47 Young Adult with Misophonia
47 患有恐音症的年轻人

Gemma Crundwell and David M. Baguley
杰玛·克伦德威尔和大卫·巴古利

CW is a 19-year-old female referred by her ear, nose, and throat (ENT) consultant for misophonia. The experience of misophonia is of sound-evoked annoyance, irritation, or rage, usually associated with a specific sound (e.g., eating or sniffing), ${}^1$${}^1$^(1){ }^{1} and it has been suggested that there are three characteristic elements of misophonia (see Rouw and Erfanian, ${}^2$${}^2$^(2){ }^{2} for review):
CW 是一名 19 岁女性，她的耳鼻喉 (ENT) 顾问转诊她患有恐音症。恐声症的体验是声音引起的烦恼、刺激或愤怒，通常与特定的声音（例如，吃东西或嗅）有关， ${}^1$${}^1$^(1){ }^{1} 有人认为恐音症具有三个特征要素（参见 Rouw 和 Erfanian， ${}^2$${}^2$^(2){ }^{2} 供审查）：

CW’s sensitivity to sound was first noted when she was 14 years old, but she believes her symptoms were evident before that. She reported over 100 problematic sounds, with “wet or slapping sounds” such as eating and slurping being the most intrusive. Her response to these trigger sounds was disgust and rage. CW expressed that her sound tolerance had deteriorated over the course of 5 years prior to seeking support with a major change coinciding with her first major depressive bipolar episode. As well as having bipolar disorder, CW has diagnoses of social anxiety, panic disorder, agoraphobia, obsessive compulsive disorder, and attention deficit hyperactivity disorder. In addition, CW is currently being assessed to determine if she has autism. Although CW was under the active care of psychiatric colleagues, none of these clinicians felt sufficiently trained to explain or manage her aversion to sound.
CW 在 14 岁时首次发现自己对声音敏感，但她相信自己的症状在此之前就已经很明显了。她报告了 100 多种有问题的声音，其中“潮湿或拍打的声音”，例如吃东西和吸食声音是最具干扰性的。她对这些触发声音的反应是厌恶和愤怒。 CW 表示，在寻求支持之前的 5 年里，她的健康耐受力已经恶化，并且在她第一次严重抑郁双相情感障碍发作时发生了重大变化。除了双相情感障碍之外，CW 还被诊断出患有社交焦虑症、恐慌症、广场恐惧症、强迫症和注意力缺陷多动障碍。此外，CW 目前正在接受评估以确定她是否患有自闭症。尽管 CW 受到精神病学同事的积极照顾，但这些临床医生中没有一个人觉得自己受过足够的培训来解释或控制她对声音的厌恶。
The impact of the misophonia upon CW and her family was substantial. She was essentially a recluse, with the majority of her friendships having dissolved due to her friends and college colleagues being indifferent to her problems who actually teased her with trigger sounds. When exposed to trigger sounds, CW would become increasingly anxious and exhibit negative behaviors including screaming, self-harm, and aggression. Her negative behaviors were exacerbated when she felt trapped or out of control.
恐音症对 CW 和她的家人产生了巨大的影响。她本质上是一个隐士，由于她的朋友和大学同事对她的问题漠不关心，甚至用触发声音取笑她，她的大部分友谊都解散了。当暴露于触发声音时，CW 会变得越来越焦虑并表现出负面行为，包括尖叫、自残和攻击性。当她感到被困或失控时，她的消极行为就会加剧。

CW had used earplugs, but did not find these beneficial and instead choose to block sound using strident music. At home, every attempt was made to reduce sound, including having the heating, electricity, and all electronic devices turned off.
CW曾使用过耳塞，但并没有发现这些好处，而是选择使用刺耳的音乐来阻挡声音。在家里，我们尽一切努力减少噪音，包括关闭暖气、电力和所有电子设备。

No abnormalities were detected on otoscopy. Pure-tone audiometry (air conduction) revealed hearing to be within normal limits bilaterally ( $▹$$▹$▹\triangleright Fig. 47.1). Tympanometry was within normal limits bilaterally. No other otologic concerns were noted. There was no history of significant noise exposure, ear surgeries, or trauma.
耳镜检查未发现异常。纯音听力测试（气导）显示双侧听力在正常范围内（ $▹$$▹$▹\triangleright 图 47.1）。双侧鼓室导抗测试在正常范围内。没有注意到其他耳科问题。没有明显的噪音暴露、耳部手术或外伤史。

Misophonia is a diagnosis that is attracting increasing attention in the audiology and psychology/psychiatry literature. ${}^1$${}^1$^(1){ }^{1} At best, this might lead to an integrated understanding of how misophonia involves the auditory system, neural systems of emotion, behavioral reaction, and learning. At worst, this might suggest that audiology, psychology, nor psychiatry fully understands or appreciates the challenges faced by a patient with misophonia and his/her family. The answer to the question then is that misophonia is generally considered an audiologic as well as psychological/psychiatric problem.
恐音症是一种在听力学和心理学/精神病学文献中越来越受到关注的诊断。 ${}^1$${}^1$^(1){ }^{1} 充其量，这可能会导致人们对恐音症如何涉及听觉系统、情绪神经系统、行为反应和学习有一个全面的理解。在最坏的情况下，这可能表明听力学、心理学或精神病学完全理解或理解恐音症患者及其家人所面临的挑战。那么问题的答案是，恐音症通常被认为是听力学以及心理/精神问题。

Many audiologists could be forgiven for being daunted by the extent of the challenges facing CW, but there are several reasons why having audiologist involvement may be beneficial to such a patient. The first reason is pragmatic because no other health care colleagues have been able to explain or attempt to manage the sound intolerance issues. Unless this care is undertaken in an audiology clinic, in such a case it will not be done at all. Second, it may be that managing the psychological or psychiatric aspects of misophonia will be enabled by audiologic counseling and the initial management of the misophonia. Third, of all the indicated problems associated with misophonia, the sound intolerance leads to social isolation that reduces quality of life.
许多听力学家对 CW 面临的挑战的程度感到畏惧是情有可原的，但有几个原因可以解释为什么听力学家的参与可能对此类患者有益。第一个原因是务实的，因为没有其他医疗保健同事能够解释或尝试处理声音不容忍问题。除非在听力学诊所进行这种护理，否则在这种情况下根本不会进行这种护理。其次，恐声症的心理或精神方面的管理可能可以通过听力咨询和恐声症的初步管理来实现。第三，在所有与恐声症相关的问题中，声音不宽容会导致社会孤立，从而降低生活质量。

During the initial assessment, CW was offered informational counseling about misophonia and its involvement of the auditory and neural systems of emotion and reaction. She was dispensed bilateral Behind-The-Ear (BTE) GN ReSound I-Fit 71 TS combination device with nonoccluding slim tube fittings. The I-Fit 71 TS can be configured to provide amplification via standard hearing instrument technology and tinnitus sound
在初步评估期间，CW 获得了有关恐音症及其对听觉和情绪和反应神经系统的影响的信息咨询。她获得了双边耳后式 (BTE) GN ReSound I-Fit 71 TS 组合装置，配有非闭塞细管配件。 I-Fit 71 TS 可配置为通过标准助听器技术和耳鸣声音提供放大功能

COMmENTS: Tympanometry was normas in each ear in the United Kingdom {UK), it air conduction thresholds are normal, bone conduction thresholds are usually not messured Speech Recognition Thresholds (SRT) and Word Recognition Scores (WRS) not performed
评论：英国（UK）每只耳朵的鼓室导抗测试正常，气导阈值正常，骨导阈值通常不混乱，未执行语音识别阈值（SRT）和单词识别分数（WRS）
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TEST DATE 测试日期

AUDIOLOGIST DB 听力学家数据库

Fig. 47.1 Pure-tone audiogram.
图 47.1 纯音听力图。
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generator features that aim to lower the perception of tinnitus. Given CW has normal hearing, the bilateral devices were programmed as ear level sound generators only, providing no amplification. CW was actively involved in fine-tuning the characteristics of the broadband signal. This was done to actively engage and empower CW in the treatment process so it would introduce a sense of control. Four sound programs ( $▹$$▹$▹\triangleright Fig. 47.2) were created: (1) low cut programmed to manufacturer’s minimum; high cut programmed at $2,000\mathrm{Hz}$$2,000\mathrm{Hz}$2,000Hz2,000 \mathrm{~Hz}; (2) low-cut programmed to manufacturer’s minimum; high cut programmed at $6,000\mathrm{Hz}$$6,000\mathrm{Hz}$6,000Hz6,000 \mathrm{~Hz}; (3) low cut programmed at $2,000\mathrm{Hz}$$2,000\mathrm{Hz}$2,000Hz2,000 \mathrm{~Hz}; high cut programmed at $6,000\mathrm{Hz}$$6,000\mathrm{Hz}$6,000Hz6,000 \mathrm{~Hz}; (4) low cut programmed at $1,000\mathrm{Hz}$$1,000\mathrm{Hz}$1,000Hz1,000 \mathrm{~Hz}; high cut programmed at $2,000\mathrm{Hz}$$2,000\mathrm{Hz}$2,000Hz2,000 \mathrm{~Hz}. Amplitude modulation was not activated. The sound was programmed in the software to an output at 40 dB SPL on all four programs with $\mathrm{a}+6/-12\mathrm{dB}$$\mathrm{a}+6/-12\mathrm{dB}$a+6//-12dB\mathrm{a}+6 /-12 \mathrm{~dB} volume range. This level was selected by CW as being clear and comfortable level ( $\downarrow$$\downarrow$darr\downarrow Fig. 47.2). CW was encouraged to use the devices instead of strident music to try and reduce the stridency of the trigger sounds and to partially mask the sounds. CW was advised to wear these devices when and where she prefers, in the hope of introducing some element of control. CW
旨在降低耳鸣感觉的发生器功能。鉴于 CW 的听力正常，双边设备仅被编程为耳平声音发生器，不提供放大功能。 CW 积极参与宽带信号特性的微调。这样做是为了在治疗过程中积极参与和授权 CW，从而引入一种控制感。四个声音程序（ $▹$$▹$▹\triangleright 图 47.2) 创建：(1) 低切编程为制造商的最小值；高切编程为 $2,000\mathrm{Hz}$$2,000\mathrm{Hz}$2,000Hz2,000 \mathrm{~Hz} ; (2) 低切编程至制造商的最小值；高切编程为 $6,000\mathrm{Hz}$$6,000\mathrm{Hz}$6,000Hz6,000 \mathrm{~Hz} ; (3) 低切编程为 $2,000\mathrm{Hz}$$2,000\mathrm{Hz}$2,000Hz2,000 \mathrm{~Hz} ;高切编程为 $6,000\mathrm{Hz}$$6,000\mathrm{Hz}$6,000Hz6,000 \mathrm{~Hz} ; (4) 低切编程为 $1,000\mathrm{Hz}$$1,000\mathrm{Hz}$1,000Hz1,000 \mathrm{~Hz} ;高切编程为 $2,000\mathrm{Hz}$$2,000\mathrm{Hz}$2,000Hz2,000 \mathrm{~Hz} 。幅度调制未激活。在软件中将声音编程为所有四个程序的输出均为 40 dB SPL $\mathrm{a}+6/-12\mathrm{dB}$$\mathrm{a}+6/-12\mathrm{dB}$a+6//-12dB\mathrm{a}+6 /-12 \mathrm{~dB} 体积范围。该级别被 CW 选为清晰舒适的级别（ $\downarrow$$\downarrow$darr\downarrow 图 47.2）。 CW 被鼓励使用这些设备而不是刺耳的音乐来尝试降低触发声音的刺耳声并部分掩盖声音。建议 CW 在她喜欢的时间和地点佩戴这些设备，希望引入一些控制元素。连续波
was also issued Sound Oasis bedside sound generator for use at bedtime. The Sound Oasis features a variety of soothing natural sounds that CW could listen to via the integrated speaker or through speakers built into a pillow. The aim was to utilize sound with minimal emotional salience to attempt to reduce attention to the trigger sounds.
还发放了 Sound Oasis 床边声音发生器，供睡前使用。 Sound Oasis 具有各种舒缓的自然声音，CW 可以通过集成扬声器或内置于枕头中的扬声器收听这些声音。目的是利用情感显着性最小的声音来尝试减少对触发声音的注意力。
A follow-up appointment was arranged 2 weeks after the initial assessment and device fitting. The appointment was scheduled so CW could attend and leave the clinic before other patients arrived because CW became distressed and experienced panic resulting in self-harming in the waiting area when leaving the clinic previously. While CW had not yet used the bedside sound generator, she reported she had worn the ear level sound generators several times, primarily while on her own and found they were beneficial at masking her trigger sounds. CW was able to sit with her pets while using the sound generators. This was something she has not been able to do for many years. CW reports that her mood had improved with the sound generators by providing her with an alternative solution to her negative behaviors and providing her with a sense of control. The audiologist set the following goals for her next
初次评估和设备安装后两周安排了后续预约。这次预约的安排是为了让 CW 能够在其他患者到达之前到达并离开诊所，因为 CW 之前离开诊所时感到痛苦和恐慌，导致在等候区自残。虽然 CW 尚未使用过床边发声器，但她报告说，她已经多次佩戴耳平发声器，主要是在她自己的时候，发现它们有助于掩盖她的触发声音。 CW 能够在使用声音发生器的同时与她的宠物坐在一起。这是她多年来都做不到的事情。 CW 报道称，声音发生器为她的消极行为提供了替代解决方案，并为她提供了一种控制感，从而改善了她的情绪。听力学家为她的下一步设定了以下目标

Fig.47.2 Device settings.
图 47.2 设备设置。
appointment: increased use of the sound generators in a wider range of sound environments, gradual acclimatization to sounds that can be triggers, and finding a method for counseling significant others about triggers and the resulting mood state to prevent negative behaviors.
预约：在更广泛的声音环境中增加使用声音发生器，逐渐适应可能触发的声音，并找到一种方法向重要的其他人提供关于触发因素和由此产生的情绪状态的咨询，以防止负面行为。

At a second follow-up appointment 6 weeks later, CW reported having recently been prescribed mood-stabilizing drugs, which she felt were having a beneficial effect on her sound sensitivity. She had been able to expose herself to sounds
在六周后的第二次随访中，CW 报告最近服用了情绪稳定药物，她认为这些药物对她的声音敏感度产生了有益的影响。她已经能够将自己暴露在声音中
she would previously have been unable to tolerate such as eating with a friend. She also has improved behavior with less self-harming and aggression in response to trigger sounds.
以前她无法忍受与朋友一起吃饭。她的行为也有所改善，对触发声音的反应减少了自残和攻击行为。

CW had a final appointment 1 year after the initial visit. While she acknowledged there were still issues with sound tolerance,
CW 在初次访问一年后进行了最后一次预约。虽然她承认健全宽容仍然存在问题，