Excerpt: It is often the case that veterans who experience hyperacusis have hearing loss and tinnitus; what sets the patient with PTSD apart is an increased likelihood that will rate sound tolerance problems as more severe than tinnitus and hearing loss

Fagelson, Marc A.

English

East Tennessee State University

East Tennessee State UniversityDigital Commons @ East Tennessee State UniversityETSU Faculty Works Faculty Works1-1-2013Military Trauma and its Influence on LoudnessPerceptionMarc A. FagelsonEast Tennessee State University, fagelson@etsu.eduFollow this and additional works at: https://dc.etsu.edu/etsu-worksPart of the Speech Pathology and Audiology CommonsThis Article is brought to you for free and open access by the Faculty Works at Digital Commons @ East Tennessee State University. It has beenaccepted for inclusion in ETSU Faculty Works by an authorized administrator of Digital Commons @ East Tennessee State University. For moreinformation, please contact digilib@etsu.edu.Citation InformationFagelson, Marc A.. 2013. Military Trauma and its Influence on Loudness Perception. ENT and Audiology News. Vol.21(6). 80-81.ISSN: 2042-2156Military Trauma and its Influence on Loudness PerceptionCopyright StatementThis document was published with permission from the publisher. It was originally published by ENT &Audiology News (https://www.entandaudiologynews.com/). It should not be used for commercial use.Direct reprint requests to Pinpoint Scotland.This article is available at Digital Commons @ East Tennessee State University: https://dc.etsu.edu/etsu-works/1602Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.ENT & audiology news |  JANUARY/FEBRUARY 2013  |  VOL 21 NO 680The sensory mislabelling of environ-mental events is one of the morepronounced disruptions associ-ated with posttraumatic stress disorder(PTSD) [1]. Mislabelling, in this context,results from an erroneous or exaggeratedneural representation of a sound, sight,tactile sensation, or smell producing aperception that does not correspond accu-rately to the magnitude of the related stim-ulus. The exaggerated perception maytrigger in the patient with PTSD a state ofhyperarousal that produces profoundnegative reactions and ultimatelycontributes to avoidance behaviours. Theresulting sensations of pain and anguishexperienced by the affected individual mayupset their most valued relationships, drivefamily members apart, and produce in thesufferer a sense of despair or self-loathing.In order to facilitate a patient’s ability tomanage hyperacusic responses, and tounderstand the physiologic mechanisms ofsensory mislabelling, it is essential for clini-cians to address the contributions ofpsychological distress to the auditory expe-rience. A management plan that incorpo-rates interdisciplinary teams of profes-sionals stands the best chance ofimproving the coping skills of individualsthus affected.It is often the case that veterans whoexperience hyperacusis have hearing lossand tinnitus; what sets the patient withPTSD apart is an increased likelihood thatthey will rate sound tolerance problems asmore severe than tinnitus and hearing loss.Patients report that they avoid certainsocial and occupational situations due tosound-triggered pain and discomfort whenin the presence of everyday sounds that donot bother their colleagues, friends, orfamily. Table 1 summarises findings fromthe last 500 patients observed at aVeterans’ Affairs clinic in the US withrespect to the rating of sound toleranceproblems compared to pure-tone sensi-tivity and ratings of hearing loss andtinnitus. It is clear that the veterans withPTSD experience the loudness of environ-mental sounds in a substantially differentway from patients with similar absolutethreshold, and similar ratings of tinnitusloudness. Patients with PTSD are also threetimes more likely to state that exposure toloud sounds exacerbates tinnitus loudnessthan members of the other groups [2]. Thedifference extends to comparisons ofpatients with tinnitus and psychologicaldisorder (that is, anxiety, depression, orpanic attacks) other than PTSD (Figure 1).To what do we attribute the apparentmislabelling of sound that affects patientswith PTSD to a greater degree thanpatients without PTSD?The DSM-IV [3] specifies the symptomsthat must be present to endorse a PTSDdiagnosis as including, 1) exposure to trau-matic stressor, 2) re-experiencing symp-toms (flashbacks), 3) avoidance andnumbing symptoms, 4) hyperarousal, 5)duration of symptoms > one month, and6) significant distress or impairment offunctioning. The symptoms associatedwith hyperarousal are consistent withpatients’ complaints regarding the experi-ence of excessive loudness associated withmoderate sound levels. When confrontedMilitary Trauma and its Influenceon Loudness PerceptionPatients with: Tinnitus Only Tinnitus + Psych Dx Tinnitus +PTSDMean SD Mean SD Mean SDPTA (better ear) 33.8 7.6 33.2 8.1 34.4 7.7PTA (worse ear) 38.1 8.8 38.8 9.2 38.3 8.9Hyperacusis Rating (1-10) 4.40 3.4 4.46 2.8 7.51 2.7Tinnitus Loudness Rating (1-10) 6.37 2.5 6.51 2.1 6.78 2.2Hearing Loss Rating (1-10) 5.13 2.6 5.28 2.7 6.10 2.7Table 1. Patient group information regarding tinnitus, hyperacusis, and hearing loss. Ratings are based on verbalresponse and a 1-10 scale.Prof Marc Fagelson,PhD, CCC-A, Director of Audiology,Department ofAudiology & SpeechLanguage PathologyEast Tennessee StateUniversity Johnson City,TN  37614, USA.CorrespondenceE: FAGELSON@mail.etsu.eduDeclaration ofCompeting InterestsNone declared.Figure 1: Patient ratings of tinnitus loudnessand degree of sound tolerance problemsexperienced during routine activities.Ratings are based on verbal response and a0-10 scale.05 ENTJF13 067-104_Layout 1  18/12/2012  16:05  Page 80Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.Copyright © Pinpoint Scotland Ltd. All rights reserved.81ENT & audiology news |  JANUARY/FEBRUARY 2013  |  VOL 21 NO 6by the perception of excessive loudness,patients respond as though they are indanger, they maintain an alert state that isdisproportionate to the stimulus magni-tude.Hyperarousal is recognised as a condi-tion in which patients experience reducedpain tolerance, anxiety, exaggerated startleresponses, insomnia, and heightenedsympathetic nervous system activation. Ifwe consider an exaggerated neuralresponse as an element of PTSD-relatedhyperarousal, then it is reasonable to thinkof hyperacusis as a sound-based analogueof reduced pain tolerance. Patients whoexperience startle responses that compelwithdrawing from social situations illus-trate the power of the sensory mislabelling.Clearly, the individual with PTSD whoexperiences an episode of hyperacusisperceives something that is not present inthe environment, and their reaction,although perhaps appropriate at sometime in the past when a similar sound signi-fied danger, would not be appropriate intheir present circumstance.The concept of hyperarousal and its rela-tion to the fight-or-flight response is attrib-uted, as early as 1915, to Walter BradfordCannon [4]. The Cannon-Bard theory ofemotion centres on the thalamus and itsoutput to cortical regions associated withresponses to powerful emotio s. Thalamicactivity could trigger aversive conditionedresponses when, for example, its output isassociated consistently with specific eventsthat evoke powerful negative emotions.For the hyperacusic veteran, the responseto unexpected impulse sounds is learned;the soldier is trained to recognise thesounds’ value as a survival threat. Combatveterans consistently lash out, sometimesviolently, at friends and family when star-tled or when woken suddenly from sleep.For those veterans with experience incombat zones, the responses are difficultto extinguish, they are not easily unlearned.Therefore, while such patients recognisethey behave inappropriately, or anti-socially, they are unable to adopt newstrategies to cope with arousing environ-mental conditions.Bremner and colleagues [5] attributedpoor coping strategies among veteranswith PTSD to trauma-related changes inneural circuitry, specifically involving thehippocampus, that impaired recalling orlearning effective coping strategies.Bremner measured reductions inhippocampal volume among returningcombat veterans and related the changesto specific deficits in memory and learning.Such impairment affected both declarativememory (that is, remembering facts) andnon-declarative memory (that is, how tobrush one’s teeth, or, for our purposes,remembering how to react to an environ-mental event) [6]. The inability to developor retain appropriate emotional (and ulti-mately physical) responses to environ-mental stimuli was viewed as a directconsequence of hippocampus impairment.PTSD-related hyperarousal is attributedto a variety of neural and biochemicalsources. In addition to hippocampusinvolvement, chronic excessive cortisollevels associated with prolonged stresssuch as those experienced by combatveterans or trauma victims contribute tocentral nervous system irritability andhyperarousal. In this way, the combat expe-rience produces similar effects to thosesuffered by victims of sexual abuse orcaptivity.Judith Herman [7] described victimisedwomen who were known to Freud andother psychoanalysts as experiencing an‘elevated baseline of arousal’ in combina-tion with ‘an extreme startle response tounexpected stimuli, as well as an intensereaction to specific stimuli associated withthe traumatic event’ (p. 36). She statedfurther that trauma victims had difficultytuning out repetitive stimuli, even ifinnocuous, as each presentation appearedto be processed as ‘a new, dangeroussurprise’. It is worth noting here the rela-tively high prevalence of tinnitus amongthis population, as tinnitus could beconsidered a repetitive stimulus generatinga similar response. The physiologic conse-quences for such women mirrored those ofveterans who reported feeling ‘on patrol’when they have misinterpreted environ-mental events to a degree that they couldnot function in routine social situations.V ctims of sexual abuse or captivity werelong known to exhibit a tendency tostartle, withdraw, suffer nightmares, andexperience psychosomatic symptoms thatwere similar to the effects seen in veteranswho had survived violent episodes, hadperpetrated violence on others, or whohad chanced upon horrific scenes of battlerecently ended (for example, those soldierswho came upon the village of My Lai afterthe massacre).Hyperacusis may be difficult to quantify,however when such patients are askeddirectly to rate the annoyance and impacton routine life of their sound toleranceproblems, the ratings typically exceedthose applied by patients to their hearingloss and / or tinnitus. Although the lack ofa well-established hyperacusis assessmentclouds the interpretation of patientcomments, their reports consistently revealthat they experience enduring discomfortand anxiety. Repeated exposures do notchange their experience; as Herman [7]described, it is as if the sensation is neweach time it is experienced.  Adaptation tosuch stimuli appears beyond the reach ofthese veterans.Mislabelling of stimuli is the result ofseveral factors: training, experience, trau-matic memories, and wholesale changes tothe baseline activity in the CNS. The aber-rant behaviours that result, such as avoid-ance, irritability, and violent reactions toneutral events, have the potential to rendrelationships and upend aspects of daily lifethat most people take for granted. It islikely that some veterans and militarypersonnel learn to be hyperacusic overtime. Their strong physical and emotionalresponses to sounds that would notbother other people have had substantialecological value at on  time and are rein-forced in life-threat ning situations. It is themisfortune of such individuals that aplethora of environmental soundsresemble the sounds of war enough so thatthey trigger extremely disturbing thoughts,memories and actions. The scope of thesedisruptions warrants the collaboration ofprofessionals devoted to ameliorating theirseverity. As Shay [8] points out, it may bethat to serve one’s nation renders theveteran unfit to be its citizen. It is our priv-ilege to help individuals enjoy the benefitsthat should accrue to their time in the mili-tary service.References1. Schnurr PP, Jankowski MK. Physical health andposttraumatic stress disorder: Review and synthesis.Sem Clin Neuropsychiatry 1999;4(4):295-304.2. Fagelson MA. The association between tinnitusand posttraumatic stress disorder. Am J Audiol2007;16(2):107-17.3. American Psychiatric Association. Diagnostic andstatistical manual of mental disorders (4th edition).Washington, DC: American Psychiatric Association;1994.4. Cannon WB. The James-Lange Theory of Emotions:A Critical Examination and an Alternative Theory.Am J Psychol 1927;39(1/4):106-24.5. Bremner JD. Brain Imaging Handbook. New York,NY: WW Norton; 2005.6. Bremner JD. Does stress damage the brain? BiolPsychiatry 1999;45(7):797-805.7. Herman JL. Trauma and Recovery. New York, NY:Basic Books; 1997.8. Shay J. Achilles in Vietnam: the undoing of charac-ter. New York, NY: Scribner; 1994.feature05 ENTJF13 067-104_Layout 1  18/12/2012  16:05  Page 81

Military Trauma and its Influence on Loudness Perception

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Military Trauma and its Influence on Loudness Perception

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