Sound Tolerance Evaluation and 

Management (STEM)

As described in the previous chapter, the Tinnitus and 

Hearing Survey (Appendix D) includes two items 

in Section C that screen for reduced sound tolerance. 

The first item determines if a patient perceives that 

he or she has a loudness tolerance problem, and, if 

so, how much of a problem. If a problem is reported, 

then the second item is used to determine if the 

patient would experience difficulty attending the 

Level 3 workshops due to the sound/loudness tolerance problem. If the patient reports a sound tolerance 

problem, but can attend the workshops to address 

a tinnitus problem, then the patient normally should 

attend the group sessions. Some patients, however, 

may express a strong desire to focus on their sound 

tolerance problem rather than the tinnitus, and those 

wishes should be honored even if the patient is 

capable of participating in the Level 3 workshops.

During the Level 3 workshops, patients learn 

how to use therapeutic sound in various ways for 

managing reactions to tinnitus. All of the suggestions for using sound to manage tinnitus also are 

relevant for managing a sound tolerance problem. 

That is, if the patient follows the suggestions for 

using therapeutic sound, then not only can the 

sound help with the tinnitus, but it also can help to 

increase tolerance to sound (Formby, Sherlock, & 

Gold, 2002). If the patient indicates on the second 

item of Section C that he or she would not be comfortable attending Level 3 Group Education, then 

that should alert the clinician to discuss sound tolerance with the patient and consider scheduling a 

special appointment to evaluate the sound tolerance 

problem. As mentioned above, some patients may 

just wish to focus on their sound tolerance problem.

What Is STEM?

The sound tolerance evaluation and management 

(STEM) protocol is an adjunct program primarily 

for patients who have a sound tolerance problem 

that precludes them from participating in the PTM 

protocol. These patients are identified at the Level 2 

Audiologic Evaluation as requiring the special STEM 

program (see Chapter 5). Their progress through 

PTM is suspended temporarily until they complete 

the STEM program. Sound-based intervention that 

6
52	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

patients receive through the STEM program also 

may resolve their tinnitus problem, in which case 

they may not need to resume the PTM program 

(see PTM Flowchart—Appendix A). As a general 

rule, however, any patients with problems specific to 

tinnitus should be advised to participate in Level 3 

Group Education.

The STEM evaluation appointment can include 

three components: administering the Sound Tolerance Interview (STI), testing loudness discomfort 

levels (LDLs), and trial use of ear-level instruments. 

Only the STI is essential for the evaluation, that is, 

it is essential to conduct an in-depth interview to 

fully understand the nature and severity of the 

problem, and to develop an appropriate management plan. The STI also provides data that can be 

used as a baseline to evaluate progress over time.

All patients who participate in STEM should 

receive counseling for reduced sound tolerance. 

A counseling protocol is provided in the patient 

counseling book (Progressive Tinnitus Management: 

Counseling Guide) (J. A. Henry et al., 2010b).

Sound Tolerance Interview

The six-question Sound Tolerance Interview (STI) 

(Appendix K) fits within the framework of PTM 

and serves to guide the STEM evaluation procedures. The interview starts with a series of questions 

(embedded in Question 1) to determine if the use 

of hearing aids contributes to the patient’s reported 

sound tolerance problem. Questions 2 through 5 

are used to obtain details concerning the kinds of 

sounds and activities that are problematic, and the 

degree of the problem in each case. Question 6 is 

intended to determine if the patient overprotects 

his or her ears through the use of hearing protection. (Overuse of hearing protection can sustain or 

exacerbate a sound tolerance problem.)

Treatment for Reduced 

Sound Tolerance

As explained in the patient handout “What to Do 

When Everyday Sounds Are Too Loud” (Appendix E), the essence of treatment for a sound tolerance problem is the systematic use of sound to 

decrease sensitivity to sound. Although there are 

different manifestations of a sound tolerance problem (as described in Chapter 1), a generic approach 

to treatment usually is adequate. The treatment 

involves increasing ambient levels of sound (with 

the possible use of ear-level instruments) as well 

as increasing activities involving active listening to 

sounds that the patient finds enjoyable. This combined approach thus includes: (a) passive listening 

procedures, which address general hypersensitivity to sound, and (b) active listening procedures, 

which address the emotional components of a 

sound tolerance problem. Procedures for addressing these different components individually are 

available using the method of tinnitus retraining 

therapy (TRT) (J. A. Henry, Trune, Robb, & P. J. Jastreboff, 2007a, 2007b; P. J. Jastreboff & Hazell, 2004). 

These TRT procedures can be used if the clinician 

has familiarity with the procedures.

Counseling for reduced sound tolerance is 

provided in a structured format using the patient 

counseling book (Progressive Tinnitus Management: Counseling Guide) (J. A. Henry et al., 2010b), 

which contains a special section for this purpose. 

The counseling book functions like a flip chart to 

facilitate the one-on-one counseling. The content 

of the counseling corresponds closely with the 

patient handout “What to Do When Everyday 

Sounds Are Too Loud” (Appendix E). The handout normally is provided to patients at the Level 2 

Audiologic Evaluation if they report any degree of 

a sound tolerance problem. The counseling leads to 

an explanation of the Sound Tolerance Worksheet 

(Appendix L). Patients learn how to complete this 

special worksheet to develop customized plans for 

self-managing their sound tolerance problem using 

therapeutic sound.

Testing Loudness Discomfort 

Levels (optional procedure)

Testing loudness discomfort levels (LDLs) is less important than information obtained from the Sound Tolerance 

Interview. At the audiologist’s discretion, LDLs can 

be tested for patients who go through the STEM 
Sound Tolerance Evaluation and Management (STEM)	 53

program, but LDL testing is not normally recommended. Although this is a debatable point, we 

consider LDL testing to be nonessential even when 

a patient has a severe problem with reduced sound 

tolerance because: (a) testing LDLs can cause discomfort and anxiety in patients; (b) the validity of 

LDLs as a measure of loudness tolerance in daily 

life has not been established; and (c) the results of 

LDL testing do not normally guide intervention 

procedures.

If a patient has reduced tolerance to sound, 

it is our position that the best indicator for establishing the degree of a sound tolerance problem, 

and to monitor progress during treatment, is the 

patient’s subjective report—which is facilitated 

through administration of a structured interview 

with the STI (see Appendix K). Results of the interview define the problem and indicate the course 

of action that should be taken, regardless of the 

results of LDL testing. Some audiologists choose to 

do LDL testing, which is acceptable as long as the 

patient is comfortable with the procedures. LDL 

procedures are described further below.

Definition of LDL

The threshold level of discomfort for a sound 

defines that sound’s LDL. The LDL should reflect 

the level just below physical discomfort and not 

just fear that the sound is going to become too 

loud (a common manifestation of phonophobia). 

Clinical LDL testing can be done using pure tones, 

speech stimuli, and narrow and broadband noise. 

Using pure tones, LDLs can be obtained at various 

audiometric frequencies, establishing the upper 

limit of the auditory dynamic range for each frequency tested. Sounds would be tolerated comfortably anywhere within the dynamic range.

Measuring Tonal LDLs

(Please refer to Loudness Discomfort Levels—Clinical Guide—Appendix M.) If tonal LDLs are tested, 

then they should be obtained minimally at octave 

frequencies between 1 and 8 kHz. LDL testing may 

be performed at additional frequencies and with 

other types of auditory stimuli. Patients often are 

inconsistent when providing repeated LDLs within 

a test session. Some providers therefore measure 

each LDL twice. This is done by first obtaining the 

LDLs in each ear, then repeating the entire set of 

measurements.

Instructions to Patients

Loudness discomfort levels can vary considerably 

depending on the test instructions given to the 

patient, and on the patient’s interpretation of the 

instructions. It is essential to read standardized 

scripted instructions verbatim and to ask patients to 

repeat back the task as they understand it. Patients 

are instructed, “You will listen to different tones. Each 

tone will be made slightly louder in steps. Tell me when 

the loudness of the tone would be ok for 3 seconds, but 

would not be OK for more than 3 seconds.” The objective is to identify the level for each frequency at 

which any further increase would cause discomfort.

Audiometric Procedures

Testing in each ear should start at 1000 Hz, with 

successive frequencies ordered from lowest to 

highest. The first tone is presented at the approximate most comfortable level (usually 60 dB HL is 

appropriate to start). Each tone is presented for 1 to 

2 seconds, and successive tones are raised in 5 dB 

steps until the LDL is reported. At each new frequency, the starting level should be about 20 dB 

below the previous frequency’s LDL.

As LDL testing is probably the patient’s least 

favorite procedure, it is important to perform the 

testing as rapidly as possible (without compromising the measures). If two sets of measures are 

obtained, only the second set should be reported. 

Reliability of responding also should be noted.

In-Clinic Trial Use of 

Ear-Level Instruments 

(optional procedure)

After the sound tolerance evaluation, which includes 

administering the STI (Appendix K) and possibly LDL testing (Appendix M), it then is decided 

if the patient should be evaluated for ear-level 
54	 Progressive Tinnitus Management: Clinical Handbook for Audiologists

instruments. This decision depends largely on the 

extent of the problem, which should be clear after 

the evaluation.

Although ear-level instruments might provide the optimal treatment for a sound tolerance 

problem, they may not be necessary. Often, sound 

enrichment using a variety of sound sources can 

provide an adequate acoustic-desensitization protocol. The clinician should weigh the pros and cons 

of ear-level instruments for each patient and decide, 

along with the patient, if these devices might be the 

best choice for treatment. If so, then in-clinic trial 

use of ear-level instruments should be performed. 

The in-clinic trial can be conducted either before or 

after the counseling, whichever is most appropriate for the patient.

When Are Ear-Level Instruments 

Indicated?

The decision to use ear-level instruments with a 

patient who has hyperacusis is based primarily on 

two factors: (a) the patient’s sound tolerance condition must be reasonably severe to justify the use of 

these instruments; and (b) the patient must be motivated to use the instruments. If either of these factors 

does not apply, then the patient should be counseled 

appropriately to use sound desensitization procedures without the use of ear-level instruments.

Conducting the In-Clinic Trial

The purpose of the in-clinic trial is to provide 

patients with the experience of wearing and listening to sound-generating devices—to help them 

decide if using ear-level instruments is desirable. 

The sound should be described as a “soothing 

shower sound” and not in negative terms such as 

noise or static. It is possible that some patients will 

not be comfortable listening to the sound, but that 

even just wearing the instruments might be appropriate for the first phase of treatment (i.e., some 

patients need to just wear the instruments turned 

off for a period of time before they can start listening to the sound emitted from the instruments). 

Conducting the trial simply is a matter of fitting 

each stock device to patients and allowing them 

to direct the process of adjusting the sound levels. 

This process might take more or less time depending on individual patient characteristics.

Definitions: Hyperacusis, 

Misophonia, Phonophobia, 

Loudness Recruitment

Definitions for these terms were provided in Chapter 1. They are reviewed briefly here. Hyperacusis is 

a physical condition of discomfort or pain caused by 

sound (J. A. Henry, Zaugg, et al., 2005a). The effect 

is restricted primarily to the auditory pathways.

Misophonia means literally “dislike of sound,” 

implying that emotions somehow are involved 

in the reaction to sound (M. M. Jastreboff & P. J. 

Jastreboff, 2002). Misophonic reactions would be 

learned responses, thus the same sound might be 

bothersome in some situations and not in others. 

Phonophobia is a subcategory of misophonia, and 

specifically is a fear response caused by sound (P. J. 

Jastreboff & M. M. Jastreboff, 2000).

Any or all of these conditions might apply to a 

patient who complains of loudness tolerance problems. None of these conditions should be confused 

with loudness recruitment, which is abnormally 

rapid growth in the perception of loudness (Vernon, 1976). Recruitment usually is a symptom of 

cochlear or sensorineural hearing loss.

For purposes of PTM, any condition of reduced 

sound tolerance (hyperacusis, misophonia, phonophobia) is referred to as hyperacusis. The STEM 

program does not make a distinction between these 

different conditions with respect to the counseling 

and sound desensitization procedures. The treatment 

procedures are designed to address both physical 

and emotional aspects of reduced sound tolerance.

Conclusion

We have conducted screenings and evaluations 

of thousands of patients with tinnitus in multiple 

clinics as part of our clinical studies. It has been 
Sound Tolerance Evaluation and Management (STEM)	 55

our experience that many of these patients report 

a sound tolerance problem, but that a very small 

number actually experience a severe problem 

warranting special evaluation and treatment procedures. If patients do have a severe hyperacusis 

problem (or if they just want treatment for reduced 

sound tolerance), then the STEM protocol should 

address their needs. The STEM protocol is implemented before the flow of PTM services continues, 

that is, these patients should be treated separately 

and then worked back into PTM as warranted by 

tinnitus-specific complaints.

With the STEM protocol, all patients with a 

severe sound tolerance problem are assumed to 

have some combination of hyperacusis and misophonia. Very few patients have “pure” hyperacusis 

or “pure” misophonia (see Chapter 1), thus a combined approach usually is appropriate. For these 

patients, special consideration should be given 

to collaborating with mental health clinicians to 

address potential psychological components of 

the problem. Behavioral interventions have been 

shown to be highly effective in decreasing patients’ 

responses to intense fear. Such interventions have 

been well described in the CBT literature (Hofmann 

& Smits, 2008). Thus, psychological interventions 

such as CBT may be used to help patients systematically modify their fear responses, habituate to 

everyday sounds, and achieve a greater sense of 

well-being and control.