Never gonna give you up: Intrusive musical imagery as compulsions

Intrusive musical imagery (IMI) is characterized by recalling pieces of music,¹ usually repetitions of 15 to 30 seconds,² without pathology of the ear or nervous system.¹ Also known as earworm—ohrwurm in German—or involuntary musical imagery, bits of music can become a constant cause of distress.¹

IMI is prevalent in the general population; in an internet survey >85% of respondents reported experiencing IMI at least weekly.² IMI can be generated by:

• hearing music
• reading song lyrics
• being in contact with an environment or people who are linked to specific song, such as department stores that play holiday music.^2,3

IMI also is associated with stressful situations or neurological insult.¹

Any song or segment of music can be the basis of IMI. The content of IMI change over time (ie, a new song can become a source of IMI).³ The frequency of experiencing IMI is correlated to how much music a person is exposed to and the importance a person places on music.² Most episodes are intermittent; however, continuous musical episodes are known to occur.³ Episodes of IMI with obsessive-compulsive features can be classified as musical obsessions (MO).¹ MO may be part of obsessive-compulsive symptoms, including washing, checking, aggression, sexual obsessions, and religious obsessions or other obsessions.¹

Diagnosing musical obsessions

No current measures are adequate to diagnose MO. The Yale-Brown Obsessive Compulsive Scale does not distinguish MO from other intrusive auditory imagery.¹

It is important to differentiate MO from:

• Musical preoccupations or recollections in which an individual repeatedly listens or recalls a particular song or part of a song, but does not have the urge to listen or recall music in an obsessive-compulsive pattern.¹ These individuals do not display fear and avoidant behaviors that could be seen in patients with MO.¹
• Musical hallucinations lack an input stimulus and the patient believes the music comes from an outside source and interprets it as reality. Misdiagnosing MO as a psychotic symptom is common and can result in improper treatment.¹

Management

Pharmacotherapy. MO responds to the same medications used to treat obsessive-compulsive disorder, such as selective serotonin reuptake inhibitors and clomipramine.¹ Cognitive-behavioral interventions could help patients address dysfunctional beliefs, without trying to suppress them.¹

Distraction. Encourage patients to sing a different song that does not have obsessive quality¹ or engage in a task that uses working memory.³

Exposure and response prevention therapy. Some case reports have reported efficacy in treating MO.¹