What is Nonorganic Functional Hearing Loss?
Normal hearing is a complex process involving many closely related parts of the ear and even beyond it. However, when someone has hearing loss, it means something is wrong causing their hearing to decrease below a certain level, which we measure using a scale called decibels hearing level (dB HL). This scale is based on average hearing levels, not the actual amount of sound produced. Hearing loss can happen if any part of the hearing system (like the ear drum, the tiny bones in your middle ear, the cochlea, nerves, and other parts of the nervous system) is damaged or not working properly. One specific type of hearing loss that often goes unnoticed is nonorganic functional hearing loss.
Nonorganic functional hearing loss happens when a person’s hearing test shows they have hearing loss, but there’s no detectable organic problem in the hearing system causing it. This could also be when a person’s hearing loss seems worse than what their actual ear condition should cause. This condition is also known by many other names including “non-organic hearing loss (NOHL),” “functional hearing loss,” “pseudohypacusis,” (fake hearing loss), “hysterical hearing loss,” “conversion hearing loss,” “malingering,” (pretending to have a condition), “feigning,” “psychogenic deafness,” (psychological caused deafness) “simulated hearing loss,” and “dissociative deafness.” Often, this type of hearing loss is not diagnosed, leading to unnecessary and sometimes harmful treatments. Regular doctors, ear doctors, hearing specialists, and psychiatrists all come across this condition in their practices.
What Causes Nonorganic Functional Hearing Loss?
Nonorganic functional hearing loss is a type of hearing loss that is not related to any physical problem with the ear, but is instead caused by psychological or personal reasons. It can vary from pretending to have a hearing loss for some reason (malingering) to genuinely believing you have hearing loss, even though medically you do not (conversion disorder). An approach to understanding why this happens is called the Austen-Lynch model, which describes this hearing loss based on how much the person meant to demonstrate hearing loss.
The three categories in this model are conversion disorder (low intention), factitious disorder (moderate intention), and malingering (high intention). This means that the less the person intends to show hearing loss, the more the rewards of the hearing loss come from their own internal thoughts and feelings, rather than external factors.
Different things can cause this hearing loss in children and adults. Also, the causes can vary within each age group. For adults, it often happens because of malingering, usually in hopes of getting money or other compensation. Conversion disorder, which usually follows a traumatic event, is less common.
For children, emotionally or physically distressing events can cause this type of hearing loss, often showing up as conversion disorder. Malingering can also happen in children who are not doing well in school.
The Austen-Lynch model also suggests that the reasons for this hearing loss may change over time. For instance, someone might begin with a conversion disorder, but as people around them show more sympathy, they might become aware of the outside benefits. This awareness could motivate them to keep showing symptoms. Depending on whether they’re now doing it for internal or external reasons, they might start pretending to have symptoms, which would be malingering or factitious disorder.
Risk Factors and Frequency for Nonorganic Functional Hearing Loss
Nonorganic functional hearing loss, a type of hearing issue not caused by physical damage or disease, is often underestimated and misdiagnosed. The frequency of this condition varies between different medical centers. It appears that this type of hearing loss is more common in children compared to adults, and it’s the leading cause of sudden hearing loss in children. It primarily affects children between the ages of 10 and 12.
In 1965, a study suggested that the transition from primary to secondary school, with its increased stress and challenges, might cause this hearing issue more frequently, especially among children with below-average intelligence.
A report from 2010 revealed that adults between the ages of 19 and 57 also have a high rate of nonorganic functional hearing loss, although no cases were found in individuals over the age of 57. Other characteristics of this hearing problem are that it typically affects both ears and is more common in females.
- Nonorganic functional hearing loss varies widely between different medical centers.
- It is often underestimated due to lack of awareness and misdiagnosis.
- Children are more affected than adults, especially between the ages of 10 to 12.
- Transition to secondary school may increase the incidence in children, particularly those with below-average intelligence.
- Adults between 19 to 57 years of age also have a high incidence of this problem.
- It occurs more frequently in both ears.
- Women are more affected than men.
Signs and Symptoms of Nonorganic Functional Hearing Loss
Diagnosing nonorganic functional hearing loss requires careful and detailed collection of the patient’s medical history and physical exams. This type of hearing loss, often associated with behavioral or psychological factors, can reveal several indications during evaluation. If a patient is heavily relying on lip reading but still responds when the examiner looks away, or if they’re speaking softly rather than loudly (which is common in people with hearing loss), it might hint towards nonorganic functional hearing loss. However, these signs aren’t as useful in cases of one-sided hearing loss.
The examiner should also take note of who referred the patient; sometimes, companies managing insurance claims will refer people who bluff or exaggerate their symptoms. A full account of the person’s hearing loss history should be considered, including when it started, how quickly it got worse, whether it changes over time, and which ear is affected. They should also ask about any additional symptoms like dizziness, aural fullness, pain, and tinnitus. History of exposure to loud noises, pressure-related injury, head trauma, harmful drug exposure, and previous ear surgery should also be considered.
The patient’s emotional and mental health history is equally vital. Issues like family problems, work stress, recent traumatic events, feeling neglected (especially in children), or receiving a diagnosis of a severe illness can be contributing factors. Details about pre-existing psychiatric conditions and any prior hearing loss or ear disease are also important. Other symptoms not directly linked to hearing, like unexplained weight loss and insomnia, could indicate underlying psychological stress causing the hearing loss.
Several scenarios could influence nonorganic functional hearing loss in children. It could happen if a child is anxious about a new school environment, feels pressure to perform well academically, or is struggling with learning difficulties. Some children with this type of hearing loss know other people with hearing troubles or might have experienced it themselves due to physical causes.
In adults, questions about financial troubles should be asked delicately as many people feigning symptoms will try to hide their financial issues.
- Anxiety in new school environments (in children)
- Academic pressure (in children)
- Learning difficulties (in children)
- Signs of child abuse (in children)
- Exposure to others with hearing loss or previous hearing loss due to physical causes (in children)
- Financial difficulties (in adults)
Additionally, thorough checks of the ear, including the outer ear, ear canal, and eardrum, should be part of the examination. Typically, the eardrums of patients reporting nonorganic functional hearing loss appear normal. However, in some cases, there might be dull eardrums, eardrum retractions, wax build-up, or healed eardrum perforations. Although these conditions point towards some pathology, the reported hearing loss might be much higher than expected. The cranial nerves should also be assessed, although they’re usually normal.
Testing for Nonorganic Functional Hearing Loss
In diagnosing a condition called nonorganic functional hearing loss, regular and consistent hearing tests are very important. This condition is typically confirmed by comparing results from two kinds of hearing assessments: objective and subjective.
An objective hearing assessment involves tests that measure physical or biological responses, like the vibrations of tiny hair cells in your ear when they’re exposed to sound. For people with nonorganic functional hearing loss, these tests usually show that their actual hearing ability is better than what they perceive to be true based on their subjective experience.
Subjective hearing tests are based on the individual’s personal perception of their hearing abilities. Examples include the Rinne and Weber tests, pure tone audiometry (PTA), and speech audiometry.
In the Rinne and Weber tests, a tuning fork is used to determine if a patient has hearing loss and, if so, whether the loss is conductive (caused by problems with the ear canal, eardrum, or middle ear and its bones) or sensorineural (caused by problems in the inner ear). Sometimes, the results of these tests do not follow the pattern predicted by the PTA test, which measures a person’s ability to hear sounds at various volumes and pitches.
In cases of nonorganic functional hearing loss, the PTA test often suggests a greater variability in hearing thresholds than what is typically expected. This condition is usually marked by flat or “saucer-shaped” PTA curves that indicate sensorineural hearing loss. A lack of response by the patient during PTA testing can also hint towards nonorganic functional hearing loss.
Speech audiometry usually shows better hearing thresholds – the quietest sound a person can hear 50% of the time – than those predicted by PTA tests.
For objective hearing tests, doctors often use Auditory Brainstem Responses (ABR), which measure how well the hearing nerve and brainstem (which connects the spinal cord to the brain) are working to process sounds. Along with ABR tests, Otoacoustic Emissions (OAE) are also helpful in confirming a diagnosis. This particular test determines if the tiny hair cells in your inner ear are working properly. Lastly, Auditory Steady-State Responses (ASSR) and Stapedial reflex tests, although not frequently used, can also help confirm the diagnosis.
It is important to note that diagnosing nonorganic functional hearing loss can be challenging, especially in children. This is because they may not fully understand the testing procedures or may not cooperate fully during tests. Therefore, repeated testing and developing different testing strategies can provide more accurate results.
Treatment Options for Nonorganic Functional Hearing Loss
Nonorganic functional hearing loss is a condition where a person experiences a decrease in their hearing abilities, but medical tests can’t find any physical causes. This is often linked to emotional or psychological issues. Treating this condition can vary from simply monitoring the patient to providing counseling and mental health treatments.
Some patients may recover on their own without any specific treatment. However, this approach can be risky if the patient has an undiagnosed mental health issue, which could cause their symptoms to return or get worse. An important part of treatment is counseling, which should involve calmly explaining the test results to the patient. Explaining, reassuring, and encouraging are methods that often help.
It’s important to acknowledge the patient’s hearing problem as a real issue – they shouldn’t be blamed for it. Avoid any confrontations and reassure the patient that it’s highly likely they’ll get better.
Determining if a patient needs mental health intervention can be tricky. These decisions have to be made on a case-by-case basis. If there’s a chance that the hearing loss is tied to psychological issues, it’s usually best to address these potential mental health concerns.
According to experts Austen and Lynch, it’s important to identify and address the underlying need or conflict that’s causing the hearing loss. That way, you prevent the hearing loss from coming back or turning into another psychological issue. It’s also recommended to avoid giving placebo medications as it might unintentionally reinforce the behavior leading to the hearing loss.
What else can Nonorganic Functional Hearing Loss be?
When we’re trying to figure out if someone’s hearing loss isn’t related to physical damage or disease, we need to first rule out other conditions that could affect hearing. One of the tools we use for this is a hearing test. If this test shows a pattern that often goes along with sensorineural hearing loss (which is due to problems in the inner ear), we have to explore the causes of this kind of hearing loss:
- Loud noise exposure
- Injury to the ear
- Infections
- Ménière disease (a disorder of the inner ear)
- Autoimmune diseases
- Abnormal communication between the middle and inner ear (perilymph fistula)
- Otosclerosis (a bone growth problem in the ear)
- Genetic hearing loss
- Earm tumors
- Exposure to certain medications or chemicals that can damage the ear
- Problems with the body’s metabolism
We also have to rule out causes of sudden sensorineural hearing loss, which can include things like ototoxicity (damage to the ear by certain medications), blockage of the blood supply to the inner ear, autoimmune diseases, viral infections, and even tumors along the nerve that carries the sound signals from the ear to the brain (acoustic neuroma).
We also consider conditions like auditory processing disorders, auditory neuropathy, and cortical auditory disorders when exploring the possible causes of the hearing loss.
If none of these conditions are identified and the hearing test results are inconsistent or there are no signs of damage in the hearing pathway, it’s likely that the hearing loss is nonorganic functional hearing loss. This is particularly true if the person recently experienced psychological stress. Doctors can often identify this kind of hearing loss by noticing certain behaviors during the examination that may tip them off.
What to expect with Nonorganic Functional Hearing Loss
Nonorganic functional hearing loss tends to have a good outcome if it’s diagnosed and treated properly. Many studies have observed that people can recover on their own from this kind of hearing loss.
However, it’s worth noting that in the case of patients who recovered naturally, there’s a chance of around 25% that their hearing loss could return within a year.
Things that can help improve the outcome include early recognition of the condition, proper treatment, understanding of the stress causing the condition, and not having any other medical or mental health problems present.
Possible Complications When Diagnosed with Nonorganic Functional Hearing Loss
Problems often occur with nonorganic hearing loss – a kind of hearing problem that isn’t caused by physical damage – because it can be hard to diagnose or can be diagnosed incorrectly. As a result, unnecessary medical procedures may be carried out, including surgeries or tests.
In some cases, patients who actually have nonorganic hearing loss may even be enrolled in programs designed for those with physical hearing loss, specifically cochlear implant programs. When this happens, the true cause of the hearing problem remains undiscovered, causing the patient to continue experiencing symptoms.
Nonorganic hearing loss can appear quite similar to sudden sensorineural hearing loss, a condition typically treated with systemic or intratympanic corticosteroids. However, before these medications are given out, it’s very important to make sure that the patient doesn’t actually have nonorganic hearing loss.
Steroids, however, are not appropriate treatments for nonorganic hearing loss and can cause harmful side effects, especially in children. In some cases, if nonorganic hearing loss is diagnosed but the underlying cause isn’t addressed, the patient may later experience other health issues that aren’t caused by physical damage, such as visual disturbances.
Key Takeaways:
- Nonorganic hearing loss can be difficult to diagnose or it may be misdiagnosed, leading to unnecessary treatments and surgeries.
- Some patients with nonorganic hearing loss may even be placed in programs for cochlear implants, which doesn’t address their actual hearing problem.
- Nonorganic hearing loss can be confused with sudden sensorineural hearing loss, which is usually treated with steroids.
- Before prescribing steroids, doctors must rule out nonorganic hearing loss because steroids can have harmful side effects.
- If nonorganic hearing loss isn’t properly treated, patients may experience other health problems not caused by physical damage, such as vision issues.
Preventing Nonorganic Functional Hearing Loss
Nonorganic functional hearing loss, a form of hearing loss not caused by physical damage to the ear, has a big influence on people’s everyday lives. It’s often linked with mental health issues, so it’s really important that patients understand what’s happening to them. Patients should be gently informed if there are inconsistencies in their hearing test results and reassured that their condition can improve. If there’s a need to consult with a mental health specialist, patients must be made to understand the importance of such visits.
It’s equally essential to explain to the patients that regularly visiting their doctor for check-ups can greatly help with their condition. Also, it is important to share with parents and teachers of children suffering from nonorganic functional hearing loss that the child’s hearing difficulty is a real experience for them, and the child should not be blamed for their condition.
