How to treat phonophobia

As we saw in the article Misophonia and Phonophobia, the treatment typically used to address these types of auditory disorders is Cognitive-Behavioral Therapy (CBT). This therapy is used to treat problems arising from certain experiences, emotions, and false beliefs, and is based on the association between thought and behavior. Although it is always best to consult a professional for your particular case, some people may manage with the advice to identify, prevent, and treat phonophobia that I will provide below. Although I focus on phonophobia, these same tips can also be useful for treating misophonia, since, as discussed in the aforementioned article, the mechanisms explaining misophonia and phonophobia are identical.

When phonophobia appears associated with hyperacusis, it is essential to treat it, as phonophobia can hinder or even block desensitization to sounds. Recovery from hyperacusis through sound therapy works thanks to brain plasticity, so the anxiety and negative emotions that arise from phonophobia are a serious obstacle to brain plasticity taking place. From this, it can be correctly inferred that a relaxed, carefree, and positive state favors brain plasticity and thus helps speed up recovery from hyperacusis. Therefore, phonophobia should be treated before or alongside sound therapy to provide the necessary conditions for desensitization.

Fear of sound can arise for different reasons. Because exposure to certain sounds can worsen hyperacusis, it is not uncommon for the false belief to develop that even moderate sounds can damage the inner ear and worsen the condition. It is important to know that, even with hyperacusis, only sounds above 85 dB can cause inner ear damage, and even at that intensity, exposure would need to be for 8 hours for damage to occur. For each 3 dB increase, the safe exposure time is halved: 4 hours at 88 dB, 2 hours at 91 dB, and so on. Therefore, if in daily life you are not exposed to those intensities and durations—which is true in most cases—there is no damage to fear.

However, fear of sound can also arise from previous experiences in which exposure to moderate sounds caused pain or other hyperacusis-related symptoms, or led to a relapse and loss of progress. Prudence is warranted when exposed to certain sounds to avoid these consequences, but if that prudence becomes exaggerated, abnormal fear that extends to all sounds within one’s tolerance, then we are talking about phonophobia.

Sometimes it can be difficult to differentiate between hyperacusis and phonophobia, especially when hyperacusis is severe. Given the wide range of everyday sounds that can worsen hyperacusis, it is somewhat logical and reasonable to develop hypervigilance toward sounds to prevent problems caused by exposure. But phonophobia can turn harmless sounds into triggers capable of worsening hyperacusis. Here, the boundary between hyperacusis and phonophobia blurs. For a given sound, what makes it capable of worsening hyperacusis? Is it its physical characteristics (intensity, frequency, duration), the context in which it occurs, or the negative association toward it? It could even be a combination of both without clear proportions.

To illustrate, I can share a personal anecdote. During the most severe phase of my hyperacusis, the motor noise of an electric toothbrush was challenging for my tolerance, but due to dental hygiene needs, I persevered and tolerated it as best I could, even requiring auditory rest afterward. Over time, that noise stopped bothering me, and oral hygiene no longer posed a challenge, despite still having severe hyperacusis. One day, while in my room conversing and holding the electric toothbrush, I accidentally turned it on. Instinctively, I turned it off immediately because the noise seemed excessively loud and dangerous, capable of worsening my hyperacusis if I did not protect myself. In that moment, I realized how absurd my reaction had been. The same sound and intensity during brushing were not perceived as too loud or dangerous; in a completely different context, it was perceived as loud and dangerous. It was clear that the worsening of hyperacusis had an exclusively psychological component, unrelated to the sound’s physical characteristics or exposure time. Subsequent experiences confirmed that, almost without realizing it, I had developed a severe phonophobia, which was seriously hindering my recovery.

The sound characteristic with the most power to worsen hyperacusis is intensity—the one we initially perceive as dangerous. For this reason, using a sound level meter is very helpful in treating phonophobia, as it allows us to know the real intensity of sounds. This way, for a sound that causes fear or anxiety, we can determine whether the perceived loudness aligns with its actual intensity or if phonophobia is causing it to be perceived as louder than it really is. This information helps break the fear barrier and allows exposure to sounds that are actually safe, aiding in both phonophobia treatment and preventing overprotection of the ears.

To treat phonophobia, as with hyperacusis, one must confront sounds; avoidance achieves nothing. However, this reintroduction must be gradual. The person should always feel in control of the decision to face fear-inducing noises, whether by avoiding certain situations, controlling exposure time, or using hearing protection. Once we know the intensity of a feared sound is safe, we can start exposure with a short duration. After confirming no worsening of hyperacusis occurs, we help break the subconscious association of danger and fear with those sounds. The next step is gradually increasing exposure time until it is no longer necessary to control it and we can be completely unconcerned about the sound.

Phonophobia involves a strong association between certain sounds and fear or danger, reinforced over time by negative experiences. To break this association, thoughts about feared sounds and other negative emotions must be changed, as well as the behavioral response. One must observe and be aware of situations and sounds that provoke fear, anxiety, anger, etc., and pay attention to negative thoughts. These thoughts should then be replaced with positive ones through mental or verbal affirmations at the moment the negative thoughts appear. Examples include: “I am calm; I know this sound cannot harm me,” “Even if this sound seems loud, it isn’t,” “The only way to solve this is by facing the sound, and that’s what I will do,” or “The intensity of this sound is much lower than others I tolerate perfectly; there is nothing to fear.” Initially, this may feel awkward or like self-deception, but success lies in consistency and not expecting immediate results. Repeating these affirmations daily gradually transfers them from conscious to subconscious, replacing negative thoughts.

As mentioned, changing thought patterns must be accompanied by changes in behavior toward problematic sounds. For example, one should stop excessively monitoring or anticipating sounds, start visiting places previously avoided due to noise, and resume activities abandoned out of fear. Alongside positive affirmations and new behaviors toward fear-inducing sounds, one should feel that life is being regained and normal functioning restored. This process must be gradual and consistent, as deep-seated changes in thought cannot occur overnight and may take months.

It is also important to monitor negative emotions (anger, hatred, aggression) arising not only from the sounds themselves but especially toward those causing the noise. Among noises caused by others, distinguish between those that are normal and those that shouldn’t occur. For instance, it is normal for young children to scream or to use a lawnmower, but loud music at late hours is uncivil. Whether justified or not, identifying and neutralizing negative reactions is crucial, as allowing these emotions to manifest only makes sounds seem louder and potentially more harmful.

Another way to associate positive thoughts and well-being with sound is by listening to favorite music, regardless of genre. Always control volume and exposure time, and try to enjoy the sound rather than see it as dangerous. Relaxing music or nature sounds can also be used while performing enjoyable activities. Anything that helps disassociate sound from negative emotions is beneficial.

Both phonophobia and hyperacusis can be treated, but exposure to sound is currently the only method. Awareness that facing fear is necessary, and that the reward—regaining normal life—is worth it, is important.

Finally, maintaining a good mood and reducing anxiety is crucial. Exercise, adequate sleep, engaging activities, meditation, or alternative therapies can help. If anxiety or depressive symptoms are significant, consulting a physician for non-ototoxic anxiolytics/antidepressants may be advisable to stabilize mood.