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Decreased sound tolerance in autism: Understanding and distinguishing between hyperacusis, misophonia, and phonophobia



Decreased sound tolerance (DST) affects a significant proportion of autistic people throughout their lifetime and, as Zachary J Williams explains, it is important that clinicians are aware of the three distinct subtypes of DST when making a diagnosis. This article also includes operational diagnostic criteria and suggested billing codes for each of the three DST syndromes described in the article, which may be applied to both autistic and non-autistic individuals.
Autism spectrum disorder
(hereaer ‘autism’) is a
heterogeneous, lifelong
neurodevelopmental condition
characterised by diculties with social
communication, repetitive behaviours,
and atypical reactions to sensory aspects
of the environment. Notably, an estimated
50-70% of autistic individuals demonstrate
clinically signicant decreased sound
tolerance (DST, i.e. an inability to tolerate
everyday sounds) at some point in their lives
[1], oen resulting in referrals of autistic
children and adults to audiologists or
other hearing health professionals. As DST
in autism appears to represent multiple
distinct yet oen overlapping syndromes
[2] (i.e. hyperacusis, misophonia, and
phonophobia), it is extremely important
that clinicians be aware of the dierences
between these conditions and feel
comfortable distinguishing between them
when making a diagnosis.
Hyperacusis (Figure 1) is a hearing
disorder in which sound of moderate
intensity is perceived as excessively
loud, painful, and/or overwhelming [2].
Individuals with hyperacusis perceive
everyday sounds, such as the sounds of
domestic appliances or electric hand driers,
as uncomfortably loud or, in some cases,
physically painful. Though frequently
associated with tinnitus and peripheral
hearing loss in the general population,
hyperacusis in autism is thought to be
neurodevelopmental in nature [2], and
additional signs of peripheral auditory
damage are frequently absent in this
population. As in cases of hyperacusis not
associated with autism, audiometric testing
of uncomfortable loudness levels can
support the diagnosis, although this test is
typically only appropriate in adolescents
and adults without signicant cognitive or
language impairment. While there is no
consensus among professionals regarding
the specic criteria used to make a clinical
diagnosis of hyperacusis, operational
criteria used by my research group to dene
hyperacusis are presented in Figure 1 to
assist clinicians in making this diagnosis.
Misophonia (Figure 2) is a newly-
described condition in which individuals
have excessive and inappropriate emotional
responses to specic ‘trigger’ sounds
(e.g. chewing, tapping, and sniing),
even when those sounds are not loud
[2]. Anger, extreme irritation, disgust, and
anxiety are the most common emotions,
though some individuals may experience
rage [3]. Misophonic triggers may evoke
a ‘ght or ight’ response, including
nonspecic physical symptoms such as
muscle tension, increased heartrate,
and sweating. Unlike in hyperacusis,
in which the acoustic properties of a
sound (i.e. intensity, frequency, and
duration) strongly predict that sound’s
aversiveness, misophonic reactions are
heavily context-dependent and may be
diminished or absent if individuals with
misophonia make the triggering sound(s)
themselves [4]. Furthermore, despite large
individual dierences in specic trigger
noises, reactions to those trigger noises,
and degree of context-dependence, the
majority of individuals with misophonia
Decreased sound tolerance in autism:
understanding and distinguishing between
hyperacusis, misophonia, and phonophobia
Decreased sound tolerance (DST) aects a signicant proportion of autistic people
throughout their lifetime and, as Zachary J Williams explains, it is important that
clinicians are aware of the three distinct subtypes of DST when making a diagnosis.
“Though frequently
associated with tinnitus
and peripheral hearing
loss in the general
population, hyperacusis
in autism is thought to be
neurodevelopmental in
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report that they are triggered at least to
some degree by oro-nasal or throat sounds
(e.g. chewing, crunching, sniing, slurping,
breathing, coughing, or throat-clearing). A
recent expert consensus paper proposed
a denition of misophonia for use in
clinical and research settings, although
concrete diagnostic criteria were not
specied [3]. To further support clinicians
in making a diagnosis of misophonia,
operational research criteria (adapted
from the consensus denition [3] and the
earlier ‘Revised Amsterdam Criteria’ for
misophonia [4]) are provided in Figure 2.
Although the word ‘phonophobia’ has
been used to refer to multiple symptoms
and conditions within the medical literature
(e.g. hyperacusis, episodic DST associated
with headaches, and loudness disturbance
due to facial nerve damage) the term
here is used to refer to a marked fear or
anxiety about specic sounds or situations
in which a person might encounter
unpleasant sounds [2]. In other words,
phonophobia refers to a specic phobia
of sound, as dened within the Diagnostic
and Statistical Manual of Mental Disorders,
Fih Edition (DSM-5) [5] and its upcoming
text revision (Figure 3). Phonophobia can
be circumscribed to very specic sounds
or generalised to all sounds with specic
qualities (e.g. loud sounds, high-pitched
sounds, sudden/unexpected sounds, or
sounds associated with a feared object/
situation). However, in all cases, the
diagnosis is only appropriate if the phobic
sound/situation almost always provokes
fear and/or anxiety and this fear/anxiety is
out of proportion to the danger posed by the
specic object/situation.
“Although hyperacusis,
misophonia, and
phonophobia are all
present in the autistic
population, there is a
notable lack of evidence-
based options for diagnosis
and treatment of these
prevalent and impairing
Figure 1. Operational Diagnostic Criteria for Hyperacusis. These criteria are used in an ongoing research study at Vanderbilt
University Medical Center to standardise the clinical diagnosis of hyperacusis. Criteria A–E must all be met for a diagnosis to be
given. This diagnosis of hyperacusis subsumes both “loudness hyperacusis” (criterion A1) and “pain hyperacusis” (criterion A2),
particularly given the unclear distinction between the two subtypes in terms of underlying pathophysiology. For billing purposes,
ICD-10-CM code H93.233 (“Hyperacusis, bilateral”) can be used.
Figure 2. Operational Diagnostic Criteria for Misophonia. Criteria are modied from the 2020 Revised Amsterdam Criteria [4],
incorporating information from the 2021 consensus denition of misophonia [3]. Criteria A–F must all be met for a diagnosis to be
given. These criteria dier from the Revised Amsterdam Criteria insofar as (a) oro-nasal sounds are not required for diagnosis and
(b) misophonia can be diagnosed regardless of other psychiatric or neurodevelopmental conditions, provided that all diagnostic
criteria are met. Although misophonia is not formally recognised within systems of medical billing, we suggest that the diagnosis
be captured under the ICD-10-CM code H93.299 (“Other abnormal auditory perceptions, unspecied ear”).
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Zachary J Williams, BS,
MD/PhD Candidate, Vanderbilt University Medical
Center, Department of Hearing and Speech Sciences,
Nashville, Tennessee, USA.
Twitter: @QuantPsychiatryle/Zachary-
Declaration of competing interests: ZJW has
received consulting fees from Roche and Autism Speaks
on projects related to autism.
Notably, phonophobia can develop
secondary to other DST conditions such
as hyperacusis or misophonia. However,
in cases where feared sounds result in
signicant pain, auditory discomfort, or
other physical symptoms, an additional
diagnosis of phonophobia should be
reserved for individuals who experience
fear and anxiety to a much greater degree
than would be expected for an individual
with their same level of hyperacusis/
misophonia symptoms. In particularly
severe cases of hyperacusis, in which
certain sounds may cause extreme pain that
persists for multiple days aer exposure,
fear and avoidance of the aversive sounds
is arguably not excessive or irrational, and
phonophobia should only be diagnosed if an
individual demonstrates the same marked
fear of sounds that are not known to greatly
exacerbate their hyperacusis symptoms.
Although hyperacusis, misophonia, and
phonophobia are all present in the autistic
population, there is a notable lack of
evidence-based options for diagnosis and
treatment of these prevalent and impairing
conditions, particularly in young children
and individuals with signicant cognitive
or language impairments. Nevertheless,
even with limited access to a patient’s
internal experiences, knowledgeable
clinicians may be able to make a clear
distinction between dierent subtypes
of DST based on consideration of the
sounds the patient nds aversive, the
degree to which context modulates their
reactions, and the presence of observable
fear or anxiety in certain situations (see
Figures 1-3). With regards to management,
strategies should be individualised to
the patient’s and family’s needs and can
include modalities such as behavioural or
cognitive-behavioural therapy (oen with
an exposure/habituation component),
occupational therapy, sound generators,
amplication, medications, use of ear
protection in certain situations, and
environmental modications. Though
there is insucient evidence to strongly
support any of these interventions for DST
in autism, the treatment of this common
symptom remains an area of great clinical
need. Thus, additional basic and clinical
research is desperately needed on DST in
autism and other populations to improve
the lives of the millions of individuals who
experience these oen-disabling sound
sensitivity syndromes..
1. Williams ZJ, Suzman E, Woynaroski TG. Prevalence of
decreased sound tolerance (hyperacusis) in individuals
with autism spectrum disorder: A meta-analysis. Ear
Hear 2021;42(5):1137-50.
2. Williams ZJ, He JL, Cascio CJ, Woynaroski TG. A review
of decreased sound tolerance in autism: Denitions,
phenomenology, and potential mechanisms. Neurosci
Biobehav Rev 2021;121:1-17.
3. Swedo SE, Baguley DM, Denys D, Dixon LJ, et al.
Consensus Denition of Misophonia: A Delphi Study.
Frontiers in Neuroscience 2022;16:841816. https://doi.
4. Jager I, de Koning P, Bost T, et al. Misophonia:
Phenomenology, comorbidity and demographics
in a large sample. Doering S, ed. PLOS One
5. American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders (DSM-5®). 5th ed.
American Psychiatric Association Publishing; 2013.
Figure 3. Operational Diagnostic Criteria for Phonophobia. Criteria are slightly modied from the DSM-5 criteria for specic
phobia [5], with additional information regarding the qualier of fear out of proportion to the circumstances and the ability for ear
protection use to qualify for the “avoidance” criterion. Note that for billing purposes, phonophobia should be coded using ICD-10-
CM code F40.298 (“Other specied phobia”).
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... In order to create operational diagnostic criteria that could be assessed using the DVMSQ, we began with the Revised Amsterdam Criteria (Jager et al., 2020), modifying each criterion to align more closely with the recent misophonia consensus definition (Swedo et al., 2021(Swedo et al., , 2022. The misophonia diagnostic criteria used in the current study (see also Williams, 2022) are presented in Table 2, along with the operationalization of each criterion by the DVMSQ items. Notable changes from the Revised Amsterdam criteria include (a) the removal of the requirement that an individual be triggered by oral or nasal sounds, (b) the removal of the requirement that individuals must acknowledge their emotional reactions to triggers as excessive, unreasonable, or out of proportion to the circumstances, (c) additional description of anxiety and/or physical symptoms accompanying the emotional reactions (though neither is required for diagnosis nor sufficient to fulfill that criterion), (d) the use of specific coping strategies (e.g., ear protection, masking trigger sounds with white noise) is described within the "avoidance" criterion, (e) the outbursts resulting from a loss of control are described in more detail and include manifestations other than aggression, and (f) emotional reactions occurring in the context of other neuropsychiatric conditions (e.g., autism, ADHD) can still count toward a diagnosis of misophonia if the remaining criteria are met. ...
... The revised DVMSQ form is freely available for use and can be found in Supplementary Material. By incorporating the recent consensus definition of misophonia (Swedo et al., 2022) into our DVMSQ-based diagnostic algorithm, this study represents the first attempt to operationalize the misophonia consensus definition into a formal set of diagnostic criteria to be applied in research or clinical practice (Williams, 2022). Using the DVMSQ algorithm to define misophonia caseness, the prevalence of clinically significant misophonia was 7.3% (102/1403) in a sex-balanced crowdsourced sample from Prolific and 35.5% (332/936) in a female-predominant sample of independent autistic adults recruited from the SPARK cohort. ...
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Misophonia is a newly described disorder of sound tolerance characterized by strong negative emotional reactions to specific “trigger” sounds, resulting in significant distress, pathological avoidance, and impairment in daily life. Research on misophonia is still in its infancy, and most existing psychometric tools for assessing misophonia symptoms have not been extensively validated. The purpose of the current study was to introduce and psychometrically validate the duke-vanderbilt Misophonia Screening Questionnaire (DVMSQ), a novel self-report measure of misophonia symptoms that can be used to determine misophonia “caseness” in clinical and research settings. Employing large online samples of general population adults (n = 1403) and adults on the autism spectrum (n = 936), we rigorously evaluated the internal structure, reliability, validity, and measurement invariance of the DVMSQ. Results indicated that 17 of the 20 original DVMSQ items fit well to a bifactor structure with one “general misophonia” factor and four specific factors (anger/aggression, distress/avoidance, impairment, and global impact). DVMSQ total and subscale scores were highly reliable in both general population and autistic adult samples, and the measure was found to be approximately invariant across age, sex, education level, and autism status. DVMSQ total scores also correlated strongly with another measure of misophonia symptoms (Duke Misophonia Questionnaire–Symptom Scale), with correlations between these two measures being significantly stronger than correlations between the DVMSQ and scales measuring other types of sound intolerance (Inventory of Hyperacusis Symptoms [General Loudness subscale] and DSM-5 Severity Measure for Specific Phobia [modified for phonophobia]). Additionally, DVMSQ items were used to operationalize diagnostic criteria for misophonia derived from the Revised Amsterdam Criteria, which were further updated to reflect a recent consensus definition of misophonia (published after the development of the DVMSQ). Using the new DVMSQ algorithm, 7.3% of general population adults and 35.5% of autistic adults met criteria for clinically significant misophonia. Although additional work is needed to further investigate the psychometric properties of the DVMSQ and validate its theory-based screening algorithm using best-estimate clinical diagnoses, this novel measure represents a potentially useful tool to screen for misophonia and quantify symptom severity and impairment in both autistic adults and the general population.
Full-text available
Misophonia is a disorder of decreased tolerance to specific sounds or their associated stimuli that has been characterized using different language and methodologies. The absence of a common understanding or foundational definition of misophonia hinders progress in research to understand the disorder and develop effective treatments for individuals suffering from misophonia. From June 2020 through January 2021, the authors conducted a study to determine whether a committee of experts with diverse expertise related to misophonia could develop a consensus definition of misophonia. An expert committee used a modified Delphi method to evaluate candidate definitional statements that were identified through a systematic review of the published literature. Over four rounds of iterative voting, revision, and exclusion, the committee made decisions to include, exclude, or revise these statements in the definition based on the currently available scientific and clinical evidence. A definitional statement was included in the final definition only after reaching consensus at 80% or more of the committee agreeing with its premise and phrasing. The results of this rigorous consensus-building process were compiled into a final definition of misophonia that is presented here. This definition will serve as an important step to bring cohesion to the growing field of researchers and clinicians who seek to better understand and support individuals experiencing misophonia.
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Objective: Hyperacusis, defined as decreased tolerance to sound at levels that would not trouble most individuals, is frequently observed in individuals with autism spectrum disorder (ASD). Despite the functional impairment attributable to hyperacusis, little is known about its prevalence or natural history in the ASD population. The objective of this study was to conduct a systematic review and meta-analysis estimating the current and lifetime prevalence of hyperacusis in children, adolescents, and adults with ASD. By precisely estimating the burden of hyperacusis in the ASD population, the current study aims to enhance recognition of this particular symptom of ASD and highlight the need for additional research into the causes, prevention, and treatment of hyperacusis in persons on the spectrum. Design: We searched PubMed and ProQuest to identify peer-reviewed articles published in English after January 1993. We additionally performed targeted searches of Google Scholar and the gray literature, including studies published through May 2020. Eligible studies included at least 20 individuals with diagnosed ASD of any age and reported data from which the proportion of ASD individuals with current and/or lifetime hyperacusis could be derived. In order to account for multiple prevalence estimates derived from the same samples, we utilized three-level Bayesian random-effects meta-analyses to estimate the current and lifetime prevalence of hyperacusis. Bayesian meta-regression was used to assess potential moderators of current hyperacusis prevalence. In order to reduce heterogeneity due to varying definitions of hyperacusis, we performed a sensitivity analysis on the subset of studies that ascertained hyperacusis status using the Autism Diagnostic Interview-Revised, a structured parent interview. Results: A total of 7783 nonduplicate articles were screened, of which 67 were included in the review and synthesis. Hyperacusis status was ascertained in multiple ways across studies, with 60 articles employing interviews or questionnaires and 7 using behavioral observations or objective measures. The mean (range) age of samples in the included studies was 7.88 (1.00-34.89) years. The meta-analysis of interview/questionnaire measures (k(3) = 103, nASD=13093) estimated the current and lifetime prevalence of hyperacusis in ASD to be 41.42% (95% CrI [37.23, 45.84]) and 60.58% [50.37, 69.76], respectively. A sensitivity analysis restricted to prevalence estimates derived from the ADI-R (k(3) = 25, nASD = 5028) produced similar values. The estimate of current hyperacusis prevalence using objective/observational measures (k(3)= 8, nASD = 488) was 27.30% [14.92, 46.31]. Heterogeneity in the full sample of interview/questionnaire measures was substantial but not significantly explained by any tested moderator. However, prevalence increased sharply with increasing age in studies using the ADI-R (BF10 = 93.10, R2Het = 0.692). Conclusions and Relevance: In this meta-analysis, we found a high prevalence of current and lifetime hyperacusis in individuals with ASD, with a majority of individuals on the autism spectrum experiencing hyperacusis at some point in their lives. The high prevalence of hyperacusis in individuals with ASD across the lifespan highlights the need for further research on sound tolerance in this population and the development of services and/or interventions to reduce the burden of this common symptom.
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Atypical behavioral responses to environmental sounds are common in autistic children and adults, with 50-70% of this population exhibiting decreased sound tolerance (DST) at some point in their lives. This symptom is a source of significant distress and impairment across the lifespan, contributing to anxiety, challenging behaviors, reduced community participation, and school/workplace difficulties. However, relatively little is known about its phenomenology or neurocognitive underpinnings. The present article synthesizes a large body of literature on the phenomenology and pathophysiology of DST-related conditions to generate a comprehensive theoretical account of DST in autism. Notably, we argue against conceptualizing DST as a unified construct, suggesting that it be separated into three phenomenologically distinct conditions: hyperacusis (the perception of everyday sounds as excessively loud or painful), misophonia (an acquired aversive reaction to specific sounds), and phonophobia (a specific phobia of sound), each responsible for a portion of observed DST behaviors. We further elaborate our framework by proposing preliminary neurocognitive models of hyperacusis, misophonia, and phonophobia that incorporate neurophysiologic findings from studies of autism.
  • I Jager
  • P De Koning
  • T Bost
Jager I, de Koning P, Bost T, et al. Misophonia: Phenomenology, comorbidity and demographics in a large sample. Doering S, ed. PLOS One 2020;15(4):e0231390.