Non-Organic Functional Hearing loss

Understanding Non-Organic Functional Hearing Loss

Non-Organic Functional Hearing loss (NOFHL) is not a common finding. In simple terms, it describes a situation where a reported hearing loss doesn't match the test findings. The hearing loss may be more severe than expected. Various terms exist for NOFHL, including pseudohypacusis and malingering. NOFHL can pose significant challenges in audiology if not properly understood.


At Audiology First, we recognize that some individuals may exaggerate or fabricate hearing difficulties for various reasons. Our team employs a range of evidence-based methods to accurately assess hearing capabilities and ensure that every patient receives the appropriate care they need. Few patients with NOFHL have a truly malicious intent, and we take every effort to treat every patient with dignity, respect and understanding for their circumstances.

  • Pathophysiology

    There's no organic issue. Malingering is driven by external gain, factitious disorder by psychological gain, and conversion disorder is an unconscious translation of emotional trauma into physical symptoms. 

  • Etiology

    The underlying causes range from unconscious conversion disorder (low intent, often after trauma) to factitious disorder (moderate intent, seeking sick role benefits) and conscious malingering (high intent, often for secondary gain like compensation). Motives can shift over time. In children, it can be linked to trauma or academic stress.

  • Epidemiology

    NOFHL prevalence is likely underestimated. It's more common in children (peak age 10-12, possibly due to educational stress) than adults, though adults aged 19-57 are also affected. Bilateral involvement and female predominance are common.

  • Clinical Presentation

    Careful observation is crucial. Inconsistencies in behavior (e.g., reacting to sound when not looking), soft speech, and referral sources (e.g., insurance companies) can be clues. History should explore onset, progression, associated symptoms, and potential emotional stressors. Otological and cranial nerve exams are usually normal.

  • Complications

    Misdiagnosis or delay can lead to unnecessary investigations, treatments (including surgery and cochlear implants), and harmful steroid use. Untreated underlying conflicts can manifest as other nonorganic symptoms

  • Evaluation

    Refer to Audiology. Oftentimes, diagnostic investigations will find a lack of consistency in audiological testing, reported difficulties, and observations of the patient's performance in the clinic. Objective tests (ABR, OAE) show better hearing than subjective tests (audiogram, speech audiometry). Variability in audiogram thresholds, unusual audiogram curves, and inconsistencies between audiometry and speech audiometry are suggestive. The Stenger test can help in unilateral cases.

  • Treatment

    Management ranges from observation to counseling (non-confrontational highlighting of inconsistencies, reassurance) and psychiatric intervention (if underlying psychological issues are suspected). Addressing the underlying motive is crucial to prevent recurrence. Placebos should be avoided. Counseling patients about test inconsistencies and the potential for improvement is important. Addressing underlying psychiatric needs and emphasizing follow-up are crucial. Parents and teachers of affected children need to understand the reality of the child's experience.

An interprofessional team (audiologist, otolaryngologist, psychiatrist/psychologist, general physician, child neurologist, parents/teachers) is vital for accurate diagnosis and management. Audiologists are key in observing inconsistencies. Psychiatrists/psychologists address underlying stressors. General physicians can provide psychological history.

References

Hussain SAS, Hohman MH. Nonorganic Functional Hearing Loss. [Updated 2023 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK580555/