Nordic Journal of Music Therapy

ISSN: 0809-8131 (Print) 1944-8260 (Online) Journal homepage: http://www.tandfonline.com/loi/rnjm20

Effects of music as an adjunctive therapy on

severity of symptoms in patients with obsessive-
compulsive disorder: Randomized controlled trial

Deldar Morad Abdulah, Salim Saadi Miho Alhakem & Rasoul Sabri Piro

To cite this article: Deldar Morad Abdulah, Salim Saadi Miho Alhakem & Rasoul Sabri Piro
(2018): Effects of music as an adjunctive therapy on severity of symptoms in patients with
obsessive-compulsive disorder: Randomized controlled trial, Nordic Journal of Music Therapy, DOI:
10.1080/08098131.2018.1546222

To link to this article: https://doi.org/10.1080/08098131.2018.1546222

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NORDIC JOURNAL OF MUSIC THERAPY
https://doi.org/10.1080/08098131.2018.1546222

ORIGINAL RESEARCH ARTICLE

Effects of music as an adjunctive therapy on severity of

symptoms in patients with obsessive-compulsive
disorder: Randomized controlled trial
a
Deldar Morad Abdulah , Salim Saadi Miho Alhakemb and Rasoul Sabri Piroc
a
Adult Nursing Department, College of Nursing, University of Duhok, Iraqi Kurdistan; bInternal
Medicine Department, Malta Campus, College of Medicine, University of Duhok, Duhok, Iraqi
Kurdistan; cNursing Department, College of Nursing, University of Duhok, Duhok, Iraqi Kurdistan

ABSTRACT
Introduction: Obsessive-compulsive disorder is a critical mental disorder. Music
listening is non-invasive, safe and harmless, well-tolerated, inexpensive, and has
therapeutic advantages in a wide range of mental disorders. The impact of passive
music listening as an adjunctive therapy on symptoms severity in patients with
obsessive-compulsive disorder was evaluated in this study.
Methods: In a parallel posttest-study only randomized controlled trial, 36 patients
(range 19 to 65 years) were randomly allocated to experimental group (n = 17) or
control group (n = 19) in Duhok, Iraq in 2017. The experimental group received
seven 50-minute relaxing music tracks to listen daily in addition to regular pharma-
cological treatment for a three-month period. The control group received regular
treatment only. The severities of obsession, compulsion, and obsessive-compulsive
symptoms were assessed using the Yale-Brown Obsessive Compulsive Scale symp-
tom severity scale following study completion only.
Results: The experimental group had significantly lower symptom severities than the
control group in terms of obsessions and compulsions, and the overall obsessive-
compulsive score, effect size: 0.77, 0.95, and 0.78,, and 95% CI: 6.29–9.43; CI: 6.22–
9.43; and CI: 12.57–18.81, respectively.
Discussion: The study showed that passive music listening as an adjunctive therapy
to regular treatment is an effective method to reduce obsessions and compulsions
severities in patients with obsessive-compulsive disorder. Clinical Trial Registration
Number in the local registry: 21082016–6 (21 August 2016).

ARTICLE HISTORY Received 19 April 2017; Accepted 28 October 2018

KEYWORDS Obsession; compulsion; obsessive-compulsive disorder; symptoms; severity; music listening

Introduction
Music is used in everyday life for a variety of purposes such as entertainment and is used
for its therapeutic benefits in public health settings and in treatment of a wide range of
mental disorders. Impacts of music therapy (MT) have been recognized owing to its
relaxing characteristics. According to one definition, MT is the “systematic use of music

CONTACT Deldar Morad Abdulah deldarmorad@gmail.com Adult Nursing Department, College of

Nursing, University of Duhok, Iraqi Kurdistan
Supplemental data for this article can be accesed from here.
© 2018 GAMUT – The Grieg Academy Music Therapy Research Centre
2 D. M. ABDULAH ET AL.

within a therapeutic relationship which aims at restoring, maintaining and furthering

emotional, physical and mental health” (Warth, Kessler, Hillecke, & Bardenheuer, 2015),
however music listening is an element of music therapy facilitated by a music therapist
within a therapeutic relationship (Spaeth, 2015).
Generally, interventions based on music in health care are low-risk and often
enjoyable interventions for patients with a wide age range from infants to elderlies
(Robb, Burns, & Carpenter, 2011). MT has not been shown to be associated with
negative side effects, and strategies are easily implementable. Many music-based
interventions are associated with high adherence and desirable therapeutic conse-
quences (Brandes et al., 2010).
Obsessive-compulsive disorder (OCD) is determined as a critical mental disorder. The
OCD patients face repetitive, obtrusive and unwanted thoughts, impulses, urges, visionary
images and repeated evident and non-evident compulsive behaviors performed by the
individuals to decrease anxiety and distress (American Psychiatric Association, 2013).
Lifetime and 12-month prevalence of OCD has been estimated to be 1.3% (CI: 0.86–1.8)
and 0.54% (CI: 0.28–0.86), respectively (Somers, Goldner, Waraich, & Hsu, 2006).

Significance of the study

The mainstay of treatment in OCD management is pharmacotherapy plus selective-
serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressant clomipramine com-
bined with psychotherapy such as exposure-response prevention and cognitive beha-
vioral therapy (American Psychiatric Association, 2013; Fundukian & Wilson, 2008).
From this perspective, the patients must be exposed to a high dose of medication for
a long time to reach complete recovery from symptoms and relapse prevention.
Currently, only a minority of patients adhere to their prescribed medications and
experience improvement; many experience minimal or no change or even exacerba-
tion (Mancebo et al., 2006). In addition, psychotherapy as another treatment is being
given to a fraction of patients, less than 25% participation in cognitive-behavioral
therapy (Mancebo et al., 2006). Accordingly, given the problems in OCD manage-
ment by medications and psychotherapy, complementary and alternative medicine
(CAM) such as music listening as non-invasive, safe and harmless, well-tolerated,
inexpensive, and accessible technique could be used for this condition (Robb et al.,
2011).
Listening to music is proposed in clinical studies owing to its positive influences
on psychological and physiological conditions. For instance, advantages of listening
to music in reducing depressive symptoms among adults were found in a meta-
analysis (Chan, Wong, & Thayala, 2011) and in two Cochrane reviews on reduction
in preoperative anxiety (Bradt, Dileo, & Shim, 2013) and anxiety in patients with
coronary heart disease (Bradt & Dileo, 2009).
The effect of music listening on symptom severity in patients with OCD has
received little attention in research across the world. To the authors’ knowledge,
Bidabadi and Mehryar (2015) is the only study to date that investigated the role of
music listening on treatment of obsessive–compulsive disorder. That study showed
a greater substantial reduction in total obsessive severity.
 NORDIC JOURNAL OF MUSIC THERAPY 3

Aim of the study

The current study aimed to evaluate effects of passive music listening on the severity of
symptoms in patients with obsessive-compulsive disorder. In the present study, inves-
tigators attempted to respond whether music listening as an intervention will reduce
symptoms severity among OCD patients. In addition, the study answered the impacts
of music listening on overall control on obsessive thoughts and compulsive behaviors.
The investigators hypothesized that the severity of symptoms in patients exposed
to music and medications together would be lower significantly in comparison with
a group who received medications only.

Methods
Study design and recruitment of participants
All 324 patients who visited a psychiatrist’s private clinic (clinic of the first author) in
Duhok, Iraq between 15 October 2016 and 20 November 2016 were screened clinically
by the psychiatrist (first author) for eligibility criteria of the study (Figure 1). The baseline
information of those patients who met eligibility criteria including age, gender, and
education level were recorded in a pre-designed questionnaire. The diagnosis was

Figure 1. Flow of participants through the study (according to intention to treat approach).
4 D. M. ABDULAH ET AL.

established according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) (American Psychiatric Association, 2013).
The psychiatrist recorded the information of those patients diagnosed with any
types of OCD in a pre-designed questionnaire. The patients’ names were coded
consecutively and entered into an SPSS file. The participants were randomly assigned
into two groups through generating a list of simple random numbers by a computer.
Hereafter, the objectives of the study were explained to patients in experimental
group and required information to the control group and they were invited by the
psychiatrist to participate in the study following random assignment.
The patients in experimental group received the music listening passively in
addition to regular pharmacotherapy for a three-month period. The patients allocated
to the control group received only prescribed medications by the study psychiatrist
for the same period. The obsession and compulsion symptoms of both groups were
measured by the psychiatrist following the study completion only.

Eligibility criteria and sample size estimation

The characteristics of diagnosed patients were reviewed independently by the study
authors for eligibility criteria. Participants were included in the study if they met the
following criteria: a) male or female patients aged 18 years or older at the data
collection time, b) able to sit for at least 30 min, c) no sign of disorientation at
recruitment and during the entire study period, and d) has a willingness to partake in
the study. Patients with auditory problems or with dementia or cognitive disability
recognized through the self-reported way were not included in the study. As close to
90% of OCD patients meet criteria for another lifetime psychiatric disorder (Ruscio,
Stein, Chiu, & Kessler, 2010), patients were not excluded if they had other concurrent
mental disorders, such as depression and anxiety disorders (Marcks, Weisberg, Dyck,
& Keller, 2011) (recognized through their signs and symptoms) which are usually
comorbid with OCD.
Of the total number of patients screened in the clinic, 57 patients met the
eligibility criteria of the study and were invited by the clinician to partake in the
study. Of them, 28 and 29 patients were randomized into the experimental and
control groups, respectively. Of the total patients assigned into the experimental
arm, 10 patients were not accessible despite all attempts done by the clinician within
the first two weeks of the study commencement, possibly owing to the insecure and
instable situation in vicinity to their regions which were not far from Duhok city and
occupied by Islamic State in Iraq and Syria (ISIS). Another patient assigned to the
control condition used the medications, but did not listen to the music at all. This
patient was moved to the control group for a per-protocol analysis, so that the final
size of the experimental group in this analysis was 17 (see Statistical analysis). Of the
29 patients allocated into the control group, 10 were not accessible for the same
reason mentioned previously. One of the patients in control group changed his
doctor and was withdrawn from the study. Thus, 36 patients were used for statistical
analysis. The patients in both control and experimental groups were followed up
between 25 November 2016 and 25 February 2017 (Figure 1).
Based on the assessments of the first 5 patients, we expected a medium-to-large
effect size of about d = 0.60 in reduction of overall obsessive-compulsive symptoms
(Cumming, 2013). We estimated power for a t-test with two independent groups
 NORDIC JOURNAL OF MUSIC THERAPY 5

using GPower 3.1.9 statistical software, and aimed to recruit as many patients as
possible to maximize test power.

Data collection and intervention process methods

Baseline information of patients, including age, gender, education level, and
hearing problems if any were recorded into a predesigned questionnaire during
clinical interview and before study conduct. After randomly dividing the sample
into two groups they were tested for homogeneity in age and education level and
test proved they are homogenous. The numbers of lost-to-follow up were 21
patients and did not impact homogeneity between two groups of the study as
this number was from both groups following second homogeneity test. The
patients allocated into the experimental group were given seven relaxing music
tracks (each 50 min) pre-selected by investigators in a pre-recorded CD. The
50 min duration for music listening was based on a previous study (Bidabadi &
Mehryar, 2015) while taking into account a slightly longer duration to reduce
possible bias of short-term listening.
The selected music tracks were relaxing music, sleep music and mediation music
by Peder B. Helland, a music composer from Norway, produced with a wide variety
of instruments, including piano, guitar, flute, harp, violin, and cello. Written and
official permission was obtained from the composer (Helland, 2014). Before study
commencement, detailed instructions on various aspects of intervention including
volume control and place were presented to the participants in the experimental
group by the study psychiatrist, who had 16 years of experience and practice in
dealing with and treating people with mental disorders.
The participants were instructed to listen daily to one of the seven prepared music
pieces for a three-month period at any time during the day or night plus their regular
pharmacological treatment prescribed by the study psychiatrist. The intervention
group were asked to adjust the music volume controls to limit and adjust decibels
by their own playback equipment and listen to the recorded music in a place at their
home far from the TV or any other sources of noise. Moreover, we instructed those
who spent considerable time outside the house to allocate one hour in any spare time
they may have to music listening. In general, patients in the experimental group were
asked to listen to a 50-minute relaxing music track once a day for a three month
period at their own favorite place. Participants in the experimental group were
followed over 3 consecutive months, every two weeks periodically by the study
clinician through direct contact to be sure that they listen to the music and take
medicines.
The patients in the control group received regular treatment only for their OCD
with no instruction on music listening and were followed up every two weeks
periodically to be sure to administer their prescribed medicines.
To take into consideration the wide variety of music-listening habits, patients in the
music group were allowed to choose using headphones or speakers. Given the nature of
the intervention, the patients in experimental group and the symptoms assessor were
not blind to the music intervention, as patients of experimental arm were aware of
music listening intervention and research team was not masked and knew the patient’s
allocation. However, patients in the control groups were unaware of the music listening
6 D. M. ABDULAH ET AL.

intervention to reduce the possible bias of music listening by this group, they were just
informed of their future symptoms severity measurement for a study.

Measurement instrument
The severity of obsessions, compulsions, and obsessive-compulsive symptoms in both
experimental and control groups were assessed using the English version of the Yale-
Brown Obsessive Compulsive Scale (YBOCS) following study completion (Baer &
Blais, 2010). The YBOCS symptom severity scale was administered and assessed
independently by the senior psychiatrist only. It is a 10-item scale to rate the severity
of obsessions and compulsions, each item with a five-point scale ranging from 0 (no
symptoms) to 4 (extremely severe symptoms). Anchors are given for each response
category, for example a rating of 1 on time occupied by obsessive thoughts indicates
“mild, less than 1 hr/day or occasional intrusions”. The total score of the scale is
between 0 and 40 (Baer & Blais, 2010). For the subscales of obsession and compul-
sion, the respective items are added together to obtain a final score ranging from zero
(no symptoms) to 20 (extremely severe symptoms). The obsessions items covered by
YBOCS are time occupied by obsessive thoughts, interference due to obsessive
thoughts, distress associated with obsessive thoughts, resistance against obsessions,
degree of control over obsessive thoughts. Compulsions items are time spent per-
forming compulsive behaviors, interference due to compulsive behaviors, distress
associated with compulsive behavior, resistance against compulsions, degree of con-
trol over compulsive behavior.

Statistical analysis
The descriptive statistics of the study included frequency (percentage) for gender and
education, and mean (SD) for age. At baseline, the homogeneity of two groups of the
study was confirmed through the independent t-test, chi-squared or Fisher’s exact
test. The symptoms severities of OCD in both arms were measured by mean and
standard deviation. The effects of intervention (music and medication together)
versus control (medication only) on the severity of obsessions, compulsions, and
obsessive-compulsive symptoms were examined through independent t-tests in both
intention-to-treat and per-protocol analyses. The null hypothesis was rejected in
a p-value of less than 0.05. The Statistical Package for Social Sciences version 23
(SPSS 23 IBM) was used for statistical analysis and effect size of music listening on
symptoms severity (Cohen’s d) was calculated by GPower 3.1.9. The individual
participant data are available online as supplementary material to promote transpar-
ency and replicability.

Ethical considerations
The confidentiality of personal information was guaranteed to the patients in both
groups and their oral and written consents with consent forms were taken prior to
study implementation. The approval of the protocol of the study was obtained from
the Scientific Research Division, Directorate of Planning, Duhok Directorate General
of Health, Ministry of Health, Kurdistan Regional Government Iraq (Clinical Trial
Registration Number: 21082016–6 in 21 August 2016) and the intervention was
 NORDIC JOURNAL OF MUSIC THERAPY 7

conducted in accordance with the Declaration of Helsinki. The music was not
expected to cause any harm to patients.

Results
Baseline characteristics of patients in the experimental and control trial arms are
depicted in Table 1a. The mean age of patients (57 persons) was 29.41
(SD = 7.85 years (range 19 to 65). More than half of the patients were male (30/57,
52.6%). The male:female ratio was 1.11. The patients in experimental and control
groups were comparable in education level (p = .280, see Table 1a). Similarly, the
mean age of patients who were followed up (36 patients) was 30.66 (SD = 8.85) years
compared to 27.33 (SD = 5.38) years in those who dropped out (21 patients;
p = .086). In addition, the followed-up and dropped-out patients were comparable
in gender and education level (p = .284 and p = .947, respectively, see Table 1b).
The intention-to-treat analysis suggested that the obsessive-compulsive symptoms,
obsessions and compulsions were significantly lower in patients randomized to

Table 1. Baseline characteristics of study patients.

a. Original groups as assigned to experimental and control conditions.
Frequency (%) or M (SD)
Total Control Intervention p-value (two-
Patients’ characteristics (57) (29) (28) sided)
Agea, M (SD) 29.41 (7.85) (Range 30.25 (9.02) 28.57 (6.53) 0.429
19–65)
Education2, n (%) 9 (16.4) 5 (17.9) 4 (14.8) 0.280
Illiterate 19 (34.5) 7 (25.0) 12 (44.4)
Primary 18 (32.7) 12 (42.9) 6 (22.2)
Secondary School 1 (1.80) 1 (3.60) 0 (0.0)
High School 8 (14.5) 3 (10.7) 5 (18.5)
College and post-
college
Gender3, n (%) 30 (52.6) 17 (58.6) 13 (46.4) 0.357
Male 27 (47.4) 12 (41.4) 15 (53.6)
Female
a 2 3
independent t-test; n = 56 due to missing data. Fishers’ exact test. Chi-squared test.

b. Patients followed up compared to those who dropped out.

Frequency (%) or M (SD)
Patients’ Followed up Dropped out p-value
characteristics (36) (21) (two-sided)
Agea, M (SD) 30.66 (8.85) (Range: 27.33 (5.38) .086
19–65)
Gender3, n (%) .284
Male 17 (47.2) 13 (61.9)
Female 19 (52.8) 8 (38.1)
Education2, n (%) .947
Illiterate 6 (17.1) 3 (15.0)
Primary School 11 (31.4) 8 (40.0)
Graduate
Secondary School 11 (31.4) 7 (35.0)
Graduate
High School Graduate 1 (2.9) 0 (0.0)
College Graduate 6 (17.1) 2 (10.0)
a 2 3
independent t-test; Fishers’ exact test. Chi-squared test.
8 D. M. ABDULAH ET AL.

Table 2. Comparison of obsessions and compulsions between intervention (music and medication) and control
(medication only).
a. Intention-to-treat approach (interventions as randomized).
Mean (SD)
Randomized to Randomized to
Patients’ control intervention p-value Effect size
Characteristics(n = 36) (n = 18) (n = 18) (two-sided) (Cohen’s d)
Obsession Severity 1 9.50 (4.69) 6.17 (3.73) 0.025 0.78
Compulsion Severity 1 10.17 (4.94) 5.89 (3.53) 0.005 0.99
OCD Severity 1 (YBOCS Scale) 18.83 (9.71) 12.06 (7.13) 0.023 0.79
1
independent t-test was performed for statistical calculations.
*The present table was performed as one patient was shifted from experimental to the control arm owing to non-adherence to
the music listening.

b. Per-protocol approach (interventions as received)

Mean (SD)
Patients’ Total Exposed to Exposed to p-value Effect size
Characteristics (n = 36) control(19) intervention(17) (two-sided) (Cohen’s d)
Obsession Severity 1 7.83 (4.50) 9.37 (4.60) 6.12 (3.84) 0.027 0.77
(Range 0–20)
Compulsion Severity 1
7.83 (4.66) 9.78 (4.81) 5.76 (3.60) 0.009 0.95
(Range 0–20)
OCD Severity 1 (YBOCS Scale) 15.44 (9.07) 18.63 (9.48) 11.88 (7.31) 0.022 0.78
(Range 0–40)
1
independent t-test was performed for statistical analyses.

intervention compared to patients randomized to control group; 12.06 vs. 18.83

(p = .023), 6.17 vs. 9.50 (p = .025); and 5.89 vs. 10.17 (p = .005), respectively
(Table 2a). These results were similar in the per-protocol analysis (Table 2b).
With a detailed focus on specific obsessions in individual items of the YBOCS
scale, patients in the experimental group were still occupied by mild or occasional
obsessive thoughts, typically less than 1 h per day (M = 1.11), a non-significant
difference to the slightly higher means in the control group (M = 1.67; p = 0.104;
Table 3). Similarly, obsessive thoughts interfered mildly with social or occupational
activities, but without impairing overall performance, with no significant differences
between groups (experimental: M = 1.11; control: M = 1.83; p = 0.056). In contrast,
the overall distress as a result of these thoughts was mild, not too disturbing in the
experimental group (M = 1.17), but moderate and disturbing in the control group
(M = 2.00; p = 0.022). Similarly, patients in the experimental group typically tried to
resist the obsessive thoughts most of the time (M = 1.11), whereas those in the
control group made only “some” effort to resist (M = 1.89; p = 0.048). However, the
control of patients over obsessive thoughts was similar between groups, indicating
moderate control and being only sometimes able to stop or divert obsessions with
some effort and concentration (experimental: M = 1.67; control: M = 2.11; p = 0.269)
as shown in Table 3.
In terms of compulsive behaviors, the patients in the experimental group spent
less than 1 h per day to perform compulsive behaviors (M = 1.00) compared to 1
to 3 h per day in the control group (M = 1.78; p = 0.022). The compulsive
behaviors had a mild or slight interference with social and occupational activities
without impairment on the performance (M = 0.94), but the patients in the
control group suffered from moderate and definite manageable interference
 NORDIC JOURNAL OF MUSIC THERAPY 9

Table 3. The severity of obsession thoughts and compulsions behaviours in control and intervention groups.
a. Intention-to-treat approach
Mean (SD)
Randomized
Randomized to
to Control Intervention p-value Effect size
Obsession and Compulsions (YBOCS Scale) (n = 18) (n = 18) (two-sided) (Cohen’s d)
Obsessions
Time occupied by obsessive thoughts 1.67 (.97) 1.11 (1.02) 0.104 0.56
Interference due to obsessive thoughts 1.83 (1.30) 1.11 (.83) 0.056 0.66
Distress associated with obsessive thoughts 2.00 (1.14) 1.17 (.92) 0.022 0.80
Resistance against obsessions 1.89 (1.32) 1.11 (.90) 0.048 0.68
Degree of control over obsessive thoughts 2.11 (1.23) 1.67 (1.14) 0.269 0.37
Compulsions
Time spent performing compulsive behaviors 1.78 (1.06) 1.00 (.77) .017 0.84
Interference due to compulsive behaviors 1.89 (1.08) .94 (.80) .006 1.00
Distress associated with compulsive behavior 2.06 (.97) 1.33 (.77) .020 0.84
Resistance against compulsions 2.11 (1.18) 1.39 (1.29) .089 0.58
Degree of control over compulsive behavior 2.06 (1.11) 1.22 (.88) .018 0.84
Independent t-test was performed for all statistical analysis.
The bold numbers show the significant differences.

b. Per-protocol analysis approach

Mean (SD)
Obsession and Compulsions Control Intervention p-value Effect size
(YBOCS Scale) (n = 19) (n = 17) (two-sided) (Cohen’s d)
Obsessions
Time occupied by obsessive thoughts 1.63 (0.95) 1.12 (1.05) 0.137 0.51
Interference due to obsessive thoughts 1.74 (1.33) 1.18 (0.81) 0.132 0.51
Distress associated with obsessive thoughts 1.95 (1.13) 1.18 (0.95) 0.033 0.74
Resistance against obsessions 1.89 (1.29) 1.06 (0.90) 0.030 0.75
Degree of control over obsessive thoughts 2.16 (1.21) 1.59 (1.12) 0.153 0.49
Compulsions
Time spent performing compulsive behaviors 1.74 (1.05) 1.00 (0.79) 0.022 0.80
Interference due to compulsive behaviors 1.84 (1.07) 0.94 (0.83) 0.008 0.94
Distress associated with compulsive behavior 2.06 (0.94) 1.29 (0.77) 0.013 0.90
Resistance against compulsions 2.11 (1.15) 1.35 (1.32) 0.079 0.61
Degree of control over compulsive behavior 2.05 (1.08) 1.18 (0.88) 0.011 0.88

(M = 1.89; p = .006). The experimental group were mildly or slightly anxious in

the time of compulsions (M = 1.33) in contrast with the manageable moderate
distress in the experimental group (M = 2.06; p = .020). The patients in the
experimental group attempted to resist against compulsions most of the time
(M = 1.39) similar with some efforts of resistance in the control group
(M = 2.11; p = .089). The patients in the experimental groups had much control
on their compulsive behaviors (M = 1.22) in contrast with a moderate control with
difficulties in the controls (M = 2.06; p = .018) as shown in Table 3. No adverse
events were observed.

Discussion
The present study showed that overall obsessive-compulsive symptoms and obses-
sions and compulsions were significantly lower in a group following adjunctive
therapy with music listening compared to those receiving standard care alone. In
10 D. M. ABDULAH ET AL.

addition, the patients who received the adjunctive therapy had a substantially lower
compulsion severity than those who received standard care only.
A growing body of literature has paid their attention to the impact of music listening
on different psychiatric disorders, however there is a dearth of research on the impact of
passive or active music listening on symptoms severity in patients with OCD. Prior to
this study, the study by Bidabadi and Mehryar (2015) was the only one available on the
effects of receptive music listening. They assigned 30 patients randomly to an interven-
tion group (pharmacotherapy and cognitive-behavior therapy) with 12 sessions of
individual music treatment (n = 15) or a control group with regular treatment only
(n = 15). The symptoms severities were assessed baseline and after one month. The study
revealed that the obsession score was reduced from 15.1 (SD = 1.7) in the control group
to 12.4 (SD = 1.9) (p < 0.001) with effect size = 56.7% (partial eta squared) With respect to
OCD subtypes, substantial differences were seen for checking (p < 0.004) and slowness
(p < 0.019), but not for washing or responsibility.
Their study focused on the impact of receptive music listening on sub-type
obsessions in patients with OCD plus depression and anxiety comorbidities through
the Maudsley obsessive–compulsive inventory (MOCI), which has limited reliability
(Chan, 1990; Grabill et al., 2008). In contrast, overall obsessive-compulsive symptoms
and obsessions and compulsions and their content were scrutinized in detail in the
present study through the Yale-Brown Obsessive Compulsive Scale, a clinical assess-
ment considered gold standard (Grabill et al., 2008). This study showed that overall
symptoms, obsessions and compulsions were significantly lower in patients who
underwent receptive music listening compared to those in regular treatment only.
Despite overall improvement in patients who received music listening, their degree of
control over some obsessive thoughts was not sufficient, whereas their overall control
over compulsive behaviors reached a significant level. Making a between-study
comparison is hard owing to using two diverse types of intervention, as we did not
use cognitive-behavior therapy for our patients in the experimental group. However,
both studies found a significant decrease in overall obsessive thoughts of the OCD
patients. It is unclear whether the time period selected in this study (three months) is
associated with a greater decrease in symptoms severity compared to one month as
applied by Bidabadi and Mehryar (2015).
It is significant to return OCD patients to their normal social environment. In this
regard, music therapy or listening activities could be used as a form of social
communication to enhance the interaction between people through cooperation
and integration of patients with other society members (Schulkin & Raglan, 2014;
Yang, Li, Weng, & Zhang, 1998), as the disorder is responsible for the significant
emotional distress and difficulties with a sound relationship with others (Fundukian
& Wilson, 2008).
The impact of music listening on symptom severity in OCD patients may refer to its
capacity to evoke positive or proper memories, which may lead to a new way of
cognitive recuperation and create controlled circumstances for a developing new
perspectives (Yang et al., 1998). Music listening can promote the exploration of
memories associated with life issues and facilitation of cognitive changes and alteration
of irrational thoughts. The positive changes in cognitive aspects could assist the person
to manage these kinds of thoughts or compulsions (Gutiérrez & Camarena, 2015). In
congruence with this phenomenon, the current study showed that the patients who
received music listening applied significantly less resistance (more control) against
 NORDIC JOURNAL OF MUSIC THERAPY 11

these obsessive thoughts and experienced less distress than those who received stan-
dard care only. However, it seems that music listening is not sufficient for a patient to
achieve complete control on these kinds of obsessive thoughts.
In effectiveness of alternative medicine as adjunct therapy for psychiatric disor-
ders, their scientific classification must be taken into consideration. Obsessive-
compulsive disorder was moved to a new category in 2013 in the fifth version of
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (American
Psychiatric Association, 2013). It is now entitled as “obsessive-compulsive and related
disorders”, while it was in the “anxiety disorders” category in the previous version
(DSM-IV) (First, 2000). In the current study, the diagnosis of an OCD was estab-
lished according to the DSM-5 (American Psychiatric Association, 2013).
The overall effect of music listening in anxiety disorders may relate to the role of
music listening as a relaxation technique and its additional capacity in worry reduc-
tion, a negative kind of preservative thought (Spaeth, 2015) reflecting a common
feature in all anxiety disorders (Barlow, Raffa, & Cohen, 2002). We cannot present
the effect of music listening on worry in our sample size due to lack of worry
measurement in this study.
The obsessive thoughts in OCD patients are different from worries, as obsessive
thoughts do not reflect real-life issues. However, a compulsive behavior is performed
by an OCD patient in response to an obsessive thought to lower the level of anxiety
created by the obsession(s) in spite of the patient’s attempts to suppress the worri-
some images and thoughts (Fundukian & Wilson, 2008). In addition, worry is
responsible for creation and maintenance of negative affective and physiological
experiences (Newman, Llera, Erickson, Przeworski, & Castonguay, 2013). OCD is
not classified as an anxiety disorder, but a combination of neurobiological, environ-
mental, hereditary, and psychological factors have a role in this disorder (American
Psychiatric Association, 2013).
The other possible impact of music listening on OCD patients may relate to fear
reduction, as the compulsion among the patients is triggered through the direct
contact with the feared thought or object stirring up intense anxiety and a forceful
provocation or incitement to compulsion engagement (Fundukian & Wilson, 2008).
We strongly make the hypothesis that music listening assists the patients to combat
worry and promote the positive affect in his/her thoughts resulting in more control
on compulsions.
To understand the impact of various kinds of music, it is recommended to
determine the type of music according to audiences’ preference using standardized
scales such as the Scale for Evaluating Music for Health Promotion (SEMHP)
(Yoshida, Kobayashi, Sapkota, & Akkhavong, 2013). This scale has a good estimation
of the reliability and validity of content. Future studies can take their concentration
on impact of music listening on distinct OCD types or compare active and receptive
music therapies.

Strengths and weaknesses of the study

The present study was successful in randomly assigning patients to experimental and
control groups in a controlled trial. In addition, the psychiatrist who collaborated on
this study had a broad experience in dealing and treating different types of mental
disorders including OCD and its comorbidities. The clinician applied restricted
12 D. M. ABDULAH ET AL.

follow-up to increase the adherence to recommended treatment among patients. The

current study rigorously followed the Consolidated Standards of Reporting Trials
(CONSORT) guidelines for the randomized controlled trial (Moher et al., 2010) and
reporting guidelines for music-based interventions (Robb et al., 2011).
However the study was not without limitations. It is important to understand the
effects of music listening on symptom severity on different types of OCD (McKay et al.,
2004; McLean et al., 2001). The current study did not examine differences in OCD
clinical sub-types. Patients with distinct OCD types may show various responses to the
intervention (McKay et al., 2004). Moreover, speakers or headphones were used by our
patients in the experimental group, which possibly establish a distinct listening experi-
ence impacting music effects (Robb et al., 2011). The psychiatrist who collaborated on
this study devised the music-based intervention, therefore, it may not be easily com-
parable with future studies delivered by music therapists, as it has been shown that the
qualifications of interventionists correspond with intervention outcomes (Standley,
2000). Although stern criteria were enforced by the authors of this study to exclude
overt comorbidities of OCD, the study may have been biased in this regard, as more
than 90% of patients with OCD are diagnosed with another mental disorder (Pinto,
Mancebo, Eisen, Pagano, & Rasmussen, 2006).
The environment of music listening was not systematically examined in the
current study, although the patients were instructed prior to study initiation to listen
to music in a calm place and far from noisy situations such as TV. The environment
with a high level of noise has been documented to be associated with increased
distress and interference with communication (Christensen, 2007).
We are unable to confirm the complete adherence of the patients to listen to the
determined music tracks in the entire three month period of intervention. Poor
adherence toward target intervention is an issue in intervention studies (Bockting
et al., 2008; Mascha, Bockting, & Schene, 2009). The receptive relaxing music was
used for the patients in the intervention group in the current study, but using active
music listening may have more effects on severity symptoms.
We could not establish a protocol of the music listening for the patients recruited
in the present study as the intervention was applied at the patients’ homes outside the
research team’s control. Finally, we were not able to assess the symptoms severity
among 21 patients lost to follow-up; however, this did not appear to cause bias
between the groups.

Conclusions and recommendations

In conclusion, the current study confirmed that OCD patients undergoing three
months of daily relaxing music listening had a substantially lower obsessions and
compulsions severities compared to a control group who did not. The overall control
over compulsive severity symptoms were better in the experimental group in com-
parison with control patients. Listening to relaxing music would be recommended to
OCD patients by clinicians owing to its reduction impact in symptoms severity as
treatment goal, so the patient can accomplish her/his daily and social activities more
efficiently. It should be recommended in particular to those patients for whom other
therapeutic techniques are unacceptable or where other alternative and complemen-
tary treatment than medication as adjunctive therapy are not available. At the end,
the investigators recommend to determine the exact type of music, as it has been
 NORDIC JOURNAL OF MUSIC THERAPY 13

confirmed that different types of music have different affective and physiological
responses (Spaeth, 2015).

Disclosure statement
No potential conflict of interests were reported by the author.

Notes on contributors
Deldar Morad Abdulah, Master in Public Health from La Trobe University, Australia and B.Sc in
Occupational Health from Iran University of Medical Sciences. Assistant Lecturer at the Adult
Nursing Department, College of Nursing, University of Duhok, Iraqi Kurdistan.

Salim Saadi Miho Alhakem, M.B.Ch.B. F.I.C.M.S (PSYCH)(M.D). Lecturer, Senior Psychiatrist,
Medicine Department, College of Medicine, University of Duhok, Iraqi Kurdistan.

Rasoul Sabri Piro, Master in Mental Health and Psychiatric Nursing from Hawler Medical
University-Iraq) and B.Sc in Nursing from Iran University of Medical Sciences-Iran. Lecturer and
Head of Adult Nursing Department, College of Nursing, University of Duhok, Iraqi Kurdistan.

ORCID
Deldar Morad Abdulah http://orcid.org/0000-0002-8986-5793

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