What is misophonia

Misophonia also called selective sound sensitivity syndrome, literally means “hatred of sound,” is a chronic condition that causes intense negative emotional reactions and dislike (e.g., anxiety, agitation, and annoyance) to specific sounds (e.g., ballpoint pen clicking (repeatedly), tapping, typing, chewing, breathing, swallowing, tapping foot, etc.) ¹. The most common misophonia triggers include those provoked by the mouth (chewing gum or food, popping lips), the nose (breathing, sniffing, and blowing) or the fingers (typing, clicking pen, drumming on the table). Each patient’s reaction is unique as it depends on the specific conditions under which the sound was experienced and any previous evaluations of that sound ². A subtype of misophonia is phonophobia, when fear to a specific sound is the dominant factor ³. It is important to recognize that “subtype” implies that the class of sounds that elicit phonophobia are drawn from misophonic sounds or that they share a similar mechanism, neither of which is necessarily true. From a phenomenological viewpoint, while fear is the dominant emotion in phonophobia, anger is the dominant emotion in misophonia ². However, more recent research suggest that other than anger there is at least four other dominant emotions present in misophonia (i.e., irritation, stress and anxiety, aggravation, feeling trapped, and impatience) ⁴.

Reactions to the specific sound may be mild or strong and include anxiety, disgust, rage, hatred, panic, fear or a serious emotional distress with violence and suicidal thoughts. Symptoms usually start in childhood or in the early teenage years, and severity increases over time ⁵.

The cause of misophonia is not yet known. Research has suggested it may relate to parts of the brain that are responsible for processing and regulating emotions ⁵. Many people with misophonia have relatives with similar symptoms ⁶.

In a recent study, Wu et al. ⁷ investigated the incidence, correlates, and impairments associated with misophonia in a student population. Out of 483 undergraduate students (mean age = 21.4 years), 22.8% were often or always sensitive to or annoyed by specific sounds (e.g., eating, repetitive tapping, or nasal noises). Dislike of throat sounds, rustling papers, and environmental sounds were reported by 19.5, 16.1, and 14% of respondents, respectively. Literature suggests that 60% of patients with tinnitus also have misophonia ⁸ and 86% of tinnitus patients have hyperacusis, 25–30% of which requiring treatment ⁹. Jastreboff ¹⁰ deduced that 1.75% of the general population has hyperacusis without tinnitus, but it is still difficult to differentiate those who have hyperacusis alone, misophonia alone, and those who have both.

Misophonia does affect daily life, but it may be managed by combining different therapies such as sound therapy with counseling, cognitive-behavioral therapy (CBT) and exposure, and dialectical behavior therapy. Hearing plugs or aids, antidepressant medications, and an active lifestyle (to manage stress) may also be helpful ⁵.

It is important to note that misophonia is not listed in any psychiatric classification systems. Some researchers believe misophonia should be considered a new mental disorder within the spectrum of obsessive-compulsive related disorders. Others think it is a feature of a broader syndrome of sensory intolerance, rather than a separate disorder ¹¹. Considerably more research is required, particularly work concerning diagnostic validity, before misophonia, defined as either as a disorder or as a key feature of some broader syndrome of sensory intolerance.

Is misophonia real?

Yes. Misophonia was originally described by Jastreboff and Jastreboff in 2001 ¹², individuals with misophonia are believed to demonstrate increased sympathetic nervous system arousal, accompanied by emotional distress in response to specific pattern-based sounds, irrespective of decibel level ¹³.

Some researchers believe misophonia should be considered a new mental disorder within the spectrum of obsessive-compulsive related disorders. Others think it is a feature of a broader syndrome of sensory intolerance, rather than a separate disorder ¹¹. Misophonia has not been formally recognized as a specific type of neurological, audiological, or psychiatric disorder and considerably more research is required, before misophonia, defined as either as a disorder or as a key feature of some broader syndrome of sensory intolerance.

Over-responsivity to auditory stimuli is a feature observed among a wide range of neurological, auditory, medical and psychiatric disorders such as tinnitus, hyperacusis ¹⁴, migraine headaches ¹⁵, autism spectrum disorder ¹⁶, posttraumatic stress disorder (PTSD) ¹⁷, borderline personality disorder ¹⁸, bipolar disorder, and schizophrenia ¹⁹. The precise nature of the relationship between misophonia and these disorders is unknown. However, intolerance to aversive sounds does not appear to be a phenomenon that co-occurs uniquely and specifically with any one disorder. Indeed, rigorously conducted research is needed to elucidate whether misophonia is a unique constellation of symptoms or a transdiagnostically co-occurring syndrome found across other disorders ²⁰.

Misophonia triggers

The most common misophonia triggers or “misophonic sounds” include those provoked by the mouth (chewing, throat clearing, slurping, chewing gum or food, popping lips), the nose (breathing, sniffing, and blowing), foot shuffling or the fingers (typing, keyboard tapping, clicking pen, finger tapping, drumming on the table) ¹⁴. Each patient’s reaction is unique as it depends on the specific conditions under which the sound was experienced and any previous evaluations of that sound ². “Misophonic responses” upon exposure to misophonic trigger sounds, emotional responses frequently include anger (ranging from irritation to rage), anxiety, disgust, avoidance, escape behavior as well as a feeling of being overwhelmed and/or overloaded by auditory stimuli. As noted in the literature, this newly defined syndrome may, for some individuals, lead to severe impairments in daily functioning (e.g., occupationally, interpersonally, academically) and may contribute to the development of behavioral health problems.

Misophonia symptoms

Misophonia usually begins during childhood or adolescence, sometimes affecting academic performance ²¹. An intense negative emotional reaction is usually triggered by bodily sounds (e.g., chewing, breathing, swallowing, and foot tapping, etc.) and may be connected to a particular person creating that sound ²². In addition to the emotional aversion, patients sometimes report physical pressure building in the chest, the desire to stop the person from making the sound, and other autonomic reactions ²³. Sometimes patients will mimic the sound to cancel it out. Rarely do physical reactions, such as assaulting the person making the sound, occur. However, because the patient is never sure when the trigger sound might be heard, the patient often lives in a perpetual state of anxiety. Patients are hyper-focused on listening for that trigger; they will avoid certain situations, people, and foods that they think will cause the sound ²². Overall, patients may suffer physical and emotional discomfort, contributing to a reduced quality of life ²².

According to Jastreboff and Jastreboff ²⁴, only 7 cases (2.2%) out of 318 misophonic patients exhibited a psychiatric disorder. Some researchers argue that misophonia and psychiatric disorders are unrelated. However, others tend to believe that psychiatric disorders and misophonia might coexist. Schroder et al. ²¹ conducted a study to classify misophonia as its own form of psychiatric disorder. Their results showed a pattern of intense reactions to specific stimuli, avoidance, and worry that matched with traits of other psychiatric disorders, i.e., social phobia, post-traumatic stress disorder, personality disorders with impulsive aggression, intermittent explosive disorder, autism spectrum disorder, sensory processing disorders, antisocial personality disorder, and phonophobia ²¹. Although the nosological nature of misophonia is still a topic of debate, Schroder’s ²¹ findings seem to call for misophonia to be classified as a subtype of a discrete psychiatric disorder.

Misophonia causes

Misophonia appears to be a neurologically based disorder in which certain auditory stimuli are misinterpreted as dangerous. Individuals with misophonia are set off, or “triggered” by repetitive, patterned-based sounds, such as chewing, coughing, pencil tapping, sneezing, etc. Some individuals with misophonia also describe visual triggers.These stimuli, or triggers, cause severe physiological and emotional stress.

Sounds (and sights) that other people may not even notice can make a person with misophonia feel bombarded by stimuli and can even propel them into the “fight/flight” response.

The literature suggests that the majority of patients with misophonia have normal hearing sensitivity ²⁵, while the limbic and autonomic nervous systems are in a heightened state of excitation and thus react abnormally to normal auditory input ²³. A recent functional and structural MRI study has revealed that trigger sounds elicited increased responses in the anterior insular cortex and abnormal functional connectivity between the anterior insular cortex and medial frontal, medial parietal, and medial temporal regions ²⁶. The findings of Kumar et al. ²⁶ implied that there was abnormal myelination in the medial frontal cortex that shows abnormal functional connectivity, and that the aberrant neural response mediates the emotional coloring and physiological arousal that accompany misophonic experiences.

Misophonia diagnosis

Clinically, diagnosing misophonia requires a detailed case history to determine onset, triggers, reactions, and co-morbid conditions. Questionnaires may also be useful when determining the severity and uniqueness of each patient’s case. Although certain questionnaires have been proposed to evaluate the severity of misophonia ²⁷, their validity needs to be confirmed. On the other hand, no one questionnaire has been consistently used across studies for the evaluation of misophonia. Examples of some of the questionnaires currently being used to evaluate misophonia are: (1) the Misophonia Questionnaire, which is a three-part self-report questionnaire developed by Wu et al. ²⁸ to assess the presence of misophonia symptoms as well as related emotions and behaviors; and (2) the Amsterdam Misophonia Scale (A-MISO-S), a concept scale based on the already validated Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) ²¹. The A-MISO-S is a six-item scale that evaluates different areas affected by misophonia such as: the time spent focusing on misophonia; interference with social functions; level of anger; impulse control; control over thoughts and anger; and time spent avoiding situations contributing to misophonia.

The audiological assessment of misophonia is complex. To date there is no agreement on a specified protocol to assess misophonia. However, audiological assessment includes pure tone thresholds and loudness discomfort levels. Patients with misophonia may have hearing loss or normal hearing. Loudness discomfort levels have been reported at normal and reduced levels ²⁹. There is no precise description of how to test loudness discomfort levels in patients with misophonia. It is therefore possible that variations can occur in the results obtained due to the specific method administrated and differences in the way patients are instructed ²⁴. Nevertheless, Jastreboff and Jastreboff ²⁴ indicated that when misophonia is present with hyperacusis, loudness discomfort level values can range from 30 to 120 dB HL. This further emphasizes that loudness discomfort levels alone are insufficient to accurately diagnose hyperacusis and/or misophonia ²⁴. Differences in auditory late potentials may be present when patients are tested using an oddball paradigm. Schroder et al. ²⁵ concluded that the deviant tone evoked a smaller N100 in misophonia patients than in healthy controls. Such responses might have been because of deficits in processing auditory information at low intensities or because of coexisting mood and psychiatric conditions. This study supports the recommendation of a thorough case history and use of questionnaires to understand all aspects of the patient’s life that may contribute to misophonia ³⁰.

Misophonia treatment

There is currently no cure for misophonia (selective sound sensitivity syndrome) ³¹.

Currently, there are no research studies that have investigated pharmaceutical options to treat misophonia. Anecdotal information suggests the prescription of antidepressants and anxiolytics to address the reactions and co-morbid conditions associated with misophonia. Despite the lack of pharmaceutical remedies, a variety of therapies have been considered, with some showing signs of potential success.

The following therapies are said to have helped certain patients with their symptoms:

Tinnitus Retraining Therapy

Tinnitus Retraining Therapy uses a combination of sound therapy and teaching/demystification/learning about mechanisms, with directions about how to return to normal life without provoking symptoms. It is based on the work of Professor Pawel Jastreboff ³² who coined the term misophonia. Tinnitus Retraining Therapy is aimed primarily at those with tinnitus and hyperacusis, but some people suffering from misophonia has claimed success with it. Although the majority of patients do find relief through Tinnitus Retraining Therapy, there are still cases that receive no relief. For further information on Tinnitus Retraining Therapy, please go here: http://www.tinnitus.org/

Cognitive Behavioral Therapy (CBT)

The Royal College of Psychiatrists defines cognitive behavioral therapy as a way of talking about:

• How you think about yourself, the world and other people
• How what you do affects your thoughts and feelings.

They say that CBT can help you to change how you think (the cognitive part) and what you do (the behavioral part). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the “here and now” difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.

If you are not sure you want to commit to a long course of sessions with a clinical psychologist, there are various resources on the Internet which will provide an introduction to CBT or even a course of computer-aided CBT sessions:

• Developed by the Australian National University, MoodGYM (https://moodgym.com.au/) is a fun, free interactive web program that teaches the principles of CBT using flashed diagrams and online exercises. MoodGYM (https://moodgym.com.au/) demonstrates the relationship between thoughts and emotions, and works through dealing with stress and relationship break-ups, as well as teaching relaxation and meditation techniques. It consists of five modules (why you feel the way you do, changing the way you think, changing ‘warped’ thoughts, knowing what makes you upset, assertiveness and interpersonal skills training), an interactive game, anxiety and depression assessments, downloadable relaxation audio, a workbook and feedback assessment. Scientific trials have shown that using two or more modules is linked to significant reductions in depression and anxiety symptoms. These benefits last after 12 months. MoodGYM has won several IT and health awards, and has over 1,000,000 users worldwide. MoodGYM (https://moodgym.com.au/)

• Living Life to the Full (https://llttf.com/) is a free online life skills course for people feeling distressed. It aims to provide easy access to CBT skills in a way that cuts through jargon. It helps you understand why you feel as you do, and to learn new ways of improving how you feel, by making changes in your thinking, activities, sleep and relationships. The course is based on the idea of helping you to help yourself. It is supported by a series of CBT self-help workbooks that can be used between the e-learning sessions. These encourage you to put what you are learning into practice, and to stop, think and reflect on what you are learning. Living Life to the Full (https://llttf.com/)

• FearFighter (http://www.fearfighter.com/) delivers CBT over the internet, useful for those who may be concerned about the stigma associated with seeing a therapist. Taking only three months to complete, with minimal telephone support, FearFighter helps you improve even if you have virtually no computer skills. You are encouraged to use FearFighter as often as you wish but for at least once a week. It helps you identify specific problems, work on realistic treatment goals, and monitor achievement of those goals by repeated self-exposure. You get scheduled brief helpline support to a total of one hour over 10 weeks. FearFighter helps you to work out exactly what brings on your fear, so you can learn how to face it until it subsides. This is called exposure therapy. It consists of nine steps that need to be worked through one by one to obtain the greatest benefits. Like a therapist, FearFighter asks you to return every week to report on how you’ve been doing. You can ask it to print out questionnaires and graphs of your progress. It guides you through CBT as much as a therapist does.
  • Step 1: Welcome to FearFighter – Introduces the system, asks you to rate your problem on the Fear Questionnaire (FQ) and Work & Social Adjustment Scale (WSA), and asks about suicidal feelings and alcohol misuse.
  • Step 2: How to Beat Fear – Explains the principles of CBT, with case examples. You are asked to keep a daily record of your triggers.
  • Step 3: Problem Sorting – Helps you identify your triggers, shows you scenarios relevant to your problem, and helps you personalise your triggers and rate them on a 0-8 scale.
  • Step 4: How to Get a Helper – Explains the value of recruiting a CBT co-therapist and gives hints on how to find one.
  • Step 5: Setting Goals – Guides you through the process of setting good goals and tests them. You record and rate these on the system and can print personalised homework diaries.
  • Step 6: Managing anxiety – Offers a menu of coping strategies for use during CBT homework.
  • Step 7: Rehearsing Goals – Guides you on how to practise personal coping strategies during both imagined and live CBT homework.
  • Step 8: Carrying On – Reviews progress with the help of graphs, allows new goals to be devised, and offers feedback and advice.
  • Step 9: Troubleshooting – Offers a menu of tips on overcoming common sticking points in treatment.

You may have found that when you avoid things that make you panic or feel uncomfortable, the situation tends to get worse and worse. FearFighter can teach you how to face your fear until you adapt and no longer want to run away from it. It helps you learn to face the things that make you panic, such that, with time, you’ll find that, one by one, they’ll get easier.

Self-exposure therapy guided by computer is as effective as clinician-guided therapy and both are superior to relaxation to improve phobia/panic. FearFighter has been tested in four clinical trials and is as effective as the best CBT therapists.

Approved by the National Institute of Clinical Excellence (NICE), free access can only be prescribed by your doctor in England and Wales. FearFighter (http://www.fearfighter.com/)

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