The remarks made here are regarding the: Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 934 Hyperacusis Clinical Studies and Effect of Cognitive Behaviour Therapy Linda Jüris ISSN 1651-6206 ISBN 978-91-554-8756-0 urn:2013 nbn:se:uu:diva-207577 Basic facts about hyperacusis are the following: Hyperacusis is in audiological testing, when a person presents reduced loudness discomfort levels (LDL), reduced loudness annoyance levels or pain thresholds (Goldsten & Shulman). There are also other, measurable levels existing (Goldsten & Shulman). All three levels can be tested and at least two should accompany each other. The most accurate in measurement is the pain threshold or loudness pain level. The difference between pain threshold and LDL is mostly 5-15 dB HL (around 10 dB HL in average). Pain threshold testing is a better and more accurate way to measure hyperacusis. It is of utter importance that the sound has exactly the same length for all frequencies tested at any moment during the test. It is also important to test the frequencies in the same sequence before and after any intervention used. Basics about scientific references. A reference should only be used when it is referred to in the thesis or scientific study. If a reference contradicts the findings which the thesis is based upon or contradicts the outcome of another or several other studies referred to in the thesis then the contradiction should be discussed. This also includes different outcomes in studies in the references. In a study contradicting studies can be excluded from the references. However, in a thesis contradictions in studies should be referred to and discussed. This is also valid for competing treatment methods/interventions. Accurate neglected references Teggi, R., Bellini, C., Piccioni, L., Palonta, F., and Bussi, M. (2009). Transmeatal low-level laser therapy for chronic tinnitus with cochlear dysfunction. Audiol. Neurootol. 14, 115– 120. Goldstein, B., and Shulman, A. (1996). Tinnitus-hyperacusis and the loudness discomfort level test-a preliminary report. Int. Tinnitus J. 2, 83–89. Katzenell, U., and Segal, S. (2001). Hyperacusis: review and clinical guidelines. Department of otolaryngology. Otol. Neurotol. 22, 321–327.

Page 11

Introduction

Regrettably, there is neither a consensus-based diagnostic procedure nor an evidence-based treatment for hyperacusis. Expressions lacking a definition shall never be used in a thesis or scientific article! “consensus-based” is not an accurately defined expression. It may be an opinion or position reached by a group as a whole but the group as a whole is not defined. If all doctors would constitute the whole group then there is no consensus at all in the world regarding any treatment. “evidence-based” is not accurately defined as there are several different evidence evaluation protocols. Observe that those are protocols that are subject to subjective assessment and therefore not accurately defined. There are international groups wherein laser therapy for hyperacusis is consensus-based. The NALMCA academy and the AENORTA consists of researchers and clinicians who have reached consensus regarding laser therapy as an intervention for the treatment of inner ear disorders. Sound therapy may be evidence-based according to the GRADE system or other evidence evaluation protocols.

Page 12

In audiological testing, a person with hyperacusis presents with reduced loudness discomfort levels (LDL), while hearing thresholds tend to be normal [2]. This statement is untrue. Other researchers than [2] have found the opposite. About half of the population suffering from hyperacusis has a measurable hearing impairment. This is actually one of the outcomes in this thesis (44 % suffering from hearing impairment). The reference [2] is irrelevant and inadequate and the researchers in [2] may incorrectly have made their statement. The statement also contradicts the findings in the thesis that 44 % of the hyperacusis sufferers have a hearing impairment. The results in the thesis (44 % suffering from hearing impairment) is a filtered result. The number of hyperacusis sufferers is in reality higher as the researchers have filtered out all patients with an impairment larger than 40 dB HL. The exclusion criteria is inadequate and may be chosen because the patient group suffering from larger hearing impairment than 40 dB HL may be more difficult to cure or improve the hyperacusis condition for. There is a possibility that the researchers therefore have chosen hearing level as an exclusion criteria.

To differentiate between hyperacusis and phonophobia, hyperacusis may be seen as an oversensitivity along the complete spectrum of frequencies, while phonophobia is an oversensitivity only to certain sounds, mostly independent of their intensity [112]. Phobia is defined as fear for something. Phonophobia is an abnormal fear of sound. The reference to [112] is without a discussion in the thesis about the difference between hypercusis and phonophobia irrelevant and inadequate as there are no purely audiological studies claiming the same as [112]. The researchers in [112] are psychologists and are viewing audiology from a psychological perspective which may account for the view in paper [112]. The difference between hypercusis and phonophobia was 1-2 March 2013 discussed at in London The First International Hyperacusis Conference (arranged by the British National Health Service, NHS), where I was one out of ten invited speakers. At the Conference there were no arguments about the differences between hyperacusis and phonophobia. Hyperacusis is acoustically measurable (lower sound tolerance than 90 dB HL) and phonophobia is a reaction to sound. A phobia for something is generally developed for something that may result in pain or discomfort. Due to the present inner ear damage, recruitment of loudness is unlikely to be affected by sound avoidance or exposure. The statement has no scientific ground and is also lacking a reference. The recruitment of loudness condition is not measurable and can therefore not be scientifically tested or evaluated with any accuracy. Page 13

Diagnosis There is no consensus-based standardized diagnostic procedure for hyperacusis [91]. The reference [91] is inadequate and irrelevant. The term “consensus-based” is not accurately defined. Besides that there are actually standardized, diagnostic procedures existing for hyperacusis. Audiologically testing LDLs are used by almost every audiological clinic where hyperacusis is diagnosed. The audiological testing is the only reliable testing for the hyperacusis condition as hyperacusis is defined as a lowered sound tolerance where the discomfort level for a tested frequency is lower than 90 dB HL. This is the utmost frequently used hyperacusis definition. This was used as the measuring tool by all scientists appearing at the the First International Hyperacusis Conference in London 1-2 March 2013, where I was an invited speakers. When a person comes to an audiology department with complaints of hypersensitivity to sounds the person is normally examined at an outpatient clinic. Common procedure is to take a medical history, followed by audiological testing. Such testing takes place in soundproof test rooms, where pure tone

audiometry is performed to detect hearing deficits. The loudness discomfort level (LDL) test is likely to be used for diagnosing hyperacusis, as it has been recommended both for diagnosis and as a treatment outcome measure [63; 99]. It is still so that the most common reception for patients is that the doctor says: “There is nothing we can do about it. You'll have to live with it” [TRI Newsletter]. Patients are rarely measured regarding their LDLs or pain thresholds. In Zazzio's study there were not even 10 % of the Swedish patient population that were measured regarding hyperacusis levels. This is still the way it is in Swedish audiology clinics. The same is valid for many other countries. In Spain it is just as rare as in Sweden that the audiology clinic will measure hyperacusis levels. An individual is suggested to meet test criteria for hyperacusis if LDLs are generally less than 90 dB in the measured ear [2]. This is the main feature for the diagnosis hyperacusis. This “suggestion” is sometimes used by many specialized clinics all over the world but the word generally is not valid for setting the diagnosis for the condition. In research there has been suggested that two of the frequencies should be lower than 90 dB HL to set the diagnosis. In published research one single frequency with a lower sound tolerance according to LDL or pain threshold has also been the inclusion criteria and there are proofs that all frequencies but one have been regarded as healthy (see attached PowerPoint file, ear number 65; also look at ear number 2 and 3). The LDL test has been criticised for having problems with reliability, and also for being highly uncomfortable or even painful for persons suffering from hyperacusis [12]. Also worth considering is the fact that stimuli used in the test situation are restricted and easily controlled, and thereby different from those experienced in daily life [100]. LDL is naturally uncomfortable. Pain thresholds are painful. It is extremely rare that the lowest LDL is painful. Almost in every case and on all LDLs there is a span of 5-15 dB HL till pain is experienced. Pain thresholds should be used as an addition to LDL to avoid unrealibility. Pain thresholds are more reliable and accurate than LDL. In a survey made by Zazzio among 20 hyperacusis patients 12 thought that discomfort was next to pain and 8 thought that annoyance was next to pain. Pain was with no exception defined by all patients as “when it hurts”. There is an endless series of daily life sounds and those cannot be copied in to a testing environment. If sounds are lower than 90 dB HL and they are painful, then they still are harmless according to the view of CBT. So, why hasn't pain thresholds been measured in these studies and thesis when LDLs have been criticized for their reliability? The reason for that is not discussed in this thesis and it should have been. Pain thresholds should have been used where the patient agreed to test those levels. Questionaires cannot replace LDLs, loudness annoyance levels or pain thresholds for sound.

Expectedly, these measures correlate moderately or not at all [91], concluding an obvious need for improved diagnostics. The statement after the reference is lacking ground as the LDL test satisfies the generally accepted definition of hyperacusis. Page 14

Pathophysiology Hyperacusis has been linked to hyperactivity within the central auditory system [43] in a group of patients with a primary complaint of tinnitus. The statement needs a developed explanation and further investigation and needs to be discussed from several point of views. It is natural that the central auditory system is hyperactive for patients who have discomforting and painful experiences from sound. Pain activates the correlating brain area. Page 15

In some studies of animals, researchers argue that acoustic trauma affects the central gain by increasing it [102; 76]. This has been discussed as being contributory to hyperacusis, assuming that acoustic trauma is a possible start of hyperacusis symptoms [76]. Why isn't this accurately discussed in the thesis? Acoustic trauma is the most common cause for hyperacusis but it is not pointed out or discussed in this thesis. The thesis tend to focus upon other causes than hearing impairment, which is apparent even when hearing thresholds are better than 30 dB HL. M Westcott, researcher from Australia found the same probable cause for hyperacusis as I have declared in my hyperacusis article where more than 90 % of the hyperacusis sufferers got the disorder after being exposed to sound trauma. However, these symptoms are associated with inner ear damage, which may point to another type of sound sensitivity than hyperacusis. “May point out”... The statement “may point out” is contradictory to the limit for suffering from hyperacusis. What is meant with ”other types of sound sensitivities” is neither defined nor discussed. In one study, women with high levels of emotional exhaustion presented with lowered LDLs, compared to women with lower levels of emotional exhaustion, after performing a stressful task [50]. The possibility of stress as a factor in tinnitus has also been investigated [117]. Basic cortisol levels have been shown to be higher in tinnitus patients [52].

“Stress” is not a defined term. Different kinds of stress may lead to an increase of free radicals, both intracellularily and extracellularily, in blood and tissue, This makes it quite evident that free radicals can have an effect on an emerging symptom and also an impact on healing processes in the ear. The Swedish professor Mats Ulfendahl has shown that antioxidants can protect the ear. Page 16

Comorbidity The comorbidity between tinnitus and hyperacusis is large [10]. Between 40 and 60 % of patients with tinnitus suffer from hyperacusis [64; 6], while up to 86 % of patients with a primary complaint of hyperacusis also report tinnitus [2]. Further, a person suffering from a hearing loss could also suffer from hyperacusis, even if persons with hyperacusis are likely to have normal hearing. This statement is untrue. About half of the population suffering from hyperacusis has a measurable hearing impairment. The statement is irrelevant and inadequate. Compare the results in the thesis and regard at the same time existing exclusion criteria. That brings along that more than half of the hyperacusis suffering population are also suffering from hearing impairment. The untrue statement is here repeated but it won't, despite repeating it, become true. Page 17

Psychiatric comorbidity In a study investigating psychiatric morbidity in patients with tinnitus and hyperacusis, 69 % of the patients had a present psychiatric diagnosis, with affective disorders diagnosed most frequently (57 %). The frequency of anxiety disorders was 43.5 % [37]. Hyperacusis has furthermore been reported in depressed patients [23]. Of course! Patients suffering from tinnitus and hyperacusis experience forms of chronic pain and they will develop psychiatric diagnosis, anxiety and depression. It would be really strange if they didn't develop those symptoms. Furthermore, there is a large co-occurrence between anxiety disorders and chronic pain [8]. Of course! Patients suffering from chronic pain get anxious because they don't want their lives to be painful. Who wouldn't get anxious before undergoing a liver biopsy? Page 19

Treatment There are no established treatment guidelines for hyperacusis, or published randomized controlled trials (RCT) of any psychological treatment for hyperacusis. The care a patient is most likely to receive at an audiology department consists merely of an audiological examination, including LDL measurement [12]. Some patients leave the clinic with prescribed, fitted earplugs with sound attenuation devices. Another common recommendation for these patients is to seek out support groups. Some form of professional counselling might be available at the audiology department or elsewhere, perhaps at a psychiatry department if depression or other psychiatric morbidity is present. The most common reception is not that LDLs are tested but that the doctor says: “There is nothing we can do about it. You'll have to live with it”. Patients are rarely measured regarding their LDLs, loudness annoyance levels or pain thresholds or sound. Most clinics neglect testing hypercusis levels. An example is a female patient whose pain thresholds were as low as 25 dB HL but the woman didn’t even benefit from any sick leave. The patient was received by the health care system in Linköping, by the health care region of Östergötland where the co-supervisor Gerhard Andersson is active. Other types of sound exposure treatments are being used in clinics. In one study patients with hyperacusis were exposed to pure tone stimuli for several hours a day for 15 weeks [103]. The patients had hearing loss and the sound stimulation was given on the frequency of the loss. Due to the existing hearing loss and other problems in this study, it is difficult to draw any conclusions, although significant effects on loudness scaling were obtained. Openfield sound exposure treatment has been shown to be possibly useful [85; 94]. How can it be difficult to draw any conclusions when significant effects on loudness scaling are obtained [85; 94]? No comment were made about laser therapy despite the fact that the treatment results are the best ever achieved. There are three existing studies in this field - two are MEDLINE indexed and one is congress reported, both at the First International Hyperacusis Conference 2013 and at the International Tinnitus Congress 2013. Linda Jüris has from Michael Zazzio received Zazzio's study as a pdf document but she has neglected to incorporate it into her thesis. Cognitive behaviour therapy (CBT) Cogni-

Page 20

tive therapy emphasizes the importance of changing unrealistic thinking patterns.

“The aim of psychological interventions is not to “cure” or to eliminate the inner noise but to reduce tinnitus-related distress and increase quality of life” [41]. The aim is not to improve inner ear conditions. Here the author of the thesis is either stating that CBT is a form of self deception. How is it possible that it is in the thesis not discussed why the LDLs were slightly improved. Sound therapy is included in the underlying work of this thesis and it should therefore be explained why the aim is not to improve inner ear conditions when it is known that sound therapy has a positive effect on the inner ear hair cells' actin-myosin tension-relaxation apparatus. This is physiologically very important and should therefore be part of the thesis. Without it the thesis is flawed. CBT in audiology

Page 21

Interestingly, sound stimulation does not seem to have any additive effect on CBT for tinnitus [57]. How reliably are tinnitus levels measured in that study [25]? This is not pointed out or discussed in the thesis. Therefore the reference is of no interest as it cannot be confirmed and as it contradicts other observations and studies, i.e. TRT studies. CBT model for hyperacusis Due to this, and to other possible consequences of avoiding sound, i.e. isolation, depressed mood and problems in maintaining relationships, it would be sensible that the main goal of CBT for hyperacusis would be to target the present avoidance behaviour. There is a contradiction between this statement and the one above [25]. Tinnitus and hyperacusis are highly related to each other. About 85 & of the hyperacusis population also suffers from tinnitus. Is it possible to get physiological effects on the inner ear from CBT or are those effects only manipulation? This hasn't been discussed in the thesis. Sound therapy at levels of 82 dB HL has in a Swedish study been proven to have training and a preventing effect on hearing thresholds. It is also known that tinnitus and hyperacusis in studies have been improved through the use of sound therapy. There is also known that sound has a physiological effect on the inner ear cells. The fact that this is not discussed in this thesis may constitute an avoidance of physiological facts and arguments. The statement that sound therapy would not have any additional effect to CBT when treating tinnitus is not cognitively conceivable as CBT is not claimed to result in physiological effects but sound therapy has such effects. How reliable is it to claim that it is interesting that sound stimulation does not seem to have any additive effect on CBT for tinnitus? This should have been discussed in the thesis as the thesis contracicts itself as the findings in study III displays an improvement on LDLs.

The frequency of occurring avoidance behaviour therefore increased. Instantly, the pain or the risk of experiencing pain decreased, but in the long run Elisabeth will be more afraid of sounds and this will also There is no 100 % certainty that Elisabeth would in the long run be more afraid of sounds. The statement is untrue and also fictitious and based upon what may be most likely. Page 22

affect her auditory gain, and her auditory system will become more sensitive to sound. There is no 100 % certainty that avoidance behavior would affect Elisabeth's auditory gain and that her auditory system would become more sensitive to sound. There could be other causes for such effects (i.e. free radical levels in blood and tissue) and such causes should have been discussed in the thesis. Page 23

Aims of the project The overall aim of the present project was to gain knowledge about the clinical condition of hyperacusis, defined as unusual intolerance to ordinary environmental sounds [132]. Unusual is a term which is not defined and upon which an aim cannot be based. How many percent of the population have an unusual intolerance to sound? This must be defined. Where is the limit where something becomes unusual? This is neither explained in the thesis nor discussed. The specific aim of Paper I was to compare the hyperacusis measurement tools often used in audiological practice in order to determine the most valid measures for assessing hyperacusis. A structured clinical interview for hyperacusis was also constructed and used to investigate the patient group. All hyperacusis measurement tools have not been used or discussed in this study or in the thesis The thesis and the study neglects pain thresholds and loudness annoyance levels and the study and thesis are therefore flawed regarding the statement above. The aim has not been reached or fulfilled and is therefore flawed.

Page 24

Methodology

2) had average loudness discomfort levels less than 90 dB in at least one ear Average is of no interest for the diagnosis. This flaws the study and the thesis. this is the only study where “average” discomfort levels were measured. Patients can have pain thresholds on two intermittent frequencies (see patient 2 and 3 in the attached PowerPoint file) that are very low. Converting those pain threshold into LDLs would give an LDL of around 55-60 dB HL. Suggesting that patients suffering from such severe hyperacusis would not suffer from hyperacusis is a scam. Those two patients, or at least one of them, would be excluded from study III as they didn't fulfill the inclusion criteria despite the fact that they may have had the most severe hyperacusis of all participating patients. In Zazzio's study only 17 our of 83 ears would meet the inclusion criteria. The study is severely flawed excluding patients who does not have hyperacusis on 500 Hz, 1 kHz and 2 kHz. 4) were between 18 and 65 years of age Other age spans are of great interest. Why limit the population to this span? This is not explained in the thesis. Limiting the span is not adequate. This limiting factor may be correlated to excluding patients with impaired hearing. Excluding older people than 65 years of age flaws the trial and the thesis Page 26

Procedure in Paper III Measures Pure tone audiometry was performed using ascending technique [7] on an audiometer AC 40 from Interacoustics. Hearing thresholds were measured in dB (HL) at 125 to 8000 Hz. Pure tone averages (PTA) were defined as the average of the frequencies 500, 1000, 2000 and 3000 Hz for each ear. For loudness discomfort levels (LDL) for tones, the measured frequencies were 250, 500, 1000, 2000, 3000 and 4000 Hz. Patients were instructed to indicate To few observations were made. Eleven (11) frequencies per ear should have been used. Only LDLs were measured. The time for each measurement has not been declared. It has not been stated whether there is an exact sound exposure time per frequency or if the exposure time is variable due to the audionomists button pressure? It has not been stated in what sequence the test frequencies were generated – treble, base or midrange first? This is a potential source for errors. Why wasn't 125 Hz, 750 Hz, 1,5 kHz, 6 kHz & 8 kHz tested in the study? Hyperacusis in the treble range is the most common form of hyperacusis. The exclusion criteria are totally unacceptable and the poor number of tested frequencies makes the study crippled.

Page 27

when the sound level became uncomfortable for them. If this occurred at an average level of 90 dB or less for the frequencies of 500, 1000 and 2000 Hz for at least one ear, the person was considered to meet test criteria for hyperacusis [2]. Two or more frequencies with LDL below 90 dB HL in the range from 125 Hz to 8 kHz is a commonly used definition of hyperacusis but also when LDL or pain threshold for only one frequency is lower than 90 dB HL the patient can be regarded as suffering from hyperacusis accoring to published studies. What is the difference between annoying and uncomfortable? Which one is closest to pain? In a survey made by Zazzio among 20 hyperacusis patients 12 thought that discomfort was next to pain and 8 thought that annoyance was next to pain. Pain was with no exception defined by all patients as “when it hurts”. Individuals are living in a verbally subjective reality and can therefore not always separate the different expressions from each other or sort them in the same order as all other patients do. Page 28

Self-reported improvement Drop-outs can be a major problem regarding being able to draw conclusions in RCTs. As a precaution, a self-report visual analogue scale was used to assess treatment response in the patients at every treatment session except What is the probability that a patient's personal outcome is consistent and reliable with the LDL levels measured? This is not discussed in the thesis. It is not possible for a patient to reliably estimate the LDLs for each frequency? A visual scale for i.e. the average LDL is not sufficient regarding that there are 11 frequencies to measure when using a standard audiometric device. In study II and in the thesis 6 frequencies were tested but the VAS scale did not separate them from each other. The self-reporting method is flawed but this has not been discussed in the thesis. Page 29

the first. This would make it possible to retrospectively analyse self-reported improvement in relation to number of treatment sessions completed. Patients were instructed to make a single vertical mark on a horizontally oriented, 100-mm VAS labeled “not at all” at the far left and “a lot” at the far right, for the following three statements: 1) “How bothering is your sound sensitivity today?”

2) “How socially disabling is your sound sensitivity today?” 3) “How afraid/annoyed are you of/to sounds?”. Sensitivity cannot reliably be estimated with one value. The hyperacuss level of all frequencies are not similar and there can be huge differences (se ear number 1 in the attached PowerPoint file). What about if different observations improves at different rates and if unmeasured frequencies improve differently than measured ones? What would the reliability of the self-reported improvement then be? Deviations such as that are not discussed in the thesis which makes the study III and the thesis flawed. Page 30

Sound exposure Exposure to sound was executed in part as the traditional CBT-technique of graded exposure that is commonly used e.g. when treating specific phobias. Sound exposure also took place with a general purpose of environmental sound enrichment. This implies that the study is actually a sound therapy study? Sound therapy have proven physiological effects. What makes the CBT important in this matter? Sound therapy studies have even better results on LDLs than this CBT study! Why isn't there any comparison between this study and other interventions reported in published studies? Page 34

P-values less than 0.05 were considered statistically significant for all analyses. Data analyses were performed using SPSS versions 18, 20 and 21 for Windows. P < 0.05 is highly discussible as a limit for significance. P < 0,01 is much more reliable. An even smaller value could have been chosen P < 0.005 or P < 0.001. Page 35

Results Papers I & II

Demography When exposed to sounds perceived as too loud, 53 % of the patients described a general sense of being uncomfortable, 47 % felt annoyed, 45 % felt pain and 32 % reported that they felt frightened. Twenty-nine per cent of the patients also described other reactions, the most common of which were stress and trouble concentrating. These figures above are not differentiated regarding different frequencies which is a flaw. What is “too loud” is not related to LDLs, loudness annoyance levels or pain thresholds and is therefore flawed. Audiological results Hearing thresholds were measured in dB (HL) at PTA at the frequencies 500, 1000, 2000 and 3000 Hz, for each ear. The patients had normal hearing levels with mean values of 10.6 dB (SD = 9.8) in the right ear and 12.3 dB (SD = 9.8) in the left ear. There was an expected significant difference in the hearing thresholds between right and left ears at the frequencies 125, 250, 500 Hz (p < 0.01) and 3000, 4000 and 6000 Hz (p < 0.05), with the right ear outperforming the left. Mean LDLs ranged from 69.3 dB (SD = 12.1) to 76.0 dB (SD = 11.7) at the frequencies 250, 500, 1000, 2000, 3000 and 4000 Hz for each ear. It has neither been explained nor discussed why hearing thresholds were only measured on those four frequencies. It has neither been explained nor discussed why LDLs were only measured on those six frequencies. Only using those frequencies makes the study and thesis severely flawed and it limits the possibilities to draw any general conclusions from it. Page 36

Table 2. Results of the clinical interview, n = 62. Characteristics N % HYPERACUSIS Onset (sudden / gradual / don’t know) 21 / 37 / 4 - 34 / 60 / 7 Development over time (worse / the same / don’t know) 39 / 18 / 4 / 1 - 63 / 29 / 7 / 2 Observe that there are four figures but only three definitions. This s a severe flaw that makes the disposition flawed and not understandable. Reaction to sounds Discomfort - 33 / 53 Annoyance - 29 / 47

Pain - 28 / 45 Fear - 20 / 32 Other (e.g. stress) 18 / 29 These figures have not been differentiated regarding different frequencies which is a flaw. Stress is not defined. It is therefore severely flawed. Page 37

OTHER AUDIOLOGICAL PROBLEMS Hearing impairment, reported 28 / 45 Tinnitus 49 / 79 These figures are flawed as the basic material is coated with serious filtering. The mean duration of hyperacusis was 11.9 years (SD = 15.0, range 1 to 60). Ten patients claimed they had always suffered from hyperacusis, and therefore the median value for hyperacusis duration was calculated to be 5.0 years, with the 25th percentile 2.4 years and the 75th percentile 14.3 years. The onset of hyperacusis had been sudden according to 59.7 % of the patients, while 33.9 % claimed that the onset was gradual and 6.5 % did not know. The mean duration of hyperacusis cannot be used as the patients have no measured history going as far back as 11.9 years. The duration is merely based upon the patients assessment and not on adequate measuring of LDLs, loudness annoyance levels or pain thresholds. The statement has no reliability at all and should not be used in a study or thesis as it is not subject to any validation at all. The estimation of the onset of hyperacusis is not reliable as patients cannot determine when their hyperacusis actually started due to the fact that most of those patients were not measured regarding hypercusis at the moment of onset. Assessment of hyperacusis (Paper I)

Page 38

Correlations between diagnostic tools Correlations were also explored between LDLs and items from the clinical interview, but no clinically useful significant correlations could be found. No correlations were found between LDLs and items from interviews. This displays that LDLs and loudness annoyance levels and pain threshold levels explicitly diagnoses hyperacusis. The thesis however states that discontinuous hyperacusis would not costitute hyperacusis. Such a statemant makes the thesis severely flawed.

Page 40

Effect of CBT (Paper III) Page 42

Audiological results The patients had mean hearing thresholds clearly within the range of normal hearing (PTA), of 10.8 dB (SD = 9.9) in the right ear and 12.6 dB (SD = 9.8). There was an expected significant difference in the average hearing thresholds between the right and left ears, with the right ear outperforming the left (t = 2.76, p < 0.01). The mean LDLs ranged from 69.3 (SD = 12.1) to 76.0 (SD = 11.7) on average for the frequencies 250, 500, 1000, 2000, 3000 and 4000 Hz for each ear. It has neither been explained nor discussed why LDLs were only measured on those six frequencies only. Using those few frequencies makes the study and thesis severely flawed and it limits the possibilities to draw any general conclusions from it as almost half of the required frequencies have been neglected in the study and the thesis. The most common is that LDLs, for patients suffering from hyperacusis, are found in the treble range. The frequencies 6 and 8 kHz have been excluded despite the fact that those frequencies are found on standard audiometers. Frequencies with low LDLs can also be found discontinuously in the frequency spectrum and solitary frequencies are also sometimes found for hyperacusis suffering patients. This is a fact that is neglected in the study and the thesis. IT is therefore severely flawed. Effect of CBT

Follow-up

When the waiting-list group later received CBT, the treatment outcomes were similar. No significant differences were observed. Follow-up assessment was conducted 12 months after post-treatment measurement, and was completed by 55 patients. Improvements were maintained at the group level for all measures in the CBT group. The control group received treatment after 6 months. The reason why the control group was not planned to wait 12 months before evalution has not been discussed in the thesis. Furthermore, the degree of sick leave before treatment due to hyperacusis was 42 %. At follow-up, 37 % were still on sick leave due to hyperacusis. A cost-benefit calculation should have been added to the thesis regarding the benefits of TRT.

Page 43

Additional results

Visual Analogue Scale The purpose of this measure was to make it possible, in the event of a large drop-out from treatment, to analyse whether the patients left treatment due to improvement or deterioration of their hyperacusis symptoms. There was a significant decrease in VAS ratings over time (p < 0.05 between session 1 and 2, and p < 0.001 between the subsequent sessions). It has not been described weather there was a VAS scale used for each frequency tested in the study. It has not been described weather there were or could have been any treatment effects on other hearing frequencies than the few ones used in the study. It has not been described how consistent or significant the VAS results were compared to the LDLs. This makes the study and the thesis flawed. Page 44

Differences between responders and non-responders

In an attempt to explore clinical significance of the LDL results, responders were considered to be individuals who had an LDL increase of at least 6 dB in one ear. Out of all the patients measured post-treatment (n = 56), including the patients who received CBT after the waiting list period, 32 individuals were found to have a positive change of at least 6 dB in one ear, Why was 6 dB HL chosen? This has neither been discussed nor explained. The common thing is to chose 5 dB HL steps. 32 patients out of 56 equals 57 % (who got at least a 6 dB HL improvement). How many received an improvement of at least 10, 15, 20, 25, 30, 35 and 40 dB HL improvement? How many improved completely and at what levels were their final LDLs and initial LDLs.

Page 45

Discussion

The overall aim of the present thesis was to obtain increased knowledge about the clinical condition hyperacusis, which was defined as an unusual intolerance to ordinary environmental sounds [132]. The more precise aims were to assess the effect of CBT as a remedy to decrease the symptoms of hyperacusis, to investigate clinical and psychiatric characteristics of the condition, and to compare tools for assessing hyperacusis. How is “unusual intolerance” defined? There are several other definitions use for hyperacusis levels but those have not been referred to in the study or thesis. Why weren't they discussed and/or measured? Leaving them outside the discussion makes the thesis flawed. Effect of CBT for hyperacusis Based on the randomized clinical trial presented in Paper III, it may be concluded that CBT can be helpful in treating patients with hyperacusis. Since there are presently no evidence-based psychological treatments for hyperacusis, this fact may instill hope in patients, their significant others, as well as in clinicians. CBT – Is it or is it not helpful? What about non-psychological treatment? Is there any evidence at all for anything? What is the definition for evidence referred to in this thesis? The results provide evidence for the hypothesis that sound-related avoidance behaviour in patients with hyperacusis maintains and exacerbates hyperacusis, and that CBT can alleviate suffering by focusing on decreasing this avoidance. The results were stable over 12 months, with effect sizes generally moderate immediately after treatment, and somewhat larger at follow-up, indicating that patients had continued applying the CBT principles after treatment ended. A comparison with other studies and the effect sizes gained when using other treatment methods should have been accompanying the discussion above. Page 46

Sound exposure therapies are sometimes used in audiological practice, mainly to treat tinnitus, such as in tinnitus retraining therapy (TRT) [106; 58], and sometimes also to treat hyperacusis [34]. A comparison with the effect sizes gained when using sound therapies should have been accompanying the discussion above.

Finally, the fact that treatment was performed in an audiology department with extensive experience of psychological treatment may have contributed to the high level of adherence. Adherence is a word with many meanings. Here it is not apparent what it means. It can be interpreted in many ways. The degree of sick leave due to hyperacusis before treatment was 42 %. After treatment 37 % were still on sick leave due to hyperacusis. Although the aim in the present study was not to have the patients How many patients were completely recovered in the study and what were their initial LDLs? This is neither reported nor discussed in the thesis. What were the best treatment results and what was the poorest? A table over improvements should have been provided in the thesis. Page 47

return to work, it is worth considering that they attended only six sessions of treatment over two months’ time. In many cases this limited amount of time made a significant difference, but for some patients it is likely that six sessions were too few. Extending the protocol over time “would probably be” useful in some cases. What scientific material is the statement “Extending the protocol over time would probably be useful in some cases” based upon? “Might be” or “could possibly be” should be used instead. “Might be” is advised. Clinical characteristics and behaviours in hyperacusis Around 30 % of the staff in preschools experience so-called burnout syndrome, supported by measures of cortisol levels [118]. This is a statement and not a discussion. The statement is not discussed and should therefore be written in the introduction of the thesis? What is the scientific foundation for that statement? This is neither presented nor discussed in the thesis. Are there other measurable levels that may contribute to the knowledge why preschool staff or/and others are prone to suffer from hyperacusis? Why isn’t that reported in the discussion? Have the researchers Linda Jûris et al observed this among any if their hyperacusis suffering patients who were preschool staff and if so – how frequently as this observed? This should have been reported in the thesis. Secondly, half of the present patients reported balance problems, which have also been reported in individuals with tinnitus [127]. This is a statement and not a discussion. The statement is not discussed and should therefore be written in the introduction of the thesis? What is the scientific foundation for the statement? This is neither presented nor discussed

in the thesis. Are there other measurable levels that may contribute to the knowledge why patients report tinnitus problems? Have the researchers Linda Jûris et al observed this among their hyperacusis patients and if so – how frequently? This should have been reported in the thesis. Page 48

Psychiatric comorbidity and personality traits in hyperacusis In agreement with the hypothesis, a high prevalence of anxiety disorders was found in the present patient group. In fact, almost every second patient could be diagnosed with an anxiety disorder, with social phobia, generalized anxiety disorder and agoraphobia being the most common. This figure is significantly higher than in extensive population-based studies [71; 70; 75; 74]. Has this statement any comparison with other disease groups where patients suffer from pain due to the disorder? What conclusions does Linda Jüris draw according to this? That should have been part of the thesis but is not. Why point something out which is not confirmed in the study/studies on which the thesis is based? Our patient cohort displayed higher levels of personality traits related to neuroticism as compared to a control group from the general population. This implies that patients with hyperacusis exhibit a greater than normal tendency to respond with negative emotional responses to threat, frustration and loss [38]. Persons with high levels of neuroticism are shown to be more vulnerable to both mental and physical disorders, e.g. depression, anxiety disorders and back pain [40; 26; 67]. This would reasonably also apply to hyperacusis. What is the scientific foundation for that statement? This is neither presented nor discussed in the thesis.? High degrees of neuroticism also increase vulnerability to stress [44; 19; 113]. Stress has been suggested to be of importance in hyperacusis [109], and it has been shown that women with high levels of emotional exhaustion become more sensitive to sound after an acute stress task, than women with low levels [51]. In the present study, however, no standardized measure of stress was included. Nevertheless, perceived stress was reported as a reaction to sounds by a significant number of patients. In addition, the present patients presented with significantly higher scores on the SSP scale of stress susceptibility. Why hasn’t any standardized stress measures been made in the study when the study points out that stress (which lacks definition and even medically can be a wide expression) can have an impact on the severity of the condition? Page 49

Assessment of hyperacusis

As previously stated, there is no consensus-based standardized diagnostic procedure for hyperacusis. This is quite natural as the most current definition of hyperacusis refers to when a patient reports discomfort for sounds that would be acceptable to most people with normal hearing [132]. This implies that the problems encountered by those affected are of a very subjective character. The expression consensus-based is not defined and therefore this part is insufficient in the thesis? Individuals who agree with statements like: “Do you have a lower tolerance for noise than other people?” or “Do you consider yourself to be sensitive to everyday sounds?” experience suffering that is sufficient for a diagnosis of hyperacusis [4; 91]. Has this been verified in any way? The thesis does not point out any such verification. Further assessments do not contribute to a firmer diagnosis, but are rather aimed at quantifying and characterizing the extent of the problems, above all at assessing clinical severity, and following the effect of treatment over time. What assessments methods does this refer to? There is an assessment method that contributes to a firmer diagnosis but Linda Jüris neglects it and does not discuss it in the paper. The statement is flawed. Page 50

Ethical and methodological considerations As there is no existing evidence-based treatment with established effect for hyperacusis, there is clearly a clinical need for attaining such a treatment. Doing so should be based on a solidly built knowledge-base where the effects of different treatment modalities are compared and studied in well designed clinical trials. Effects of different treatment modalities could have been compared and studied in this thesis but Linda Jüris have neglected to do so and even neglected to report results from other treatment methods such as TRT, sound therapy, laser therapy and laser therapy in combination with pulsed electromagnetic field therapy and control and analysis of free radicals in blood. Neglecting to compare with existing studies for which scientific articles are published on the MEDLINE/PubMEd makes the thesis severely flawed. A randomized controlled trial (RCT) is the gold standard for such a trial. RCT is not equivalent with “gold standard”. Gold standard means double blind, placebo controlled, prospective and randomized. Neither of the studies that this

thesis is based upon fulfills the criteria for gold standard. An RCT is not a gold standard. RCTs are used to test the efficacy and/or effectiveness of various types of interventions within a patient population. Randomization is needed to allow statistical hypothesis testing and to make sure unknown factors and factors that may have possible effect are evenly distributed between groups. Randomization does not necessarily guarantee that unknown factors are evenly distributed between control group and verum group and maybe also other groups. Page 51

An ethical aspect is that in addition to the diagnostic procedures, parts of the CBT program contained elements that might have been difficult for the participants to endure, i.e. the element of exposure to sounds. In fact, patients with hyperacusis often find audiological testing to be highly uncomfortable, or even painful [12]. Measuring discomfort levels must be measured in order to be able to set the diagnosis hyperacusis as the diagnosis is entirely based upon LDLs. Pain thresholds are exactly what the expression says –painful – and that is sentence with the expression. The meaning with testing what is painful is to find the limit for different frequencies where pain is experienced. How could it be any other way. To imagine or hypothesize that there could be a way to through questionnaires to investigate the LDLs, Loudness Annoyance Levels or Pain Thresholds of 11 different frequencies, is of course ridiculous. No questionnaire in the world could do that and patients are also living in different verbal subjectivities – so, believing that basing a medical upon a questionnaire is possible is a foolish thought and only reveals an unrealistic point of view. To minimize their discomfort in this project, the LDL testing started with low sound volumes and the entire procedure was carried out with caution so as not to exceed volumes that caused severe discomfort. What were these volumes? Did they differ between different frequencies. What was the length of each sound generated and was it equal for all patients and for all frequencies? All this hasn’t been declared or defined in the study or in the thesis. Clinical implications

In hyperacusis, hearing thresholds are normal, LDLs decreased, and the patient claims to be bothered by everyday sounds. The statement is not true. Hearing thresholds are according to study III not normal among almost half of the subjects studied (44 %). Patients suffering

from hearing impairment were also excluded from the study. This severely flaws the statement above. All hyperacusis patients are not bothered by everyday sounds – only when they pass a certain sound limit which varies a lot among the patients. LDLs are decreased but so are also Loudness Annoyance Levels and Pain Thresholds. When diagnosing hyperacusis, especially when the patient is referred for CBT treatment, it is advisable for clinicians to use the present clinical interview and the HQ. Why that is advised, and especially for CBT patients has not been explained in the thesis. Why would patients undergoing different therapies be the target for different interviews? This has no scientific foundation but is merely an opinion that lacks scientific basis. The HADS could be helpful for CBT treatment planning, but further investigation is needed. It is not common to investigate psychiatric problems in an audiological department, but the HADS could at least screen for anxiety and depressive symptoms. Audiological measuring, that is measuring hearing thresholds and LDL testing, may be necessary to exclude other problems and to evaluate treatment effects. LDL testing is always necessary in order to be able to set the diagnosis hyperacusis. LDLs should be accompanied by measuring Pain Thresholds and maybe also Loudness Annoyance Levels. Page 52

Future research Extending the protocol to include a focus on returning to work could also be a possibility for future research. In the present study we did not include patients with significant hearing loss. What is the reason for that? This has not been explained in the study and not discussed in the thesis? A sound hypothesis, and a possible aim for future research, is that this often over-looked group of patients would benefit from CBT. It is not possible to draw such conclusions from this thesis and its underlying CBT studies as no such patients have either been treated in this study nor been part of a control group?

Page 53

Conclusions

Hyperacusis is an unexplored condition. The aim of this thesis was to contribute to the knowledge concerning assessment, comorbidity and treatment of hyperacusis. The main conclusions are: There are hundreds of scientific articles and studies on the PubMed exploring hyperacusis. There are several studies displaying positive and very good results - up to 23,19 dB HL improvement on a larger group than in paper III in this thesis. What is then the foundation for claiming that the hyperacusis field is unexplored? � The Hyperacusis Questionnaire and the Hospital Anxiety and Depression Scale are useful tools in the diagnostic evaluation of hyperacusis, especially when considering patients for treatment with cognitive behavioural therapy. Wouldn't it be better if the measrement of LDLs were supported by measuring Pain Threshold Levels and Loudness Annoyance Levels? LDLs alone have been critisized and should therefore be avoided as the only hyperacusis level measurement. � Anxiety disorders and personality traits related to neuroticism are overrepresented in patients with hyperacusis. What has the group compared this with – other painful disorders or healthy individuals or what? The statement lacks underlying scientific data and therefore the conclusion is incorrect and unsupported. � Cognitive behavioural therapy, with focus on exposure to sound, psychoeducation, applied relaxation and behavioural activation, is a promising treatment option for patients with hyperacusis. Treatment effects are maintained for at least twelve months. How can a treatment method reaching average improvement levels of 6-8 dB HL be a promising treatment option for patients with hyperacusis when CBT patients get moderately better (6-7 d-B HL) effects but laser therapy group patients has reached average improvements from 13.52 dB up to 23.19 dB HL?

Page 54

Acknowledgements

This thesis is a result of collaboration between the Department of Neuroscience, Uppsala University, and the Hearing and Balance Clinic at the Department of Ear, Nose and Throat diseases at Uppsala University Hospital. I have had the opportunity to do this work together with many excellent people, which has been a great privilege, and I cannot thank all of you enough! First and foremost, my supervisor Lisa Ekselius, thank you! You are an excellent role model in scientific work, in clinical practice, and also in life. I am so grateful to have met and gotten to know you. And you look great, too! Gerhard Andersson, my co-supervisor. Without you none of this would have become a reality. You sparked my interest in audiology and are responsible for starting up this project. Thank you for taking me on. Lisa Ekselius has forbidden Linda Jüris to cooperate with the researcher Michael Zazzio and his clinic (the Audio Laser Clinic/AudioLaser-Kliniken). Linda Jüris has complied with the fact that he would not be allowed to mention laser therapy in her work. A thesis requires some kind of history and comparison with other treatment methods. What has been written in the thesis is in this way flawed. It is unscientific to forbid a doctorate student to seek knowledge in the work preceding the final thesis. It is just as unscientific to comply with such an order. In the acknowledgement the doctorate student writes “And you look great, too!”. Such an expression certifies a limitless obsequiousness, which is extremely inappropriate in doctorate studies. Why is Linda Jüris greasing up Lisa Ekselius with such written statement? Obsequiousness is commonly found in stiff environments and dictatorships. Linda Jüris is a psychologist and so is her supervisor and one of the co-supervisors. They should know better than themselves fall into the traps of social psychology mechanisms. The visual appearance of Lisa Ekselius has nothing to do with a thesis and the existence of such a remark reveals a juvenile approach to the work. Linda Jüris is here displaying an excellent example of how to adapt, comply and follow the leading authority/authorities. Gerhard Andersson once threatened to leave the TV-studio in the tinnitus program Livslust in early 2000 if Michael Zazzio would be permitted to talk about laser therapy during the broadcast of the program. He and Alf Axelsson and Kajsa Mia Holgers agreed to do so. The reason for Gerhards threat was stated that he and his colleagues claimed that laser therapy for tinnitus was unscientific despite several published studies, even with control groups. Hans Christian Larsen, also my co-supervisor. We worked together every day during the treatment phase of this project, and experienced both good and bad times, professionally and personally. Thank you for those days, for always taking time to help me, and for worrying about me.

If I had such poor knowledge in audiology as H C Larsen has I would certainly worry for the one (the student) that I would be the co-supervisor for. Was H C Larsen the best that Akademiska sjukhuset/Uppsala universitet could come up with and offer Linda Jüris in her work? if so, I doubt that the patients received at that hospital can be assured that they get good treatment. Hans Arinell, I have so enjoyed your statistical workshops! Thank you for all your advice, thereby preventing psycho-statistical meltdown. I promise not to stand in your way for Beach 2014. Bengt Gerdin, thank you for all your help with the thesis; I can’t even imagine how many EndNote work hours you saved me. Mats Holmström, thank you for believing in the project and supporting it in the very beginning. Mats Holmström was the guy who in June 2006 reported to the Socialstyrelsen that a competing clinician was not serious in his clinical work and that his examination and treatment of patients was not based upon science and tried experience (vetenskap och beprövad erfarenhet). Mats Holmström devoted himself to be slandering. Besides, the Swedish expression “vetenskap och beprövad erfarenhet” does not have any definition at all, neither in law or in the medical branch. The expression is not commonly used internationally, not even in the translated form. Belief is not science and not scientific. Linda Jüris is thanking Mats Holmström for not being scientific! Jane Wigertz, thank you for the excellent linguistic help in making all three papers and my thesis readable. Thank you, Kerstin Mattsson for keeping track of things and individuals who are out of my control (you know who I mean). Lena Bohlin and A C Fält, thank you for keeping track of me. In addition, I am grateful to Viktor Kaldo and Monica Buhrman for introducing me to CBT in audiology, and for many interesting discussions and good times. Monica, thanks also for all the advice concerning my thesis, the lovely/awful flow chart, our numerous social and recreational activities, for

Page 54

enduring all my compulsive planning sessions, and above all for being a great friend. Thomas Haak, Sven Alfonsson, and Daniel Porsaeus, thank you for treating the patients in this project and for being great co-workers in general. Katarina

Molin, thank you for helping me with organising research and other matters, and for singing beautifully. Karolina Hansson, Åsa Klingstedt, Anne Strand, Ann Wäneskog and Ruth Åberg, thank you for performing the audiological testing. Elsa Erixon, thank you for advice concerning the thesis. I would also like to thank the rest of the staff at the Hearing and Balance Clinic at Uppsala University Hospital, including my trainees, who all excelled. In addition, I am grateful to all my colleagues at Neuroscience, Uppsala University, and at KBT-Centrum Uppsala. To all the patients who participated in this project: I think we have accomplished something important together. Thank you so much for your participation! My family and friends have been a great support throughout all of this work. My mother Anne, you have been absolutely invaluable in helping out with the children and with all types of practical chores. My father, Enn, who passed away when I was a teenager, you had enough time to instill your favourite subject, mathematics, in me, which led me to this course in life. I am sure you would have approved of this work, and I miss you every day. Juha, thank you for being my partner in life. I love you, and I love the life we have created for us and the children. I am now looking forward to the next phase of it, and I am very sure you are, too. Financial support was provided by the Swedish Research Council, Uppsala County Council, the Nicke and Märta Nasvell Foundation, the Swedish Association of the Hearing Impaired and Tysta Skolan. Uppsala, September 2013 Linda Jüris This thesis is severely flawed and the work also lacks important information that would be necessary to understand the field. None of the researchers were neither invited to speak at the First International Hyperacusis Conference in London 1-2 March 2013, nor did anyone of them visit the event. This reveals the poor interest in this medical field and the specialist doctor Larsen, who participated in this work as a co-supervisor, has obviously not been able to point out flaws, errors and important information that should have been incorporated in this work to make it appropriate. If Linda Jüris would have had me as a co-supervisor, then flaws, errors and neglected fact could have been included and the thesis could have been much more complete than the sieve that it constitutes in the present condition.

Page 54

References 1 American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Fourth ed. Washington, D.C.: American Psychiatric Association, 1994. 2 Anari M, Axelsson A, Eliasson A, Magnusson L. Hypersensitivity to sound - questionnaire data, audiometry and classification. Scand Audiol 1999;28: 219-30. 3 Andersson G, Baguley D, McFerran D, McKenna L. Tinnitus: a multidisciplinary approach. Second ed. London: Whiley-Blackwell, 2013. 4 Andersson G, Lindvall N, Hursti T, Carlbring P. Hypersensitivity to sound (hyperacusis): a prevalence study conducted via the internet and post. Int J Audiol 2002;41: 545-54. 5 Andersson G, Lyttkens, L. A meta-analytic review of psychological treatments for tinnitus. Br J Audiol 1999;33: 201-10. 6 Andersson G, Vretblad P, Larsen HC, Lyttkens L. Longitudinal follow-up of tinnitus complaints. Arch Otolaryngol Head Neck Surg 2001;127: 175-9. 7 Arlinger S, Kinnefors C. Reference equivalent threshold sound pressure levels for insert earphones. Scand Audiol 1989;18: 195-8. 8 Asmundson GJ, Katz J. Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art. Depress Anxiety 2009;26: 888-901. 9 Axelsson A, Ringdahl A. Tinnitus - a study of its prevalence and characteristics. Br J Audiol 1989;23: 53-62. 10 Baguley D. Hyperacusis. J R Soc Med 2003;96: 582-85. 11 Baguley D. Hyperacusis and disorders of loudness perception. In: Textbook of Tinnitus. Eds. Møller A R, et al. New York, N.Y.: Springer, 2011. pp. 13-23. 12 Baguley D, Andersson, G. Hyperacusis: mechanisms, diagnosis, and therapies. San Diego; Oxford: Plural Pub., 2007. 13 Beck A. The Diagnosis and management of depression. Philadelphia; Penn.: University of Pennsylvania Press, 1973. 14 Beck JS. Cognitive behavior therapy; basics and beyond. Second ed. New York, NY: Guilford Press, 2011. 15 Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res 2002;52: 69-77. 57 16 Blaesing L, Kröner-Herwig B. Self-reported and behavioral sound avoidance in tinnitus and hyperacusis subjects, and association with anxiety ratings. Int J Audiol 2012;51: 611-7. 17 Blomberg S, Rosander M, Andersson G. Fears, hyperacusis and musicality in Williams syndrome. Res Dev Disabil 2006;27: 668-80. 18 Boersma K, MacDonald S, Linton SJ. Longitudinal relationships between pain and stress problems in the general population: Predicting trajectories from cognitive behavoiral variables. J Appl Biobehav Res 2012;17: 229-48.

19 Bolger N, Zuckerman A. A framework for studying personality in the stress process. J Pers Soc Psychol 1995;69: 890-902. 20 Bryngelson A. Long-term sickness absence and social exclusion. Scand J Public Health 2009;37: 839-45. 21 Burns J, Day MA, Thom BE. Is reduction in pain catastrophizing a therapeutic mechanism specific to cognitive-behavioral therapy for chronic pain? Transl Behav Med 2012;2: 22-29. 22 Butler RW, Braff DL, Rausch JL, Jenkins MA, Sprock J, Geyer MA. Physiological evidence of exaggerated startle response in a subgroup of Vietnam veterans with combat-related PTSD. Am J Psychiatry 1990;147: 1308-12. 23 Carman JS. Imipramine in hyperacusic depression. Am J Psychiatry 1973;130: 937. 24 Carterette EC, Friedman, MP. Hearing. Handbook of perception. New York: Academic Press, 1978. 25 Cohen J. Statistical power analysis for the behavioural sciences. Rev. ed. New York, NY: Academic Press, 1977. 26 Cuijpers P, Smit F, Penninx BW, de Graaf R, ten Have M, Beekman AT. Economic costs of neuroticism: a population-based study. Arch Gen Psychiatry 2010;67: 1086-93. 27 Dauman R, Bouscau-Faure F. Assessment and amelioration of hyperacusis in tinnitus patients. Acta Otolaryngol 2005;125: 503-09. 28 Dimidjian S, Barrera MJr, Martell C, Munoz RF, Lewinsohn PM. The origins and current status of behavioral activation treatments for depression. Annu Rev Clin Psychol 2011;7: 1-38. 29 Dobie RA. A review of randomized clinical trials in tinnitus. Laryngoscope 1999;109: 1202-11. 30 Dworkin SF, Turner JA, Wilson L, Massoth D, Whitney C, Huggins KH, et al. Brief group cognitive-behavioral intervention for temporomandibular disorders. Pain 1994;59: 175-87. 31 Edelman S, Mahoney AE, Cremer PD. Cognitive behavior therapy for chronic subjective dizziness: a randomized, controlled trial. Am J Otolaryngol 2012;33: 395-401. 32 Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;196: 129-36. 33 Florentine M. Loudness. In: Springer handbook of auditory research (Loudness). Eds. Florentine M, Popper A and Fay R. Vol. 37. New York: Springer, 2011. pp. 1-15. 58

34 Formby C, Hawley M, Sherlock LP, Gold S, Parton J, Brooks R, et al. Intervention for restricted dynamic range and reduced sound tolerance: Clinical trial using a Tinnitus Retraining Therapy protocol for hyperacusis (presentation 4pPPc10). 2013. 3717. Vol. 133. 35 Formby C, Sherlock LP, Gold SL. Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background. J Acoust Soc Am 2003;114: 55-8. 36 Frisch MB, Clark MP, Rouse SV, Rudd MD, Paweleck JK,

Greenstone A, et al. Predictive and treatment validity of life satisfaction and the quality of life inventory. Assessment 2005;12: 66- 78. 37 Goebel G, Floetzinger U. Pilot study to evaluate psychiatric comorbidity in tinnitus patients with and without hyperacusis. Audiol Med 2008;6: 78-84. 38 Goldberg LR. The structure of phenotypic personality traits. Am Psychol 1993;48: 26-34. 39 Goldin PR, Ziv M, Jazaieri H, Werner K, Kraemer H, Heimberg RG, et al. Cognitive reappraisal self-efficacy mediates the effects of individual cognitive-behavioral therapy for social anxiety disorder. J Consult Clin Psychol 2012;80: 1034-40. 40 Goubert L, Crombez G, Van Damme S. The role of neuroticism, pain catastrophizing and pain-related fear in vigilance to pain: a structural equations approach. Pain 2004;107: 234-41. 41 Greimel KV, Kröner-Herwig B. Cognitive behavioral treatment (CBT). In: Textbook of Tinnitus. Eds. Møller AR, et al. New York, N.Y.: Springer, 2011. pp. 557-61. 42 Griffin MG, Resick PA, Galovski TE. Does physiologic response to loud tones change following cognitive-behavioral treatment for posttraumatic stress disorder? J Trauma Stress 2012;25: 25-32. 43 Gu JW, Halpin CF, Nam EC, Levine RA, Melcher JR. Tinnitus, diminished sound-level tolerance, and elevated auditory activity in humans with clinically normal hearing sensitivity. J Neurophysiol 2010;104: 3361-70. 44 Gunthert KC, Cohen LH, Armeli S. The role of neuroticism in daily stress and coping. J Pers Soc Psychol 1999;77: 1087-100. 45 Gustavsson JP, Bergman H, Edman G, Ekselius L, von Knorring L, Linder J. Swedish universities Scales of Personality (SSP): construction, internal consistency and normative data. Acta Psychiatr Scand 2000;102: 217-25. 46 Hallberg LR, Hallberg U, Johansson M, Jansson G, Wiberg A. Daily living with hyperacusis due to head injury 1 year after a treatment programme at the hearing clinic. Scand J Caring Sci 2005;19: 410-18. 47 Hannaford PC, Simpson JA, Bisset AF, Davis A, McKerrow W, Mills R. The prevalence of ear, nose and throat problems in the community: results from a national cross-sectional postal survey in Scotland. Fam Pract 2005;22: 227-33. 59

48 Hannula S, Bloigu R, Majamaa K, Sorri M, Mäki-Torkko E. Selfreported hearing problems among older adults: prevalence and comparison to measured hearing impairment. J Am Acad Audiol 2011;22: 550-59. 49 Harrop-Griffiths J, Katon W, Dobie R, Sakai C, Russo J. Chronic tinnitus: association with psychiatric diagnoses. J Psychosom Res 1987;31: 613-21. 50 Hasson D, Theorell T, Bergquist J, Canlon B. Acute stress induces

hyperacusis in women with high levels of emotional exhaustion. PLoS One 2013;8: e52945. 51 Hasson D, Theorell T, Wallen MB, Leineweber C, Canlon B. Stress and prevalence of hearing problems in the Swedish working population. BMC Public Health 11 (2011). <http://www.biomedcentral.com/1471-2458/11/130>. 52 Hebert S, Paiement P, Lupien SJ. A physiological correlate for the intolerance to both internal and external sounds. Hear Res 2004;190: 1-9. 53 Heinonen-Guzejev M, Jauhiainen T, Vuorinen H, Viljanen A, Rantanen T, Koskenvuo M, et al. Noise sensitivity and hearing disability. Noise Health 2011;13: 51-58. 54 Hesser H, Andersson G. The role of anxiety sensitivity and behavioral avoidance in tinnitus disability. Int J Audiol 2009;48: 295-99. 55 Hesser H, Weise C, Westin VZ, Andersson G. A systematic review and meta-analysis of randomized controlled trials of cognitivebehavioral therapy for tinnitus distress. Clin Psychol Rev 2011;31: 545-53. 56 Hilgenberg PB, Saldanha AD, Cunha CO, Rubo JH, Conti PC. Temporomandibular disorders, otologic symptoms and depression levels in tinnitus patients. J Oral Rehabil 2012;39: 239-44. 57 Hiller W, Haerkötter C. Does sound stimulation have additive effects on cognitive-behavioral treatment of chronic tinnitus? Behav Res Ther 2005;43: 595-612. 58 Hobson J, Chisholm E, El Refaie A. Sound therapy (masking) in the management of tinnitus in adults. Cochrane Database Syst Rev 2012;11: CD006371. 59 Hofmann SG, Meuret AE, Rosenfield D, Suvak MK, Barlow DH, Gorman JM, et al. Preliminary evidence for cognitive mediation during cognitive-behavioral therapy of panic disorder. J Consult Clin Psychol 2007;75: 374-79. 60 Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry 2008;69: 621-32. 61 Jastreboff PJ, Hazell JW. A neurophysiological approach to tinnitus: clinical implications. Br J Audiol 1993;27: 7-17. 62 Jastreboff PJ, Hazell JW, Graham RL. Neurophysiological model of tinnitus: dependence of the minimal masking level on treatment outcome. Hear Res 1994;80: 216-32. 60

63 Jastreboff PJ, Hazell JW. Tinnitus retraining therapy: implementing the neurophysiological model. Cambridge: Cambridge University Press, 2004. 64 Jastreboff PJ, Jastreboff MM. Tinnitus Retraining Therapy (TRT) as a method for treatment of tinnitus and hyperacusis patients. J Am Acad Audiol 2000;11: 162-77. 65 Kaldo V, Andersson, G. Kognitiv beteendeterapi vid tinnitus

(Swedish). Lund: Studentlitteratur, 2004. 66 Katzenell U, Segal S. Hyperacusis: review and clinical guidelines. Otol Neurotol 2001;22: 321-26; discussion 26-7. 67 Kendler KS, Czajkowski N, Tambs K, Torgersen S, Aggen SH, Neale MC, et al. Dimensional representations of DSM-IV cluster A personality disorders in a population-based sample of Norwegian twins: a multivariate study. Psychol Med 2006;36: 1583-91. 68 Kendler KS, Gatz M, Gardner CO, Pedersen NL. Personality and major depression: a Swedish longitudinal, population-based twin study. Arch Gen Psychiatry 2006;63: 1113-20. 69 Kennedy WP. The nocebo reaction. Med World 1961;95: 203-05. 70 Kessler RC, Angermeyer M, Anthony JC, de Graaf R, Demyttenaere K, Gasquet I, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization's world mental health survey initiative. World Psychiatry 2007;6: 168-76. 71 Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994;51: 8-19. 72 Khalfa S, Dubal S, Veuillet E, Perez-Diaz F, Jouvent R, Collet L. Psychometric normalization of a hyperacusis questionnaire. ORL J Otorhinolaryngol Relat Spec 2002;64: 436-42. 73 Klein AJ, Armstrong BL, Greer MK, Brown FR. Hyperacusis and otitis media in individuals with Williams syndrome. J Speech Hear Disord 1990;55: 339-44. 74 Kringlen E, Torgersen S, Cramer V. Mental illness in a rural area: a Norwegian psychiatric epidemiological study. Soc Psychiatry Psychiatr Epidemiol 2006;41: 713-19. 75 Kringlen E, Torgersen S, Cramer V. A Norwegian psychiatric epidemiological study. Am J Psychiatry 2001;158: 1091-98. 76 Kujawa SG, Liberman MC. Adding insult to injury: cochlear nerve degeneration after “temporary” noise-induced hearing loss. J Neurosci 2009;29: 14077-85. 77 Kunz R, Vist G, Oxman AD. Randomisation to protect against selection bias in healthcare trials. Cochrane Database Syst Rev 2007: MR000012. 78 Landon J, Shepherd D, Stuart S, Theadom A, Freundlich S. Hearing every footstep: noise sensitivity in individuals following traumatic brain injury. Neuropsychol Rehabil 2012;22: 391-407. 61

79 Laszlo HE, McRobie ES, Stansfeld SA, Hansell AL. Annoyance and other reaction measures to changes in noise exposure - a review. Sci Total Environ 2012;435-436: 551-62. 80 Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The Fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007;30: 77-94. 81 Lethem J, Slade PD, Troup JD, Bentley G. Outline of a Fearavoidance

model of exaggerated pain perception - I. Behav Res Ther 1983;21: 401-08. 82 Lisspers J, Nygren A, Söderman E. Hospital Anxiety and Depression Scale (HAD): some psychometric data for a Swedish sample. Acta Psychiatr Scand 1997;96: 281-86. 83 Litt MD, Shafer DM, Kreutzer DL. Brief cognitive-behavioral treatment for TMD pain: long-term outcomes and moderators of treatment. Pain 2010;151: 110-16. 84 Ljotsson B, Falk L, Vesterlund AW, Hedman E, Lindfors P, Rück C, et al. Internet-delivered exposure and mindfulness based therapy for irritable bowel syndrome - a randomized controlled trial. Behav Res Ther 2010;48: 531-39. 85 López González MÁ, López Fernández, RE, Ortega, F. Terapia sonora secuencial en acúfenos y hiperacusia: manual de instrucciones (Spanish). Barcelona, Spain: Premura, 2006. 86 Mansell W, Harvey A, Watkins E, Shafran R. Cognitive behavioural processes across psychological disorders: A review of the utility and validity of the transdiagnostic approach. Int J Cogn Ther 2008;1: 181- 91. 87 Marciano E, Carrabba L, Giannini P, Sementina C, Verde P, Bruno C, et al. Psychiatric comorbidity in a population of outpatients affected by tinnitus. Int J Audiol 2003;42: 4-9. 88 Marriage J, Barnes NM. Is central hyperacusis a symptom of 5- hydroxytryptamine (5-HT) dysfunction? J Laryngol Otol 1995;109: 915-21. 89 McFarlane AC, Weber DL, Clark CR. Abnormal stimulus processing in posttraumatic stress disorder. Biol Psychiatry 1993;34: 311-20. 90 McKenna L, Baguley D, McFerran D. Living with tinnitus and hyperacusis. London: Sheldon Press, 2010. 91 Meeus OM, Spaepen M, Ridder DD, Heyning PH. Correlation between hyperacusis measurements in daily ENT practice. Int J Audiol 2010;49: 7-13. 92 Miller R, Kori S, Todd D. The Tampa Scale: a measure of kinesiophobia. Clin J Pain 1991;7: 51-52. 93 Minor LB, Carey JP, Cremer PD, Lustig LR, Streubel SO, Ruckenstein MJ. Dehiscence of bone overlying the superior canal as a cause of apparent conductive hearing loss. Otol Neurotol 2003;24: 270-78. 62

94 Moliner Peiro F, López González MA, Alfaro García J, Leache Pueyo J, Esteban Ortega F. Open-field treatment of hyperacusis. Acta Otorrinolaringologica (English Edition) 2009;60: 38-42. 95 Moore BCJ. Cochlear hearing loss. London: Whurr, 1998. 96 Morley S, Eccleston C, Williams A. Systematic review and metaanalysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain 1999;80: 1-13.

97 Morris CA, Mervis CB. Williams syndrome and related disorders. Annu Rev Genomics Hum Genet 2000;1: 461-84. 98 Mowrer OH. Learning theory and behavior. New York, London: John Wiley & Sons 1960. 99 Møller AR, Berthold Langguth B, DeRidder D, Kleinjung T. Textbook of tinnitus. New York: Springer, 2010. 100 Neisser U. Cognition and reality: principles and implications of cognitive psychology. San Francisco: WH Freeman, 1976. 101 Nelting M, Rienhoff NK, Hesse G, Lamparter U. The assessment of subjective distress related to hyperacusis with a self-rating questionnaire on hypersensitivity to sound (German). Laryngorhinootologie 2002;81: 327-34. 102 Niu Y, Kumaraguru A, Wang R, Sun W. Hyperexcitability of inferior colliculus neurons caused by acute noise exposure. J Neurosci Res 2013;91: 292-99. 103 Norena AJ, Chery-Croze S. Enriched acoustic environment rescales auditory sensitivity. Neuroreport 2007;18: 1251-55. 104 Okeson JP, Moody PM, Kemper JT, Haley JV. Evaluation of occlusal splint therapy and relaxation procedures in patients with temporomandibular disorders. J Am Dent Assoc 1983;107: 420-24. 105 Perlman HB. Hyperacusis. Ann Otol Rhinol Laryngol 1938;47: 947- 53. 106 Phillips JS, McFerran D. Tinnitus Retraining Therapy (TRT) for tinnitus. Cochrane Database Syst Rev 2010: CD007330. 107 Rauch SD. Clinical practice. Idiopathic sudden sensorineural hearing loss. N Engl J Med 2008;359: 833-40. 108 Rosenhall U, Nordin V, Sandström M, Ahlsen G, Gillberg C. Autism and hearing loss. J Autism Dev Disord 1999;29: 349-57. 109 Sahley TL, Nodar RH. A biochemical model of peripheral tinnitus. Hear Res 2001;152: 43-54. 110 Salkovskis PM, Clark DM, Hackmann A, Wells A, Gelder MG. An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia. Behav Res Ther 1999;37: 559-74. 111 Sammeth CA, Preves DA, Brandy WT. Hyperacusis: case studies and evaluation of electronic loudness suppression devices as a treatment approach. Scand Audiol 2000;29: 28-36. 63

112 Schaaf H, Klofat B, Hesse G. Hyperacusis, phonophobia, and recruitment. Abnormal deviations of hearing associated with hypersensitivity to sound (German). HNO 2003;51: 1005-11. 113 Schneider TR, Rench TA, Lyons JB, Riffle RR. The influence of neuroticism, extraversion and openness on stress responses. Stress Health 2012;28: 102-10. 114 Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric

interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20: 22-33. 115 Sieurin L, Josephson M, Vingard E. Positive and negative consequences of sick leave for the individual, with special focus on part-time sick leave. Scand J Public Health 2009;37: 50-56. 116 Silberstein SD. Migraine symptoms: results of a survey of selfreported migraineurs. Headache 1995;35: 387-96. 117 Simoens VL, Hebert S. Cortisol suppression and hearing thresholds in tinnitus after low-dose dexamethasone challenge. BMC Ear Nose Throat Disord 12.4 (2012). <http://www.biomedcentral.com/1472- 6815/12/4>. 118 Sjödin F, Kjellberg A, Knutsson A, Landström U, Lindberg L. Noise and stress effects on preschool personnel. Noise Health 2012;14: 166- 78. 119 Sjödin F, Kjellberg A, Knutsson A, Landström U, Lindberg L. Noise exposure and auditory effects on preschool personnel. Noise Health 2012;14: 72-82. 120 Skarzynski H, Rogowski M, Bartnik G, Fabijanska A. Organization of tinnitus management in Poland. Acta Otolaryngol 2000;120: 225-26. 121 Stansfeld SA. Noise, noise sensitivity and psychiatric disorder: epidemiological and psychophysiological studies. Psychol Med 1992;Suppl 22: 1-44. 122 Stansfeld SA, Clark CR, Turpin G, Jenkins LM, Tarnopolsky A. Sensitivity to noise in a community sample: II. Measurement of psychophysiological indices. Psychol Med 1985;15: 255-63. 123 Statens beredning för medicinsk utvärdering (SBU). Diagnostik och uppföljning av förstämningssyndrom. En systematisk litteraturöversikt. Statens beredning för medicinsk utvärdering (SBU). SBU-rapport nr 212 (Swedish). Stockholm, Sweden, 2012. 124 Sundel M, Sundel S. Behavior change in the human services: behavioral and cognitive principles and applications. Fifth ed. Thousand Oaks, CA.: Sage, 2005. 125 Tolin DF. Is cognitive-behavioral therapy more effective than other therapies? A meta-analytic review. Clin Psychol Rev 2010;30: 710-20. 126 Tuz HH, Onder EM, Kisnisci RS. Prevalence of otologic complaints in patients with temporomandibular disorder. Am J Orthod Dentofacial Orthop 2003;123: 620-23. 64

127 Tzaneva L, Savov A, Damianova V. Audiological problems in patients with tinnitus exposed to noise and vibrations. Cent Eur J Public Health 2000;8: 233-35. 128 Walander A, Ålander, S., Burström, B. Sociala skillnader i vårdutnyttjande: yrkesverksamma åldrar (Swedish). Vård på lika villkor. Stockholm: Enheten för socialmedicin och hälsoekonomi, Samhällsmedicin, Stockholms läns landsting, 2004. 129 Valente DL, Plevinsky HM, Franco JM, Heinrichs-Graham EC, Lewis DE. Experimental investigation of the effects of the acoustical

conditions in a simulated classroom on speech recognition and learning in children. J Acoust Soc Am 2012;131: 232-46. 130 Weinstein ND. Individual differences in reactions to noise: a longitudinal study in a college dormitory. J Appl Psychol 1978;63: 458-66. 131 Vernon J, Schleuning A. Tinnitus: a new management. Laryngoscope 1978;88: 413-19. 132 Vernon J. Pathophysiology of tinnitus: a special case - hyperacusis and a proposed treatment. Am J Otol 1987;8: 201-02. 133 Westbrook D, Kennerley H, Kirk J. An introduction to cognitive behaviour therapy: skills and applications. Second ed. Los Angeles, CA.: Sage, 2011. 134 Westin V, Hayes SC, Andersson G. Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact. Behav Res Ther 2008;46: 1259-65. 135 Vingen JV, Pareja JA, Storen O, White LR, Stovner LJ. Phonophobia in migraine. Cephalalgia 1998;18: 243-49. 136 Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain 2000;85: 317-32. 137 Woodhouse A, Drummond PD. Mechanisms of increased sensitivity to noise and light in migraine headache. Cephalalgia 1993;13: 417-21. 138 World Medical Association General A. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. J Int Bioethique 2004;15: 124-29. 139 Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67: 361-70. 140 Zöger S, Svedlund J, Holgers KM. Psychiatric disorders in tinnitus patients without severe hearing impairment: 24 month follow-up of patients at an audiological clinic. Audiology 2001;40: 133-40. 141 Öst LG. Applied relaxation: description of a coping technique and review of controlled studies. Behav Res Ther 1987;25: 397-409. All in all this thesis is severely flawed. The opponent has not had sufficient knowledge – because if she would have had, then she would have pointed out most of the remarks that I have made. She has not! The opponent must therefore be biased and/or useless in audiology. Anyway she was the wrong person as an opponent. The examiners have insufficient knowledge as they have been approving Linda Jüris’ disputation and made her pass the “exam”. The examiners must therefore be biased and/or useless in audiology. Anyway they were the wrong people as examiners. The supervisor and the co-supervisors obviously have insufficient knowledge in audiology as they have allowed Linda Jüris to include all errors in their own study and in the thesis of the dissertation of Linda Jüris. They have proven themselves to obstruct the collection of sufficient knowledge and they have agreed to neglect important scientific references and knowledge. The scientific level of the studies and the thesis must therefore be of ridiculously poor quality and this discovery is planned to be included in a coming scientific article.

I am attaching documents (emails) revealing that Linda Jüris has confirmed to me that she is forbidden by her supervisor/co-supervisors to cooperate with me. Attached is also a recording where Lisa Ekselius in an interview answers that a supervisor would never steer their pupils/students. The remarks made here are regarding the: Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine 934 Hyperacusis Clinical Studies and Effect of Cognitive Behaviour Therapy Linda Jüris ISSN 1651-6206 ISBN 978-91-554-8756-0 urn:2013 nbn:se:uu:diva-207577 Hovmantorp on the 21st of November 2013 Michael Zazzio AudioLaser-Kliniken Parkgatan 2 360 51 Hovmantorp Sweden Phone: +46-478-41737 Cell phone: +46-70-2748080