Hyperacusis and Misophonia

Question 1

What is decreased sound tolerance?

Answer 1

Any condition in which a patient exhibits any kind of negative reactions to ordinary sounds, which do not elicit such reactions in the average listener
There are several forms of loudness perception disorders

Question 2

What is hyperacusis?

Answer 2

Significantly reduced tolerance to sound that do not trouble most people
Negative reactions depend on the physical characteristics the sounds
A reduced tolerance for sounds that are of medium to loud intensity

Question 3

What are the types of hyperacusis?

Answer 3

Loudness hyperacusis
Annoyance hyperacusis
Fear hyperacusis
Pain hyperacusis

Question 4

What is the misophonia?

Answer 4

A dislike of certain specific sounds that trigger emotional reactions
Patients with misophonia can tolerate high levels of other sounds such as music or environment noise
It can occur together with tinnitus and hyperacusis but may also occur alone
Some researchers classify misophonia as a psychiatric disorder
Trigger sounds are typically soft sounds but could be of medium or loud intensity as well; intensity does not dictate whether the sound is bothersome

Question 5

What is the 2022 consensus definition of misophonia?

Answer 5

Misophonia includes a low tolerance for pattern-based and repetitive sounds, regardless of loudness
Triggers have specific meaning to people and are most often sounds (or related stimuli) emanating from other human beings
Context and perceived control over a trigger can determine a reaction
Once an individual with misophonia notices a trigger, they are unable to “distract themselves” from that trigger
Misophonia appears to vary from mild to severe and may impact social, academic, and occupational functioning Finally, misophonia typically begins in childhood and adolescence

Question 6

What are some misophonia triggers?

Answer 6

Oral or Eating Sounds (81%): Chewing, lip smacking, yawning
Breathing Sounds (64.3%): Sniffling
Repetitive Sounds (59.5%): Keyboard typing, pen clicking
Speech Sounds: The “s” sound, tongue clicking
Household Sounds: Dishes clinking, silverware clinking, plastic bags or wrappers crinkling
Footsteps
Finger Tapping
Whistling
Low-Frequency Sounds: Unspecified in studies
Animal Sounds: Toenails clicking on floors, barking
Visual Triggers: Leg rocking (reported in some cases)

Question 7

What is phonophobia?

Answer 7

Specific case of misophonia when fear of sound is involved
Defined as an anxiety disorder that is characterized as a persistent, abnormal, and unwarranted fear of sound (often everyday sounds) shaped by an emotional meaning
Negative reaction to certain sounds, including anxiety and fear that is intensified with anticipation of the sound

Question 8

What is loudness recruitment?

Answer 8

Abnormally rapid growth of loudness with increasing sound level; caused by loss of outer hair cells
It is not a sound tolerance problem (not happening in hyperacusis)

Question 9

What is the prevalence of hyperacusis in adults?

Answer 9

Between 8% and 15.2%
Higher prevalence in women and individuals with hearing disorders
Certain occupations, such as musicians, music students, and teachers, are associated with a higher risk of developing hyperacusis

Question 10

What is the prevalence of hyperacusis in children and adolescents?

Answer 10

Ranging from 3.2% to 17.1%
More prevalent in children with autistic spectrum disorders than in the general pediatric population
Children with tinnitus are significantly more likely to exhibit hyperacusis symptoms compared to those without tinnitus
Not very good at articulating symptoms

Question 11

What percentage of children with hyperacusis also have tinnitus?

Answer 11

41.9% to 50%

Question 12

What are the presenting symptoms for hyperacusis in children?

Answer 12

React to sounds in ways that impact daily life and family activities
Covering their ears, showing distress, crying, or running away from the sound, even in dangerous situations
Some develop phobic responses, avoiding situations where distressing sounds might occur
Troublesome sounds include children shouting or screaming, alarms, sirens, hand or hair dryers, vacuum cleaners, and traffic

Question 13

What is the impact of hyperacusis?

Answer 13

Hearing and communication
Sleep
Concentration
Emotional well-being

Question 14

What are secondary effects of hyperacusis?

Answer 14

Secondary effects include poorer socialization, physical health, work performance, education, and finances
Discomfort
Headache
Concentration difficulties
Fatigue
Anxiety

Question 15

What is the impact of misophonia and phonophobia?

Answer 15

Common, everyday sounds triggering strong emotions, such as anger, fear, or disgust
Reduced quality of life and distress in various areas
Difficulty concentrating in school or the workplace
Strained relationships with family and friends due to the urge to confront, avoid, or leave situations
Challenges in social interactions, such as meeting new friends or eating meals with others

Question 16

What are some causes of hyperacusis?

Answer 16

Autoimmune disease
Endocrine disorders
Fibromyalgia
Head or neck trauma or injury
Medication side effects and withdrawal symptoms
Menieres disease
Metabolic disorders
Migraine
Neurologic conditions
Noise exposure and acoustic trauma
Ototoxins
Perilymph fistula
PTSD
Sudden SNHL
SSCD
TMJ
TBI
Viral infections of the inner ear or facial nerve
Williams syndrome

Question 17

What are the likely mechanisms of hyperacusis?

Answer 17

Likely involves multiple, similar to tinnitus
Excessive central gain enhancement is considered a key mechanism
Genetic predisposition
Stress, anxiety, and fear (can exacerbate hyperacusis by misinterpreting safe sounds as dangerous)
Neural changes (altered neural synchronization and auditory cortex reorg linked with tinnitus)
Brain hyperactivity (increased activity in auditory and nonauditory brain regions as shown in neuroimaging)
Blast exposure

Question 18

What are the mechanisms for misophonia and photophobia?

Answer 18

Research suggest that the brains of people with misophonia behave differently than typical brains (enhanced connections between the auditory and limbic system without abnormal activation of the auditory pathways and the limbic system)
Neuroimaging studies reveal increased activation and connectivity in areas related to fight-or-flight responses, emotional processing, unconscious auditory and visual attention, and motor functions when exposed to specific sounds

Question 19

What are the components of assessment for hyperacusis and misophonia?

Answer 19

Case history
Pure tone audiometry
LDL
Immittance
OAEs
Self-report questionnaires

Question 20

Why is the case history important?

Answer 20

Provides critical information about the etiology, such as noise exposure
Guides the selection of laboratory tests, radiological exams, and treatments
Frequently reveals comorbidities, including anxiety, depression, concentration difficulties, and sleep problems

Question 21

Why is pure tone audiometry important?

Answer 21

Essential to determine the nature and extent of hearing loss if present and to evaluate the audibility threshold
Might have clinically normal thresholds

Question 22

What is a limitation of pure tone audiometry?

Answer 22

Doesn’t predict auditory function in everyday situations

Question 23

What are some considerations for pure tone audiometry?

Answer 23

BC testing at low frequencies (250 Hz), especially testing BC below 0 dB HL - crucial when symptoms align with SSCD (differentiate between them)
Thresholds can be measured using ascending technique to minimize discomfort
EHF testing may reveal a hidden hearing loss

Question 24

What is the goal of assessing LDL?

Answer 24

Assess the dynamic range of hearing, particularly how loud sounds can be before they become uncomfortable
Important for fitting hearing aids and managing tinnitus and hyperacusis
This can be uncomfortable for patients because it might exacerbate their hyperacusis

Question 25

What is severe hyperacusis?

Answer 25

LDL of 60 dB HL or less for at least 2 frequencies
Dynamic range is 35 dB or less for at least one frequency

Question 26

What is moderate hyperacusis?

Answer 26

LDL of up to 75 dB HL for at least 2 frequencies
Dynamic range of up to 45 dB for at least one frequency

Question 27

What is mild hyperacusis?

Answer 27

LDL of up to 90 dB for at least 2 frequencies
Dynamic range of up to 55 dB for at least one frequency

Question 28

Is immittance helpful when assessing someone with hyperacusis and misophonia?

Answer 28

It is generally useful in audiological assessments
Doesn’t have specific relevance unless indicated by other symptoms

Question 29

Are OAEs useful for assessing someone with hyperacusis and misophonia?

Answer 29

Useful for exploring cochlear function and potentially identifying efferent auditory system dysfunctions that might relate to these conditions

Question 30

What are the self report measures for hyperacusis?

Answer 30

Hyperacusis Questionnaire (HQ)
Multiple-Activity Scale for Hyperacusis (MASH)
Sound Sensitive Tinnitus Index
Hyperacusis Impact Questionnaire (HIQ)

Question 31

What are the self report measures for misophonia?

Answer 31

Duke Misophonia Questionnaire (DMQ)
Misophonia Assessment Questionnaire (MAQ)
Amsterdam Misophonia Scale (A-MISO-S)
Misophonia Coping Responses
Misophonia Emotional Responses
Misophonia Physiological Response Scale (MPRS)
Misophonia Activation Scale (MAS-1)
Misophonia Questionnaire (MQ)
Misophonia Impact Survey (MIS)

Question 32

Should people with hyperacusis and misophonia wean from earplugs?

Answer 32

Yes
Teach patients to use hearing protection only when sound is damaging
Encourage gradual exposure to higher sound levels, avoiding obsessive SLM use
Recommend level-dependent earplugs that adjust attenuation based on sound intensity (marketed for activities like shooting or motorcycling)
Encourage patients to gradually decrease the hours they use ear protection

Question 33

What is the goal of providing hearing aids for patients with hyperacusis and misophonia?

Answer 33

Provide “gain without pain” by balancing amplification needs with sound tolerance
These hearing aids require tailored adjustments, prioritizing patient comfort and gradual amplification increases
First step is to manage this, then hearing loss, and then tinnitus (for patients with all three)

Question 34

When are ear-level instruments indicated for someone who has hyperacusis?

Answer 34

The patient’s sound tolerance condition must be reasonably severe to justify the use of these instruments
The patient must be motivated to use the instruments

Question 35

What do people with hyperacusis need in a hearing aid?

Answer 35

Flexible output and compression settings (customization of max output and compression to match UCL)
WDRC (reduces gain as sound level increases)
Noise reduction (improves comfort and reduces listening effort)
Directional and remote mics (improves SNR, reduces background noise that can trigger)
Transient impulse control (detects and limits amplification of sudden loud sounds)
Datalogging
Custom molds with variable venting (allows gradual transition from occluded to open fit, accommodating to patient comfort level)
Combination devices with sound generators (enables use of desensitizing sounds before transitioning to amplification)
Volume control
Multiple programs (including a safe program)
Off button (provides a sense of control)

Question 36

What are some common strategies for using sound therapy to manage hyperacusis?

Answer 36

Continuous low-level broadband noise is a common method, showing success in increasing LDLs for some patients, although benefits may take 6 months to 2 years to manifest
Gradual increases of the level and/or duration of the sound treatment should be implemented
Targeted Exposure to Specific Sounds: Plays back specific bothersome sounds at low volumes, gradually increasing loudness to reduce sensitivity
Adjusting Hearing Aids: Starts with lower amplification for loud sounds in hearing aids, gradually adjusting to normal levels for better sound tolerance

Question 37

What are the counseling goals for patients with hyperacusis and misophonia?

Answer 37

Encourage patients to describe their reluctance or fear of sound exposure and identify specific problematic situations
Explore behaviors and emotions linked to those making the noise (e.g., perceived lack of consideration)
Discuss repressed behaviors tied to annoyance or fear of sounds
Identify controllable noisy situations to help patients gain confidence in tolerating some sounds

Question 38

What are the core components of CBT for hyperacusis and misophonia?

Answer 38

Education: Patients learn about the nature of hyperacusis and how it affects hearing and daily activities
Applied Relaxation: Techniques such as deep breathing, progressive muscle relaxation, or guided imagery are taught to help patients manage their physiological responses to sound
Graded Exposure to Sounds: This involves systematic desensitization to sounds that the patient finds distressing
Cognitive Therapy: Helps patients reframe negative thoughts about sounds to reduce anxiety and improve coping

Question 39

Does CBT significantly improve loudness discomfort and psychological well-being in hyperacusis patients?

Answer 39

Yes
With lasting effects at 12 months

Question 40

How is TRT used for hyperacusis?

Answer 40

The key to treating hyperacusis is to desensitize the auditory system to sound. This involves systematic exposure to sounds that cause absolutely no annoyance

Question 41

How is TRT used for misophonia?

Answer 41

The connections between the auditory, limbic, and autonomic nervous systems that cause the emotional reactions must be retrained
The most effective way of reversing the conditioned reflexes in misophonia is to associate the sounds with something positive