When Everyday Sounds Become Uncomfortable: Hyperacusis and Mental Health in Normal-Hearing Palestinian Middle-Aged and Older Adults

Description

Some individuals find everyday sounds particularly uncomfortably loud, painful, or annoying, even when a standard hearing test shows normal hearing levels. This condition of sound intolerance, known as hyperacusis, can profoundly disrupt daily life, making everyday sounds distressing or even painful, limiting participation in conversations, family gatherings, work, and social activities, and contributing to emotional distress, social isolation, and reduced quality of life. Previous research by Shehabi et al. (2025) found that 18.8% of Palestinian university students aged 18 – 25 were classified as exhibiting at least moderate hyperacusis, and about 7% had severe hyperacusis. In a follow-up study, self-reported anxiety, stress, and depression were strongly associated with greater hyperacusis handicap in the same population (Shehabi et al., 2026). The currently proposed study builds on this work by investigating whether similar relationships occur in middle-aged and older Palestinian adults with normal hearing, and whether hyperacusis symptoms, sound tolerance, and their relationships with mental health vary with age. This question is particularly relevant in Palestine, where prolonged conflict, exposure to violence, and restrictions on access to healthcare place substantial pressures on psychological well-being. The World Health Organization has documented the mental health consequences of violence and barriers to healthcare in the occupied Palestinian territory. (WHO, 2024) This context provides an important reason to investigate sound intolerance alongside mental health, without assuming that conflict causes hyperacusis. Middle-aged and older adults require specific attention because their health needs and circumstances differ from those of university students. Factors such as chronic illness, bereavement, reduced mobility, and social isolation can affect mental health alongside the accumulated effects of earlier experiences (WHO, 2026). Sound intolerance could create an additional barrier to family and community participation. Studying Palestinian adults aged 40 – 75 years will therefore extend previous research beyond young adulthood and allow age-related differences to be examined across middle and older age. Clinically, the findings could help audiologists recognise sound intolerance in people with normal hearing levels and identify those who may benefit from mental health support. They could also help psychologists and other mental health professionals recognise sound-related difficulties that warrant referral for audiological assessment, thus promoting coordinated care across both healthcare fields. This cross-sectional study will aim to recruit approximately 250 Palestinian adults aged 40 – 75 years with normal hearing levels, seeking approximately equal numbers of men and women and a balanced spread of participants across the age range. Recruitment will be monitored within three age bands of 40 – 49, 50 – 59, and 60 – 75 years to ensure adequate representation of both middle-aged and older adults. Recruitment is planned through community organisations, workplaces, services supporting older adults, and local announcements, with assessments conducted at Birzeit University’s audiology laboratories. Participants will undergo audiometric hearing screening, complete the Arabic Khalfa Hyperacusis Questionnaire and standardised Arabic-language measures of anxiety, stress, and depressive symptoms (i.e., DASS-21 questionnaire), and undertake uncomfortable loudness level (ULL) testing. ULLs identify the sound levels at which participants report that sounds become uncomfortably loud. The protocol will specify the hearing-threshold eligibility criteria, questionnaire scoring rules, and ULL procedures before recruitment begins. Normal hearing thresholds will define the study population but will not be treated as evidence that all aspects of auditory function are normal. The study will estimate the proportion of eligible participants meeting a predefined questionnaire criterion for hyperacusis (i.e., Khalfa hyperacusis questionnaire score of => 21 points), examine the relationship between its reported impact on daily life and ULLs, and investigate how both measures relate to anxiety, stress, and depressive symptoms. A specific aim will be to examine whether hyperacusis questionnaire scores and ULLs vary with age across the 40 – 75-year range. Age will be analysed primarily as a continuous variable, with age-band summaries used to aid interpretation. Exploratory analyses will assess whether the associations of hyperacusis questionnaire scores and ULLs with anxiety and depressive symptoms differ by age. Ethical approval will be sought from the Research Ethics Committee at the Faculty of Pharmacy, Nursing, and Health Professions before recruitment. Procedures will include informed consent, confidential data handling, standardised assessment instructions, and clear stopping rules during sound-tolerance testing. Participants will be informed that they may pause or discontinue testing at any time without penalty. Dr Adnan Shehabi at Birzeit University and Dr Samuel Couth at the University of Manchester will jointly supervise the project. The proposed division of responsibilities includes local recruitment and clinical supervision at Birzeit, with joint input into study design, analysis, and interpretation. Regular online meetings with both supervisors will allow four undergraduate audiology students to discuss progress, resolve methodological questions, and receive feedback on their work. The project is planned over eight months starting in mid-November 2026. Month 1 will focus on protocol preparation, the ethics application, and student training; Months 2 – 6 on recruitment and data collection following ethical approval; Month 7 on final data checks and analysis; and Month 8 on the research report, presentation, and manuscript preparation. Data checking will run alongside collection. Recruitment progress, including representation across the age range, will be reviewed early against the target, and delays in ethical approval or recruitment will be discussed with the programme. Subject to academic approval and student commitment, the work will continue as the students’ shared audiology graduation project next semester. ------------------------------------------------------------------------------------------------------------------------------------------------ References: Shehabi, A. M., Prendergast, G., Sufran, J. G., Awwad, L. L., Abu Rmeleh, A. B., Abu Khalil, S. A., & Couth, S. (2025). Prevalence, severity, and mental health correlates of hyperacusis in Palestinian youth. International Journal of Audiology, 65(2), 207–219. https://doi.org/10.1080/14992027.2025.2521744 Shehabi, A. M., Prendergast, G., Couth, S. (2026). Hyperacusis beyond hearing loss: Psychological distress, sound tolerance, and handicap in young Palestinian adults under chronic conflict. In Press. Trends in Hearing. World Health Organization. (2024, January 22). Health conditions in the occupied Palestinian territory, including East Jerusalem: Report by the Director-General (EB154/51). https://apps.who.int/gb/ebwha/pdf_files/eb154/b154_51-en.pdf World Health Organization. (2026, July 20). Mental health of older adults. https://www.who.int/en/news-room/fact-sheets/detail/mental-health-of-older-adults