Semin Hear 2014; 35(02): 105-120
DOI: 10.1055/s-0034-1372527
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia)

Pawel J. Jastreboff
1   Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia
Margaret M. Jastreboff
2   JHDF, Inc., Columbia, Maryland
› Author Affiliations
Further Information

Publication History

Publication Date:
29 April 2014 (online)


Decreased sound tolerance (DST) is an underappreciated condition that affects the lives of a significant portion of the general population. There is lack of agreement regarding definitions, specific components, prevalence, methods of evaluation, and methods of treatment. Limited data are available on the results of treatments. Research is scant and constrained by the lack of an animal model. This article proposes a definition of DST and its division into hyperacusis and misophonia. The potential mechanisms of these phenomena are outlined, and the results of treatment performed at Emory University are presented. Out of 201 patients with DST, 165 (82%) showed significant improvement. Of 56 patients with hyperacusis (with or without misophonia), 45 (80%) showed significant improvement. This proportion was higher for the group with hyperacusis and concurrent misophonia (33 of 39, or 85%) and lower for patients with hyperacusis only (13 of 17, or 76%). Effectiveness of treatment for misophonia with or without hyperacusis was identical (152 of 184, 83% and 139 of 167, 83%, respectively, for misophonia accompanied by hyperacusis and for misophonia only). Even with current limited knowledge of DST, it is possible to propose specific mechanisms of hyperacusis and misophonia and, based on these mechanisms, to offer treatments in accordance with the neurophysiological model of tinnitus. These treatments are part of Tinnitus Retraining Therapy (TRT), which is aimed at concurrently treating tinnitus and DST and alleviating the effects of hearing loss. High effectiveness of the proposed treatments support the postulated mechanisms.

  • References

  • 1 Baguley D, McFerran D. Hyperacusis and disorders of loudness perception. In: Moller A, Kleinjung T, Langguth B, De Ridder D, , eds. Textbook of Tinnitus. New York, NY: Springer; 2010: 13-23
  • 2 Jastreboff PJ, Hazell JWP. Tinnitus Retraining Therapy: Implementing the Neurophysiological Model. Cambridge, UK: Cambridge University Press; 2004
  • 3 Jastreboff PJ, Jastreboff MM. Decreased sound tolerance. In: Snow JB, , ed. Tinnitus: Theory and Management. London, UK: BC Decker; 2004: 8-15
  • 4 Jastreboff MM, Jastreboff PJ. Decreased sound tolerance and Tinnitus Retraining Therapy (TRT). Aust N Z J Audiol 2002; 21 (2) 74-81
  • 5 Jastreboff PJ, Jastreboff MM. Using TRT to treat hyperacusis, misophonia and phonophobia. ENT Audiology News 2013; 21 (6) 88-90
  • 6 Jastreboff MM, Jastreboff PJ. Hyperacusis. Audiology On-line 6–18–2001. Available at: . Accessed on March 19, 2014
  • 7 Jastreboff PJ. Tinnitus Retraining Therapy. In: Moller A, Kleinjung T, Langguth B, De Ridder D, , eds. Textbook of Tinnitus. New York, NY: Springer; 2010: 575-596
  • 8 Jastreboff PJ, Jastreboff MM. Tinnitus and decreased sound tolerance. In: Ballenger JJ, Snow JB, Ashley WP, , eds. Ballenger's Otorhinolaryngology Head and Neck Surgery. 17 ed. San Diego, CA: Singular Publishing; 2009: 351-362
  • 9 Schröder A, Vulink N, Denys D. Misophonia: diagnostic criteria for a new psychiatric disorder. PLoS ONE 2013; 8 (1) e54706
  • 10 Fabijanska A, Rogowski M, Bartnik G, Skarzynski H. Epidemiology of tinnitus and hyperacusis in Poland. In: Hazell JWP, , ed. Proceedings of the Sixth International Tinnitus Seminar. Cambridge, UK: THC; 1999: 569-571
  • 11 Baguley DM. Hyperacusis. J R Soc Med 2003; 96 (12) 582-585
  • 12 Andersson G, Lindvall N, Hursti T, Carlbring P. Hypersensitivity to sound (hyperacusis): a prevalence study conducted via the Internet and post. Int J Audiol 2002; 41 (8) 545-554
  • 13 Vernon J, Press L. Treatment for hyperacusis. In: Vernon JA, , ed. Tinnitus Treatment and Relief. 1st ed. Boston, MA: Allyn & Bacon; 1998: 223-227
  • 14 Byrne D, Dirks D. Effects of acclimatization and deprivation on non-speech auditory abilities. Ear Hear 1996; 17 (3) 29S-37S
  • 15 Cox RM, Alexander GC, Taylor IM, Gray GA. The contour test of loudness perception. Ear Hear 1997; 18 (5) 388-400
  • 16 Hawkins DB, Walden BE, Montgomery A, Prosek RA. Description and validation of an LDL procedure designed to select SSPL90. Ear Hear 1987; 8 (3) 162-169
  • 17 Ricketts TA, Bentler RA. The effect of test signal type and bandwidth on the categorical scaling of loudness. J Acoust Soc Am 1996; 99 (4 Pt 1) 2281-2287
  • 18 Sherlock LP, Formby C. Estimates of loudness, loudness discomfort, and the auditory dynamic range: normative estimates, comparison of procedures, and test-retest reliability. J Am Acad Audiol 2005; 16 (2) 85-100
  • 19 Blomberg S, Rosander M, Andersson G. Fears, hyperacusis and musicality in Williams syndrome. Res Dev Disabil 2006; 27 (6) 668-680
  • 20 Klein AJ, Armstrong BL, Greer MK, Brown III FR. Hyperacusis and otitis media in individuals with Williams syndrome. J Speech Hear Disord 1990; 55 (2) 339-344
  • 21 Hazell JWP, Sheldrake JB, Graham RL. Decreased sound tolerance: predisposing / triggering factors and treatment outcome following tinnitus retraining therapy (TRT). Paper presented at: 7th International Tinnitus Seminar; March 5–9 2002; Fremantle, Western Australia; Perth, Australia: University of Western Australia. 255-261
  • 22 Herráiz C, Plaza G, Aparicio JM. [Mechanisms and management of hyperacusis (decreased sound tolerance)]. Acta Otorrinolaringol Esp 2006; 57 (8) 373-377
  • 23 Herráiz C, Hernández Calvín J, Plaza G, Toledano A, de los Santos G. [Study of hyperacusis at a tinnitus unit]. Acta Otorrinolaringol Esp 2003; 54 (9) 617-622
  • 24 Jastreboff PJ, Jastreboff MM, Sheldrake JB, Audiometrical characterization of hyperacusis patients before and during TRT. In: Hazell JWP. , ed. Proceedings of the Sixth International Tinnitus Seminar. Cambridge, UK: THC; 1999: 495-498
  • 25 Anari M, Axelsson A, Eliasson A, Magnusson L. Hypersensitivity to sound—questionnaire data, audiometry and classification. Scand Audiol 1999; 28 (4) 219-230
  • 26 Hoffman HJ, Reed GW. Epidemiology of tinnitus. In: Snow JB, , ed. Tinnitus: Theory and Management. London, UK: BC Decker; 2004: 16-41
  • 27 Baguley D, Andersson G. Hyperacusis Mechanisms, Diagnosis, and Therapies. San Diego, CA: Plural Pub; 2007. 144.
  • 28 Niu Y, Kumaraguru A, Wang R, Sun W. Hyperexcitability of inferior colliculus neurons caused by acute noise exposure. J Neurosci Res 2013; 91 (2) 292-299
  • 29 Sahley TL, Nodar RH. A biochemical model of peripheral tinnitus. Hear Res 2001; 152 (1–2) 43-54
  • 30 Marriage J, Barnes NM. Is central hyperacusis a symptom of 5-hydroxytryptamine (5-HT) dysfunction?. J Laryngol Otol 1995; 109 (10) 915-921
  • 31 Gopal KV, Daly DM, Daniloff RG, Pennartz L. Effects of selective serotonin reuptake inhibitors on auditory processing: case study. J Am Acad Audiol 2000; 11 (8) 454-463
  • 32 Jastreboff PJ, Hazell JWP. A neurophysiological approach to tinnitus: clinical implications. Br J Audiol 1993; 27 (1) 7-17
  • 33 Attias J, Zwecker-Lazar I, Nageris B, Keren O, Groswasser Z. Dysfunction of the auditory efferent system in patients with traumatic brain injuries with tinnitus and hyperacusis. J Basic Clin Physiol Pharmacol 2005; 16 (2–3) 117-126
  • 34 Baguley DM, Axon P, Winter IM, Moffat DA. The effect of vestibular nerve section upon tinnitus. Clin Otolaryngol Allied Sci 2002; 27 (4) 219-226
  • 35 Scharf B, Magnan J, Chays A. On the role of the olivocochlear bundle in hearing: 16 case studies. Hear Res 1997; 103 (1–2) 101-122
  • 36 Jastreboff PJ. Phantom auditory perception (tinnitus): mechanisms of generation and perception. Neurosci Res 1990; 8 (4) 221-254
  • 37 Boettcher FA, Salvi RJ. Functional changes in the ventral cochlear nucleus following acute acoustic overstimulation. J Acoust Soc Am 1993; 94 (4) 2123-2134
  • 38 Gerken GM. Alteration of central auditory processing of brief stimuli: a review and a neural model. J Acoust Soc Am 1993; 93 (4 Pt 1) 2038-2049
  • 39 Noreña AJ, Farley BJ. Tinnitus-related neural activity: theories of generation, propagation, and centralization. Hear Res 2013; 295: 161-171
  • 40 Jastreboff PJ. The role of subconscious pathways in tinnitus and decreased sound tolerance. Paper presented at: 9th International Tinnitus Seminar; June 15–18 2008 ; Goteborg, Sweden
  • 41 Edelstein M, Brang D, Rouw R, Ramachandran VS. Misophonia: physiological investigations and case descriptions. Front Hum Neurosci 2013; 7: 296
  • 42 Klochoff I. Impedance fluctuation and a “Tensor Tympani Syndrome”. Penha R, Pizarro P, , eds. Paper presented at: Proc 4th International Symposium on Acoustic Impedance Measurements; September 25–28 1979. Lisbon, Portugal: Universidad Nova de Lisboa; 69-76
  • 43 Konorski J. Conditioned Reflexes and Neuronal Organization. Cambridge, UK: Cambridge University Press; 1948
  • 44 Khalfa S, Dubal S, Veuillet E, Perez-Diaz F, Jouvent R, Collet L. Psychometric normalization of a hyperacusis questionnaire. ORL J Otorhinolaryngol Relat Spec 2002; 64 (6) 436-442
  • 45 Dauman R, Bouscau-Faure F. Assessment and amelioration of hyperacusis in tinnitus patients. Acta Otolaryngol 2005; 125 (5) 503-509
  • 46 Jastreboff MM, Jastreboff PJ, Questionnaires for assessment of the patients and treatment outcome. In: Hazell JWP. , ed. Proceedings of the Sixth International Tinnitus Seminar. Cambridge, UK: THC; 1999: 487-490
  • 47 Henry JA, Jastreboff MM, Jastreboff PJ, Schechter MA, Fausti SA. Guide to conducting tinnitus retraining therapy initial and follow-up interviews. J Rehabil Res Dev 2003; 40 (2) 157-177
  • 48 Hood JD, Poole JP. Tolerable limit of loudness: its clinical and physiological significance. J Acoust Soc Am 1966; 40 (1) 47-53
  • 49 Jastreboff PJ, Gray WC, Gold SL. Neurophysiological approach to tinnitus patients. Am J Otol 1996; 17 (2) 236-240
  • 50 Formby C, Sherlock LP, Gold SL. Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background. J Acoust Soc Am 2003; 114 (1) 55-58
  • 51 Formby C, Hawley M, Sherlock LP , et al. Intervention for restricted dynamic range and reduced sound tolerance: clinical trial using a Tinnitus Retraining Therapy protocol for hyperacusis. J Acoust Soc Am 2013; 133 (5) 3382-3383
  • 52 Hawley ML, Keaser ML, Formby C. Predicting hyperacusis in tinnitus patients. Semin Hear 2007; 28 (4) 261-275
  • 53 Formby C, Gold SL, Keaser ML, Block KL, Hawley ML. Secondary benefits from Tinnitus Retraining Therapy: Clinically significant increase in loudness discomfort level and expansion of the auditory dynamic range. Semin Hear 2007; 28: 227-260
  • 54 Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol 2000; 11 (3) 162-177
  • 55 Johnson M. Pink sound protocol for tinnitus & hyperacusis. Available at: . Accessed: January 7, 2014
  • 56 Andersson G, Jüris L, Kaldo V, Baguley DM, Larsen HC, Ekselius L. [Hyperacusis—an unexplored field. Cognitive behavior therapy can relieve problems in auditory intolerance, a condition with many questions]. Lakartidningen 2005; 102 (44) 3210-3212
  • 57 Hiller W, Haerkötter C. Does sound stimulation have additive effects on cognitive-behavioral treatment of chronic tinnitus?. Behav Res Ther 2005; 43 (5) 595-612
  • 58 Henselman LW, Henderson D, Subramaniam M, Sallustio V. The effect of “conditioning” exposures on hearing loss from impulse noise. Hear Res 1994; 78 (1) 1-10
  • 59 Niu X, Tahera Y, Canlon B. Protection against acoustic trauma by forward and backward sound conditioning. Audiol Neurootol 2004; 9 (5) 265-273
  • 60 Niu X, Tahera Y, Canlon B. Environmental enrichment to sound activates dopaminergic pathways in the auditory system. Physiol Behav 2007; 92 (1–2) 34-39
  • 61 Jastreboff PJ, Jastreboff MM. Potential impact of stochastic resonance on tinnitus and its treatment. Association for Research in Otolaryngology February 23, 2000. Meeting materials, pg. 5542
  • 62 Jastreboff PJ, Jastreboff MM, Payne L. Real ear measurements in tinnitus retraining therapy. Paper presented at: 7th International Tinnitus Seminar; March 5–9 2002; Freemantle, Australia
  • 63 Formby C. Hyperacusis and related sound tolerance complains: differential diagnosis, treatment effects, and models. Semin Hear 2007; 28: 227-259
  • 64 Jastreboff MM. Sound therapies for tinnitus management. In: Langguth B, Hajak G, Kleinjung T, Cacace A, Moller A, , eds. Tinnitus: Pathophysiology and Treatment. Amsterdam, the Netherlands: Elsevier; 2007: 449-454
  • 65 Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy. In: Baguley D, , ed. Perspectives in Tinnitus Management. New York, NY: Thieme; 2001: 51-63
  • 66 Jastreboff PJ, Jastreboff MM. Decreased Sound Tolerance (Hyperacusis and Misophonia): Theory and Clinical Practice. Boston, MA: American Academy of Audiology; 2012