Hyperacusis: Over-Sensitivity to Sound

Hyperacusis is NOT a hearing loss. That said, when a child or student shows signs of oversensitivity to sound it is typical for those concerned to reach out to specialists in hearing loss for answers. Negative reactions to sound can occur regardless of whether a person has typical hearing or a hearing loss. The purpose of this page is to summarize some of the issues and suggested interventions.

What is hyperacusis?

0 Mjc2NzIuanBnThis term is used when an individual complains about being intolerant of the loudness of sounds that most people do not feel are loud. They can report pain in loud sounds, but more often it is discomfort, aversion, dislike, fear or anxiety related to sounds. Some ways individuals express this problem include, ‘My ears are painful when I am exposed to sound.’ ‘My ears are very sensitive to sounds.’  ‘When I am in a noisy surrounding I experience a troublesome sensation in my ears.

Hyperacusis can be defined as an abnormally strong reaction to sound along the auditory pathways. The person can describe experiencing physical discomfort as a result of exposure to sound (quiet, medium or loud). The same sound would not evoke a similar reaction in an average listener. The strength of the reaction is controlled by the physical characteristics of the sound, e.g., its pitch and loudness. In some cases hyperacusis occurs due to damage to the cochlea in which an abnormal increase in loudness as perceived in the auditory pathways occurs. This sensitivity to sound is due to cochlear recruitment and only appears in persons with hearing loss. Persons with normal hearing who have abnormally strong reactions to sound that is not loud cannot have recruitment. That said, persons with hearing loss can also be very sensitive to sound without having recruitment.

Misophonia and phonophobia is an abnormally strong reaction of the autonomic and limbic (fight or flight reaction) systems resulting from enhanced connections between the auditory and limbic systems. Importantly, misophonia and phonophobia do not involve a significant activation of the auditory system. Individuals have negative attitude to sound (misophonia), or are afraid of sound (phonophobia). The strength of the individual’s reaction is only partially determined by the pitch/loudness of the upsetting sound. The reaction is more heavily dependent on the individual’s recollections of the sound (e.g., sound as a potential threat, and/or the belief that the sound can be harmful), their psychological profile and the context in which the sound is presented.

Most frequently, significantly decreased sound tolerance results from a combination of hyperacusis and misophonia /phonophobia. In other words, a person who has experienced discomfort from sound can develop anxiety or fear when that sound or other sounds occur that are not really uncomfortable, but are judged to be somehow similar.  Importantly, note that neither hyperacusis, misophonia or phonophobia have any relation to hearing thresholds. Individuals with these complaints may have normal hearing, and they may also have impaired hearing. Sound tolerance issues often occur in ears where an individual experiences tinnitus, or ringing in the ears.

First Step: Defining Factors Related to Reactions to Sound

  1. what are the types of sound that the child reacts to negatively
  2. what are the behaviors observed that demonstrate negative reactions
  3. what are any coping mechanisms the child uses that can help

A diary can be used to provide a profile of the sounds and aversion behaviors observed. Recording observations at school, child care, and home for a full week, including weekends is suggested. In general, how much impact (1-10 scale) is there for the aversion to sound at school and home (specific situations can be considered, i.e, bus, lunch). The family and school should work together to develop a hierarchy listing sounds with no response, minimal response, significant response, and extreme responses. How the reaction to sound changes with the extremity of response should be identified.

Hyperacusis Intervention

Noise overloadThe first, and most controversial, is to have the individual avoid the concerning sounds and to use hearing protection (ear plugs) on a regular basis. This recommendation is based on the belief that because they are more sensitive to sound they are more susceptible to hearing damage due to sound (untrue) or to ‘protect’ them from aversive experiences. Continually dampening perception of sound through the use of earplugs results in making the auditory system even more sensitive to sound (after listening in quiet even typical sounds can be perceived of as loud). The end result is that the hyperacusis is exacerbated rather than improving the functionality of the individual.

The second approach involves desensitizing the individual by exposing them to a variety of sounds. For example, expose the individual to low level sounds for an extended period of time. Slowly increase the loudness of the exposures over a number of periods (i.e., across weeks of time). Desensitization is also the most effective method of intervention for individuals with negative emotional reactions to sound. In this case presenting increasingly loud levels of the sounds associated with negative reactions are paired with engaging in fun or interesting activities.

Level 1 Intervention: Provide information about hyperacusis to the family

Many parents will be relieved to know that hyperacusis is a recognized condition, both in adults and children, and that it is not a figment of their imagination, or their child using attention-getting behaviors. They may feel empowered to develop
their own coping and informal desensitization strategies for use at home if there are very specific causes of aversion behaviors. If the hyperacusis is not impacting on family/ school life on a regular basis, or causing avoidance of particular
situations, providing information and discussing management strategies may be sufficient intervention.

Level 2 Intervention: Behavioral Desensitization of Anxiety about Sounds

Hyperacusic adults describe hearing noise as feeling like “knives through the ears or head”, extreme pain or a “grating
of the nerves.”  They may have a panic response, with possible outbursts of aggression, crying or escape strategies. They further describe the isolating nature of the condition, and the impossibility of getting others to understand what it is they experience, which can lead to withdrawal and depression. How much more difficult must it be for a child with limited communication skills! There is likely to be a learned association of fear and anxiety when the child is in situations where uncontrolled sound exposure may occur. In order to break down the learned association of anxiety with noise exposure, a desensitization program is usually appropriate. The physical occurrence of pain with noise exposure should be acknowledged, even though the condition may be maintained by anxiety. Assume that any noise which is seen to be aversive to the child, is also uncomfortable, and work to break down the fear association. A clinical psychologist can develop a program of behavioral desensitization, but the following suggestions can be used by everyone.

               Specific Intervention Suggestions

1. When the child becomes distressed by exposure to sound, move the child away from the sound source if possible and then comfort and reassure him/her.
2. Try to explain the source of the sound to the child.
3. The child’s fear reaction will often diminish if s/he can exercise some control over the sounds. So encourage the child to clap his own hands, to play with noise makers or to start and stop the vacuum cleaner at home. One therapy program requires the child to produce a range of different sounds in a play activity area. This may involve tapping a table top in a certain rhythm or shaking rattles. The child is always in control of the sounds.
4. Repeated gentle exposure to the noise may help the child to reduce anxiety and desensitize the auditory aspect of the sensitivity. Audio record one or more of the problem sounds (e.g., laughter, clapping, thunder, sirens, machine-noise) and help him to switch the media device to a very low volume. Gradually, over a period of days or weeks, increase the volume. Practice with the sounds under play conditions that the child can control, to help break the association
of that sound with fear. Although presenting sound through this process is not the same as unexpected exposure to the sound (they can often cope better if they are warned that a sound is about occur), people with hyperacusis say that this desensitization process is helpful.
5. Children should not be forced to stay in a situation that is causing them obvious distress (for example during singing in assembly). This may compound their apprehension and make them associate that situation (e.g., the assembly hall) with pain. If fear of a specific situation has become established, it is important to gradually desensitize the child, with time and care.
6. Older children may be reassured if they are told they have the teacher’s permission to leave the classroom for a few minutes at any point if they are exposed to an aversive noise. Most children do not abuse such an arrangement and are greatly reassured to know that they can leave a room, for a short time, if noise becomes distressing to them.
7. The use of ear plugs, muffs or hearing defenders should be avoided except in extreme or short-term, unavoidable situations (e.g., during a journey). Exposure to normal and tolerable sound is crucial if the ear and brain are to establish normal sensitivity.

               Auditory Desensitization

Auditory desensitization aims to reduce the over-sensitivity of the hearing system to the sounds that the child finds uncomfortable. If this is a very specific sound source (e.g., the sound of material being rubbed) it may be easy to design a hierarchy of acceptable noises, incrementally presenting more challenging sounds, and building up to more aversive ones. The important aspect is to keep the signal carefully graded to be acceptable, and under the control of the listener. A recording of sounds played by the child at their own comfortable level may be helpful. This approach may be undertaken by the family, without requiring professional support. However if there is a wide range of sound sources and situations a more proactive approach is needed.

Level 3 Intervention: Using Noise Generators to Reduce Auditory Over-Sensitivity

Noise generators (which are also tinnitus maskers and look like hearing aids) can be used to reduce the sensitivity of hearing for people with hyperacusis. A noise generator produces a steady, wide-band noise. It has a volume control to allow the noise level to be turned up or down. This is an established method of helping hearing over-sensitivity in adults. The application of this technique to children, particularly those with learning disabilities, requires time and support, but
has been found to be very effective, even for children with limited communication skills. There should be someone in the local audiology department who is able to advise you on the availability of this technique. It would be recommended that an incident diary is completed at home and school for a full week prior to starting use of maskers, to give a base-line of
hyperacusis profile and behaviours. This allows outcome measures to be kept for the intervention and to build support for funding requests for maskers.

The aim of using noise -generators is to improve a person’s ability to tolerate normal exposure to sound, by reducing the sensitivity of the ear. The precise way that this occurs is not understood. The addition of a masking noise to hearing of everyday sounds gives an immediate improvement, presumably by reducing the harshness of individual sound signals. However there is a longer-term benefit that is seen when the maskers are not in use in that there is a gradual improvement in the tolerance of sounds, which suggests some sort of control on the overexcitability in the auditory system. Whether this is to do with changing the excitation patterns in the auditory system, or whether it gives people more control over their anxiety (or both), is not yet clear. Most adults report that over about one year to eighteen months of noise-generator use, their sensitivity to sound is much more normal.

The most effective management of hyperacusis is to use noise-generators in parallel to a program aiming to reduce fear and anxiety associated with sound exposure. It is not aiming to mask out or reduce the level at which the person can hear the sounds causing discomfort. This technique requires long-term, low level, noise exposure while maintaining normal access to everyday environmental and speech information. There is no possibility of damage to the hearing mechanism through use of sound generators.

               Fitting Noise Generator Devices
Noise generators are worn behind the ear in a similar way to post-aural hearing aids. The sound is fed into the ears through an open ear mold, which is designed so that it does not block the ear canal, as this would result in loss of some background sounds. Although there are noise generators which go into the ear canal, they are not appropriate for hyperacusis desensitization as they reduce access to normal sound. (The use of ear plugs and muffs for extended periods of time is also counter-productive). The ear mold and device must be comfortable and secure so that it is realistic to build up the daily hours of use. As hearing sensitivity usually occurs in both ears, binaural fittings need to be made. Occasionally the hyperacusis is reported from one ear in which case only that side needs to be fitted.

Setting the initial output level

The device has a volume control to change the intensity level of the sound that it gives out. This should be set at the beginning of the session or day in a quiet situation when the subject is calm and relaxed. The child may be able to say, or indicate, when the sound is just perceptible to him / her. It may be necessary to allow some practice so that a reliable technique can be established, because if the child is asked “Can you hear that?” they are very likely to answer “yes” regardless of whether they can or not. If a child is not able to communicate detection of the sound, maskers should be fitted at the just-audible output for another normally hearing person.

It is important that the device can only just be heard initially. The sound should not be intrusive in daily activity. If the background level of sound increases in any situation, the noise generator output should be kept at the initial setting even if the wearer can no longer hear it. Only if the environmental noise level is uncomfortable should the device output be
increased to cope with the discomfort.

Duration of Use

The aim is to build up the time that the device is worn to at least six hours a day. This will usually be in the home in quiet situations, but will gradually include other environments such as in school and while travelling. As the wearer becomes used to the devices, it may be helpful to keep a short-term diary of times of use and any perceived effects. This is not to raise the profile of the hearing sensitivity, but to keep a note of changes in behavior or reaction to sounds while the noise-generators are being used.

Increasing the Output Level Over Time

When the child has been using the maskers quite comfortably for six hours per day without any problems, the level of the noise output should be fractionally increased. The new level should not be challenging to the wearer, but they may need time to acclimate to the new level. Again, if there are still specific situations, or sounds that the child cannot tolerate
with the maskers at this output level, the level should be minimally increased again. This gradual increase in output should be used to improve the child’s ability to tolerate different environments of everyday life. Once a child is able to comfortably go in all typical situations throughout the day, and cope with all the different sound sources around him, there is no need to increase the masker noise level further. Some children very quickly get the hang of changing the masker output volume themselves depending on the environment they are in. This is fine and can be encouraged and supported. They may choose to have a different masker level in each ear. As hyperacusis is a subjective condition, this is
very helpful. There is no set output level that the wearer must reach, but when he can tolerate all the different noise situations that he typically goes in, with noise generators on, there is no need to continue to increase the volume of the
masker. In practice, with the majority of children who have been fitted to date, there has been immediate acceptance of the maskers, and the children have very quickly got used to volume changes, sometimes even turning them up and down as necessary in different listening conditions.

Repeat Diary of Hyperacusis Incidents

After about two months of use it is helpful to repeat the incident diary for a full seven day week, recording all noise-associated behaviors, as done at the outset of the masker use.

When does one start to reduce the masker use, or noise level?

You may find that there are situations that they can now happily tolerate without their maskers in and that the auditory over-sensitivity is improving. Don’t over-challenge the child with situations that they are nervous about, without the maskers in, until they are ready to do so. Some children have just suddenly decided not to wear the maskers anymore, having worn them happily and to great benefit for many months. Unless there are situations which still have to be avoided because of hyperacusis, Accept the child’s improved auditory sensitivity, though you may choose to keep the
maskers for use in new or more challenging situations. When the child can cope with all circumstances without their maskers, clearly the process has reset the “volume control” in the brain.

How long will it take?

The use of noise generators with hyperacusis in adults may typically go on for 12 to 18 months. After this period, most people find a long-term improvement has occurred in their sensitivity without the noise generators. Although we cannot predict how long this may take in children (and those with a learning disability) the desensitization should still be carried out over a finite period of time. As it seems that auditory over-sensitivity is increased with generalized stress and anxiety, it is important that anxiety issues are addressed in parallel to this process. Complete a third incident diary to check that there are no residual behaviors that can be identified. As the impact of hyperacusis is much less now, there is a tendency for people to be reluctant to fill in the form consistently at this stage. It is very important that this is done, as it builds
evidence for the value of the intervention (or not) and will underpin the availability of resources for other children to be helped. Many families and children keep their maskers in case of use for a new activity (for example attending a film, or football game).

 

Information has been based on Jastreboff & Jastreboff and Josephine Marriage. For additional information go to http://www.hyperacusis.net/  For a review and future directions go to: Hyperacusis Part 1: Definitions and Manifestations, Hyperacusis Part 2: Measurement, Mechanisms, and Treatment

Information excerpted by Karen L. Anderson, PhD, Supporting Success for Children with Hearing Loss. January 2015

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