Department of Psychiatry; University of British Columbia; Vancouver, BC, Canada (Hadjipavlou)
Department of Psychiatry British Columbia Children's Hospital and University of British Columbia; Vancouver, British Columbia, Canada (Baer)
Department of Medicine University of British Columbia Vancouver, British Columbia, Canada (Lau)
British Columbia Neuropsychiatry Program and University of British Columbia; Vancouver, British Columbia, Canada (Howard)
We report two cases of selective sound intolerance associated with intense emotional distress and functional impairment. To our knowledge, there have not been any previous cases of this nature documented in the psychiatric literature.
Case 1 – Over the course of 4 to 5 months, a 13-year-old girl became increasingly unable to tolerate the sounds of people licking their lips, eating, and speaking. This decreased sound tolerance was accompanied by intense feelings of anxiety and avoidant behavior. She experienced intrusive images of mouths, and urges to mimic the distressing sounds resulting in repetitive lip movements and mouth-smacking noises. As a consequence, she experienced a rapid decline in social function, and was no longer able to attend school or participate in family and social activities. She had no previous psychiatric history and was otherwise healthy. She reported some additional mild obsessive-compulsive symptoms such as checking. There were no inciting stressors or illnesses identified. Medical work-up, including hearing assessment and computed tomography scan of the head, was normal. Relaxation techniques and a trial of fluoxetine provided some symptomatic improvement and decrease in distress, although she currently remains out of school. Exposure therapy to stereotyped distressing sounds was limited by noncompliance.
Case 2 – A 25-year-old woman presented with intense emotional distress precipitated by the sounds of people eating, speaking, or picking their nails. This began when she was 12 years old and has persisted without remission over the past 13 years. Triggering stimuli have increased over time to include visual images (e.g., lips moving). Although she endorsed some mild premorbid obsessive-compulsive behaviors, there was otherwise no clear evidence of mental illness prior to the onset of decreased sound tolerance. She was subsequently diagnosed with panic disorder, social phobia, body dysmorphic disorder, mixed personality disorder, and marijuana abuse, although her primary complaint remained sound sensitivity. Medical workup, including hearing assessment, was normal. During two hospitalizations of several months she showed minimal response to trials of antidepressants, typical and atypical antipsychotics, anxiolytics, stimulants, and mood stabilizers. Exposure therapy was limited by noncompliance and perceived lack of benefit. Treatment with sound generators also showed no therapeutic effect.
The etiology of the selective sound intolerance in these young women is unclear. One potential model to understand this is found in the audiology and otolaryngology literature where the term “misophonia” has been used to describe a condition of decreased sound tolerance(1). Misophonia is said to arise in individuals with normal hearing or, more commonly, in the context of hyperacusis or tinnitus, with one center reporting misophonia in 60% of its tinnitus patients(2). Both misophonia and tinnitus are postulated to result from similar mechanisms by which abnormal activation of limbic and autonomic systems occurs with benign sounds. This sets up a conditioned negative response cycle with hypervigilance and increasing emotional distress, similar to a number of the functional somatic syndromes in other systems of the body. Recommended treatment includes tinnitus retraining therapy, which involves a systematic conditioning paradigm that shares aspects of cognitive behavioral therapy(1).
Another potential model for understanding these two cases is as an obsessive-compulsive disorder spectrum illness. In both cases, the egodystonic repetitive preoccupation with sounds as well as the associated intrusive images of lips and mouths appear phenomenologically similar to obsessions. The younger patient also had urges to mimic the sounds resulting in repetitive lip smacking, which could be seen as a compulsion. In support of this model, both patients also disclosed obsessive-compulsive symptoms unrelated to their sound sensitivity.
Although we could find no mention of selective sound intolerance in the psychiatric literature, search of the World Wide Web revealed an online support group of over 600 members for people with selective sound sensitivities suggesting this condition is more common than previously recognized (http://health.groups.yahoo.com/group/Soundsensitivity/).
Clinicians not familiar with this poorly understood condition may misdiagnose such patients, or worse, be unwittingly dismissive of their complaints. For instance, the patient in the second case described having her complaints of sound sensitivity attributed by multiple physicians to personality-related behaviors. However, it is worth highlighting that neither of these two patients experienced any functional impairment prior to the onset of their decreased sound tolerance.
Our two cases reported herein are intended to alert clinicians to selective sound intolerance and its associated emotional distress and functional impairment. Research clarifying the phenomenology, pathophysiology, prevalence, and treatment of this putative condition is in order.
George Hadjipavlou, MD, MA
Department of Psychiatry
University of British Columbia
Vancouver, BC, Canada
Susan Baer, MD, PhD
Department of Psychiatry British Columbia Children's Hospital and University of British Columbia
Vancouver, British Columbia, Canada
Department of Medicine
University of British Columbia Vancouver, British Columbia, Canada
Andrew Howard, MD
British Columbia Neuropsychiatry Program and University of British Columbia
Vancouver, British Columbia, Canada
1. Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy for patients with tinnitus and decreased sound tolerance. Otolaryngol Clin N Am 2003;26:321–36.
2. Jastreboff PJ, Jastreboff MM. Tinnitus retraining therapy: a different view on tinnitus. Otolaryngology 2006;68:23–30.