Hyperacusis & Misophonia

While hyperacusis and misophonia can occur concurrently, the subconscious negative evaluation of these sounds is different, so they are separate and distinctly different conditions. Both conditions involve an enhanced perception of loudness and awareness of intolerable sounds, and distress following exposure to these sounds. Both conditions have the potential to escalate, so that an increasing range of sounds become intolerable.

What is Hyperacusis?

Hyperacusis is an abnormal sound sensitivity characterised by an intolerance of everyday sounds.  People with hyperacusis experience a heightened sense of volume and physical discomfort to sounds that other people can comfortably tolerate, particularly loud sounds, unexpected sounds and sounds close to the ears. 

Watch Myriam Westcott interview with Joey Remenyi about tinnitus, hyperacusis, acoustic shock, misophonia and TTTS.

What is Misophonia?

Misophonia is a strongly aversive response or abnormal sensitivity to certain specific sounds, irrespective of their volume.  These trigger sounds are usually made by other people and can include eating/breathing sounds, as well as repetitive sounds (such as keyboard tapping).   Exposure to trigger sounds involuntarily induces disproportionally high levels of anger or rage, along with strong reactions of irritation or disgust. 

Misophonia is enhanced by trigger sounds often being perceived as an intolerable intrusion into one’s sense of personal space, as well as by hypervigilance towards trigger sounds and anticipatory anxiety about trigger sound exposure.

How does misophonia develop?

Misophonia often stems from a specific instance in childhood where a sound made by a family member elicited a strongly negative reaction of irritation and/or disgust.  This reaction has the potential to escalate, at both a conscious and subconscious level, so that an increasing range of trigger sounds become increasingly intolerable. 

Myriam Westcott interview about misophonia with Libby Gorr on ABC Radio Melbourne.

How do Hyperacusis and Misophonia affect people?

Hyperacusis and misophonia can range from mild to severe to extreme.   

Avoidance of intolerable sounds can have a major impact on the lives of people with significant hyperacusis and misophonia, severely limiting their horizons and creating high levels of isolation, anxiety and distress.  Most people with hyperacusis will have physical symptoms in and around their ears consistent with tonic tensor tympani syndrome (TTTS), causing further anxiety and distress.  TTTS symptoms can often be sound-induced or aggravated by sounds.  With severe hyperacusis, sound-induced pain is a daily occurrence which is severe, highly debilitating and causes significant suffering.

There is little understanding of hyperacusis and/or misophonia in the community.  Hyperacusis, misophonia, acoustic shock disorder, TTTS and the sound-induced pain associated with severe hyperacusis are involuntary and subjective.  All these conditions and symptoms are readily misunderstood or not believed.  Explaining such an abnormal reaction to sound to other people, including at times health professionals, is difficult and patients with hyperacusis and/or misophonia and/or acoustic shock often feel misunderstood, isolated or trivialised. 

How is the brain involved in the development of Hyperacusis and Misophonia?

P Jastreboff’s neurophysiological model of tinnitus and hyperacusis/misophonia: As part of the processing of sound in the brain, all sounds are evaluated subconsciously with regard to their meaning or importance to us.  Sounds that are considered important (in either a positive or negative way) will be transmitted to the more conscious parts of our brain, while unimportant sounds remain “half-heard”. 

If a sound acquires a negative association, the limbic system in the brain becomes activated, inducing fear or irritation.  The autonomic nervous system also becomes activated, provoking the “fight or flight” reaction.  A conditioned response develops so that repetition of this sound enhances the activation of the limbic and autonomic systems. 

Our brain at a subconscious level is strongly aimed at using our senses, particularly our hearing, to warn us of danger and keep us safe in our environment.  In people with hyperacusis and misophonia, certain sounds become evaluated by their subconscious brain as unsafe and thereby judged as potentially threatening or damaging or intolerable or invasive etc.  These judgements are below the level of rational thought and out of conscious control.  For those with hyperacusis, if this judgement evaluates a sound as unsafe because it poses a risk to tinnitus/hearing/the ears, TTTS symptoms can develop from a subconscious ‘need to protect’ the ear. 

People with hyperacusis and/or misophonia can readily (and understandably) become highly focused or hypervigilant in listening for intolerable sounds in their environment.  The subconscious brain will be highly alert to a sound deemed as unsafe.  Reinforcing this by excessive monitoring at a conscious level entrenches hyperacusis/misophonia and promotes escalation. 

An essential part of desensitisation, therefore, is reducing environmental sound monitoring, to allow the brain to develop the opportunity to feel safer and better tolerate the vast range of unpredictable sounds we are typically exposed to on a daily basis.  This is highly challenging, can seem counter-intuitive and naturally needs to be approached gently without raising anxiety levels. 

Our brain is a highly plastic organ, constantly reorganising and developing new neural connections.  This means that the brain can be retrained to reverse the pathway which has led to hyperacusis and misophonia.  Complete desensitisation may be difficult to achieve and an unrealistic expectation.  However, partial desensitisation can make a big difference to the emotional impact, lifestyle constraints and suffering for those with hyperacusis/misophonia.

Our Hyperacusis and Misophonia Program

We provide a unique, individualised program to assist you in achieving increased tolerance to everyday sound, utilising Ms Myriam Westcott’s experience and research in hyperacusis and misophonia therapy.  Our program is part of a holistic multidisciplinary team, working with uniquely skilled and experienced physiotherapists, psychologists, a hypnotherapist and pain physicians.

A detailed description of the peripheral (the outer, middle and inner ear) and central (the brain) auditory pathway is essential to understand how hyperacusis and/or misophonia develops.

Our Program involves:

  • an evaluation of your hyperacusis and/or misophonia and its impact on you.
  • providing a detailed understanding about the development of your hyperacusis and/or misophonia.
  • a personalised explanation of the peripheral and central auditory system, including the neurophysiological basis of hyperacusis/misophonia and TTTS (if symptoms are present).
  • a hyperacusis/misophonia therapy program.

It has been our experience that once patients understand how the brain processes sound and understand in depth how their hyperacusis/misophonia developed, they have a possible pathway for reversal utilising the concepts of brain plasticity.  This understanding provides reassurance, relief and insight, and is often helpful at relieving the suffering, distress, anxiety and bewilderment that tends to accompany both hyperacusis and misophonia, as well as the guilt, shame and anger that often accompanies misophonia.



For hyperacusis patients with frequent or severe sound-induced pain, the priority is effective pain management ahead of a hyperacusis desensitisation process.  Consulting a Pain Physician is recommended, where the treatment should be as for trigeminal neuralgia using nerve pain medication, such as Endep, Lyrica (Pregabalin, anticonvulsant).  This approach, combined with neural desensitisation from a skilled physiotherapist and our hyperacusis therapy program, has been uniquely effective in these patients.

Practical self-managed strategies to assist hyperacusis/misophonia desensitisation and reduce auditory hypervigilance, personalised to suit each person’s individual coping style, are developed.  Sound enrichment and low level sound therapy are recommended as part of the desensitisation process. 

Hyperacusis/misophonia desensitisation therapy involves:

  • identifying how and why sounds changed from being tolerable to intolerable over time, so the process can be unravelled
  • an explanation of the peripheral and central auditory pathway, including the mechanisms of hyperacusis/misophonia and a personalised explanation of TTTS
  • a discussion about your thoughts and beliefs about your hyperacusis/misophonia – you may need to be open to accepting a new perspective
  • management of hypervigilance towards the auditory environment and any TTTS symptoms. Hypervigilance to intolerable sounds enhances and perpetuates the subconscious brain’s interpretation of these sounds as threatening.  In the same way, excessive monitoring of TTTS symptoms perpetuates the subconscious brain’s “need to protect” the ears. 
  • Sound enrichment strategies, creating a “safe space” where sound enrichment strategies can be used to create “auditory bubble” providing a cocoon to shield you from intolerable sounds
  • Advice on the use of ear plugs, including hearing aids set up as electronic filters. The careful use of ear protection can help maintain or allow expansion of lifestyle horizons. This may be in the form of customised solid silicon rubber plugs like those used to provide hearing protection at work and/or customised filtered musician’s earplugs. 

There are no guarantees that therapy will result in an improvement.  The factors resulting in hyperacusis and misophonia are complex and outside a patient’s conscious control, so desensitisation is slow, requiring determination and belief in the prospect of change.  Complete desensitisation may be difficult to achieve and an unrealistic expectation.  However, partial desensitisation can make a big difference to the emotional impact and lifestyle constraints of hyperacusis and misophonia. 

What can I expect from hyperacusis and misophonia therapy?

Desensitisation to intolerable sounds is a gradual process, where the situations previously uncomfortable will become gradually less so.  If hyperacusis and tinnitus are present, the hyperacusis is usually addressed first.  Frequently, as the hyperacusis becomes more under control, the tinnitus becomes less of an issue. 

For many people, the information and guidance provided in one appointment may be sufficient to move towards a self-managed program of hyperacusis and misophonia desensitisation.  For this reason, our initial appointment time is one and a half hours.  However, the time involved in a program will vary, depending on the severity of your sound intolerance and the on-going guidance and support you require. 

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