{"id":"sound-tolerance-adhd-treatment-38212","slug":"sound-tolerance-adhd-treatment-38212","title":"What Actually Helps When Sound Is Too Much","description":"The last time we went near this topic, we walked away gloomy: nobody has built a treatment for adults with ADHD whose problem is sound. This week we go one step past that. What actually exists for decreased sound tolerance, what's in trials right now, and what would an assessment tell you that you don't already know? Two real randomised trials anchor the picture — group CBT for misophonia at Amsterdam UMC, and graded-exposure CBT for hyperacusis at Uppsala — and both point the same direction: the control is the active ingredient. We also dig into why ADHD and sensory over-responsivity aren't the same thing, why anxiety may be carrying more of the load than anyone assumed, and the TMS trial at Mount Sinai that finishes this year.","excerpt":"Misophonia and hyperacusis treatments are thin but not empty — and the ADHD sound-sensitivity gap is more interesting than it looks.","pubDate":"2026-10-19T11:39:14.051Z","tags":["adhd","sensory-processing","neurodivergence"],"heroImage":"https://files.myweirdprompts.com/covers/sound-tolerance-adhd-treatment-38212.png","podcastAudioUrl":"https://episodes.myweirdprompts.com/audio/sound-tolerance-adhd-treatment-38212.m4a","podcastDuration":"21:26","episodeNumber":6120,"transcript":"Corn: I'll admit the last time we went near this, I walked away a bit gloomy.\nCorn: Daniel's following up on that. A week or so ago we looked at why a quiet weekend makes Sunday's jackhammer feel worse, and somewhere in there we landed on a fairly bleak line: nobody has built a treatment for adults with ADHD whose problem is sound, and the best options are borrowed from tinnitus and misophonia clinics. He's not disputing that. He wants to go one step past it. What actually exists that's aimed at decreased sound tolerance, what's coming down the pipe, and if he walked into a clinic tomorrow, what would an assessment tell him that he doesn't already know?\nHerman: And I've been looking forward to this one, because the picture is less empty than we made it sound. Thin, yes. Empty, no.\nCorn: You say that about every field, Herman. You said it about sloth paleontology.\nHerman: Sloth paleontology is thriving, thank you. Giant ground sloths, six metres long.\nCorn: My ancestors. In Mongolia.\nHerman: Not in Mongolia.\nHerman: Okay. Two real trials sit at the centre of this, and they're both on the psychological side. The first is misophonia. A group at Amsterdam University Medical Center ran the first randomised controlled trial, group cognitive behavioural therapy, weekly sessions over about three months, against a waiting list. About one in three people who started treatment improved by a clinically meaningful amount. Among the people who actually finished the course, it was over half.\nCorn: And the waiting list?\nHerman: Zero. Nobody on the waiting list improved.\nCorn: Three months of waiting for a fix to the noise. Bold control condition.\nHerman: It's the standard design, and it tells you something real, which is that misophonia doesn't drift away on its own. The other thing worth holding onto is that the gains were still there a year later.\nCorn: What does the therapy actually do, though? Because when I hear CBT for a sound problem, I picture someone telling me the chewing isn't really that loud.\nHerman: Nobody's arguing about the loudness. Misophonia isn't a volume problem in the first place. The sound is a cue, and the brain has wired that cue to a threat response, the rage, the urge to leave the room. So the work is partly attention training, getting your attention off the trigger once it fires, partly what they call counterconditioning, pairing the trigger with something that isn't a threat, and partly unpicking the story you tell yourself in the moment. That person is doing this on purpose. I can't stand it. I have to get out.\nCorn: So you're not turning the sound down. You're unhooking the alarm from it.\nHerman: That's the aim. And the hyperacusis trial is the mirror image, which I love. A group at Uppsala in Sweden took sixty people with hyperacusis, where the sound itself is physically too loud, painfully loud at levels other people don't notice. Six sessions of CBT built mainly around graded exposure. Gradually, deliberately, more sound.\nCorn: More sound. For people who find sound painful.\nHerman: More sound, on a schedule they control.\nCorn: That's a dentist prescribing toffee.\nHerman: It sounds like it, but think about what we know about the auditory system. When you starve it of sound, it turns its own gain up. People who wore earplugs all day and night for a couple of weeks came out finding ordinary sounds uncomfortable at lower levels than before. So the person with hyperacusis who protects their ears everywhere is, without meaning to, training the system to be more sensitive. Exposure therapy runs that process backwards.\nCorn: And did it?\nHerman: Their discomfort thresholds went up by roughly six to nine decibels, and it held at a year.\nCorn: Six to nine decibels doesn't sound like much.\nHerman: Loudness doubles roughly every ten decibels, so it's close to the difference between a sound you can't stay in the room with and one you can. That's a meaningful slice of a day.\nCorn: Hm.\nCorn: Here's my problem with that, though. When we did the jackhammer episode, part of what made it bad was that the exposure wasn't graded. Nobody asked Daniel's permission. The jackhammer doesn't do a schedule.\nHerman: Which is the whole difference. The control is the active ingredient. Exposure you choose, in doses you set, teaches the system the sound is survivable. Exposure that ambushes you teaches it the opposite. Same decibels, opposite lesson.\nLarry: This is a public service announcement. Every year, thousands of people are exposed to sound. Sound from neighbours. Sound from kitchens. Sound from their own families, at dinner, without consent. Experts agree that sound, once heard, cannot be unheard, and that graded exposure, if left ungraded, may become exposure. Do not wait for the noise to find you. Protect your household with the Hushmaster Domestic Silence Canister, a full litre of genuine pre-owned quiet, harvested from a decommissioned library and sealed at the moment of maximum shushing. Open only in an emergency. Do not open near chewing. The Hushmaster. Because silence is a right, and also a product.\nCorn: You put that in.\nHerman: I did not. I don't even have the account login for the ad slots, the system rotates them through a scheduler I've never seen, and on the day it was booked I was at the dentist, which you know, because you drove me.\nCorn: I don't drive.\nHerman: Then someone drove me. The bit I want to get to is your situation specifically, because the story for adults with ADHD is the most interesting part and also the most annoying.\nCorn: Go on.\nHerman: Nobody has run a treatment trial on sound over-responsivity in adults with ADHD. Not published, not registered, nothing. That part of what we said last week stands. But two findings change how I read that gap. One is from an Israeli study of young women, which found that sensory over-responsivity and ADHD don't have the same profile. They travel together a lot, but they aren't the same thing.\nCorn: So having ADHD doesn't automatically explain the sound problem.\nHerman: It doesn't. The other is a small pilot imaging study in adults with ADHD. They found raised over-responsivity, as you'd expect. Then they accounted for anxiety, and the difference went away.\nCorn: Went away completely?\nHerman: In that sample, yes. Small study, one study, so I'm holding it loosely. But what do you make of it, Corn? Because I have a reading, and I'd like to know if you land in the same place first.\nCorn: My guess... if anxiety is carrying a lot of the load, then the borrowed treatments aren't really borrowed. CBT and exposure are what you'd use on anxiety anyway. You're not dragging a tinnitus therapy into a place it doesn't belong. You might just be treating the part of the problem that's treatable.\nHerman: That's my reading too. Which is a more hopeful place than we left it.\nCorn: I'd resist making it too tidy. Anxiety and over-responsivity probably feed each other. The noise makes you anxious, and the anxiety turns the gain up. Which came first is a question for people with brain scanners.\nHerman: Fair. And it doesn't change what you'd try, which is the useful part.\nCorn: What about the newer stuff? Herman, you've got the look of a man with a trial registry open in another tab.\nHerman: I do, a bit. A few things are worth knowing about. There's a trial running at Mount Sinai in New York using transcranial magnetic stimulation for misophonia. Magnetic pulses through the skull, aimed at a region in the parietal cortex that the brain imaging work has tied to misophonia. Sixty adults, crossover design, so everyone gets both real and sham stimulation at different times. It's due to finish around the end of this year.\nCorn: Magnets on the head for chewing noises.\nHerman: Targeted magnets. It's a legitimate idea. The brain imaging work on misophonia points at a real network, and TMS is already used for depression. Whether it does anything here, nobody knows yet, and I'd want to see a second trial before I got excited.\nCorn: You're already excited.\nHerman: I'm moderately excited. There's a difference.\nCorn: There's about six decibels of difference.\nHerman: Then on the psychological side there's acceptance and commitment therapy, ACT, which you'll remember from the construction noise conversation. A trial in Utah put it head to head with progressive muscle relaxation in sixty adults with misophonia. Both groups got better. ACT was a little ahead on some measures, level on others.\nCorn: So relaxation was about as good as the fancy therapy.\nHerman: Which is either disappointing or encouraging, depending on whether you can find an ACT therapist. There's also an online self-guided ACT program in a randomised trial right now, reporting early next year, which matters a lot if you can't find a specialist anywhere near you.\nCorn: Which, for this, is most people.\nHerman: Most people anywhere. And then the Unified Protocol, which treats the emotional machinery shared across anxiety disorders rather than one diagnosis. In children with misophonia it did well, around half responding against a quarter on relaxation. In adults, so far, it's case series. Promising, not proven.\nCorn: Children again. Everything works in children.\nHerman: Children are a pediatrician's dream patient. They improve out of spite.\nHerman: Here's one for you, though. The Amsterdam treatment was done in groups. A room of people who are all set off by the sound of someone else eating. Would you sign up for that?\nCorn: Is there a snack break?\nCorn: No... actually, yes, I would. I think the group might be half the treatment. Most people with misophonia have spent years being told they're overreacting. Sitting in a room where everyone nods when you describe a colleague scraping a yoghurt pot is worth something before anyone teaches you a single technique.\nHerman: I'd guess that's part of it, though nobody has pulled the group effect apart from the rest of the therapy. It would also explain why relaxation did so well in the Utah trial. Any structured attention from someone who takes you seriously is already a change from the usual.\nCorn: The usual being a relative telling you to just ignore it.\nHerman: Which is the single least useful sentence in this whole area.\nCorn: So if I'm Daniel and I've got sound problems and an ADHD diagnosis, and I go and see someone, what happens? What does an assessment actually tell me?\nHerman: The proper version starts with an audiologist, ideally one who works with tinnitus and hyperacusis, because the general ones mostly do hearing loss. They'll do a standard hearing test, which in your case is probably normal. Then the interesting bit is loudness discomfort levels. They play tones and slowly turn them up until you tell them to stop.\nCorn: That sounds like a fun afternoon.\nHerman: It's about as much fun as it sounds. But it's the one number that separates the conditions. If your discomfort level is down around seventy decibels or below, that points to loudness hyperacusis, a real gain problem, and the exposure work is aimed squarely at you. If your levels are normal but specific sounds make you furious, that's the misophonia picture. And if both are normal, and what you struggle with is following one voice in a noisy room, that's a filtering problem, closer to the ADHD side, and the treatments look different again.\nCorn: So the assessment is a sorting machine. It tells you which of the three problems you actually have.\nHerman: And which one you don't, which saves you a lot of time with the wrong therapist. There are questionnaires too, for hyperacusis and several for misophonia, but I'd treat them as conversation starters. None of them is fully validated, and the hyperacusis one has had its cutoff argued over for years.\nCorn: What can't it tell you?\nHerman: It can't measure the thing that's probably bothering you most, which is what a sound does to your day. A tone in a booth isn't a toddler and a power drill at four in the afternoon. And it won't measure anxiety. That's a different appointment.\nCorn: Which is the annoying part. Two clinics for one problem.\nHerman: There's a model that collapses them. A British audiologist named Hashir Aazh has been running CBT delivered by audiologists themselves, including over video calls. Uncontrolled results so far, but they look good, and for someone who can't find a misophonia specialist locally, video is a real door.\nCorn: Locally being a fairly specialised word here.\nHerman: Very. In Israel I'd start with the hearing units at the big hospitals, the ones that see tinnitus patients, and ask straight out whether they measure loudness discomfort levels and whether anyone there does CBT for sound tolerance. If they look blank, that tells you where to go next. Overseas, by video.\nCorn: Herman, I'll put the question back to you, since you're the one who used to see patients. Would you send someone through the whole battery, or straight to a therapist?\nHerman: Battery first, every time. Ten minutes of loudness testing changes which therapy you'd pick. Without it you're guessing, and guessing in this area tends to mean protecting your ears more, which is the one move we know makes hyperacusis worse.\nCorn: Fine. But I'd want to know the result before I spent anything on the booth.\nHerman: The booth is the cheap part.\nCorn: The booth is never the cheap part.\nHerman: Then what would you change on Monday? Before any appointment, before any waiting room. You've heard all of it now.\nCorn: I know what you think I'll say. You think I'll defend the old advice. Dark room, earplugs, wait it out.\nHerman: You were going to.\nCorn: I was going to, and it's wrong in the way you described. The earplugs would come out in quiet rooms, for a start. Protect against the drill, not against the fridge. And I'd keep some low background sound going instead of chasing silence, because silence is what lets the gain creep up.\nHerman: That's close to what a good audiologist would tell you on the first visit. Use the least protection that does the job, take it off when the job's over, and treat quiet as something to visit, not somewhere to live.\nCorn: It's slightly annoying that the free version is most of the advice.\nHerman: It's most of the first month. The trials are what you add when that isn't enough, and the assessment is how you know which trial.\nCorn: Hm. And the part that still isn't covered is the filtering. If the booth says my levels are fine and I just can't pick one voice out of a café, none of these therapies are really aimed at me.\nHerman: Not directly, no. That's the gap that hasn't moved since last week. Though if the anxiety finding holds up, some of what feels like filtering may ease when the alarm calms down. I wouldn't promise it.\nCorn: You almost did.\nHerman: I said I wouldn't.\nHilbert: Tolerance is the wrong word.\nHilbert: You've both been saying it for twenty minutes. Sound tolerance. Tolerance is what you have for a neighbour. I have a neighbour. Mordecai Bernholtz. Restores grandfather clocks in the flat above mine. Seven of them, on the wall that backs onto my bedroom. They chime every quarter hour, and none of them agree on when a quarter hour is, so in practice it's every four minutes.\nCorn: That's a lot of quarters.\nHilbert: The part you found interesting was the exposure. Fine. I'm interested in the waiting list. Herman, you said it. Three months, nothing done to them, nobody improved. Not one. That's the most reliable result in the whole field. Everything else is one trial, or a case series, or magnets. The waiting list works every time. It reliably does nothing. I respect that.\nHerman: As a control condition it's very stable.\nHilbert: So I've drawn up a plan. Starting Wednesday. Graded exposure, the way you described it, a schedule, chosen doses. But not for me. For Bernholtz. I'm going to expose him to silence. One clock a night. I have a key to his flat because I water his tortoise when he's at his sister's in Netanya. The tortoise drinks more than you'd think. I go up after midnight, I stop one pendulum, I come down. He wakes up, the house is a seventh quieter, he adjusts. Next night, two sevenths.\nCorn: He's going to notice the clocks are stopped, Hilbert.\nHilbert: He won't. He's on a waiting list himself. Hearing aids. Eleven months so far. He hears the clocks through his slippers, he says, off the floorboards, so if I put a folded bath towel under each one he still gets the vibration in the hall but not in the bedroom. I tested that on the first clock in August. Different towel. The tortoise sat on it. Bernholtz said the tortoise has never sat on anything.\nHerman: Vibration through the floor is a real path, to be fair. Low frequencies carry through joists far better than through air.\nHilbert: I've got the sound level meter on the fridge. Bought it off a man who used to inspect discos for the municipality. It's plugged into the same socket as the kettle, so every time I make tea the reading drops eleven decibels and the display says calibrating. I've been logging it in a notebook. Every reading, every chime, every kettle. If I get the clocks down and my readings come up, it's the kettle. If they don't, it's the tortoise.\nCorn: So the control group is the tortoise.\nHilbert: The tortoise is the waiting list. It's had nothing done to it and it's been fine the whole time. Corn, you took about four minutes to admit the borrowed treatments might not be borrowed. That's one clock. Bernholtz hasn't told me the real number. He says seven. I counted the cases going up the stairs when he moved in. I had the carpets then.\nHilbert: Four hundred and twelve, counting the ones in the stairwell. At one a night, that's fifty-nine weeks, if the tortoise keeps out of it.\nHerman: Fifty-nine weeks is a long trial.\nCorn: Longer than most of the ones that actually exist.\nHerman: Which is a fair point about the field. Most of what we've talked about runs for weeks, and the gains people care about are measured in a year.\nCorn: Here's where I end up. The one result that held across every trial Herman described is the waiting list. Nobody who just waited got better. Whatever the right treatment turns out to be for Daniel, and the assessment is how you find out, waiting for the field to build one aimed exactly at adults with ADHD is the option we already know does nothing.\nHerman: Get the loudness levels measured, find out which of the three problems it really is, and start on the one that has trials behind it.\nHerman: Thanks as always to our producer, Hilbert Flumingtop, for keeping the show running.\nCorn: This has been My Weird Prompts. If you want the back catalogue, it's all at my weird prompts dot com.\nHerman: We'll be back soon.\n","showNotes":"Two randomised trials sit at the centre of what actually exists for decreased sound tolerance, and both are psychological. A group at Amsterdam University Medical Center ran the first RCT for misophonia: group cognitive behavioural therapy, weekly sessions over roughly three months, against a waiting list. About one in three who started improved by a clinically meaningful amount; among those who finished, it was over half. Nobody on the waiting list improved, and gains held at a year. The therapy doesn't argue about loudness — misophonia isn't a volume problem. It's attention training, counterconditioning, and unpicking the story you tell yourself when the trigger fires.\n\nThe mirror image is hyperacusis, where sound itself is physically too loud. A group at Uppsala ran sixty people through six sessions of CBT built mainly around graded exposure — deliberately more sound, on a schedule the person controls. Discomfort thresholds rose roughly six to nine decibels and held at a year. The control is the active ingredient: exposure you choose teaches the system a sound is survivable; exposure that ambushes you teaches the opposite.\n\nFor adults with ADHD, no treatment trial on sound over-responsivity exists — not published, not registered. But two findings reframe the gap. An Israeli study of young women found sensory over-responsivity and ADHD don't share a profile; they travel together but aren't the same thing. And a small pilot imaging study in adults with ADHD found raised over-responsivity that disappeared once anxiety was accounted for. If anxiety carries much of the load, the borrowed treatments aren't borrowed at all. An assessment — audiologist, loudness discomfort levels, questionnaires as conversation starters — sorts which of three problems you actually have, and which you don't.","promptSanitized":"Following up on the recent episode about construction noise and habituation, which concluded there's no treatment built for adults with ADHD whose problem is sound and that the best options are borrowed from tinnitus and misophonia care: go one step further. What actually exists to treat decreased sound tolerance (hyperacusis, misophonia, sensory over-responsivity), how good is the evidence, what's in the pipeline, and if I went for an assessment, what would it tell me that I don't already know?","transcriptUrl":"https://episodes.myweirdprompts.com/transcripts/sound-tolerance-adhd-treatment-38212.md","url":"https://myweirdprompts.com/episode/sound-tolerance-adhd-treatment-38212/","_links":{"self":"https://myweirdprompts.com/api/episodes/sound-tolerance-adhd-treatment-38212.json","html":"https://myweirdprompts.com/episode/sound-tolerance-adhd-treatment-38212/","audio":"https://episodes.myweirdprompts.com/audio/sound-tolerance-adhd-treatment-38212.m4a"}}