To the Editor: Musical obsessions are rarely reported by patients with obsessive-compulsive disorder. We report a case of musical obsessions along with multiple obsessions and compulsions, and a comorbid tic disorder.

Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and which cause distress. Obsessive thoughts, ruminations, impulses, phobias, and compulsive rituals all find mention in standard textbooks. Intrusive nonsense sounds or music, however, have rarely been reported and are discussed as one of the obsessive ideas.¹ Musical obsessions are uncommon symptoms that were initially described by Kraepelin and are listed almost as an afterthought under the category "miscellaneous obsessions" in the Yale-Brown Obsessive Compulsive Symptom Checklist. There are very few reports of musical obsessions, and they have not been reported along with a tic disorder in the same subject. This patient had musical obsessions, along with multiple obsessions and compulsions and a comorbid tic disorder.

A 22-year-old man presented with complaints of making repetitive circular head movements for 10 years, concern over dirt and germs for 8 years, thoughts of wanting to jump in front of a vehicle for 7 years, making sudden throat-clearing acts for 6 years, having to do work in a particular manner for 5 years, having to make mental lists of pending jobs and repeat them aloud for 4 years, music playing inside his head for 3 years, and images of naked women and goddesses appearing in his head for 2 years. On inquiry, it was also found from his mother that he had hoarded a variety of apparently useless articles from his school days such as old exam question papers, empty refills of pens, and the like.

The symptom of music playing in his head began while he was listening to a song, and even after the radio stopped, the music kept playing inside his head. The tune continued and changed every time he listened to a new tune. He recognized the tune as not coming from some outside source and heard it with reasonable clarity. It continued throughout the day and ceased only when he slept or while he was engaged in some conversation or work. He had full insight into the dysfunctional nature of his experience and regarded it to be intrusive, unwanted, and anxiety-provoking. He tried to resist this music playing inside his head but failed to do so for more than a few seconds.

He had no past history of any significant medical illness, including rheumatic fever, seizures, or head trauma. He had never used illicit drugs, and his personal history was unremarkable. Mental status examination revealed an anxious mood, thought revealed obsessive thoughts, impulses, images, ideas, musical obsessions, mental compulsions, and magical thinking. However, there was no formal thought disorder or perceptual disturbance.

He was initially misdiagnosed with schizophrenia because of his symptoms of music playing inside his head, talking to himself, and withdrawn behavior and was put on olanzapine 10 mg, but his symptoms had worsened. After the current consultation, he was reevaluated and diagnosed with obsessive-compulsive disorder (OCD) with chronic vocal tic disorder. He was started on clomipramine 50 mg daily, with gradual increase up to 150 mg/ daily. Flupenthixol 1 mg was later added as an augmenting agent. The patient reported marked improvement with most of his symptoms on this regimen except for the musical obsessions. He was instructed to perform thought-stopping, exposure, and response-prevention, and Morita therapy, on which he reported around 20% improvement on his musical obsessions and about 70% reduction in his other obsessive and compulsive features and 50% lessening of tics, leading to an overall feeling of well-being and a better quality of life. Keeping in mind the subject’s prepubertal onset of illness, multiple obsessive symptom forms, comorbid tic and hoarding behavior, all of which tend to portend a bleak prognosis, extensive psychoeducation was given to the patient, and his family was actively involved in therapy. The patient maintains his response on the above regimen with a good compliance and a minimal side effect of dry mouth.

The case described here was unique in the sense that the patient had an early onset OCD with the extremely rare presentation of musical obsessions as well as a vocal tic disorder. A MEDLINE search up to November 2011 revealed that none of the handful of cases of musical obsessions reported so far had a comorbid tic disorder.

From a biological point of view, OCD and tic disorder fall in the obsessive-compulsive spectrum. Our patient had a conglomeration of multiple obsessional thoughts, impulses, images, and obsessional phobias, along with an early onset of the illness and tics. This is interesting, as, with the exception of one,² most reports of musical obsessions have noted isolated pure musical obsessions. Indeed, so rare is the musical obsession that authors have thought it may represent a special form of auditory imagery or a sensory obsession.³ This is important in our case, as just about a year after the musical symptoms emerged, the patient began to experience obsessive visual imagery. The relatively close proximity of appearance of the two imagery symptoms in the evolution of the illness may lend support to the hypothesis of musical obsessions potentially being an imagery symptom in the auditory modality. Moreover, it is observed that musical obsessions are notoriously resistant to specific serotonin reuptake inhibitor (SSRI) therapy, as was noted in our patient, who was initially tried on two different SSRIs and then shifted to clomipramine.

Functional imaging and electrophysiological studies have noted perfusion defects in frontal, temporal, and basal ganglia of the brain of subjects with musical obsessions, and some evidence exists for similar dysfunctions in Tourette disorder also, thus providing a putative link between these two conditions and suggesting a common platform for management.⁴

Taking into consideration all the above, a combined psychological and pharmacological approach was adopted for the management. Exposure and response-prevention was used for some of the components, such as dirt and contamination, and relaxation techniques were employed as an adjunctive means to lessen some of the general anxiety features. Thought-stopping technique was used for the musical obsessions, as it has been used with success earlier in a case with similar symptomatology.² Morita therapy, based upon the principle of arugamama, was offered to him as an adjunct that emphasizes the process of accepting reality as it is and leading one’s life despite the concomitant presence of some symptoms.⁵

Psychopharmacological approaches included clomipramine at 150 mg/day and add-on flupenthixol 1 mg/day was used, considering the fact that earlier reports have noted response to clomipramine in SSRI-resistant musical obsessions.⁶ Low-dose flupenthixol was added, both to augment the anti-obsessive action of clomipramine and also for the management of the tics.⁷

In conclusion, musical obsessions represent an uncommon psychopathology in psychiatric patients, and the above report may suggest that clinicians should have a lower threshold to detect them, differentiate them from close differentials like musical hallucinations, search for comorbidities, and manage them in a holistic manner.