Patient with musical hallucinations and obsessive compulsive disorder. Individualised statistical parametric mapping 18FDG PET and repetitive transcranial magnetic stimulation (rTMS)
Abstract
Musical hallucinations are associated with hypacusis, psychiatric disorders (obsessive - compulsive disorder, schizophrenia, mood disorders, etc.), brain focal lesion, epilepsy and intoxication. A 60 year-old woman (with a history of epilepsy since age 15, anteromesiobasal resection of the right temporal lobe at the age of 50 and hypacusis from the age of 58) was hospitalized at the Psychiatric centre Prague with musical hallucinations which started at age 56 and obsessive-compulsive disorder (OCD) since age 57.
She was treated with fluvoxamine, sertraline, haloperidole, tiapride, melperone, lamotrigine, gabapentine and with escitalopram and risperidone during current hospitalizations. These CNS drugs had no effect on the musical hallucinations or obssessive- compulsive symptoms.
She was assessed by 18FDG PET. Results: 18FDG PET detected a decreased metabolism in the right anterior temporal lobe and an increased metabolism in the orbitofrontal cortex BA 11, middle/inferior frontal gyrus BA 46 bilateraly, left ncl. putamen.
Based on the PET scan we started rTMS over the prefrontal cortex bilateraly (1 Hz, 100 % motor treshold, 900 pulses under both prefrontal cortices in 17 sessions). We did not see clinical improvement in the specific rating scale for OCD (Y- BOCS), but rTMS led to a reduction (Visual analog scale) in musical hallucinations by 44%.
Hypometabolism in the right temporal lobe reflects the state after anteromesiobasal resection of the right temporal lobe. Hypermetabolism in the prefrontal cortex and nc. putamen is in agreement with neuroimaging findings for OCD and musical hallucinations.
To the best of our knowledge, this is the first report concerning the possibility for a decreased intensity of musical hallucinations with prefrontal rTMS.