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Misophonia, Phonophobia, and Hyperacusis: Auditory Sensitivity Overlaps Anxiety and Mental Health

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There are at least three different types of sound sensitivities. And this matters because sound sensitivities sometimes co-occur with other mental health conditions like OCD, autism, anxiety, trauma, and sensory processing disorders. 

So let’s talk about what the three conditions are, and then you’ll learn a little bit about what the treatment options are. 

The other day I got an email from a follower, and here’s what it said: 

“I have been in and out of therapy for many, many years, mostly trying to find someone to help me with anxiety and depression related to environmental noise, which usually came from neighbors living in surrounding apartments, but no one has been able to give me any skills to get some relief from all this anxiety. And yes, my whole body does want to just avoid the sound because it feels horrible, more horrible than anything. 

“So after decades of that apartment, living in turmoil, I finally moved to a house in a state park. The house was quiet for a year except for the leaf blowers, mostly in the autumn, but the last two months the airport must have redirected their flights to go right over my house every 15 minutes or so. 

“So finally, living in my own house and in nature has become stressful, and even taking hikes in the woods have become very stressful for me to the point where I don’t take care of myself anymore except for the basics. I don’t know what to do. Do you have any suggestions?” 

So first, I’ve got to say I usually don’t have time to reply to all the emails and questions I get, and it’s unethical for me to diagnose or recommend treatment to anyone over email. 

But here’s what I told him. The first thing I recommended to him was that he worked with some informed provider to get a really good diagnosis of what’s going on because it doesn’t sound as much like an anxiety disorder to me as a sensory sensitivity or a hearing disorder. 

But then I got really curious because I don’t know that much about sound sensitivities. So me being me, I spent the last month researching it and talking with experts, and here’s what I’ve learned. 

There are at least three different types of sound sensitivities. And this matters because sound sensitivities sometimes co-occur with other mental health conditions like OCD, autism, anxiety, trauma, and sensory processing disorders. 

So let’s talk about what the three conditions are, and then you’ll learn a little bit about what the treatment options are.

3 Types of Sound Sensitivities

So there are three different types of sound sensitivities that we’ll talk about today. If you get really angry about certain noises, that’s misophonia. If you get really anxious or scared around certain sounds, that’s phonophobia. And if everyday normal sounds are painfully loud, that’s hyperacusis. 

1. Hyperacusis

So let’s start with hyperacusis. Hyperacusis is when you perceive sounds as being louder than they objectively are. Everyday sounds seem louder than they should. Now, this can be caused by physical damage to the ears from loud noises or head injuries or acoustic trauma, but it’s also associated with a ton of other physical conditions. 

47% of people with hyperacusis also have anxiety. And while it does have overlap with the other forms of noise sensitivity, hyperacusis can sometimes be diagnosed as physically occurring within the ears. But because of the interplay of the brain’s auditory processing system and how the brain interprets noise, hyperacuity can also be more of an issue with the nervous system hyperarousal. So it’s essentially the brain perceiving loud noises to be a threat. 

Now, auditory sensitivity can occur on a spectrum where hyperacuity can be more on the more severe end of the spectrum and a dislike of loud noises can be more on the less severe side of the spectrum. 

Auditory sensitivity can also be associated with sensory differences that often occur with autism, and it can stand alone. It can be that you just have really sensitive ears. 

2. Misophonia

Now let’s talk about misophonia. Misophonia is when specific sounds trigger an intense reaction, usually anger, but it can also be irritation, rage, anxiety, and disgust. The most common triggers are repetitive sounds, like chewing, breathing, lip smacking, or tapping. 

Essentially, these sounds are triggering the nervous system reaction of fight in the fight/flight/freeze response, and this can lead to people to react with hostility or avoidance. 

Now, like hyperacusis, misophonia is not a recognized disorder in the DSM-5, and research is just beginning to understand the causes and treatment. There are some early studies indicating that there are brain differences in people with misophonia and that there’s heightened response to sounds in the brain. 

Misophonia commonly occurs with other disorders, including anxiety, obsessive-compulsive personality disorder, autism spectrum disorder, and sensory processing disorder. There’s also a higher incidence in people with tinnitus and hyperacusis. 

The co-occurrences may be better explained by symptom overlap. So for example, “That sound makes me anxious, but when I’m anxious that sound bothers me more.” But the fact that the sound bothers you is not just anxiety. 

3. Phonophobia

Now let’s talk about phonophobia. Phonophobia is an intense fear reaction to certain sounds. So like other phobias, it can be connected to anxiety disorders or a history of trauma, but it can also stand alone. 

One case study I read about was a girl who was 12. After Chinese New Year, where she heard a lot of loud fireworks go off, she developed an acute electrifying intensified noise sensation in both ears when hearing sudden loud noises. And then she began experiencing abnormally intensified sounds followed by unpleasant buzzing noises every time she was exposed to normal intensity sounds. 

So for example, the sound of a balloon popping or the rustle of a plastic bag were almost unbearable to her, to the point where she developed palpitations, shivering, excessive sweating, and crying. Her condition gradually worsened until she only wanted to spend time in a quiet room and was no longer attending social functions in school. 

So her parents took her to a doctor, and the ENT assessed her ears and her hearing and they found nothing wrong, nothing different about her hearing. They did an MRI and they found nothing wrong there, and then she got a thorough psychiatric evaluation and she was diagnosed with phonophobia. 

Now, phonophobia is generally considered an anxiety disorder, not a disorder in hearing. It’s an intense fear of loud sounds. So for someone with phonophobia, watching someone blow up a balloon until it bursts could possibly trigger a panic attack. Now, for the average person, loud sounds might be uncomfortable or anxiety-inducing, but with phonophobia it’s extremely anxiety producing.

Options for Treatment

So now let’s talk about treatment. With all three of these types of disorders, there are two main approaches to treating these noise sensitivities. 

1. Work With an Audiologist

So first I’m going to encourage you all to work with an audiologist to get a good diagnosis. An audiologist will rule out other conditions, and an audiologist who specializes in sound sensitivities can provide acoustic therapy.

2. Work With a Therapist

The second part of treatment is psychological. 

So counseling can help people decrease their anxiety response to sounds. You can learn to regulate your nervous-system response through grounding skills. 

But first, before we even go into that, we need to talk about how avoidance can make these conditions worse. 

Now, I want you to notice how, both with this girl from the case study and with the man who emailed me, they both had a drive to avoid noises, but as they did their symptoms worsened. 

So this man who emailed me, he moves all the way out to a state park where it’s really quiet. And for a year things were okay, but then gradually noises, even the quietest noises, like an airplane overhead, would bother him more and more. 

And that’s because sounds aren’t just processed in the ears; they’re processed in the brain. Our brain and our nervous systems are plastic. So that means that they adapt to the situations we experience. 

So when we experience a trigger like leaf blowers or a plastic bag rattling and then we avoid that trigger and we don’t die, our brain thinks, “Whoo, I survived! Let’s make my human avoid those things again because they must be dangerous.” So your brain actually increases your anxiety response to those sounds. It’s going to increase your sensitivity to those sounds. 

Avoiding triggers makes you more anxious. It’s like if you’re in a very dark room and you turn on a flashlight, it might feel uncomfortably bright. But if you’re outdoors during the daytime and you turn on the exact same flashlight, it doesn’t seem that bright. Your eyes adjusted so that the situation isn’t so uncomfortable. 

So with sound sensitivities your natural tendency is going to be to avoid or escape those sounds or to wear earplugs or headphones to block them out, but this will make things worse. So now a regular sound is like a flashlight in a dark room; it hurts even more. 

We can’t completely eliminate sound. All we can do is develop greater courage in the face of these triggers. 

So the first thing to remember is don’t avoid or overprotect against sound, and then second is learn to change how you think about the sounds and the reactions you’re having to them. 

So you’ve got to work on catastrophizing and blaming and labeling these triggers as bad. You’ve got to learn to accept sounds and refocus your attention and let go of self-pity and trying to change everyone else. 

So these are essential skills that we use in acceptance and commitment therapy. We use the skills of willingness, acceptance, defusion, and understanding that the trigger, these noises, are actually neutral, but our interpretations of them and our emotional response is what we can change. 

Now, let me put in a quick caveat because some therapists are going to teach coping skills and avoiding skills in response to these sounds, and that’s actually going to make it worse. So that’s why it’s really important to find an informed provider. 

That’s one of the reasons why I spent the last month researching this, and I still don’t consider myself an expert in this in any way. I would definitely send someone with these disorders to a specialist. 

Then after you’ve started learning how to face these sounds and how to think differently about them, and perhaps you’ve done some acoustic therapy, we’re gonna talk about how to soothe your nervous system. 

So if you can learn skills to calm yourself down, this will retrain your nervous system to not react to these triggering sounds in the same way. So some of these nervous system skills include deep breathing, the yawn, and progressive muscle relaxation. 

Now, I teach about 15 of these in my Grounding Skills for Anxiety course. It’s free. So you can check that out. The link is in the description. But there’s a lot of other ways to learn these grounding skills, and I’ve also got a bunch of these videos on my YouTube channel, so check out my grounding skills playlist too. 

So after you have stopped avoiding these sounds, you’ve worked on how you think about these sounds a little bit, and you’ve learned some grounding skills, the next step is usually super-duper gentle, systematic exposure. 

This means that you’re going to super gently face uncomfortable sounds. This literally rewires your brain to realize that these sounds aren’t a threat. It’s really important to know that you don’t just expose yourself or a child to an uncomfortable sound just to get the child used to it. This can actually make sound sensitivities much worse. 

Advice From a Sound-Sensitivity Specialist

Now, let’s listen to Dr. Lindsey Tubaugh, who is a specialist in sound sensitivities, describe how she would use acoustic therapy to treat one of these sound sensitivities. 

“Sound therapy for any of the types of hyperacusis should really include a form of passive sound therapy, which is enriching your environment with soft, pleasant sound for as much of the day and night as possible. 

“We don’t want it loud. We don’t want to hurt your ears. And if you need to take a listening break, that’s great. But that’s passive sound therapy. The idea is that it’s a sound that your brain learns to tune out. 

“And then active sound therapy. Active sound therapy is using that window of tolerance for 20 minutes a day. This is really for misophonia. 

“This is what active sound therapy looks like. A lot of times we start with the triggering sound. I’ll either create it for them myself or I’ll have a loved one create it for them. So you’re doing something fun for 20 minutes. Every five minutes you turn it on, turn it off. 

“And typically that’s not long enough for people to trigger. You can start with a three-second exposure and then get back to another five minutes of doing what you love. So basically we’re exposing that person to that sound without having that trigger response. 

“Next, just in general when you’re treating these things you want to decrease your overall stress and increase your overall health, and that’s going to improve your resilience. 

“And then of course, as always, like I said, you want to get professional support — an audiologist, an ENT, and a trained mental health professional who can help with these co-occurring conditions.” 

Conclusion

So let’s go back to this 12-year-old girl. She and her parents, this is how treatment went for them. They had two therapy sessions where they learned all about phonophobia and its treatment. Just psycho-education. And then the therapist taught the girl how to calm her nervous system using deep breathing and progressive muscle relaxation. 

Then after she mastered those skills, they started with gradual exposure. So they started with the least provoking stimulus at first, like drawing a smiling balloon and then drawing a bursting balloon. 

So just to be super clear, they’re not just taking this girl and popping balloons around her all the time. Super gradual. Just drawing pictures of balloons. 

After the child was comfortable with this, the stimulus was then increased to bursting inflated balloons in the clinic and at home with parents. The parents acted as a co-therapist in this situation. And each successful session was rewarded accordingly. 

The child showed tremendous improvement in her symptoms after three months of therapy. And then gradually the child was brought to public places, like a restaurant, and finally she watched a fireworks show with no resulting complications after six months of therapy. 

So going back to the man who emailed me. Again, I recommended that he visit an audiologist and a mental health professional who specialize in these conditions to get a good diagnosis and treatment. 

And you can too. With the right support and education you really can learn the skills to manage and decrease sound sensitivities like hyperacusis, misophonia, and phonophobia. 

I hope you found this video helpful. Thank you for watching, and take care.

Sources and Resources

I use both Academic and Lay Sources to make education more accessible

Dr. Tubaugh’s website: https://littleheroeshearingclinic.com/

https://health.clevelandclinic.org/5-ways-to-cope-with-sensitivity-to-sound/
https://pubmed.ncbi.nlm.nih.gov/8339063/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3216140/
https://www.sciencedirect.com/science/article/abs/pii/S2211364918300034
https://academic.oup.com/book/34432/chapter-abstract/292198153?redirectedFrom=fulltext
https://youtu.be/Ls34Jk7AXu0
https://www.youtube.com/watch?v=rUWAwkpDhWI

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