A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
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Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ] 32 was obtained from the patient to report this case. CASE REPORT Mr. B was a 47-year-old man who was referred to the psychiatry outpatient services of a tertiary referral neurosciences center by his treating psychiatrist for evaluation of anxiety symptoms that were not responding to a conventional anti- anxiety regimen. The patient primarily reported feeling anxious in social situations and during conversations with his superiors at his place of employment over the last 25 years. The anxiety was associated with autonomic arousal, thoughts of being scrutinized by others, and avoidance of social situations. Mr. B's family members described him as shy and reserved since childhood, with no intellectual disability. His past medical, psychiatric, and developmental history was uneventful. Detailed physical examination and biochemical tests inclusive of renal, liver, thyroid functions, serum electrolytes, and fasting blood glucose were normal. Mr. B was currently taking escitalopram for anxiety. Mr. B's clinical presentation fulfilled criteria for social phobia as per the International Statistical Classification of Diseases and Related Health Problems, Tenth Edition (ICD-10). 3 However, during the clinical interview, Mr. B was observed to have difficulty in understanding our questions unless they were repeated two to three times. He attributed his anxiety to difficulty in understanding conversations, a symptom that had been present since childhood. He reported continued difficulty understanding instructions from his superiors at work that affected his work performance and made him feel more anxious. His anxiety was most pronounced during phone conversations. Hence, the specific sound of a mobile ringtone or a ringing land phone would trigger autonomic arousal in him that was characterized by palpitations, sweating, tremors, and dryness of mouth. Examination by the otorhinolaryngologist ruled out any middle ear pathology. Magnetic resonance imaging (MRI) of the brain a nd an electroencephalography (ECG) did not reveal any abnormalities. Consultation from the Department of Speech Pathology and Audiology was sought for the assessment of his difficulties in perceiving speech. The audiological history was ascertained and reconfirmed. A host of audiological tests were administered that included pure tone and speech (speech recognition threshold [SRT], speech identification score [SIS], and speech-in-noise [SPIN] test); audiometry acoustic stapedius reflex test (ASRT); auditory brain stem responses (ABR); distortion product otoacoustic emissions (DPOAE); gap detection threshold (GDT); and dichotic digits test (DDT). These audiological tests were performed using standard clinical test procedures. The audiological test results are presented in Table 1. The patient demonstrated the following: mild-to-moderate sensorineural hearing loss (pure tone average [PTA] of 500Hz, 1K.Hz, and 2K.Hz: right ear 31.6dB, left ear 35dB), absence of acoustic stapedius reflex with "A" type tympanograms, and absence of ABR with presence of cochlear microphonics. The speech identification score was poor (right ear 40%, left ear 45%) and was pronounced under speech-in-noise conditions (right ear 20%, left ear 18%). The DDT demonstrated bilateral suppression (right: 37.5%, left: 47.5%). The GDT was greater than 20m.sec in both ears, which suggested impairment in temporal resolution. The audiological findings indicated a diagnosis of ANSD, although the otoacoustic emissions (OAE) were absent in both ears. DISCUSSION Mr. B initially presented with social anxiety disorder, and through the course of interviews, he was observed to have difficulties in speech perception, which led to an audiological evaluation with a clinical TABLE 1. Results of audiological investigations performed on Mr. B RIGHT EAR AUDIOLOGICAL TESTS LEFT EAR 31dB HL PTA 35dB HL 40dB HL SRT 50dB HL 40% SIS 50% 20% SPIN 18% A type Tympanogram A type Absent ASRT Absent 37.50% DDT-FR 47.50% >20m.sec GDT >20 m.sec Absent ABR Absent Present CM Present Absent DPOAE Absent PTA: puretone average of 500, 1000, and 2000Hz; SRT: speech recognition threshold; SIS: speech identification score; SPIN: speech-in-noise; ASRT: acoustic stapedius reflex test (ipsilateral and contralateral); DDT-FR: dichotic digits test-free recall; GDT: gap detection threshold; ABR: auditory brainstem response; CM: cochlear microphonic; DPOAE: distortion product otoacoustic emission