The song and binding mode: Musical hallucinations in video game playing

According to a 2015 review in the journal Frontiers in Psychology by Jan Coebergh and colleagues, musical hallucinations (MHs) “are auditory hallucinations characterized by songs, tunes, melodies, harmonics, rhythms, and/or timbres…and that the mechanisms responsible for the mediation of MH are probably diverse”. While Danilo Vitorovic and Jose Biller reported in a 2013 issue of Frontiers in Neurology that the prevalence rate of MHs among the general population is at present unknown and/or rare, ‘involuntary musical imagery’ (INMI) is thought to be more commonplace. For instance, in a 2012 Finnish study in the journal Psychology of Music, Lassi Liikkanen reported that 89% of the total sample (n=12,519) reported experiencing INMI at least once a week. Music hallucination prevalence rates among various groups have been reported including obsessive-compulsive disorder patients (41%; Journal of Clinical Psychiatry, 2004), elderly people with auditory problems (2.5%; International Journal of Geriatric Psychiatry, 2002), and general hospital setting patients (0.16%; Psychosomatics, 1998).

Although Coebergh and colleagues described MHs, they were not explicitly defined. In a review in a 2014 issue of the Journal of Medical Case Reports, Woo and colleagues defined MHs as “complex auditory perceptions in the absence of an external acoustic stimulus and are often consistent with previous listening experience” whereas the 2013 review by Vitorovic and Biller (see above) noted that MHs “represent a specific form of auditory hallucinations whereby patients experience formed songs, instrumental music, or tunes, without an external musical stimulus”. In a 2015 paper in the journal Psychomusicology: Music, Mind, and Brain, Tim Williams provided a classification of INMI and noted they cover a number of different types of involuntary musical experience (including MHs). Despite the lack of detailed definition, it is known that MHs occur within the context of an individual’s culture and are often viewed by those experiencing them as intrusive and sometimes unpleasant.

In 2015, Dr. Angelica Ortiz de Gortari and I wrote a commentary paper on musical hallucinations in videogame playing in response to the review by Coebergh and colleagues. As far as we were aware, we noted that no review paper examining musical hallucinations had ever included papers referring to musical hallucinations arising from playing video games. The earliest report in the psychological literature is by Sean Spence (published in 1993 in the Irish Journal of Psychological Medicine) who reported the case of a 20-year-old female patient with a family history of psychosis. She presented with persecutory delusions, suicidal ideation, violent behaviour and third-person auditory hallucinations comprising 48 hours of constant MHs from the Mario Brothers videogame that developed into delusional thoughts. No drugs were found in her urinary system and her EEG was normal when MHs occurred. The MHs from the videogame decreased within 48 hours of treatment (using antidepressants and neuroleptics).

More recently, a series of papers by Dr. Ortiz de Gortari and I examined Game Transfer Phenomena (GTP). GTP research has demonstrated how the videogame can keep on playing even after the game has been turned off. GTP are non-volitional phenomena (e.g., altered perceptions, automatic mental processes, and involuntary behaviors). In an analysis of over 1600 gamers’ self-reports, our research has shown that videogame playing can lead to (i) perceptual distortions of physical objects, environments, and/or sounds, (ii) misperceptions of objects and sounds that are similar to those in the videogame, (iii) interpretation of events in real life contexts that utilize the logic of the videogame, (iv) ghost perceptions and sensations of images, sounds, and tactile experiences, and (v) involuntary actions and behaviors based on experiences from the videogame.

One study that we published in a 2014 issue of the International Journal of Cyber Behavior, Psychology and Learning specifically examined auditory GTP experiences. Gamers’ experiences identified as GTP in one or more modalities (e.g., visual, auditory) were collected from 60 online videogame forums over seven months. Of these, there were 192 auditory experiences from 155 gamers collected. The largest numbers of experiences (90%) were identified as involuntary auditory imagery. This manifested as hearing music (n = 73), sound (n = 83), or voices from within the game (n = 12). Some experiences were triggered by external cues associated with the game, while others were not. Experiences with music included hearing high pitch music in addition to calm and classical music.

Music from the videogames was usually experienced persistently, while sound effects or voices appeared to have occurred more episodically. Hearing the music persistently provoked sleep deprivation, annoyance, and uncertainty. When the music was re-experienced very vividly, the gamers attributed them to external sources associated with the videogame. More specifically, when auditory cues were associated with adverse videogame content, they resulted in irrational thoughts, reactions and changes in behaviour. In many cases, the gamers said that they had been playing intensively (i.e., either playing long sessions or playing frequently). Previous studies have linked hearing music in absence of auditory stimuli with the recent or repeated exposure to music (see ‘Further reading’ below including: Gardner, 1985; Gerra et al., 1998; Hyman et al., 2012).

In our study, one gamer said that he heard the sound of music coming out from the speakers so he stood up to check them while another heard music from Pokémon when vacuuming. It also appears that musical hallucinations can cross sensory modalities. For instance, some gamers have reported hearing music while seeing images from the video game. An online survey about GTP with a convenience sample of 2,362 gamers found that hearing music from videogames when not playing were the more prevalent (74%) than hearing sounds (65.0%) or voices (46%) when not playing (Ortiz de Gortari & Griffiths, 2015b).

Based on what is known empirically, our paper concluded that (i) MHs from videogame playing – although not well documented – appear to be relatively commonplace among gamers and prevalence appears to be higher than found in other populations, (ii) individual interpretation of MHs from videogames are influenced by the meanings and uses of auditory cues in the videogames, (iii) MHs can manifest beyond one sensory modality and has been reported across-sensory channels (e.g., hearing music while seeing ghost images from the game), (iv) there is little evidence that MHs among videogame players are linked to other underlying pathology (e.g., epilepsy, psychiatric disorder, etc.), (v) those researching in the field of MHs and INMI appear to have overlooked the literature on these phenomena related to videogame playing, and (vi) better definitions are needed for MHs and a distinction between MHs and INMI is required.

(Please note: This blog is based on material used in the following paper: Griffiths, M.D. & Ortiz de Gortari, A.B. (2015). Musical hallucinations: Review of treatment effects. Frontiers in Psychology, 6, 1885. doi: 10.3389/fpsyg.2015.01885).

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Coebergh, J. A. F., Lauw, R. F., Bots, R., Sommer, I. E. C., & Blom, J. D. (2015) Musical hallucinations: review of treatment effects. Frontiers in Psychology, 6, 814.

Cole M.G., Dowson, L., Dendukuri, N., & Belzile, E. (2002). The prevalence and phenomenology of auditory hallucinations among elderly subjects attending an audiology clinic. International Journal of Geriatric Psychiatry (2002) 17, 444–52.

Fukunishi, I., Horikawa, N., & Onai, H. Prevalence rate of musical hallucinations in a general hospital setting. Psychosomatics (1998) 39, 175.

Hermesh H. (2004). Musical hallucinations: prevalence in psychotic and nonpsychotic outpatients. Journal of Clinical Psychiatry, 65, 191–7. doi:10.4088/JCP.v65n0208

Gardner, M. P. (1985). Mood states and consumer behavior: A critical review. Journal of Consumer Research, 12, 281-300.

Gerra, G., Zaimovic, A., Franchini, D., Palladino, M., Giucastro, G., Reali, N., . . . Brambilla, F. (1998). Neuroendocrine responses of healthy volunteers to `techno-music’: relationships with personality traits and emotional state. International Journal of Psychophysiology, 28(1), 99-111.

Griffiths, M.D. & Ortiz de Gortari, A.B. (2015). Musical hallucinations: Review of treatment effects. Frontiers in Psychology, 6, 1885. doi: 10.3389/fpsyg.2015.01885

Hyman, I. E., Burland, N. K., Duskin, H. M., Cook, M. C., Roy, C. M., McGrath, J. C., & Roundhill, R. F. (2012). Going gaga: Investigating, creating, and manipulating the song stuck in my head. Applied Cognitive Psychology, 27, 204-215.

Liikkanen, L. A. (2012). Musical activities predispose to involuntary musical imagery. Psychology of Music, 40(2), 236-256.

Ortiz de Gortari, A. B, Aronsson, K. & Griffiths, M. D. (2011). Game Transfer Phenomena in video game playing: A qualitative interview study. International Journal of Cyber Behavior, Psychology and Learning, 1(3), 15-33.

Ortiz de Gortari, A. B. & Griffiths, M. D. (2014). Auditory experiences in Game Transfer Phenomena: An empirical self-report study. International Journal of Cyber Behavior, Psychology and Learning, 4(1), 59-75.

Ortiz de Gortari, A. B. & Griffiths, M. D. (2014). Altered visual perception in Game Transfer Phenomena: An empirical self-report study. International Journal of Human-Computer Interaction, 30, 95-105.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2014). Automatic mental processes, automatic actions and behaviours in Game Transfer Phenomena: An empirical self-report study using online forum data. International Journal of Mental Health and Addiction, 12, 432-452.

Ortiz de Gortari, A.B. & Griffiths, M.D. (2015). Game Transfer Phenomena and its associated factors: An exploratory empirical online survey study. Computers in Human Behavior, 51, 195-202.

Ortiz de Gortari, A. B., Pontes, H. M. & Griffiths, M. D. (2015). The Game Transfer Phenomena Scale: An instrument for investigating the non-volitional effects of video game playing. Cyberpsychology, Behavior and Social Networking, in press.

Ortiz de Gortari, A.B. & Griffiths, M.D (2015b). Prevalence and characteristics of Game Transfer Phenomena: A descriptive survey study. Manuscript under review.

Spence, S. A. (1993). Nintendo hallucinations: A new phenomenological entity. Irish Journal of Psychological Medicine, 10, 98–99.

Vitorovic, D. & Biller, D. (2013). Musical hallucinations and forgotten tunes – case report and brief literature review. Frontiers in Neurology, 4, 109. doi: 10.3389/fneur.2013.00109

Williams, T. I. (2015). The classification of involuntary musical imagery: The case for earworms. Psychomusicology: Music, Mind, and Brain, 25(1), 5-13.

Woo, P. Y. M. Leung, L. N. Y., Cheng, S. T. M. & Chan, K-Y. (2014). Monoaural musical hallucinations caused by a thalamocortical auditory radiation infarct: a case report. Journal of Medical Case Reports, 8, 400.

Stitches brew: A brief look at self-harm lip sewing

In previous blogs I have examined both self-harming behaviour (such as cutting off one’s own genitals, removing one’s own eye, removing one’s own ear, self-asphyxial risk taking in adolescence, and religious self-flagellation) and extreme body modification. One area where these two areas intersect is lip sewing. According to the Wikipedia entry on lip sewing:

“Lip sewing or mouth sewing, the operation of stitching together human lips, is a form of body modification. It may be carried out for aesthetic or religious reasons; as a play piercing practice; or as a form of protest. Sutures are often used to stitch the lips together, though sometimes piercings are made with needle blades or cannulas and monofilament is threaded through the holes. There is usually a fair amount of swelling, but permanent scarring is rare. Lip sewing may be done for aesthetic reasons, or to aid meditation by helping the mind to focus by removing the temptation to speak. BMEzine, an online magazine for body modification culture, published an article about a 23-year-old film student Inza, whose quest for body modifications was very varied. She spoke about her experiences with lip sewing as a form of play piercing”.

My reason for writing this blog was prompted by a case study published by Dr. Safak Taktak and his colleagues in the journal Health Care Current Reviews. (I ought to add that I have read a number of papers by Taktak and his colleagues as they have reported some interesting other interesting case studies including those on shoe fetishism, semen fetishism, and fetishes more generally – see ‘Further reading’ below). In this particular paper, they reported the case of a male prisoner who had continually sewed his lips together. Although they were aware of cases of sewing lips together as a form of protest, they claimed that there had never been any case reported in the medical literature.

The case report involved a male 37-year old Turkish (imprisoned) farmer, father of two children, with only basic education. After sewing his lips together, the man was brought into the hospital by the police, along with a handwritten note that read: “My jinns imposed speech ban to me and they made me sew my lips unwillingly. Otherwise, they threaten me with my children. I want to meet a psychiatrist urgently”. (Jinns I later learned are – in Arabian and Muslim mythology – intelligent spirits of lower rank than the angels, able to appear in human and animal forms and are able to possess humans). Not only were his lips sown together with black thread but he had also sewn both of his ears to the side of his head (these are also photographed in the paper and you can download the report free from here). This was actually the fourth time the man had sewed his lips together (but the first that he had sewn his ears). Each time, the doctors took out the stitches and dressed the wounds. The authors examined previous documentation about the man and reported that the man had been in prison for four years after injuring someone (no details were provided) and had been diagnosed with both anxiety disorder and anti-social personality disorder. On a prison ward comprising ten other prisoners, he had attempted suicide when trying to hang himself (in fact, you can clearly see the marks on his neck in the paper’s photographs). The authors reported that:

[The man] had blunted affect. He wasn’t able to stay in the [prison] ward because of the directive voices in his head. He declared he needed to stay in the ward alone. He heard all the words as swearing and he was punished by some people as well as some entities. He also said that some jinns in the form of animals threatened him not to speak and listen to anyone; otherwise they were going to kill his kids. He wanted to protect his children [and] he stitched his lips not to speak anyone and stitched his ears not to hear anyone. In his family history, he stated that his uncle committed suicide by hanging himself and saying ‘the birds are calling me’; his father was schizophrenia-diagnosed”.

The authors then reported:

“The patient stated that he sewed his lips with any colour of thread he could find. He had approximately fifteen pinholes on his upper and lower lips. He tended to suicide with directive auditory and visual hallucination (sic) and reference paranoid delirium. As he was imprisoned, he wasn’t able to use drugs. The patient who was thought to have a psychotic disorder was injected [with] 10 mg haloperidol intramuscularly and he was sent to a safe psychiatry hospital”.

As I have noted in my previous blogs on self-harming behaviour (and as noted in this particular paper), there are many different definitions of what constitutes self-destructive behaviour. This particular case was said to be suited to the psychotic behaviours characterised by Dr. Armando Favazza’s three self-destructive behaviours (i.e., compulsive, typical, and psychotic) outlined in his 1992 paper ‘Repetitive self-mutilation’ (published in the journal Psychiatry Annals). In their discussion of the case, the authors noted:

“The cases like sewing one’s own lips which we observe as a different type of destructing oneself in our case are mostly regarded as intercultural expression of feelings. The ones, who sew their lips in order to protest something, show their reactions by blocking the nutrition intake organ to the ones who want to continue their superiority. It can be expected in psychotic cases that the patients or his beloved ones might be harmed, damaged or affected emotionally. Thus, the patient who is furious and anxious might react by [attempting] violence as a reaction to these repetitive threats. Auditory hallucinations giving orders can cause the aggressive behaviours to start…In our psychotic case, this kind of behaviour is a way to prevent the voices coming from his inner world, not to answer them and hence making passive defending to world which he does not want to interact. By this means, he may harmonise with the secret natural powers which affect him and he may protect himself his children…[also] there can be a relief through sewing lips and ears or strangulation against the oppression created by the person not being able to adapt the prison…It should not be forgotten that the prison is a stressful environment and stressful living [increases] the disposition to psychopathologic behaviour that the living difficulties in prisons can affect the way of thinking and the capacity of coping and it may cause different psychiatric incidences”.

As noted at the start of this article, lip sewing is typically attributed to religious reasons, reasons of protest or aesthetic reasons. In this particular case, none of these reasons was apparent (and therefore notable – in the medical and psychiatric literature at the very least). The addition of sewing his ears appears to be even more rare, and thus warrants further research.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Favazza, A.R. (1992). Repetitive self-mutilation. Psychiatric Annals, 22(2), 60-63.

Taktak, S., Ersoy, S., Ünsal, A., & Yetkiner, M. (2014). The man who sewed his mouth and ears: A case report. Health Care Current Reviews, 2(121), 2.

Taktak, S., Karakus, M., & Eke, S. M. (2015). The man whose fetish object is ejaculate: A case report. Journal of Psychiatry, 18(276), 2.

Taktak, S., Karakuş, M., Kaplan, A., & Eke, S. M. (2015). Shoe fetishism and kleptomania comorbidity: A case report. European Journal of Pharmaceutical and Medical Research, 2, 14-19.

Taktak, S., Yılmaz, E., Karamustafalıoglu, O., & Ünsal, A. (2016). Characteristics of paraphilics in Turkey: A retrospective study – 20years. International Journal of Law and Psychiatry, in press.

Wikipedia (2016). Lip sewing. Located at: https://en.wikipedia.org/wiki/Lip_sewing

A noise that annoys: A brief look at exploding head syndrome

Over the past few years I have suffered occasional bouts of tinnitus and have to say that when it occurs it completely dominates all my thoughts and thinking (although I’ve been told by more than one person that my excessive i-Pod use is to blame and therefore somewhat self-inflicted medical condition). A condition that must be a hundred times worse is that of ‘exploding head syndrome’ (EHS). The condition was first reported by the Welsh psychiatrist Dr. Robert Armstrong-Jones almost 100 years ago in The Lancet (and described as “a snapping of the brain”). A much more recent detailed description of 50 EHS cases was reported by British neurologist Dr. John Pearce in a 1989 issue of the Journal of Neurology Neurosurgery and Psychiatry (following an initial short report of 10 cases that Pearce published in a 1988 issue of The Lancet).

EHS is known to be a type of hypnagogic auditory hallucination where the person experiences a very sudden and brief loud (but usually painless) noise originating from inside their head for a fraction of a second. Some EHS sufferers also report that the loud noise may sometimes be accompanied by breathing irregularities and/or intense light flashes (so called ‘visual sleep starts’). Those who have experienced such loud noises have likened it not only to an explosion, but to a wide range of very loud noises. The 1989 paper by Dr. Pearce listed 50 patient descriptions that included gunshot, loud electrical buzzing, a loud Xmas cracker, thunderclap, a clash of cymbals, loud ringing, crashing waves, loud screaming and roaring, loud electrical static, and/or slamming car doors). There doesn’t appear to be any typical pattern among sufferers, although most EHS sufferers claim the number of attacks diminish over time following initial frequent occurrences. Some individuals experience it just once without any reoccurrence.

Any hypnagogic condition means by definition that it occurs around the onset of sleep (or the early stages of getting to sleep) and EHS is no different. (Hypnagogia refers to the state of being between awake and asleep, often called the ‘twilight of sleep’). Although the loud noise may be part of dreaming, many sufferers report that dreaming is not a necessary condition to induce the inner noise. Following an EHS attack (often experienced in the left side of the head), some individuals may experience fear and anxiety and/or heart palpitations. It is thought to be slightly less prevalent among men than women, and is more prevalent as people get older (i.e., there is much higher incidence in individuals aged over 50 years although there are reports among pre-pubescents).

Although there is no formal treatment for EHS, various therapies have been tried. Case reports have shown that some medicines appear to reduce EHS symptoms including clonezapam (reported in the journal Neurology [2008]), clomipramnine (reported in the journals Sleep [1991] and Cephalalgia [2008]), and nifedipine (reported in the journal Cephalalgia [2001]). Two cases were successfully treated using flunarizine (in the journal Cephalalgia [2008]). Other medications have been tried but EHS sufferers have not shown any improvement including doxepin, citalopram, trimipramine, and amitriptyline, valproic acid, amitriptyline, propranolol oxycodone, and gabapentin. The most recently published case study involving treatment of EHS that I am aware of was a short 2010 paper by Dr. Gaurang Palikh and Dr, Bradley Vaughn and published in the Journal of Clinical Sleep Medicine. They described the case of a women with EHS who was successfully treated using pharmacotherapy (in this case, topiramate medication). The authors reported that:

“A 39-year-old female reported symptoms of a loud bang and buzzing noise at sleep onset for 3 years. She said that, if the sound was external, her ‘husband should be able to hear it downstairs when she was up in her bedroom. Associated with this noise, she experienced brief jerking movement of her head, leg, or arms at sleep onset on a daily basis. She noted these symptoms for years; because of the increase in intensity and frequency, she saw a neurologist. The patient had become anxious about these events, fearing that they were a hallmark of more serious medical issues. Her neurological exam, laboratory test results, and neuroimaging were normal. Because of the stereotypic nature of the events and the level of disturbance to the patient, she was admitted for continuous video EEG monitoring for 4 days. Coincidently, the patient’s neurologist prescribed topiramate 50 mg twice a day for migraine prophylaxis…Two months after admission, she reported improvement in the intensity of the noise. At a daily dose of topiramate 200 mg, the patient reported the bang had significantly improved, and now sounded like a low buzzing noise. The frequency of the events was unchanged, but the intensity of the events decreased to the point of being mildly noticeable. She had marked improvement in subjective ability to fall asleep and felt these events were no longer disruptive”.

It is not known why EHS occurs although there is some speculation that it is associated with the withdrawal from prescription drugs, extreme fatigue, and/or stress. There are also some reports that EHS attacks sometimes occur when individuals have out-of-body experiences. As a consequence, some EHS sufferers develop insomnia because of a fear about going to sleep or resting. Others experience a loss in appetite. The mechanism by which the loud noise is heard is also unknown although there are speculative reasons such as being due to minor seizures in the brain’s temporal lobe (the location of hearing’s nerve cells) or sudden movements in the middle ear. Some research has monitored EEG brain activity during actual EHS attacks that show atypical brain activity among some (but certainly not all) EHS sufferers. Although the condition appears to be very rare, it certainly exists and most people appear to get better over time (with or without treatment).

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Armstrong-Jones, R. (1920). Snapping of the brain. The Lancet, 196, 720.

Chakravarty, A. (2008). Exploding head syndrome: Report of two new cases. Cephalalgia, 28, 399-400.

Gordon, A.G. (1988). Exploding head (letter), The Lancet, 198, 625-626.

Jacome, D.E. (2001). Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia, 21, 617-618

Palikh, G.M. & Vaughn, B.V. (2010). Topiramate responsive exploding head syndrome. Journal of Clinical Sleep Medicine, 6, 382-383.

Pearce, J.M. (1988). Exploding Head Syndrome. The Lancet, 332, 270-271.

Pearce, J.M. (1989), Clinical features of the exploding head syndrome. Journal of Neurology Neurosurgery and Psychiatry, 52, 907–910.

Sachs, C. & Svanborg, E. (1991), The exploding head syndrome: polysomnographic recordings and therapeutic suggestions. Sleep, 14, 263-266.

Salih, F., Kleingebiel, R., Zschenderlein, R., & Grosse P. (2008). Acoustic sleep starts with sleep onset insomnia related to a brainstem lesion. Neurology, 70, 1935-1936.

Jacome, D.E. (2001). Exploding head syndrome and idiopathic stabbing headache relieved by nifedipine. Cephalalgia, 21, 617-618.