İşitmeAtölyesiAt a glance
An umbrella concept combining changes in sound processing with emotional reactions; hearing may be normal.
Hyperacusis (generally excessive loudness), misophonia (anger/disgust to specific sounds), phonophobia (fear/avoidance of sound), noise sensitivity.
Not an emergency; but assessment is advised when it leads to social isolation and anxiety.
Multidisciplinary rehabilitation: counselling, sound enrichment, gradual desensitisation, CBT.
Medical disclaimer. This content is for informational purposes only and does not replace a physician’s examination, diagnosis or treatment; it should not be used as medical advice. For your complaints or personal situation, always consult an ear, nose and throat physician and an audiologist.
If everyday sounds (dishes clattering, traffic, applause) cause discomfort, pain or intense anger/disgust, and this disrupts your social life, sleep or mood, consult an audiologist. Assessment should be done with safe protocols that protect the ear from further acoustic trauma; high-intensity test stimuli should be avoided.
Definition and epidemiology
Decreased sound tolerance is an umbrella concept combining changes in sound processing with emotional reactions. Four main phenotypes are defined: hyperacusis, misophonia, phonophobia and noise sensitivity.
In hyperacusis there is a perception of excessive loudness/discomfort to sounds in general. In misophonia, an intense anger or disgust reaction develops to specific sounds such as chewing or breathing; it is the type, not the loudness, of the sound that is decisive. Phonophobia is fear/avoidance of sound; noise sensitivity is feeling overwhelmed and cognitively fatigued in complex environments.
These pictures are mostly seen together with tinnitus and hearing loss; their exact frequency in the community varies with definitions but is considerable (Tyler et al., 2014).
Symptoms and signs
In hyperacusis, ordinary sounds (dishes, traffic, applause) are perceived as uncomfortable, even sometimes painful. By Tyler’s subtypes, loudness, annoyance, fear and pain hyperacusis are distinguished; the pain type is the most resistant to treatment.
In misophonia, when the trigger sound is heard, palpitations, sweating, muscle tension and intense anger/disgust arise within seconds; the person is aware that this reaction is excessive (Swedo et al., 2022).
In phonophobia the symptom is anxiety about the possibility of a sound occurring rather than the sound itself; this leads to avoidance and social isolation, making the picture chronic.
Causes and risk factors
Hyperacusis usually stems from a pathological increase in gain in the central auditory system; the system, trying to compensate for reduced auditory input, becomes over-sensitive to sounds.
In misophonia the connection between the salience network and limbic structures is prominent; sound triggers an unusually strong emotional-autonomic response.
Hyperacusis is statistically associated with tinnitus, migraine, traumatic brain injury and certain psychiatric conditions; most patients also have tinnitus (Aazh et al., 2018).
Audiological and clinical assessment
The core principle in assessment is to collect data with safe protocols without exposing the patient to further acoustic trauma.
- Pure-tone audiometry and OAE: determine hearing status and cochlear function (usually normal).
- Loudness Discomfort Level (LDL/ULL) measurement: should be done carefully starting from low levels; high intensities should be avoided.
- Standard scales: the validated Turkish forms of the Khalfa Hyperacusis Questionnaire and misophonia scales are used in clinical follow-up (Erinç & Derinsu, 2020).
- Differential assessment: third-window pictures that cause autophony, such as SSCD, are excluded when needed.
In children, assessment should be planned with a special appointment scheme to prevent acoustic fatigue.
| Feature | Hyperacusis | Misophonia | Phonophobia |
|---|---|---|---|
| Decisive factor | Loudness/intensity of sound | Type of sound (trigger) | Possibility of a sound occurring |
| Reaction | Discomfort/pain | Anger/disgust (autonomic) | Fear/avoidance |
| Example stimulus | Traffic, applause, dishes | Chewing, breathing, tapping | Anticipated sudden sounds |
| Core mechanism | Increased central gain | Limbic/salience network | Anxiety-based |
| Approach | Sound therapy, desensitisation | Counselling, CBT | CBT, graded exposure |
Treatment and audiological rehabilitation
The “gold standard” of management is multidisciplinary rehabilitation; rather than a single drug, counselling and gradual sound approaches are prominent.
Tinnitus retraining therapy (TRT) and sound enrichment aim at desensitisation to sounds by gradually reducing auditory gain. Cognitive behavioural therapy is effective at reducing maladaptive thoughts and avoidance in misophonia and phonophobia (Jastreboff & Jastreboff, 2014).
An important warning: using constant earplugs (over-protection) further increases the brain’s sensitivity and feeds the vicious cycle. Hearing protectors should be used only at genuinely harmful noise levels.
Impact on quality of life and advice
Decreased sound tolerance is an invisible condition that can drag the person into social isolation and mental fatigue. A constant state of alertness can increase anxiety and sleep problems.
Rather than fleeing from sounds, enriching the environment with low-level, neutral background sounds; creating a stable acoustic baseline instead of sudden sounds; and sharing with those around you that this is “a neurophysiological response, not a psychological choice” are helpful.
If you used this review, you can cite it as follows (APA 7):
İşitme Atölyesi. (2026). Decreased Sound Tolerance (Hyperacusis, Misophonia, Phonophobia). Hearing & Balance Health Guide. https://www.isitmeatolyesi.com/en/guncel-haberler/categories/isitme-sagligi-rehberi/azalmis-ses-toleransi/Permanent link: isitmeatolyesi.com/en/guncel-haberler/categories/isitme-sagligi-rehberi/azalmis-ses-toleransi/ · Last reviewed: July 2026 · License: CC BY-NC-ND 4.0
References
- Aazh, H., Landgrebe, M., Danesh, A. A., & Moore, B. C. J. (2018). Cognitive behavioral therapy for alleviating the distress caused by tinnitus, hyperacusis and misophonia. Journal of the American Academy of Audiology, 30(4), 249-265.
- Erinç, M., & Derinsu, U. (2020). Turkish adaptation of the Khalfa Hyperacusis Questionnaire. The Journal of International Advanced Otology, 16(1), 89-94.
- Jastreboff, P. J., & Jastreboff, M. M. (2014). Treatments for decreased sound tolerance (hyperacusis and misophonia). Seminars in Hearing, 35(2), 105-120.
- Swedo, S. E., Baguley, D. M., Denys, D., et al. (2022). Consensus definition of misophonia: A Delphi study. Frontiers in Neuroscience, 16, 841816.
- Tyler, R. S., Pienkowski, M., Rojas Roncancio, E., et al. (2014). A review of hyperacusis and future directions: Part I. American Journal of Audiology, 23(4), 402-419.
Frequently asked questions
Should I use earplugs all the time?
No. Using constant earplugs in quiet environments can worsen the condition over time by increasing the brain’s sensitivity to sound. It is recommended to use hearing protectors only in genuinely loud environments such as concerts and workshops.
Is misophonia a purely psychological condition?
No. Misophonia is a neurophysiological condition related to overactivity of the brain’s emotional and autonomic response circuits to specific sounds. It is not due to the person ‘not being able to control themselves’; however, the intensity of the reactions can be reduced with counselling and therapies.
Does hyperacusis treatment work?
Yes. With sound therapy, gradual desensitisation and counselling-based approaches, tolerance to sounds increases markedly in many patients. The process requires patience, but most people gradually cope more comfortably with everyday sounds.
Why don’t sounds I make myself bother me?
In misophonia the brain codes sounds the person makes as ‘expected’ and does not produce a strong reaction. Discomfort develops more toward unpredictable, repetitive sounds made by others; this ‘selective reaction’ is a typical feature of the condition.
My child is very affected by sounds at school; what can I do?
The most appropriate approach is first a safe assessment by an audiologist, then creating acoustic arrangements and a gradual plan in cooperation with the school. Rather than steering the child into complete silence, supported and gradual exposure is recommended.
Scales that can be used to assess sound tolerance and noise sensitivity: