The 5 Distinct Sound Hypersensitivity Disorders
By James Henry, Ph.D.
Sound hypersensitivity disorders are deeply personal to me. In my teens and 20s I played guitar in rock bands. I remember often lying in bed after a performance and noticing the “roar” in my ears.
I admit I didn’t think much of it. But performing became more and more uncomfortable, with the loudness of the music beginning to hurt my ears. Knowing nothing about earplugs, I started stuffing wet toilet paper in my ears to block the sound. The roaring in my ears didn’t stop, though. I had persistent tinnitus.
After playing music I worked as a carpenter, so I went from one loud occupation to another. Every day I was exposed to hammering, power tools, and all forms of loud machines. I really had no idea what lasting damage I was doing to my ears.
Eventually I started wearing earplugs, but it was too little, too late.
After four years of carpentry, I decided to go back to school to become a clinical audiologist. My daughter Erin, who is deaf, was the impetus to study audiology.
After earning my M.S. in audiology, I worked at the Veterans Affairs (VA) hospital in Portland, Oregon, as a research audiologist in their auditory research lab, known as the National Center for Rehabilitative Auditory Research. Working in that lab inspired me to go back to school to earn a doctorate so that I could conduct my own research.
In 1988 I enrolled in the behavioral neuroscience program at Oregon Health & Science University (OHSU) and spent the next six years as a full-time student while working half-time at the VA.
Part of my doctoral program was doing lab work at the OHSU Oregon Hearing Research Center, which housed the OHSU Tinnitus Clinic, the first comprehensive tinnitus clinic in the world, which was founded and directed by the late Jack Vernon, Ph.D.
Since then, through my career conducting clinical research, I’ve trained hundreds of clinicians and authored or coauthored 257 (and counting) publications, including 142 published in scientific peer-reviewed journals.
I’ve published a number of books to help explain these conditions and treatments in lay terms. Now my latest, “The Hyperacusis and Misophonia Book,” aims to educate the public and clinicians alike about sound hypersensitivity disorders.
Sound Hypersensitivity Disorders
Sound hypersensitivity disorders are conditions that disrupt a person’s ability to participate in normal daily activities due to physical discomfort, emotional distress, or excessive fear triggered by everyday sounds.
For many, sounds that are manageable or even pleasant for others can cause physical pain, intense emotional reactions like anger or anxiety, or a persistent fear that sound will lead to discomfort or harm.
The severity of the disorder can range from mild symptoms a person can live with, to extreme symptoms that make working, socializing, and simply living life feel impossible.
Recognizing that sound hypersensitivity disorders are not a single condition is critical for proper diagnosis and treatment. I know that increased awareness and research are essential to help clinicians distinguish between these disorders and provide effective care, improving the lives of those who are affected.
I will note that these disorders are often grouped together under the single term “hyperacusis,” but in reality there are five distinct sound hypersensitivity disorders, each with unique symptoms and effects.
1. Loudness hyperacusis
Definition: Loudness hyperacusis is the experience of uncomfortable to unbearable physical sensations—such as ear fullness, earaches, or headaches—in the ears and/or head when exposed to any sound at intensity levels that would not be uncomfortable for most people.
Causes: Extensive evidence suggests that central auditory gain—the brain’s “volume control” for the auditory system—increases following damage to the cochlea. This heightened sensitivity may underlie the physical discomfort. In addition, everyday sounds can trigger the contraction of the tensor tympani muscle, leading to a sensation of fullness in the ear and other unpleasant symptoms. This condition is sometimes referred to as tonic tensor tympani syndrome.
2. Pain hyperacusis (noxacusis)
Definition: Pain hyperacusis (noxacusis) is the experience of burning, stabbing, or jabbing pain in the ears or head when exposed to, and/or following, any sound at an intensity level that would be comfortable for most people.
Causes: Pain hyperacusis can originate from multiple points within the auditory system. In the inner ear, neurons connecting the outer hair cells in the cochlea to the brainstem can be the source of pain when exposed to sound. In the middle ear, damage, overload, or myoclonus (uncontrollable twitching) of the tensor tympani muscle may irritate the trigeminal nerve, contributing to discomfort and pain. Additionally, damage to the middle or inner ear can lead to increased neural activity in the central auditory pathway as another possible source of pain.
3. Misophonia
Definition: Misophonia is characterized by strong negative emotional, physiological, and behavioral responses to “trigger” sounds, especially sounds from the mouth and nose of others.
Causes: It is debated whether misophonia is an auditory or a psychiatric disorder, as it involves an abnormal reaction of the limbic and autonomic nervous systems to sounds of normal intensity. Symptoms often emerge in childhood or early adolescence, and individuals with obsessive-compulsive personality disorder (OCPD) may be more susceptible to developing the disorder. Additionally, research suggests that there may be a genetic predisposition to misophonia, further indicating that both neurological and psychological factors contribute to its development.
4. Noise sensitivity
Definition: Noise sensitivity is hypersensitivity to usual sounds that are interpreted as unwanted “noise” and cause annoyance, tension, anxiety, fear, isolation tendency, and/or anger. A universal trait since everyone experiences annoyance by some sounds, it becomes a disorder when daily life is significantly impacted.
Causes: Noise sensitivity is often believed to be influenced by personality traits, with anxiety, depression, introversion, extraversion, and conscientiousness all being linked to heightened sensitivity to sound. Individuals with PTSD may also experience hypervigilance, or hyperarousal, in response to environmental stimuli, including sounds. Neuronal mechanisms in the brain have been proposed to underlie noise sensitivity, with changes in the cortex and other brain regions playing a role. Additionally, studies have identified a possible genetic basis for noise sensitivity.
5. Phonophobia
Definition: Phonophobia is an excessive, persistent state of fear that either specific sounds or sound in general will cause discomfort, distress, or pain. A person with phonophobia either tries to avoid the sound that triggers the fear or endures it with great anxiety and distress. A phobia is a type of anxiety disorder.
Causes: Phonophobia usually develops because of the experience of loudness hyperacusis, pain hyperacusis, misophonia, and/or noise sensitivity. It may involve mechanisms underlying the development of any specific phobia. For example, a traumatic experience can result in a specific phobia toward whatever caused the trauma, so that a traumatic noise (firecracker, airhorn blast, gunshot, etc.) and acoustic shock can result in phonophobia due to the emotional impact of the traumatic event. Fear becomes associated with the event, and this conditioned fear can last a lifetime.
Additional details to note are that two of these disorders involve physical hypersensitivity to sound, where average noises that are tolerable for most people become uncomfortably or painfully loud. These conditions are loudness hyperacusis and pain hyperacusis.
Two of the other disorders involve emotional reactions to sound. In misophonia, specific sounds trigger strong emotional responses such as annoyance, irritation, or anger. Similarly, noise sensitivity causes heightened reactions to general noise, leading to tension, anxiety, or frustration.
The fifth condition, phonophobia, is characterized by an excessive and persistent fear that sound will cause discomfort, pain, or emotional distress.
Diagnoses and Treatments
Diagnosing these disorders requires ruling out other potential causes, such as general annoyance to sound, hearing aids amplifying too much, or loudness recruitment (abnormally rapid increase in loudness due to hearing loss).
I use tools like the Tinnitus and Hearing Survey and in-depth interviews to identify a patient’s specific condition. Unfortunately, no universal test exists.
Since the five types of sound hypersensitivity conditions are distinct, treatment also differs. This becomes risky when one commonly used treatment is applied to all conditions. In particular, using sound or exposure therapy can potentially worsen symptoms for those with pain hyperacusis.
Here is an overview of management techniques to date:
1. Loudness hyperacusis
Treatment focuses on desensitizing the auditory system and addressing emotional and physical responses to sound. Common approaches include educational counseling and sound therapy (e.g., Tinnitus Retraining Therapy, Hyperacusis Activities Treatment, Progressive Tinnitus Management), cognitive behavioral therapy (CBT), and the use of sound therapy apps. For severe cases, migraine-based treatments or surgery may be considered.
2. Pain hyperacusis
For this severe condition, sound therapy may not be viable. Treatment options include educational counseling, CBT, lifestyle changes, and various pharmaceuticals such as nerve blockers, Botox injections, or medications like benzodiazepines, gabapentinoids, and pain relievers.
3. Misophonia
Misophonia treatment targets emotional and physiological responses to specific trigger sounds. Approaches include CBT, exposure techniques, Tinnitus Retraining Therapy, Dialectical Behavior Therapy (DBT), and pharmacotherapy using selective serotonin reuptake inhibitors (SSRIs), antipsychotics (e.g., risperidone), or beta-blockers (e.g., propranolol).
4. Noise sensitivity
Treatment for noise sensitivity often involves addressing co-existing conditions like post traumatic stress disorder (PTSD), migraines, or autism spectrum disorders. Strategies include CBT, third-wave psychotherapies (e.g., acceptance and commitment therapy or mindfulness), exposure therapy, and Tinnitus Retraining Therapy.
5. Phonophobia
Since phonophobia stems from anxiety, treating the underlying sound hypersensitivity disorder may resolve it. When needed, CBT, exposure therapy, or digital interventions (e.g., mobile-based therapies) can be used to target the fear and anxiety related to sound.
Each treatment plan is tailored to the specific disorder and its severity, often combining counseling, therapy, and medical interventions to improve quality of life. But the challenge is that clinicians often may not truly understand that there are five distinct sound hypersensitivity disorders and how they differ so that a potentially harmful treatment is recommended.
My own experiences with tinnitus and sound hypersensitivity have shaped the research to which I have devoted my career. Over the decades, I’ve been inspired by the resilience of patients and the growing research in this field.
But I also see the gaps in treatment and the lack of widespread understanding among clinicians, which motivates me to continue raising awareness and pushing for advancements.
If you’re struggling with sound hypersensitivity, know you’re not alone. There’s a growing community of patients, researchers, and clinicians working together to find solutions. My goal is to educate, empower, and ultimately help people reclaim their lives.
“The Hyperacusis and Misophonia Book” will be available in March 2025. Learn more at earsgonewrong.org. Special thanks to Hyperacusis Research and the Adult Loss of Hearing Association for their help sharing this information.