Fear of Sound

What phonophobia means

The Online Etymology Dictionary dates phonophobia to 1877 and glosses it as intolerance or dread of loud sounds. The word was reintroduced in 1949 as a straight synonym for hyperacusis, out of a concern that hyperacusis might be read as implying sharper hearing rather than a lower tolerance. Neurology inherited that usage and keeps it: the sound intolerance seen during a migraine attack is called phonophobia, and its presence supports the diagnosis. The definitions and measures used there emphasise discomfort and auditory pain, which means that what neurology calls phonophobia is hyperacusis.

Margaret and Pawel Jastreboff introduced the contemporary concept in 2001 and classed it as a type of Misophonia. It has since been generally recognised as distinct from misophonia too. Three meanings, two of them current in different specialities, is unusual even in this vocabulary.

The printed encyclopedia of phobias adds a fourth reading, and then attaches fear of telephones to the same word. Its entry defines phonophobia as a fear of four things, in this order:

1. noise
2. talking
3. speaking aloud
4. one's own voice

Read the list in that order and the object migrates inward: from noise arriving, to speech, which needs somebody, to speaking aloud, which needs the person themselves, to their own voice, which is as far in as a sound can get.

Why phonophobic sounds are often quiet

Loud sounds and sounds that signal a threat are feared by most people, and that is not phonophobia unless the fear and anxiety are out of proportion. The sounds actually reported are often harmless and quiet. Kitchen noises. A door closing.

The clearest example is not acoustic at all. Watching somebody inflate a balloon past its normal capacity is unsettling for a person with phonophobia because of the sound they expect. Nothing has been heard yet. The fear is of a noise that has not happened.

Why phonophobia and hyperacusis need different treatment

Three neighbouring conditions have to be separated, and the reason is practical. Hyperacusis is discomfort or pain caused by sounds most people would not find uncomfortably loud, arising, in the account by Pawel Jastreboff and Jonathan Hazell that most sources follow, from within the auditory system itself. Phonophobia and misophonia, on their description, involve abnormally strong reactions in the limbic and autonomic systems without significant activation of the auditory system. Some authors fold phonophobia into hyperacusis as fear hyperacusis; others keep them apart on exactly that basis.

Exposure therapy is the standard treatment for a specific phobia, and exposing somebody to sounds that cause them real physical discomfort or pain could injure them. Conventional exposure therefore suits pure phonophobia with no other sound tolerance condition present, and specialised approaches exist for misophonia and hyperacusis. The same caution applies to the tests: acoustic reflex and auditory evoked potential measurements involve loud sounds and can aggravate the intolerance, particularly in children.

How phonophobia was treated in a published case

Zamzil Amin Asha'ari and colleagues published a case in 2010 of a girl of twelve referred to an ear, nose and throat clinic with acute, electrifying noise sensations in both ears. It had started after a Chinese New Year celebration a few months earlier at which she was exposed to the sudden noise of firecrackers. Afterwards, ordinary sounds arrived intensified and were followed by an unpleasant buzzing. A balloon popping or a plastic bag rustling was almost unbearable, and brought palpitations, shivering, heavy sweating and crying. She stopped attending school social functions and wanted only to be in a quiet room.

Everything came back normal:

• the otological and neurological examination
• pure tone audiometry
• the stapedius reflex
• the auditory evoked potential
• an MRI of the skull, showing no lesion in the brain, the pons or the auditory pathway

A psychiatrist then diagnosed a specific phobia under the DSM-IV criteria.

Treatment was two sessions a week of psychoeducation for the girl and her parents, relaxation and breathing exercises, and graded exposure that began below the level of any sound. She drew a smiling balloon. Then she drew a bursting one. Only after that were inflated balloons burst in the clinic, and then at home with her parents acting as co-therapists, each successful step rewarded. She had improved markedly by three months. At six months she was taken to a fireworks display, with no consequences.

What avoiding sound does to phonophobia

Avoiding the contexts where a feared sound might occur may make the auditory system more sensitive rather than less. That is the loop this catalogue records repeatedly in psychological form, appearing here in a physiological one: avoiding sound can lower the threshold at which sound becomes intolerable, which enlarges the set of sounds to be avoided.

Counselling about the harmlessness of the sounds is recommended as a treatment in its own right, which is unusual. In most entries here reassurance is described as ineffective or as feeding the problem. These sounds genuinely are harmless, and saying so is part of the intervention.

How common phonophobia is

One estimate covering hyperacusis and phonophobia together in school-aged children put the prevalence at around 10 per cent. The two are counted as one figure there, which is the difficulty in miniature: the boundary the treatment depends on is the boundary the surveys do not draw.