#1. Get informed (you’re in the right place!)
It can be incredibly confusing and discouraging when reading up on Decreased Sound Tolerance, especially when you’ll come across a bunch of different terms thrown around: hyperacusis, misophonia, phonophobia, or Selective Sound Sensitivity Syndrome. Even more confusingly, these terms are often used interchangeably. You’re probably wondering what the heck all this means and what’s going on, and I don’t blame you! This is a complex issue, and today, Dear Reader, I’ll try to be as clear and concise as I can to give you a good starting point as to what’s going on and what can be done about Decreased Sound Tolerance.
First, let’s make sure we’re both talking about the same thing.
The fact that you’re reading this today probably means either yourself (or someone close to you) is suffering from some sort of negative reaction when exposed to sound that would not trigger the same response in the average listener; this is known as Decreased Sound Tolerance (DST). Whether you are suffering from any of the specific groups of DST mentioned above (don’t worry, I’ll get into those shortly), there is always a negative emotional impact such as:
DST often comes hand and hand with tinnitus and hearing loss, and can be reported in many medical conditions including head injuries, migraines, Lyme disease, Williams Syndrome, autism, Bell’s palsy, benzodiazepine withdrawal, and post stapedectomy. However, it’s not unusual for DST to be reported as the sole complaint.
DST results from the combined effects of hyperacusis and misophonia. Let’s take a look at what these different groups mean:
Hyperacusis: occurs in about 25-30% of tinnitus patients, is the experience of moderately-intense sounds (e.g., dishes clanging) being perceived as overly loud and annoying. In other words, there is a negative reaction to sound that depends only the physical characteristics of the sound itself (e.g., loudness).
Misophonia: occurs in about 60% of tinnitus patients, and is a dislike, fear, or negative reaction to a specific sound with a certain pattern and meaning (e.g., chewing of a specific person). Reactions are usually context-specific (e.g., eating at a restaurant would not bother you, but eating at home does). Unlike hyperacusis, someone with misophonia can tolerate a high level of other sounds, such as music or traffic noise. Patients with misophonia tend to have an increased awareness of external sounds as well as somatosounds (internal body sounds, like chewing).
Other terms you’ll see associated with misophonia include:
- Phonophobia, a specific case of misophonia where fear is the dominant emotion
- Selective Sound Sensitivity Syndrome (4S), another variation of misophonia that includes only very soft particular noises, called Trigger Sounds, which are often associated with oral functions (e.g., chewing, lip licking, smacking, or breathing).
Although hyperacusis and misophonia differ in terms of how we approach treatment, there is no fundamental difference with how you treat misophonia vs phonophobia vs 4S, so for simplicity’s sake, I prefer the term “misophonia”.
Let’s talk about why these sounds only seem to affect you and not others around you…
Hyperacusis reflects a disproportionate reaction of your auditory system to sound, which leads to enhanced activity in the brain’s non-auditory areas, particularly the limbic (the emotional centre) and autonomic nervous systems (controls body reactions).
Meanwhile, misophonia reflects disproportionate reactions of the limbic and autonomic nervous systems resulting from enhanced connections between the auditory, limbic, and autonomic systems for specific patterns of sound.
However, the link between hearing, emotion, and reaction can work in many ways; changes in emotion, like anxiety, can increase your attention to sound. The same can happen with increases in your state of arousal, such as when you’re irritable. Notice how things that normally wouldn’t bother you suddenly become unbearable when you’re in an irritable mood?
So what’s going on? Any time you have an emotional reaction to the loudness of sounds, the limbic system is behind it. In particular, there is a strong association between hearing and emotion when it comes to fear and anxiety. Because your auditory system is also linked to systems of reaction, for example, you get startled when there is an unexpected sudden sound. These conditioned responses act like survival reflexes and works quickly and effectively. When the autonomic nervous system prepares us for “fight or flight”, this leads to increases in heart rate, sweating, muscle tension, and other adrenaline-mediated body responses.
What’s also important to note is that hyperacusis and misophonia can trigger the same emotional and autonomic reactions, so it is impossible to tease the two apart based on observed reactions alone. DST sufferers may have normal hearing or hearing loss, and may also suffer from tinnitus. That’s why, in your quest for answers and solutions, there’s only so much online research you can do before you start going in circles. What then?
#2. The next step: consult a compassionate healthcare professional that is informed about DST
Because of the complex link between your auditory, limbic, and autonomic nervous systems, it is not enough to address only what’s going on in your ears. To effectively treat DST, make sure you speak to a hearing healthcare professional that considers not just one, but FOUR dimensions of DST:
- Biological dimension: what’s going on in your ears and brain
- Psychological dimension: your emotions and your beliefs regarding your situation
- Social dimension: how you are dealing with the outside world (e.g., are you only able to function in busy environments like restaurants if you wear hearing protection?)
- Time dimension: how has your situation developed over time? Has it been gradual? Or was it triggered by something specific (e.g., head injury after a car accident)?
Depending on the complexity of your specific case, you may see more than one healthcare professional from a variety of disciplines. For example, as an audiologist, I specialize in non-medical/surgical rehabilitation for auditory disorders, so if I suspect that there’s an underlying medical condition that’s causing your symptoms, I may refer to you an Ear, Nose, and Throat Specialist.
Regardless of whom you speak to, make sure it’s someone you are comfortable with and know they will LISTEN to your concerns rather than tell you to “just live with it”.
#3. Use sound therapy, either guided by a professional or on your own.
I have previously written about using sound therapy as Sound Enrichment for tinnitus, but those principles apply to DST as well.
While some may prefer an informal, self-guided approach, others will benefit from a more structured sound therapy program monitored by a hearing healthcare professional.
Depending on whether my patient has hyperacusis or misophonia (or both), I will recommend sound therapy in different ways. For example, someone with hyperacusis will undergo a desensitization procedure that introduces soft, low-level sound which we gradually increase over time to induce “auditory toughening”; the idea is to gradually desensitize your auditory system. Although white noise is typically used, my rule is to only use sounds that are not annoying or bothersome to my patients. If the idea of listening to noise is not appealing, there are TONS of other sound options out there; flexibility is crucial to getting you to restore a sense of control so that we can “reset” your relationship with sound. There are discreet, portable ear-worn solutions as well as table-top sound machines, all the way down to free sound generating apps for your phone.
When in doubt, speak to a hearing health professional. I find that the self-guided approach only works for milder cases. Where I tend to brought in is when patients come to me when their DST is causing significant distress and is negatively affecting their quality of life.
#4. Ease up on the hearing protection (except when exposed to intensely loud sound)
As an audiologist, I absolutely advocate the use of hearing protection when there’s a chance of exposure to potentially damaging sounds. However, when it comes to DST, it’s not unusual for hyperacusis sufferers to overprotect themselves from everyday sounds by using earplugs or earmuffs even though there’s no chance of harming their hearing.
Overusing hearing protection will make your hypersensitivity to sound WORSE.
Normally, hearing protection is supposed to be used when you’re going to be exposed to dangerously loud sound, like jet engines. How it works is it dampens the sound so that even though you will still hear the engine noise , it’s enough to take the edge off so it’s no longer at damaging levels.
However, what happens if you wear hearing protection when there’s no loud sound? Everything gets dampened, so little to no sound gets up to the brain. However, sound is life and your brain craves stimulation. If it doesn’t get it, it cranks up its internal sensitivity; think of how your eyes adjust if suddenly the lights go on when you’re in a dark room. The lack of stimulation will only make DST symptoms worse. It is the fear that drives earplug use, not the possibility of actual risk.
But I’m not ready to give up my earplugs! What then?
Not to worry, Dear Reader. I’m not one to push my clients beyond what’s comfortable for them. If you are someone that overuses hearing protection and can’t fathom letting go, I recommend a gradual process of weaning off those earplugs/earmuffs.
If you are using conventional foam earplugs/earmuffs, I would suggest investing in a set of custom musician’s earplugs, which contain special filters to dampen sound levels more evenly so that music and speech are clear and natural, not muffled as with regular foam earplugs. To obtain a set of musician’s earplugs, you will need to make an appointment with me to get impressions of your ears taken. For more information on the earplugs themselves, visit Etymotic Research.
Next, start limiting your earplug use to specific situations/environments only when absolutely necessary. For example, let’s say you hate shopping at the grocery store because the sounds of the shopping carts is too much for you. Try to limit yourself to only wearing them at the store, but not in other situations, like around the house, or when you’re at work.
If you’ve been living for DST for quite some time, it can take time to re-establish what are “normal” levels of sound, especially if you’ve been prone to wearing ear protection in everyday situations. In those cases, I usually work with these patients to gradually reduce your over-use of hearing protection, especially if we are also using sound therapy at the same time.
#5. Find ways to relax!
None of us are strangers to stress, but as life gets busy, it can be challenging to find effective ways to relax, even if it is good for us. I know I’m certainly guilty of this!
However, we know that DST itself can cause a great deal of stress (on top of whatever life throws at us). One thing you can do for yourself is to follow good practices to manage stress in your life, and to engage in relaxing activities. Some examples of relaxing activities include (but are certainly not limited to):
- Taking time for yourself
- Listening to soft music
- Exercising (e.g., yoga)
- Performing your favourite relaxing hobby (e.g., reading a good book)
Other DST sufferers may also benefit from more formal relaxation approaches, such as Progressive Muscle Relaxation (PMR), which teaches your muscles to relax. AnxietyBC has a great “cheatsheet” that guides you through how to do PMR in two steps.
However you choose to relax, remember it’s about calming your state of mind; when you’re in a relaxed state, you are far less likely to be bothered by sound than if you are tense and anxious.
If you don’t mind, then it don’t matter!
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