Misophonia

Misophonia
Other names	selective sound sensitivity syndrome, [1] misophonic disorder, [2] select sound sensitivity syndrome, [3] soft sound sensitivity symptom, [3] sound-rage [3] [4] [5]
Pronunciation	/ˌmɪ.səˈfəʊ.ni.ə/
Specialty	Psychiatry, clinical psychology, audiology
Complications	social isolation, extreme trigger avoidance, relationship difficulties, anxiety (particularly phonophobia), maladaptive coping strategies (including suicidality, aggression, and self-harm) [3] [6] [7]
Usual onset	Variable (childhood through adulthood), with most common onset in childhood/early adolescence [6]
Causes	Neuropsychological and perceptual processing differences of unclear etiology [3] [8]
Treatment	Most evidence for specialized forms of cognitive-behavioral therapy, [9] [10] [11] with extremely limited (case report/series-level) evidence for other psychotherapy modalities, Tinnitus Retraining Therapy, and certain medications. [10] [11]

Misophonia (or selective sound sensitivity syndrome) is a disorder of decreased tolerance to specific sounds or their associated stimuli, or cues. These cues, known as "triggers", are experienced as unpleasant or distressing and tend to evoke strong negative emotional, physiological, and behavioral responses not seen in most other people. ^[7] Misophonia and the behaviors that people with misophonia often use to cope with it (such as avoidance of "triggering" situations or using hearing protection) can adversely affect the ability to achieve life goals, communicate effectively, and enjoy social situations. ^{[3] [6]} Originating within the field of audiology in 2001, ^[12] the condition remained largely undescribed in the clinical and research literature until 2013, when a group of psychiatrists in Amsterdam published a detailed misophonia case series and proposed the condition as a "new psychiatric disorder" with defined diagnostic criteria. ^[13] At present, misophonia is not listed as a diagnosable condition in the DSM-5-TR, ICD-11, or any similar manual. ^{[7] [14] [15] [16]} But an international panel of experts on misophonia has rigorously established a consensus definition of it as a medical condition, ^[7] and since its initial publication in 2022, this definition has been widely adopted by clinicians and researchers studying the condition. ^{[17] [18]}

When confronted with specific "trigger" stimuli, people with misophonia experience a range of negative emotions, most notably anger, extreme irritation, disgust, anxiety, and sometimes rage. ^[7] The emotional response is often accompanied by a range of physical symptoms (e.g., muscle tension, increased heart rate, and sweating) that may reflect activation of the fight-or-flight response. ^[7] Unlike the discomfort seen in hyperacusis, misophonic reactions do not seem to be elicited by the sound's loudness but rather by the trigger's specific pattern or meaning to the hearer. ^{[19] [20] [21]} Many people with misophonia cannot trigger themselves with self-produced sounds, or if such sounds do cause a misophonic reaction, it is substantially weaker than if another person produced the sound. ^{[6] [7]}

Misophonic reactions can be triggered be many different auditory, visual, and audiovisual stimuli. ^[7] The most commonly reported auditory triggers are mouth sounds (chewing/eating, lip-smacking, slurping, coughing, throat clearing), nasal sounds (breathing, sniffing, nose-whistling), repetitive sounds produced by other people or objects (pen clicking, clacking of a mechanical keyboard, foot-tapping, clock-ticking), and sounds produced by animals. ^{[6] [7]} Although less well studied, reported visual triggers include another person's repetitive movements (foot/leg shaking, arms swinging, hands rubbing together, hair twirling, fidgeting), as well as the sight of an auditory trigger that one cannot actually hear (such as someone chewing with their mouth open or tapping their fingers on a desk). ^{[6] [7] [22]} The term misokinesia has been proposed to refer specifically to misophonic reactions to visual stimuli. ^{[13] [22]} Once a trigger stimulus is detected, people with misophonia may have difficulty distracting themselves from the stimulus and may experience suffering, distress, and/or impairment in social, occupational, or academic functioning. ^[7] Many people with misophonia are aware that their reactions to misophonic triggers are disproportionate to the circumstances, ^[7] and their inability to regulate their responses to triggers can lead to shame, guilt, isolation, and self-hatred, as well as worsening hypervigilance about triggers, anxiety, and depression. ^{[23] [24] [25]} Studies have shown that misophonia can cause problems in school, work, social life, and family. ^[17] In the United States, misophonia is not considered one of the 13 disabilities recognized under the Individuals with Disabilities Education Act (IDEA) as eligible for an individualized education plan, ^[26] but children with misophonia can be granted school-based disability accommodations under a 504 plan. ^[27]

The expression of misophonia symptoms varies, as does their severity, which can range from mild and sub-clinical to severe and highly disabling. ^{[2] [7]} The reported prevalence of clinically significant misophonia varies widely across studies due to the varied populations studied and methods used to determine whether a person meets criteria for the condition. ^[28] But the three highest-quality studies (i.e., those that used probability-based sampling methods) estimated that 4.6–12.8% of adults may have misophonia that rises to the level of clinical significance. ^{[29] [30] [31]} Misophonia symptoms are typically first observed in childhood or early adolescence, though the onset of the condition can be at any age. ^{[6] [7]} Treatment primarily consists of specialized cognitive-behavioral therapy, ^[10] with limited evidence to support any one therapy modality or protocol over another and some studies demonstrating partial or full remission of symptoms with this or other treatment, such as psychotropic medication. ^[11]

Terminology and origins of the concept

Pawel Jastreboff and Margaret M. Jastreboff coined the term "misophonia" in 2001 with the assistance of Guy Lee, ^{[32] [33]} introducing it in their article "Hyperacusis", ^[34] with further explanation in the International Tinnitus and Hyperacusis Society's ITHS Newsletter. ^[12]

"Misophonia" comes from the Ancient Greek words μῖσος (IPA: /mîː.sos/), meaning "hate", and φωνή (IPA: /pʰɔː.nɛ̌ː/), meaning "voice" or "sound", loosely translating to "hate of sound", and was coined to differentiate the condition from other forms of decreased sound tolerance, such as hyperacusis (hypersensitivity to certain frequencies and volume ranges) and phonophobia (fear of sounds). ^{[5] [35] [12]}

The term "misophonia" was first used in a peer-reviewed journal in 2002. ^[36] Before that, the disorder was more commonly called "selective sound sensitivity syndrome", or "4S", a term coined by audiologist Marsha Johnson. ^[17] Other names formerly used for the condition include "soft sound sensitivity symptom", "select sound sensitivity syndrome", "decreased sound tolerance", and "sound-rage". ^[3]

In their seminal 2013 case series of patients with misophonia, Schröder and colleagues coined the term "misokinesia" (a term analogous to misophonia translating to "hatred of movement") ^[13] to describe misophonia-like reactions that occur when people are "triggered" by specific repetitive visual stimuli, such as another person's foot shaking, fingers tapping, or gum chewing. ^[22] Other authors have proposed "Conditioned Aversive Response Disorder" (C.A.R.D.) as a more suitable name, which seeks to incorporate both auditory and non-auditory aspects of misophonia/misokinesia into a single condition. ^[37]

Adopting DSM-5-like terminology, some research groups have also advocated the term "misophonic disorder" ^[2] to distinguish clinically significant and disabling misophonia from what they term "misophonic reactions" (i.e., sub-clinical manifestations of misophonia that do not cause marked distress or substantially impair a person's daily life, relationships, or activities). ^[2]

Notably, of the above terms, only "misophonia" is widely used by researchers, clinicians, and sufferers of the condition. It is the primary term used for the condition in mainstream journalistic coverage ^{[38] [39] [40] [41]} and by the primary philanthropic agency funding research into it (The Misophonia Research Fund [MRF]), ^[42] and the term selected for use in an (MRF-funded) project to derive a field-wide consensus definition of the condition for clinical and research use. ^[7]

Signs and symptoms

Misophonia is a disorder of sound tolerance characterized by extreme and disproportionate emotional reactions to specific sounds (or less commonly, visual stimuli) in one's environment, termed "triggers." ^[7] Trigger stimuli are experienced as extremely unpleasant or distressing and tend to evoke a "misophonic reaction" that consists of both unpleasant negative emotions (i.e., extreme irritation, anger, anxiety, or disgust; less commonly rage or panic) and increased sympathetic arousal(manifested in physical symptoms such as muscle tension, increased heart rate, and sweating). ^{[6] [7]}

Trigger stimuli are highly varied and sometimes idiosyncratic, but certain stimuli such as chewing and other oronasal sounds are among the most commonly reported triggers in both clinically referred and population-based samples. ^{[6] [7]} The Duke Misophonia Questionnaire, ^[43] a commonly used misophonia symptom measure, groups misophonia triggers into the following categories:

• People making mouth sounds while eating or drinking (e.g., chewing, crunching, slurping).
• People making nasal/throat sounds (e.g., sniffing, sneezing, nose-whistling, coughing, throat-clearing).
• People making mouth sounds when not eating (e.g., making the "tsk" sound, heavy breathing, snoring, whistling).
• People making repetitive sounds (e.g., typing, tapping nails on table, pen clicking, writing, construction work, using machinery).
• Rustling or tearing objects (e.g., paper, plastic).
• Speech sounds (e.g., "p" sounds, hissing "s" sounds, someone speaking with a lisp, high-pitched voices).
• Body or joint sounds (e.g., snapping fingers, cracking joints, jaw clicking).
• Rubbing sounds (e.g., hands on pants, hands against one another, Styrofoam rubbing together).
• Stomping or loud walking (e.g., heels clicking, flip flops, etc.).
• Muffled sounds (e.g., voices separated by a wall, TV/music in another room).
• People talking in the background (e.g., phone calls in public, many people talking at once).
• Repetitive or continuous sounds not made by a person (e.g., clock ticking, air conditioner humming, water running).
• Animals making repetitive sounds (e.g., licking, chirping, barking, eating, drinking).
• Seeing someone making or about to make a sound that bothers you, even if you can't hear it (e.g., seeing someone reach into a bag of chips, seeing someone eating on TV with the volume off).

Reactions to triggers can range from mild (extreme irritation, anxiety, disgust, and/or physical discomfort) to severe (anger, rage, hatred, fear, panic, and/or profound emotional distress). ^[7] A number of physical symptoms may also accompany the misophonic response, including muscle tension, increased heart rate, sweating, and a feeling of pressure in one's body. ^{[6] [7] [17]} Other idiosyncratic physical and cognitive symptoms are also possible. ^{[6] [17]}

Cognitive and behavioral reactions to misophonic triggers fall into the following domains, based on the "S-Five Model" of the condition: ^{[44] [45] [46] [47] [48]}

• Internalizing appraisals such as self-critical thoughts, feeling guilty about one's reactions, and feeling ashamed for reacting to triggers
• Externalizing appraisals such as blaming others for making triggering sounds, feeling that others are being selfish or disrespectful, and believing that specific sounds are "just bad manners" and should never be made by anyone
• Anxiety/avoidance responses such as isolating oneself, moving away from the sound, or limiting opportunities to avoid potential trigger exposure
• Feeling threatened/overwhelmed such as feeling trapped, having thoughts of helplessness, or panicking when one can't escape a trigger
• Aggressive outbursts such as yelling, screaming, pushing, hitting, throwing things, or (rarely in adults) becoming physically violent

People with misophonia, particularly adults, are typically aware that their emotional reactions and behaviors in response to triggers are disproportionate to the situation, ^[17] and this frequently causes some degree of internal conflict due to a desire to suppress these reactions. ^[23]

The first misophonic reaction typically occurs when a person is young, often between the ages of 9 and 13. ^[6] But misophonia can have an onset at any age, with cases as young as two years old and a number of adult-onset cases reported in the literature. ^{[17] [6]} The initial misophonic reaction will often originate from someone in a close relationship or a pet. ^[49]

Fear and anxiety associated with trigger sounds can cause people with this condition to avoid important social and other interactions that may expose them to these sounds. ^[6] This avoidance and other behaviors can make it harder for them to achieve their goals and enjoy interpersonal interactions. ^{[5] [25]} It can also have a significant adverse effect on their careers and relationships. ^[17] Many people with misophonia experience worsening mental health, and some develop psychopathology secondary to their misophonia, including depression, anxiety, phonophobia, self-harm behaviors, and suicidality. ^{[17] [25] [50] [51]}

Mechanism

Misophonia's mechanism is not yet fully understood, but it appears that it may be caused by a dysfunction of the central nervous system in the brain and not of the ears. ^{[16] [4]} The perceived origin and context of the sound appears to play an important role in triggering a reaction. ^[4]

A 2017 study ^[52] found that the anterior insular cortex (which plays a role both in emotions like anger and in integrating outside input, such as sound, with input from organs such as the heart and lungs) causes more activity in other parts of the brain in response to triggers, particularly in the parts responsible for long-term memories, fear, and other emotions. It also found that people with misophonia have higher amounts of myelin (a fatty substance that wraps around nerve cells in the brain to provide electrical insulation). It is not clear whether myelin is a cause or an effect of misophonia and its triggering of other brain areas. ^[53]

A 2021 study found that the orofacial motor cortex, a part of the brain representing lip, jaw, and mouth movement, has enhanced activation for typical trigger sounds much more than for aversive or neutral sounds in misophonia sufferers. It also found enhanced functional connectivity between orofacial motor cortex and secondary auditory cortex during sound perception for any sound. It further reported resting state fMRI functional connectivity between orofacial motor cortex and secondary auditory and visual brain areas as well as secondary interoceptive cortex (left anterior insula). This suggests that misophonia, which is typically thought of as a disorder of sound emotion processing, is a result of overactivation of the motor mirror neuron system involved in producing the movements associated with these trigger sounds or images. ^[54]

Diagnosis

In 2022, clinical and scientific leaders convened to create a consensus definition of misophonia, ^[7] agreeing that it is a disorder of decreased tolerance to specific sounds and their associated stimuli. Before this consensus definition was reached, scholars and clinicians debated how to describe and define misophonia, which has limited comparison of study cohorts and hampered the development of standard diagnostic criteria. ^[7]

Misophonia is distinguished from hyperacusis, which is not specific to a given sound and does not involve a similar strong reaction, and from phonophobia, which is a fear of loud sounds, ^[49] but it may occur with either. ^[55] There are no standard diagnostic criteria, ^{[14] [49]} and many doctors are unaware of the disorder. ^[7]

Studies show that misophonia often has related comorbid conditions, including anxiety disorders, post-traumatic stress disorder, ^[56] OCD, ^{[57] [58] [59]} and depressive disorders. ^{[60] [61]} Some research supports the belief that misophonia is genetic, but more research is needed. ^[62] It appears that misophonia can occur on its own or along with other health, developmental, and psychiatric problems. ^[7] When attempting to diagnose a patient with misophonia, doctors sometimes mistake its symptoms for an anxiety disorder, bipolar disorder, or obsessive-compulsive disorder. ^[7]

Despite misophonia's relative phenotypic distinctiveness, it has been suggested that it belongs to the spectrum of obsessive-compulsive-and-related disorders. ^{[63] [15] [17]} Indeed, distinguishing certain elements of misophonia from those of obsessive-compulsive disorder and obsessive-compulsive personality disorder may be difficult, as many features often overlap. ^{[64] [65] [66] [67] [68]}

Classification

The diagnosis of misophonia is not recognized in the DSM-5-TR or the ICD-11, and it is not classified as a hearing or psychiatric disorder. ^[49] It may be a form of sound–emotion synesthesia, and has parallels with some anxiety disorders. ^[16] A 2022 structured study of prominent researchers resulted in the creation of the consensus definition of misophonia, determining that misophonia should be classified as a disorder, and not a symptom of another condition or syndrome. ^[7] During the early phase of research on misophonia, it was defined by different criteria with variable methods used to diagnose and assess symptom severity. As a result of lack of consensus about how to define and evaluate misophonia, comparisons between study cohorts were difficult, measurement tools were not psychometrically well-validated, and the field could not rigorously assess the efficacy of different treatment approaches. The creation of the definition serves as the foundation of future diagnostic criteria and validated diagnostic tools, and brings cohesion to the diverse and interdisciplinary misophonia research and clinical communities. ^[7]

Management

Health care providers generally try to help people cope with misophonia by recognizing what the person is experiencing and working on coping strategies. ^[49] A majority of smaller studies done on the subject have focused on the use of tinnitus retraining therapy, cognitive behavioral therapy and exposure therapy, which is believed to decrease the person's awareness of their trigger sounds. ^[5] These treatment approaches have not been sufficiently studied to determine their effectiveness. ^{[5] [35]} Other possible treatment options have been theorized by researchers, including acceptance-based approaches and mindfulness. ^[5] Ultimately, it is speculated that treatment methods may vary significantly in effectiveness from patient to patient. ^[5]

Minimal research has been conducted on the possible effects of neuromodulation and pharmacologic treatments. A study published in 2022 suggests that some forms of misophonia treatment may vary in effectiveness based on the preference of each patient, particularly in cases of parents with children who have misophonia. ^[69] In addition, the use of propranolol has also been found to be helpful in some patients. ^[70]

Clomipramine has anecdotally been found to be of use in at least a certain subset of people suffering from disorders allied with hyperacusis; ^[71] given its success in the treatment of obsessive-compulsive disorder, it may have a place in the treatment of misophonia, ^[72] which appears to have parallels with both conditions. Clomipramine does appear to have a distinct potential mediating effect on auditory-tone processing. ^{[73] [74]} One specific phenomenon observed to this end with clomipramine in at least one instance is reduced electrodermal reactivity to innocuous auditory stimuli. ^[75]

Whether pindolol (a beta-blocker with similar action to propranolol and augmentative therapeutic effects in obsessive-compulsive disorder ^[76] ) and certain selective serotonin reuptake inhibitors (e.g., fluvoxamine, escitalopram, fluoxetine) can also prove effective in the treatment of misophonia likewise remains to be seen.

Large-scale research has not yet been conducted, but observation of coping strategies people with misophonia use has shown some consistent results. ^[5] People with misophonia often cope by avoiding distressing situations or distracting themselves from such situations, ^[77] for example by using earplugs or headphones, mimicking trigger sounds, and playing music. ^[78]

Sequent repatterning therapy

The SRT process is associated with this logo, registered in 2019

Sequent Repatterning therapy for misophonia (SRT) is based on the idea that emotional responses are learned and consolidated over time, rather than innate, which makes it a form of cognitive behavioral therapy. ^[79] Development of this therapy began in 2012 when researcher Christopher Pearson applied aspects of hypnotherapy, parts work therapy, and NLP to create a therapy model for misophonia. He presented his work to the International Association of Neuropsychotherapy in 2017 and an article, "Reviewing Misophonia and its Treatment", ^[80] was published in International Journal of Neuropsychotherapy later that year. Pearson also contributed to the proposals for diagnostic criteria for misophonia, published in Frontiers. ^[81] Sequent Repatterning practitioners apply these diagnostic steps when assessing potential clients. Sequent Repatterning Therapy is not generally accepted by the clinical community and has not been shown to be an effective therapy for misophonia, which has not been shown to be caused by habituation. Habituation-based therapies often exacerbate symptoms instead of easing them.

Epidemiology

Research is still being conducted on misophonia's global prevalence, but a 2023 study found its prevalence in the UK to be around 18%. ^[82] This study has been cited in popular outlets, including BBC, ^[83] Medscape, ^[84] and Medical Xpress. ^[85] Studies of misophonia's global prevalence have found it to be as low as 5% and as high as 20%. ^[82] Its prevalence and severity seem to be similar across genders. ^[82] In the U.S., it is estimated that 3% of people are affected by misophonia. But in multiple studies, it was determined misophonia may be underdiagnosed (it is not yet an officially diagnosable condition), as it is correlated with other auditory disruptions; 92% of patients who are hyperaware of sounds also have misophonia. ^[17] There is evidence that significant numbers of undergraduate students in some psychology and medical-science departments suffer from misophonia. ^[86] The University of Nottingham conducted a study of misophonia in one sample of undergraduate medical students. ^[87] In 2017, similar rates were found in one university in China, ^[88] suggesting that the disorder is not specific to a culture.

It may be the case that people with misophonia are more likely to have high fluid intelligence. ^[89]

Associated symptoms

Some people^{[ who? ]} have sought to relate misophonia to autonomous sensory meridian response, or auto-sensory meridian response (ASMR), a pleasant form of paresthesia, a tingling sensation that typically begins on the scalp and moves down the back of the neck and upper spine. ^[90] ASMR is described as the opposite of what can be observed in reactions to specific audio stimuli in misophonia. ^[91] There are plentiful anecdotal reports of people who claim to have both misophonia and ASMR. Common to these reports is the experience of ASMR in response to some sounds and misophonia in response to others. ^{[91] [92] [93]}

Society and culture

People who experience misophonia have formed online support groups. ^{[94] [13]}

In 2016, a documentary about the condition, Quiet Please, was released. ^[95]

In 2020, a team of misophonia researchers ^[13] received the Ig Nobel Prize in medicine "for diagnosing a long-unrecognized medical condition". ^[96]

The 2022 film Tár depicts a conductor with misophonia. ^[97]

Season 1, episode 4 of Hulu's The Old Man has a brief discussion of misophonia. ^[98]

Notable cases

This is a dynamic list and may never be able to satisfy particular standards for completeness. You can help by adding missing items with reliable sources.

• Melissa Gilbert ^[99]
• Richard E. Grant ^[100]
• Barron H. Lerner ^[101]
• Lisa Loeb ^[102]
• Melanie Lynskey ^[103]
• Laila McQueen ^[104]
• Pharrell Williams ^[105]
• Kelly Osbourne ^[106]
• Kelly Ripa ^[107]
• Sarah Silverman ^[108]

See also

• Stimulus control
• Safe listening
• Hyperacusis
• Phonophobia
• Sensory Processing Disorder
• Tinnitus retraining therapy
• Noise control
• Hearing protection device
• Active noise control

References

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Further reading

• Jastreboff PJ (January 2017). "Tinnitus, Hyperacusis, Misophonia☆". Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier. doi:10.1016/B978-0-12-809324-5.02028-9. ISBN   978-0-12-809324-5.

External links

• The Duke Center for Misophonia and Emotion Regulation, part of Duke University Health System
• Misophonia Research Fund, initiative of a private family foundation
• Quiet Please , official website of 2016 documentary about misophonia, with trailer