My thinking is that hyperacusis exists when the actual sound you perceive is distorted, over-amplified or in any other way changed from what you recall as "normal". Symptoms of TTTS are more likely to present as added symptoms over and above the changes to perceived sound, such as thumps, clicks, pain/ache/other discomfort coming along with or some time after being exposed to sounds (volume and/or frequency related). Because we still don't really know our causes that well, its hard to say if H and TTTS exist completely on the same continuum or whether they are interconnected but separate pathologies occurring in different locations. IOW: does all hyperacusis arise from inner ear and/or auditory nerve injury, and does TTTS occur as a deranged reaction of the hearing and limbic system to the mis-perception of sound at the central level, or is the sound altered at middle ear level through deranged middle-ear muscle function, causing the mis-perception of sound. Is the problem of sound perception one of delivery of the message, or interpretation of the message? is it a chook or is it an egg?
that's just how I think of it right now. Japongus is a poster who explores this area pretty intensively if you look up some of his stuff.
I tell you how I see the problem right now. In 2015 and at the beginning of 2016 I had similar doubts to the ones you and Lapidus have now. I used to think I had "hyperacusis", although I thought it was more or less the same thing as TTTS. Then I began to see everything more clear and to accommodate my ideas. My ideas apply to my case, but, unless I am a creature from another galaxy, they could apply to other cases of TTTS. Everyone has to see how these ideas reverberate with their symptoms, over time. Anyway, I write some raw notes in my precarious English in case they are useful for someone.
I think there are two or three common types of distorted perception. The first one is "real", the third one illusory, and there could be a second one which is real (or illusory).
The first one concerns internal volume. It is present when the person gets unused to real sounds (real dynamics, real spectrum of frequencies) and the brain loses its normal calibration. Also, it could happen when the person, because of an ear pathology which is bothersome or painful, becomes confused and afraid of sounds. Or probably because of a certain state of mind with no connection to any otologic problem. Or because of all this. For example, a man who begins to have TTTS symptoms, and who is not diagnosed properly by his doctor. As a consequence, because the symptoms are uncomfortable/painful, and also because the tension of the TT system, which he thinks has certain analogy to loudness, frightens him and make sounds louder and the TT system more tense, he begins to use earplugs/cotton balls too much (sometimes suggested by his doctor himself) and to have an avoidance attitude towards sounds. As a consequence, after days doing this, the internal volume is increased, especially for high frequencies, which are the ones cut the most by earplugs. The dynamics get distorted. This distortion is "real", the person really hears louder. And this distortion (call it increased loudness perception –ILP-, distorted dynamics, distorted hearing, hearing louder, or the way you want, even "hyperacusis" if you like the word) is non-pathological and "natural", in the sense that any healthy person in the same position could end up having this distortion. It is not a disease and it is not caused by any damage in the cochlea, the brain, the middle ear, or whenever. And of course, ILP could be completely reversed. But as Hazell, one of the architects of the precarious "model", advices on his website, if you were using earplugs for a long time, you should be quit them very gradually, because if you found yourself perceiving a tsunami of sound you could make a disaster, especially if you have TTTS.
Another example would be a film soundtrack designer who spends a whole day listening to bird sounds in his studio. Using headphones, he obsessively selects the bird sounds from a huge library to create the proper atmosphere to a certain scene. And then he mixes and processes the sounds. When he goes out to the urban streets, he finds himself hearing birds in the foreground of his internal "mix", with great detail, when he normally doesn't pay attention to birds. Just another example to show that this is a natural phenomenon and that it doesn't imply any damage. In this case, the sound designer could enjoy the peculiar perception, because it doesn't include any physical discomfort. It is only about perception, not a bothersome physiological abnormality like TTTS. And we could talk also about some recreational drugs...
But when ILP is originated from wrong management of TTTS, it is integrated to the vicious circle of TTTS, complicating things further. From one problem, you end up having two problems. From an uncomfortable sensation, you end up having a nightmarish psychedelic experience.
Marketing strategies of some commercial audiological treatments take advantage of this first distortion. A lot of people who goes to those clinics have ILP from using earplugs or being terrified of sounds for a long time. So when they naturally calibrate their brain to real sounds, their audiologists tell them it is because the white noise machine "retrained" their brains. And yes, it could have helped, or it could just have been an illusion, a placebo, as they say. Besides, an expensive dedicated apparatus could not have been the best option for playing the "therapeutic" sounds. And some of the tools used in those treatments could help to relax the TT system, just by chance. But the thing is: ILP is not pathological. And if those treatments ignore the real etiology of the problem, if they consider TTTS just "a common reason for blocked ears", as Hazell wrote on his site linking to Klochoff's famous paper, if they don't know how a setback is produced, or why patients are specially sensible to sudden noises, when there is nothing in their theories that explain it, the patient could be worsened by the treatment, or he/she could get relatively better but after years and after agonizing setbacks. Let alone the money they paid... Making this packed treatments not imperfect but necessary, but avoidable and dangerous.
Moreover, what if one of the creators of TRT, Jastreboff, the abstract poet of otology, having in front of him a patient who is locked in his house because he is suffering an evident TTTS, and probably feeling very bad and depressed, told the patient that he thinks he has "misophonia", because he didn´t improve with his treatment, when TRT always works in cases of "hyperacusis", instead of diagnosing him with TTTS, and acting accordingly? And what if another doctor, after listening to a patient who complains of an ear pain, "fullness in the ear" and the sensation that everything sounds louder, sends the patient to do the LDL test, and because their levels of tolerance are around 60db, he diagnoses him/her with "hyperacusis", instead of "TTTS"? What a disaster, uh?
The second and the third distortions are the ones intrinsic to TTTS. TTTS symptoms could be somehow different from one person to another. But, just by reading some anecdotes in this kind of forums, it seems that we all share some sensations, with some differences in their intensity (painful or not painful could be a quantitative difference, not a qualitative one; or a spasm compared to a subtle vibration). (
@Lex, you don't have TTTS, or do you? How can you describe your discomfort towards certain sounds?)
I can only speak from my symptoms, knowing that they could be more or less similar to the ones of others.
The second distortion is objective and real (or completely illusory). The TT could make noises when vibrates and/or touches adjacent tissues. This is not signal distortion (which is what we are talking about), it is added noise, although it could contribute to the general confusion, in the same way a subjective tinnitus could. But in some cases, there could be another subtle (or not so subtle) extra reverberation of the sound signal itself, as a consequence of muscle abnormal movements. This would be the second distortion. Even Klochoff wrote that some sensations "may involve distortion". But this extra reverberation could be also illusory, because when the person focuses all his attention on the sound and how it provokes the movement of the middle ear muscles, the extra reverberation could be easily created only by this excess of attention, which, by the way, could be responsible for the muscle movement in the first place. So, in fact, this second distortion could be inexistent, it could be the same as the third distortion I will describe later (someone with "extra reverberation" and good analytic skills would know it better). But those sounds (tissues sounds, extra reverb of external sounds or its illusion) are provoked without a doubt by TTTS, and not by a previous stage called "hyperacusis".
Finally, the third distortion is illusory and psychological. The illusion is originated from the action of mixing the sound signal with the physical sensation. Or, better said, from not separating intellectually both things, the sound and the sensation, with all its psychological scopes. It is like saying: this sound is painful, when the sound is not painful, only that you feel pain because the TT is tensed (and also there could be some irritation/inflammation there). And the TT is tensed because of TTTS and not because of a previous stage called "hyperacusis". There is no chicken and egg question here. And if there is, it should be formulated within the frontiers of TTTS, and not in the faraway, illusory and transcendental space of a supposed "hyperacusis". The concept of "hyperacusis" is not necessary to understand this audiological problem.
By the way, the third distortion, as it sometimes produces fear, could trigger ILP. Also, I think it is possible that when the TTs are extremely tensed and irritated, after some kind of acoustic trauma/shock, the internal volume is "automatically" raised, a situation that should be resolved promptly, unless the person began to develop a vicious circle of fear and TTTS. But most probably, that perception of increased loudness is only a consequence of having this new intimate sensation of crappy TTs, and to the fact that the brain still didn't have the chance to calibrate to "normal" dynamics (it's like listening to the details of loud sounds). And to this calibration to happen, a more relaxed TT system is needed.
Now, as I said, if you want to use "hyperacusis" as synonym of ILP, if you like the word, you can do it. ILP as a consequence, for example, of wrong management of TTTS and misinformation, or by becoming phonophobic after the pitiless attack of a loud tinnitus sound, causing or not TTTS as a consequence. "Hyperacusis" is not uniformly and clearly defined by medical texts. It is generally considered a pathological entity, which involves the inexact "decreased sound tolerance", or "increased sensibility", or "strong reaction to sound", and, according to Jastreboff, "is manifested by a patient experiencing physical discomfort as a result of exposure to sound (quiet, medium, or low)". But J, how can you even talk about "physical discomfort", if you ignored olympically TTTS in relationship to what you call "hyperacusis", or, as your comrade in abstractions Hazell, you considered it only "a common reason for blocked ears"?
So I asked the Nobel Prize songwriter, invasive "moderator", and TRT spokesman of the Imperial Chat about his "hyperacusis" discomfort. You can see the "conversation" here, thanks to Sen:
https://www.tinnitustalk.com/thread...ening-at-the-hyperacusis-network-forum.18843/
He answered me with a lie ("D.M. moderates the board"). I asked again. He told me to "see post 9", a post who didn't respond my question directly, but described two kinds of pain, according to him. So I told him that an ear pain wasn't enough for diagnosing with "hyperacusis" and asked what his doctor told him about his pain, whose origin should be determined. Instead of answering openly my very clear and precise questions, he skipped them and lied to me again: "I am just like you, a poster". I can only take his silences and skippings as a tacit recognition that I was right, that is: that he had TTTS, not "hyperacusis", and that "hyperacusis" doesn't exist. What is funny is that user Jirimenzel was attacking on another front, with some coincidences with my point of view, but with a more cryptic style, and Coronel Bob answered obsessively every intervention of Menzel, in a circular and repetitive competition. Anyway...
As I was saying, we don't need the concept of "hyperacusis".
- TTTS is self-sufficient.
- TTTS has its own pain.
- TTTS has its own "decreased sound tolerance". When the TT system is abnormally tensed/nervous, not functioning well, sudden sounds, but also loud sounds, or the fear experiencing or just anticipating loud sounds, could create more tension and in some cases pain and more drastic movements (spasms, vibrations). And all this is from uncomfortable to tormenting, and thus not tolerated. This DST is explained by TTTS itself, not by a previous and transcendental stage called "hyperacusis".
- So, TTTS could have its own LDLs, but because these LDLs could be not rigid, could fluctuate in time, and could be dependent on a lot of reasons, especially regarding emotions towards the experience of the test itself, LDL tests are not very useful. Not to mention LDL tests using a scale of pure tones, which are absurd. Why to even bother the patient to go to the test cabin when it could worsen the situation, let alone other louder tests usually administered. A description is enough. And it is not, some real sounds from speakers (not headphones) could complement.
- TTTS has its own "sensibilities". But the patient is not sensible to sounds, but sensible to the uncomfortable and intimate sensations provoked by TTTS. As Purztruq wrote: "There is no discomfort beyond the physical discomfort and the consequent sensations (tension, vibration, tt pain, non-tt pain, or whatever the person has)." When a healthy TT patient is "sensible" to a sound, could it be also because of a subtle TT tension which anticipates further discomfort...?
- TTTS has its own psychological dimension. When healthy, the TTs have to do with startle reaction and with other functions like pre-vocalization and probably subtle hearing functions (subtle extra attention for certain sounds). They have a contact with emotional centres and that is why, when not functioning well for a while (TTTS), certain bad habitudes of the mind could sustain it, like a stubbornness to tense the TT system. From this point of view, it could be seen as an incarnation of a psychological pathology/characteristic, mainly OCD, depression, and serious anxiety. Klochoff, the creator of "TTTS", and seemingly a very technical doctor, after seeing 250 TTTS cases, wrote a paper where his hands didn't tremble to call it "psychosomatic".
- There is no need to diagnose TTTS with a mixture of "phonophobia", as J&H do with "hyperacusis", because TTTS include psychology and an obvious fear or stress about sound when the person is very affected. Concerning "misophonia", I don't know much about it. Everybody has aversion to some sounds which provoke "rage in the brain". Probably it is pathologic when the person gets insanely obsessed by a sound heard frequently? If there is a man who hates his wife's sounds while eating, or another one who lives next to a blacksmith where they scrape rusty metal every day, and that provokes TTTS in the long term, well, that is possible, though very rare. But once TTTS begins, it would affect the whole auditory experience of the patient, not only the repetition of the sound that provoked it in the first place.
- TTTS explains setbacks. As Longinus suggested in a post deleted by the Nobel Prize moderator of the TRT propaganda forum: "the logic of setbacks is the logic behind progress/worsening of TTTS" and "the particularities of progress and setbacks are the particularities of how the delicate TT muscle and system work when they are not functioning well, and not the particularities of a "brain plasticity" which after a relatively loud sound would mysteriously disorganize the neurons laboriously reprogrammed by an expensive white noise machine hooked to the ear and thus provoking a setback.". I'll try to write the text in this forum, in a more developed form. Also, user Dave2 wrote it better than me: "It seems to me that if it could be determined what is going on with a setback, that would provide useful information about what is wrong." I haven't read any definition of "hyperacusis" which explains implicitly or explicitly how setbacks are produced.
- TTTS explains why sudden sounds are the most bothersome. Just because when the TT system is abnormally tensed/nervous, not calibrated, the TTs react to sudden sounds like crazy, producing discomfort and, sometimes, pain. The problem is the tension or vibration itself, and the fact that that zone is in a physiological state of alert or self-reproducing nervousness. When a new acoustic reflex is added to this situation, the TT system contracts further (extra tension, thump). The bigger the initial tension and nervousness, the lower the threshold of the reflex. This "LDL" is quite plastic, and although it could be dependent on loudness, it is more dependent on suddenness and the kind of sound as a whole, in a way that couldn't be determined in a test by individual pure tones frequencies (I hope this sentence doesn't give a brilliant audiologist the idea to torture a patient with a test with a lot of sudden noises of different kinds). Again, there is no definition of "hyperacusis" as a separate and previous stage which explains the problem with sudden sounds.
- Another thing is ILP, which concerns the internal volume and is non-pathological, "natural", and fully reversible. When ILP is originated from wrong management of TTTS, it is integrated to the vicious circle of TTTS, complicating things further.
The history of the concept of "hyperacusis" is a history of vagueness where confusion in how to define it is arisen, precisely, from analytic confusion. In other words, from theorists trying to conceptualize something which they don't know what it is, immersed in a swamp of false assumptions and misunderstandings. The object of the study being uncertain, they don't even think for a moment if that object really exists. "Hyperacusis" has a transcendental, religious-like quality. It is to TTTS what "God" is to human beings, only in the sense that implies a previous and superior stage of existence. But definitely the biggest mistake is to underestimate TTTS and to not understand it fully. Very rarely TTTS is diagnosed when it is all about it.
P.S. I don't have the time or knowledge to talk about ILP or DST or phonophobia caused by non-otologic problems. There are also some people who relate having pain associated to the act of hearing and without TTTS. The real causes are unknown (Nerve pain? Fibromyalgia? Cochlear pain? An unknown virus? And does the pain originate from a physical problem, or is it about phonophobia which somatises? And what if it is the same mechanism of TTTS, related to the startle reaction, only that it is not manifested with muscle contractions, but with nerve overstimulation?). But the reason why I asked my first question is because all of you (except probably Lex) described the symptoms of TTTS. And in these kind of forums almost all the anecdotes I read are about what is called "TTTS".
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