the scans and to implement individual and
group regression analyses to find areas where blood flow
increased with symptom severity. The significance of this
regression was assessed with the t statistic at each voxel.
These statistics (after transformation to a Z score) constitute
a SPM{Z}.
Results
Systematic study of phenomenology
Systematic interrogation of the subjects every 8 min over the
course of the PET experiment yielded the features reported
in Table 2. All of the subjects showed variation in the severity
of the hallucinosis except for Subject 5, in whom the severity
was fixed. All subjects reported hearing normal patterns of
pitch and rhythm that formed recognizable tunes consistent
with their listening experience and interests. Only Subjects 1
Musical hallucinosis 2069
and 2, who had the least severe hearing loss (~50 dB),
experienced contemporary tunes. In a single scan for one
subject, the reported experience was of music without a
recognizable tune, although it had similar characteristics to
other pieces heard during scanning. All of the subjects, except
Subject 4, heard singers during their imaging, with or without
distinct lyrics. Four of the subjects heard distinct or indistinct
instruments.
PET study to demonstrate areas of activity
correlated with hallucinosis
Individual analyses were carried out on each of the six
subjects except Subject 5, who failed to show any variation
in the severity of the hallucinations over the course of the
experiment. In Subjects 1–4, the analyses were carried out
on realigned, normalized and smoothed data. In Subject 6
the analysis was carried out on realigned and smoothed data,
because of the markedly abnormal brain structure. The
individual analyses were carried out primarily to seek
activation in the primary auditory cortex in Heschl’s gyrus
(HG) as a linear function of hallucinosis strength, taking HG
as the a priori region of interest. The centre of mass of
HG from the probabilistic map of Penhune and colleagues
(Penhune et al., 1996) (left coordinates –45, –20, 8; right
coordinates 45, –15, 5) was used to define the centre of a
spherical volume of interest within HG of diameter 1 cm.
Within this volume, two subjects showed significant activation
at the P ⬍ 0.05 voxel level with correction for the size of
the volume of interest: Subject 2 for the left HG (P ⬍ 0.001
corrected voxel level) and Subject 3 for the right HG
2070 T. D. Griffiths

Table 2 Phenomenology
Scan Score Tune/artist Instrument Singer Distinct lyrics

Subject 1
1 3 ‘Football’s coming home’ No Several male No
2 3 ‘Football’s coming home’ No Several male No
3 2 ‘Football’s coming home’ No Several male No
4 2 ‘Football’s coming home’ No Several male No
5 2 ‘Football’s coming home’ No Several male No
6 2 ‘Football’s coming home’ No Several male No
7 4 ‘Football’s coming home’ No Several male No
8 4 ‘Football’s coming home’ No Several male No
9 4 ‘Football’s coming home’ No Several male No
10 5 ‘Football’s coming home’ No Several male No
11 5 ‘Football’s coming home’ No Several male No
12 4 ‘Football’s coming home’ No Several male No

Subject 2
1 7 ‘What can I do?’, Corrs No Several female Yes
2 7 ‘24 hours from Tulsa’ No One male Yes
3 7 ‘I’ll take you home, Kathleen’ No Single male Yes
4 7 ‘You are my heart’s delight’ Piano Single male Yes
5 7 ‘Edelweiss’ Orchestra 2 female Yes
6 7 ‘Maria’ Guitar 1 male Yes
7 1 No music No No No
8 2 Unrecognized tune Orchestra No No
9 1 No music No No No
10 1 No music No No No
11 4 ‘Sweatheart’ No 1 male/1 female Yes
12 1 No music No No No

Subject 3
1 5 ‘While shepherds’ Organ 1 male/1 female Yes
2 4 ‘While shepherds’ Organ 1 male/1 female Yes
3 6 ‘Poor old Joe’ Organ 1 male Yes
4 7 ‘While shepherds’ Organ No No
5 6 ‘All things bright’ Organ No No
6 7 ‘All things bright’ Organ Several Yes
7 7 ‘Daisy, daisy’ Organ Single male Yes
8 7 ‘Daisy, daisy’ Organ Single male Yes
9 7 ‘Stand up for Jesus’ Organ Single male Yes
10 7 ‘Auld Lang Syne’ Organ 1 male/1 female Yes
11 7 ‘Auld Lang Syne’ Organ 1 male/1 female Yes
12 7 ‘Daisy, daisy’ Organ 1 male/1 female Yes

Subject 4
1 2 ‘Oh my beloved father’ Buzzy pitch No No
2 3 French Christmas carol Buzzy pitch No No
3 3 French Christmas carol Buzzy pitch No No
4 2 ‘Sweet Caroline’, Diamond Buzzy pitch No No
5 3 ‘Pomp and circumstance’ Buzzy pitch No No
6 4 The trout Buzzy pitch No No
7 3 ‘Sound of music’ medley Buzzy pitch No No
8 5 ‘Doe a deer’ Buzzy pitch No No
9 5 ‘Doe a deer’ Buzzy pitch No No
10 5 ‘Doe a deer’ Buzzy pitch No No
11 5 ‘Doe a deer’ Buzzy pitch No No
12 5 ‘Doe a deer’ Buzzy pitch No No

Subject 5
1 5 ‘Che sera sera’ Band Yes several Yes
2 5 ‘Lilly Marlene’ Band Yes several Yes
3 5 ‘Hey there’ Band Yes several Yes
4 5 ‘Runaway train’ Band Yes several Yes
5 5 ‘Three caballros’ Band Yes several Yes
 Musical hallucinosis 2071

Table 2 Continued
Scan Score Tune/artist Instrument Singer Distinct lyrics

Subject 5
6 5 ‘Danny boy’ Band Yes several Yes
7 5 ‘When you’re in love’ Band Yes, 4 Yes
8 5 Irish national anthem Band Yes, large group Yes
9 5 ‘More than ever’ Band Yes Yes
10 5 ‘Yellow rose of Texas’ Band Yes Yes
11 5 ‘Lilly Marlene’ Band Yes Yes
12 5 ‘Lilly Marlene’ Band Yes Yes

Subject 6
1 3 ‘Don’t laugh at me ’cause I’m a fool’ Band Yes, several Yes
2 5 ‘Moonlight and roses’ Band Yes, several Yes
3 5 ‘Dreaming’ Piano Yes, several Yes
4 5 ‘Just a rose in a garden of weeds’ Band Yes, several Yes
5 6 ‘Just a rose in a garden of weeds’ Band Yes, several Yes
6 6 ‘Pal of my cradle days’ Piano Yes, several Yes
7 7 ‘Just a rose in a garden of weeds’ Band Yes, several Yes
8 7 ‘Don’t laugh at me ‘cause I’m a fool’ Piano Yes, several Yes
9 7 ‘Just a rose in a garden of weeds’ Band Yes, several Yes
10 7 ‘Just a rose in a garden of weeds’ Band Yes, several Yes
11 7 ‘Good night Vienna’ Piano Yes, several Yes
12 7 ‘Good night Vienna’ Band Yes, several Yes

(P ⬍ 0.005 corrected voxel level). Analysis was also carried
out on the individual data sets to seek activation as a function
of hallucinosis strength in the planum temporale (PT) as a
region of a priori interest. The centre of mass of the PT
from the probabilistic map of Westbury and colleagues
(Westbury et al., 1999) (left coordinates –60, –30, 10; right
coordinates 65, –30, 10) was used to define the centre of a
spherical volume of interest within the PT of diameter 1 cm.
Three subjects showed significant activation within this
volume at the P ⬍ 0.05 voxel level with correction for the
size of the volume of interest. Significant activation was
demonstrated in the three subjects as follows: Subject 1 (left
PT, P ⬍ 0.05 corrected); Subject 2 (right PT, P ⬍ 0.05
corrected); Subject 3 (right PT, P ⬍ 0.005 corrected).
Group analysis was carried out for Subjects 1–4 (Table 3
and Figs 3 and 4). Subject 5 was excluded from the analysis
because of lack of variation in the severity of hallucinosis,
and Subject 6 was excluded from the analysis because of
markedly abnormal brain structure. The group analysis was
carried out to demonstrate the typical behaviour of the group.
Formally, this represents a fixed-effects analysis. The four
subjects’ similar experiences during scanning, age,
handedness and musicality justify such an analysis. No
activation as a function of hallucinosis strength was
demonstrated in HG on either side in the group analysis.
Using the same volume-of-interest method for HG as in the
individual analyses, no activation was shown at the P ⬍ 0.05
level with correction for the size of the volume. Using the
same method for PT as in the individual analyses, significant
activation as a function of hallucinosis strength was shown
in the left and right plana temporale (left P ⬍ 0.005, right
P ⬍ 0.05, corrected voxel level). The activation in each
planum temporale (Fig. 4) formed part of a cluster extending
on to the lateral surface of the posterior superior temporal
gyrus, as shown in Fig. 3. In the whole-brain analysis,
without taking any prior hypotheses into account (Table 3
and Figs 3 and 4), significant clusters of activation were
demonstrated in the right basal ganglia and right frontal
operculum, the posterior temporal lobes (especially the right),
both lobes of the cerebellum, the left deep sylvian cortex
and the left frontal lobe.
Discussion
In this study I observed the detailed phenomenology of
musical hallucinosis in six patients with acquired deafness.
The subjects all had musical hallucinations that occurred
after the onset of deafness in the absence of features to
suggest psychosis or epilepsy. Based on the phenomenology,
I will argue for a model for the production of musical
hallucinations in such patients based on activity within a
common mechanism for the perception of pattern in
segmented sound. The functional imaging data suggest a
neural substrate for this common mechanism.
Model
Figure 5 shows a model for the normal and abnormal
perception of patterned–segmented sound. This is a cognitive
neuropsychological model (Ellis and Young, 1988) based on
modular psychological mechanisms, although I will also
argue for the likely neural substrate for its implementation.
2072 T. D. Griffiths

Table 3 Functional imaging (areas of significant activation Fig. 5, between the perception/imagery module and encoding/
as a linear function of hallucinosis intensity): group recognition modules.
analysis for Subjects 1–4 The model predicts first that musical hallucinosis due to
Region Coordinates (mm) Z score acquired deafness will be associated with the perception of
normal temporal patterns within segmented sound that are
x y z consistent with the subject’s previous experience. This is the
case in all six subjects observed. In the model, this is the
Right basal ganglia 24 –10 2 5.45
(putamen/globus pallidus) 28 –8 –6 4.77 result of the interaction between the perception/imagery and
16 –10 0 4.55 recognition modules, the latter accessing patterns encoded
Right frontal 54 12 –4 4.15 during previous listening experience. All of the subjects
56 12 0 4.09 experienced music that had been heard before they developed
36 8 –6 4.07 severe deafness, and it is notable that Subjects 1 and 2, who
Left sylvian fissure –40 –24 24 5.24 had experienced more contemporary music, have less severe
–34 –14 24 4.77 hearing loss than the others. In the subjects with the most
–34 –20 14 3.69 marked hearing loss (Subjects 4 and 5), there was a disparity
between the normal experience of old tunes during
Right posterior temporal 72 –38 –16 5.07 hallucinosis and the distorted perception of actual music; this
74 –38 –8 4.62
is entirely consistent with the model. Subject 4 is of particular
Left cerebellum –42 –82 –24 4.66 interest with respect to her normal perception of temporal
–44 –82 –36 4.31 pattern during hallucinosis. She perceives normal temporal
–32 –78 –28 4.23 patterns of pitch, although the individual pitches are not
associated with normal musical notes. This is consistent with
Right cerebellum 16 –54 –32 4.43
22 –62 –26 3.65 distinct mechanisms for the processing of the features of
24 –70 –22 3.44 individual sounds compared with the processing of higher-
level patterns formed by these sounds. Essentially, I am
Left frontal lobe –32 16 34 4.25 arguing in her case that abnormal activity in the module for
–50 28 32 3.71 the perception of individual sounds can have a normal higher-
–38 20 40 3.70
–20 36 2 4.23 order structure imposed by the perception/imagery module.
Some studies of tinnitus (Lockwood et al., 1998) suggest
Left posterior temporal lobe –62 –38 4 4.02 low-level activity in the individual sound module (which, I
–70 –44 8 3.88 have argued, is the primary auditory cortex), whereas others
–60 –30 0 3.69 suggest more distributed high-level processing (Giraud et al.,
Clusters demonstrating significant activation as a linear function 1999). This difference might reflect whether the tinnitus has
of hallucinosis intensity at the P ⬍ 0.05 level (corrected for associated high-level temporal or spatial structure associated
multiple comparisons using Gaussian field theory) are shown. The with it.
three most significant maxima within each cluster are shown, Secondly, the model allows for the ‘triggering’ of activity in
except for the large cluster involving the right basal ganglia and
frontal cortex, where six local maxima are shown.
the perception/imagery module by the impoverished auditory
input. For some sounds the low signal-to-noise ratio in such
input might lead to misperception and misrecognition of
certain incoming sounds as music followed by mental
During normal listening to patterned–segmented sounds ‘amplification’ due to the positive feedback loop between
such as music, the auditory input is processed by two the perception/imagery and recognition modules. The model
perceptual mechanisms, operating in a hierarchical fashion also allows for the triggering of activity in the perception/
(Fig. 5, top). The perceptual mechanism for individual sounds imagery module by any abnormal activity from the module for
operates before that for the perception of the pattern formed the perception of individual sounds. Gordon has particularly
by these sounds. After the pattern has been perceived, it is stressed the possible contribution of early parts of the auditory
encoded into memory. The model is based on a single module pathway to musical hallucinations (Gordon, 1994). I would
being active during both the perception and the imagery of point out here only that the proposed model does not require
patterned sound. In acquired deafness there is impoverished the ascending auditory system to represent a true musical
normal input to this module. I propose that this allows pattern to produce the phenomenon of musical hallucinosis.
spontaneous activity within the module (Fig. 5, bottom). I Triggered activity would also provide a mechanism for the
also propose that the recognition system for patterned sound phenomenon of palinacousis seen in Subject 6.
can interact strongly and reciprocally with the perception/ Two questions arise immediately from the model. First,
imagery module in the absence of normal processing activity the model is based on the processing of patterned sound
in the latter. This may produce positive feedback, represented rather than music per se. The question arises of why the
by the bold arrows in both directions in the lower part of subjects do not usually perceive other forms of patterned–
 Musical hallucinosis 2073

Fig. 3 Functional imaging (correlated activity with hallucination strength surface reading). PET group
analysis for Subjects 1–4 showing areas where regional cerebral blood flow increased as a linear
function of hallucinosis intensity. The functional data shown were thresholded at the P ⬍ 0.001
(uncorrected) voxel level and rendered on to an MRI surface template with the same degree of
smoothing as the PET data.

segmented sound, such as speech. Speech, like music,
contains a high-level structure at the level of hundreds of
milliseconds, called prosody or the ‘melody of language’
(Monrad-Krohn, 1947). Speech, unlike music, is also
characterized by spectral and temporal complexity within the
segmented sounds (in terms of temporal structure, at the level
of milliseconds and tens of milliseconds). The production of
verbal hallucinosis in this model would therefore require
additional abnormal activity in the module for the perception
of individual sounds, as well as in that for the perception of
higher-order pattern. This is possible within the model,
although less likely. Only one of the six subjects in this study
also suffered verbal hallucinations in the form of spoken
speech, although in 41 of the 72 scans observed the subjects
perceived speech with accentuated pattern or prosody in the
form of singing. Previous studies in a broader population,
including subjects with psychiatric disorders, epilepsy and
structural lesions (Berrios, 1990), have also reported verbal
hallucinations in subjects with musical hallucinations. As in
the present study, associated auditory verbal hallucinations
in the form of spoken speech were found only in a minority
of subjects. A second question is why all subjects with
acquired deafness of the degree shown by these subjects do
not experience musical hallucinosis, if this is due to the
activity of a normal module cut off from its normal input?
This might reflect differences between subjects in a threshold
for spontaneous or triggered activity within the perception/
imagery module.
2074 T. D. Griffiths

Fig. 4 Functional imaging. (Top) PET group analysis for Subjects 1–4 showing areas where regional
cerebral blood flow increased as a linear function of hallucinosis intensity (no sound stimulus). The data
shown were rendered on to an axial section of the mean T1-weighted MRI for the four subjects.
(Bottom) For comparison, data for the activation during the normal perception of patterned–segmented
sound in nine normal subjects (Griffiths et al., 1999a) are shown superimposed on an axial section at
the same level. Both sections are at the vertical level z ⫽ 0 mm. A line at y ⫽ –30 mm corresponds to
the anteroposterior maximum for the planum temporale (Westbury et al., 1999). Notice the bilateral
activation in the region of the planum temporale in both analyses.

Fig. 5 (Top) The processes occurring during the normal perception of pattern in segmented sound.
(Bottom) The proposed basis for musical hallucinations, due to spontaneous activity in the module for
the perception and imagery of pattern in segmented sound.

Model implementation
In terms of the neural mechanisms that might underlie this
model, I argued earlier that the perception of the features of
individual sounds involved neural mechanisms at or close to
the primary auditory cortex in HG, whilst the perception of
higher order patterns formed by such sounds involved more
widely distributed mechanisms, including the planum
temporale. A prediction of the model is therefore that
increasing intensity of hallucinosis with increasing
spontaneous activity in the module for pattern perception
will be associated with increasing activation in a network
distinct from HG, including the planum temporale. The group
analysis has demonstrated that the typical behaviour of the
group is to show such increasing activation with increasing
hallucinosis strength in the planum temporale. The typical
behaviour of the group is not to show such activation in HG,
although it was shown in one or other HG in two of the
individual analyses.
A striking feature of this study is the similarity of the
activation produced by musical hallucinosis when there is
perception without input and the perception of actual
patterned–segmented sound in controls (Fig. 4). This is
consistent with the proposed model. However, the perception
of actual patterned–segmented sound also leads invariably to
activation in the primary auditory cortex, something that has
not been demonstrated in this study of hallucinosis. The
analysis of hallucinating patients is not consistent with the
primary auditory cortex being a sufficient substrate for higher-
order pattern perception. The model in Fig. 5 does not make
strong predictions about activation in the module for the
perception of individual sounds in hallucinosis, but this could
occur with descending excitation from the pattern-perception
module to the module for the perception of individual sounds.
If this were the mechanism, the present data suggest that
such feedback activation is not universal.
Activation in a cortical network including the right planum
temporale has been shown in previous studies of the basis
of musical perception (Zatorre et al., 1994). Moreover, studies
of musical imagery have demonstrated a network similar to
that for perception (Zatorre et al., 1996; Halpern and Zatorre,
1999), which supports the common mechanism for musical
perception and imagery proposed in this model. This network
includes predominantly the right auditory association cortex
(including the planum temporale) and the right and left
frontal cortices.
The model I propose is based on activity within a module
for the perception and imagery of pattern within segmented
sound rather than music per se. Imaging studies that
incorporate a task which demands imagery of simple auditory
patterns (Rao et al., 1997; Penhune et al., 1998) have also
demonstrated activation of the right planum temporale in the
absence of activity in the primary auditory cortex. This is
consistent with the activation of the planum temporale in the
current study being a mechanism for the perception and
imagery of patterned–segmented sound, the primary auditory
cortex having an obligatory role in perception only.
Musical hallucinosis 2075
The role of central lesions
The role of central lesions in producing musical hallucinations
has been the subject of controversy. Although gross structural
lesions in the brainstem or either hemisphere can be associated
with musical hallucinosis (Tanabe et al., 1986; Paquier et al.,
1992; Inzelberg et al., 1993; Murata et al., 1994) such lesions
are not seen in most patients with this condition. In the
present study, one subject had a large structural anomaly
(arachnoid cyst), of uncertain relevance, in addition to a
major-territory vascular event. Two other subjects had
multiple vascular lesions affecting the white matter, whilst
two others had vascular risk factors (in addition to age)
without demonstrated lesions on MRI.
Central vascular lesions might be the additional factor that
distinguishes subjects with musical hallucinosis from subjects
with the same degree of deafness without hallucinosis. Several
mechanisms are possible. First, it is possible that diffuse
vascular disease might lead to a degree of disconnection
between the primary auditory and association cortices. In
such a way the input to the perception/imagery module might
be more diminished in the group with vascular disease. A
second possibility is that a vascular lesion or lesions within
the network for the perception and imagery of segmented
sound alters the threshold for spontaneous activity within
this network. I favour the second mechanism, as the
distributed nature of the network would make it more likely
to be affected by a stochastic process such as small vessel
disease. Moreover, the second mechanism involves a network
that includes deep brain structures, which are more likely to
be affected by small vessel disease than the superior temporal
cortex. For either mechanism, vascular disease would act as
a factor to augment the suggested process in the model
dependent on peripheral deafness. Such vascular disease
would not be an adequate explanation in itself.
Conclusion
I have proposed a model for the production of musical
hallucinations in subjects with acquired deafness in the
absence of psychosis or epilepsy. This model is based on
spontaneous activity in a module usually involved in the
normal perception of pattern in segmented sounds. Functional
imaging data support the hypothesis that such a module is
physically realized in a distributed cortical network distinct
from the primary auditory cortices.
All of the subjects considered here found the experience
of musical hallucinations distressing and requested treatment.
Only one subject benefited from any treatment, in the form
of improved amplification. I recommend that subjects within
this group are assessed by an audiology service to decide if
improved amplification may be of benefit, but in general the
prognosis for improving the condition is poor.
Acknowledgements
I wish to thank the patients, many of whom travelled long
distances to undergo detailed assessment and scanning, the
2076 T. D. Griffiths
referring clinicians (R. Brenner, D. Burn, M. Jackson, J.
Palace, S. Pereira, P. Reading, J. Spillane, B. Toone, R.
Wise), members of the Neurootology Department, National
Hospital for Neurology, Queen Square and the Department
of Audiology, Kings College Hospital for carrying out the
audiograms, the radiographers at the Wellcome Department
of Cognitive Neurology for expert technical assistance, and
R. S. J. Frackowiak for helpful comments. I am supported
by the Wellcome Trust (UK).
References
Annett M. A classification of hand preference by association
analysis. Br J Psychol 1970; 61: 303–21.
Berrios GE. Musical hallucinations. A historical and clinical study.
Br J Psychiatry 1990; 156: 188–94.
Binder JR, Frost JA, Hammeke TA, Rao SM, Cox RW. Function
of the left planum temporale in auditory and linguistic processing.
Brain 1996; 119: 1239–47.
Ellis AW, Young AW. Human cognitive neuropsychology. Hove:
Lawrence Erlbaum; 1988.
ffytche DH, Howard RJ, Brammer MJ, David A, Woodruff P,
Williams S. The anatomy of conscious vision: an fMRI study of
visual hallucinations. Nat Neurosci 1998; 1: 738–42.
Friston KJ, Ashburner J, Frith CD, Poline J-B, Heather JD,
Frackowiak RSJ. Spatial registration and normalization of images.
Hum Brain Mapp 1995; 3: 165–89.
Giraud AL, Chery-Croze S, Fischer G, Fischer C, Vighetto A,
Gregoire M-C, et al. A selective imaging of tinnitus. Neuroreport
1999; 10: 1–5.
Gloor P. Experiential phenomena of temporal lobe epilepsy.
[Review]. Brain 1990; 113: 1673–94.
Gordon AG. Musical hallucinations. [Review]. Neurology 1994;
44: 986–7.
Griffiths TD, Jackson MC, Spillane JA, Friston KJ, Frackowiak
RSJ. A neural substrate for musical hallucinosis. Neurocase 1997;
3: 167–72.
Griffiths TD, Buechel C, Frackowiak RS, Patterson RD. Analysis
of temporal structure in sound by the human brain. Nat Neurosci
1998; 1: 422–7.
Griffiths TD, Johnsrude I, Dean JL, Green GGR. A common neural
substrate for the analysis of pitch and duration pattern in segmented
sound? Neuroreport 1999a; 10: 3825–30.
Griffiths TD, Rees A, Green GGR. Disorders of human complex
sound processing. Neurocase 1999b; 5: 365–78.
Halpern AR, Zatorre RJ. When that tune runs through your head:
a PET investigation of auditory imagery for familiar melodies.
Cereb Cortex 1999; 9: 697–704.
Inzelberg R, Vishnievskaya S, Korczyn AD. Transient musical
hallucinosis [letter]. J Neurol Neurosurg Psychiatry 1993; 56: 833.
Keshavan MS, David AS, Steingard S, Lishman WA. Musical
hallucinations: a review and synthesis. Neuropsychiatry
Neuropsychol Behav Neurol 1992; 5: 211–23.
Lockwood AH, Salvi RJ, Coad ML, Towsley ML, Wack DS,
Murphy BW. The functional neuroanatomy of tinnitus: evidence for
limbic system links and neural plasticity. Neurology 1998; 50:
114–20.
Monrad-Krohn GH. Dysprosody or altered ‘melody of language’.
Brain 1947; 70: 405–15.
Mummery CJ, Ashburner J, Scott SK, Wise RJ. Functional
neuroimaging of speech perception in six normal and two aphasic
subjects. J Acoust Soc Am 1999; 106: 449–57.
Murata S, Naritomi H, Sawada T. Musical auditory hallucinations
caused by a brainstem lesion. Neurology 1994; 44: 156–8.
Pantev C, Hoke M, Lutkenhoner B, Lehnertz K. Tonotopic
organization of the auditory cortex: pitch versus frequency
representation. Science 1989; 246: 486–8.
Paquier P, van Vugt P, Bal P, Cras P, Parizel PM, van Haesendonck
J, et al. Transient musical hallucinosis of central origin: a review
and clinical study. J Neurol Neurosurg Psychiatry 1992; 55: 1069–73.
Penfield W, Perot P. The brain’s record of auditory and visual
experience. Brain 1963; 86: 595–696.
Penhune VB, Zatorre RJ, MacDonald JD, Evans AC.
Interhemispheric anatomical differences in human primary auditory
cortex: probabilistic mapping and volume measurement from
magnetic resonance scans. Cereb Cortex 1996; 6: 661–72.
Penhune VB, Zatorre RJ, Evans AC. Cerebellar contributions to
motor timing: a PET study of auditory and visual rhythm
reproduction. J Cogn Neurosci 1998; 10: 752–65.
Phillips DP, Hall SE. Response timing constraints on the cortical
representation of sound time structure. J Acoust Soc Am 1990; 88:
1403–11.
Rao SM, Harrington DL, Haaland KY, Bobholz JA, Cox RW, Binder
JR. Distributed neural systems underlying the timing of movements.
J Neurosci 1997; 17: 5528–35.
Silbersweig DA, Stern E, Frith C, Cahill C, Holmes A, Grootoonk S,
et al. A functional neuroanatomy of hallucinations in schizophrenia.
Nature 1995; 378: 176–9.
Talairach P, Tournoux J. Co-planar stereotaxic atlas of the human
brain. Stuttgart: Thieme; 1988.
Tanabe H, Sawada T, Asai H, Okuda J, Shiraishi J. Lateralization
phenomenon of complex auditory hallucinations. Acta Psychiatr
Scand 1986; 74: 178–82.
Westbury CF, Zatorre RJ, Evans AC. Quantifying variability in the
planum temporale: a probability map. Cereb Cortex 1999; 9:
392–405.
Zatorre RJ. Pitch perception of complex tones and human temporal-
lobe function. J Acoust Soc Am 1988; 84: 566–72.
Zatorre RJ, Evans AC, Meyer E. Neural mechanisms underlying
melodic perception and memory for pitch. J Neurosci 1994; 14:
1908–19.
Zatorre RJ, Halpern AR, Perry DW, Meyer E, Evans AC. Hearing
in the mind’s ear: a PET investigation of musical imagery and
perception. J Cogn Neurosci 1996; 8: 29–46.
Received December 17, 1999. Revised March 1, 2000.
Second revision May 16, 2000. Accepted May 30, 2000