Musical obsession or musical hallucination? A psychopathological and psychopharmacological reflection based on a fictional vignette

Abstract

Introduction: Persistent musical phenomena occupy an underdiscussed clinical boundary between intrusive musical imagery, musical obsession, and musical hallucination. This distinction matters because each formulation guides different diagnostic investigation, management, and communication. Objective: To propose a psychopathological and psychopharmacological reflection on the diagnostic question “musical obsession or musical hallucination?”, using an entirely fictional clinical vignette not derived from a real case. Discussion: Musical obsession tends to present as intrusive, repetitive, unwanted, and ego-dystonic mental content, often accompanied by anxiety, preserved insight, and efforts at resistance or neutralization. Musical hallucination, by contrast, is a perceptual experience of music without a corresponding external source, often associated with hearing impairment, sensory deprivation, neurological conditions, medications, neurocognitive disorders, or psychiatric disorders. Neither DSM-5-TR nor ICD-11 defines “musical obsession” or “musical hallucination” as autonomous diagnoses; both require syndromic, contextual, and differential formulation. Psychopharmacological treatment depends on the formulation: anti-obsessional strategies such as serotonin reuptake inhibitors and clomipramine may be considered when obsessive-compulsive phenomenology predominates; antipsychotics, anticonvulsants, medication review, auditory management, or neurological approaches may be required in specific contexts of musical hallucination or comorbidity. Conclusion: The question “musical obsession or musical hallucination?” should not be answered hastily. The clinical value lies in sustaining diagnostic doubt, describing the experience with phenomenological precision, and individualizing treatment without inappropriately labeling the patient as psychotic.