Misophonia

By Marcello Cherchi, MD PhD

For patients

Misophonia consists of negative feelings promptly triggered by particular sounds (such as chewing, lip-smacking, swallowing). Misophonia can occur by itself, though it can co-occur with some psychiatric diseases and ear diseases. The cause of misophonia is unknown. Workup may include checking for several ear diseases. There are no proven treatments, though some patients benefit from psychological interventions.

For clinicians

Overview

Misophonia (“dislike of sound”) is an aversive behavioral, emotional and autonomic response to specific sounds that are usually (though not always) human-generated, often by orofacial movements (e.g., chewing, lip smacking, swallowing). Misophonia can occur in isolation, though risk factors include various psychiatric disorders (particularly obsessive-compulsive disorder) and auditory disorders (hyperacusis, tinnitus). The underlying pathophysiology remains unknown, and no set of diagnostic criteria has been widely accepted. Workup may include tests for related conditions such as various etiologies of hyperacusis. There have been no replicated randomized, prospective, double-blinded, placebo-controlled treatment trials, so management may include trigger avoidance, cognitive-behavioral therapy and psychiatric approaches. Prognosis is uncertain.

Introduction

The term “misophonia” (meaning, “dislike of sound”) was introduced by Jastreboff and Jastreboff (Jastreboff and Jastreboff 2001). Synonymous designations in the medical literature include “selective sound sensitivity syndrome” (Cavanna 2014).

To clarify this nomenclature it may be helpful to put it in the context of related terms, including “decreased sound tolerance,” “hyperacusis” and “phonophobia.”

The Figure below depicts the hierarchical relationships among these terms in the form of a Venn diagram.

Decreased sound tolerance is a broad category, with respect to which they state that, “decreased sound tolerance consists of more than one problem. It is not necessarily loud sounds, but even quiet sounds, which can cause discomfort. Decreased sound tolerance might reflect a physical discomfort, or can be related to a dislike or a fear of sound” (Jastreboff and Jastreboff 2001). This supercategory of decreased sound tolerance subsumes hyperacusis and misophonia.

Hyperacusis is a subcategory of decreased sound tolerance that, “can be defined as an abnormally strong reaction to sound occurring within the auditory pathways. At the behavioral level, it is manifested by a patient experiencing physical discomfort as a result of exposure to sound… The same sound would not evoke a similar reaction in the average listener. The strength of the reaction is controlled by the physical characteristics of the sound, e.g., its spectrum and intensity” (Jastreboff and Jastreboff 2001).

Misophonia is a subcategory of decreased sound tolerance, and phonophobia is a subcategory of misophonia. Jastreboff and Jastreboff state:

“Misophonia and phonophobia can be defined as abnormally strong reactions of the autonomic and limbic systems resulting from enhanced connections between the auditory and limbic systems. Importantly, misophonia and phonophobia do not involve a significant activation of the auditory system. At the behavioral level, patients have a negative attitude to sound (misophonia), or are afraid of sound (phonophobia). In cases of misophonia and phonophobia, the strength of the patient’s reaction is only partially determined by the physical characteristics of the upsetting sound. It is also dependent on the patient’s previous evaluation and recollection of the sound (e.g., sound as a potential threat, and/or the belief that the sound can be harmful), the patient’s psychological profile and the context in which the sound is presented” (Jastreboff and Jastreboff 2001).

Misophonia is a subcategory of decreased sound tolerance. “Misophonic patients are simply disliking these sounds without necessarily fearing them, which are then creating negative emotional responses” (Jastreboff and Jastreboff 2001). Furthermore, “Misophonia [is] a separate disorder since, unlike hyperacusis… the symptomatology was associated exclusively with one type of sound; and it [is] distinct from phonophobia (fear of sounds) because the primary emotional response differed” (Ferrer-Torres and Gimenez-Llort 2022).

Phonophobia is a subcategory of misophonia. The term, “describes a specific type of misophonia, when fear is the dominant emotion involved in the dislike of the sound. The majority of patients with decreased sound tolerance have misophonia, but only some of them are phonophobic. A common reason for phonophobia is the fear that sounds, frequently ‘normal’ environmental sound, may damage the ear, or make symptoms worse” (Jastreboff and Jastreboff 2001).

They further state that:

“Clinical observations reveal that in many cases, decreased sound tolerance consists of more than one problem. It is not necessarily loud sounds, but even quiet sounds, which can cause discomfort. Decreased sound tolerance might reflect a physical discomfort, or can be related to a dislike or a fear of sound” (Jastreboff and Jastreboff 2001).

It is important to recognize that the auditory stimuli in question do not necessarily need to be of large amplitude (“loud”); sometimes they can be sounds which healthy people would perceive as rather quiet. As Jastreboff and Jastreboff state, “Please note that neither hyperacusis, nor misophonia nor phonophobia have any relation to hearing thresholds. Patients with hyperacusis, misophonia or phonophobia may have normal hearing, or they may be hearing impaired” (Jastreboff and Jastreboff 2001).

Thus, these definitions by Jastreboff and Jastreboff depend more on behavioral characteristics (emotions elicited by sounds) and on physiological characteristics (such as autonomic responses) of the misophonic response, rather than on particular features of the misophonic stimulus. Ferrer-Torres and Gimenez-Llort depict this emotional, behavioral and physiologic complexity in the Figure below.

Ferrer-Torres and Gimenez-Llort (Ferrer-Torres and Gimenez-Llort 2022) summarize misophonia as, “a complex neurophysiological and behavioral disorder of multifactorial origin [that] is characterized by an increased physiological and emotional response produced by intolerance to specific auditory stimuli.”

Numerous self-administered questionnaires have been explored for diagnosing misophonia, but none has been universally accepted; these are reviewed by Ferrer-Torres and Gimenez-Llort (Ferrer-Torres and Gimenez-Llort 2022). There have been several proposals for diagnostic criteria of misophonia (Aazh 2022; Dozier et al. 2017; Schroder et al. 2013), but none has been universally accepted. As Ferrer-Torres and Gimenez-Llort bluntly state, “there is currently no consensus on the criteria to establish the diagnosis” (Ferrer-Torres and Gimenez-Llort 2022).

Nevertheless, it is instructive to review some of the proposals. Building on the work of Schroder and colleagues (Schroder et al. 2013), Dozier and colleagues (Dozier et al. 2017) propose the following criteria, which focus on characteristics of the misophonic stimulus and of the response, and their contextual dependency:

1. A misophonic stimulus can be produced by any source (i.e., human, animal, electronic, equipment, etc., and not limited to stimuli from humans.
2. A misophonic stimulus can be virtually any sensory modality, with auditory and visual stimuli being the most common and not limited to auditory stimuli.
3. The eliciting stimulus is a conditioned stimulus and so excludes responses to innate sensitivities, such as those with sensory processing disorder or sensory over-responsiveness.
4. The strength of the response is controlled by the context and experience with the stimulus and not the physical characteristics of the stimulus. Therefore, a minimal intensity stimulus will elicit the response.
5. The response is elicited by a single or small number of minimal intensity stimulus instances, and is not the response from persistent, annoying stimuli.
6. The stimulus elicits an immediate physical response, which is often a skeletal muscle response, but can be any physical response.
7. A moderate duration of the stimulus (e.g., 15 s) elicits physiological arousal.

A partially overlapping list of criteria is suggested by Aazh (Aazh 2022), who additionally requires that the symptoms not be better explained by another diagnosis:

1. General description. Misophonia is characterized by decreased tolerance to specific sounds or stimuli associated with such sounds (known as triggers). Exposure to triggers can evoke disproportionate emotional, physiological, and behavioral reactions leading to distress, and/or impairment in social, occupational, or academic functioning. Triggers often, but not exclusively, are stimuli generated by another human being’s body.
2. Misophonic triggers. Most common triggers are auditory, but some may react to visual triggers too. Common triggers include but not limited to sounds associated with oral functions (e.g., chewing, eating, smacking lips, slurping, coughing, throat clearing, and swallowing.), nasal sounds (e.g., breathing and sniffing), non-oral/nasal sounds produced by people (e.g., pen clicking, keyboard typing, finger or foot tapping and shuffling footsteps), as well as sounds produced by objects (e.g., clock ticking) or sounds generated by animals. Examples of visual triggers are cracking knuckles and jiggling or swinging legs or watching someone eat.
3. Reactions to misophonic triggers. Emotional: Anger, irritation, disgust, and anxiety. Physiological: Increased muscular tension, increased heart rate, and sweating. Behavioral reactions: Agitation, aggression, avoidance, seeking to discontinue the triggering stimuli, and mimicking.
4. Influences on reactions. The strength of the reaction can be influenced by (1) the context, (2) the individual’s perceived degree of control, and (3) the relationship with individual who is the source of the trigger.
5. Functional impairments. Impaired occupational and/or academic functioning, concentration difficulties, impaired social functioning, strained social relationships, and social isolation.
6. Relationship to other conditions/disorders. The symptoms of misophonia should not be better explained by any co-occurring disorders including but not limited to hearing impairment, tinnitus, hyperacusis, anxiety disorders, mood disorders, personality disorders, obsessive compulsive related disorders, post-traumatic stress disorder, autism spectrum disorder, and attention deficit hyperactivity disorder.

We find some of these criteria to be broader than may be clinically warranted given the current state of knowledge of this condition. For instance, the idea that misophonia is “not limited to auditory stimuli” suggests that misophonia may belong to a broader sensory processing disorder that can involve other sensory modalities — but taking that step conflates problems such as misokinesia with misophonia, even though these may be distinct clinical entities.

Several brief reviews (Cavanna and Seri 2015; Zai et al. 2022) and more extensive reviews (Brout et al. 2018; Ferrer-Torres and Gimenez-Llort 2022; Potgieter et al. 2019) summarize well the emerging literature on this topic.

Epidemiology

The range of reported prevalence of misophonia is quite broad depending on the population studied, varying by over an order of magnitude, ranging from 3.2% (Jastreboff and Jastreboff 2014) to 19.9% of undergraduates (Wu et al. 2014) to 49.3% of medical students (Naylor et al. 2021). Even if one takes the low end of these estimates, it suggests that misophonia is quite common.

One study reported the mean age of symptom onset to be 13 years (Schroder et al. 2013), though the mean age at the time of diagnosis may be 37 years (Schroder et al. 2013) to 39 years (Quek et al. 2018).

There appear to be psychiatric and auditory risk factors for misophonia. Aazh and colleagues (Aazh et al. 2022) retrospectively reviewed records of 257 patients consulting at an audiology clinic for symptoms of hyperacusis and/or tinnitus; the patients’ mean age was 53 ± 16 years (range 17 – 97 years). They noted that 23% of patients reported symptoms compatible with what the authors judged to be misophonia, and that the risk of misophonia increased with increasing impact of tinnitus, with increasing impact of hyperacusis, and with symptoms of anxiety and depression.

Genetics

Familial clusters of misophonia, have been reported (Sanchez and Silva 2018) — sometimes with different family members experiencing aversion to the same misophonic trigger — implicating a genetic contribution, but so far, the genetics of misophonia remain unknown (Smit et al. 2022).

Pathophysiological mechanism of disease

Research has not yet clarified the pathophysiological mechanism(s) underlying misophonia.

Psychiatric etiologies of misophonia have been considered (Taylor 2017) on the basis of the emotional responses that are provoked in misophonia (Bagrowska et al. 2022; Cassiello-Robbins et al. 2020b; Daniels et al. 2020; Ferrer-Torres and Gimenez-Llort 2021a, b; Guetta et al. 2022; Rinaldi et al. 2023; Savard et al. 2022; Wang et al. 2022), and the greater than chance comorbidity with several psychiatric disorders (Banker et al. 2022; Cassiello-Robbins et al. 2020a; Erfanian et al. 2019; Guzick et al. 2023; McKay et al. 2018; Robinson et al. 2018; Rosenthal et al. 2022; Sharan and Sharma 2020; Siepsiak et al. 2022; Siepsiak et al. 2020; Webber et al. 2014; Yektatalab et al. 2022), including obsessive-compulsive disorders. However, most investigators conclude that there is insufficient evidence to warrant classifying misophonia as a purely psychiatric disorder.

Given the core clinical feature of an auditory trigger, another logical candidate etiology would be that misophonia is a primary auditory disorder, but this probably cannot be the full picture. Ferrer-Torres and Gimenez-Llort comment that:

“Misophonia cannot be classified as an auditory disorder since no relationship has been found between it and hearing thresholds, as the disorder can occur in people with normal hearing, with hearing loss, or with some auditory pathology… Additionally, the specificity of the triggering stimuli suggests that the symptoms are unlikely to be caused by an alteration of the auditory system” (Ferrer-Torres and Gimenez-Llort 2022).

Brout and colleagues (Brout et al. 2018) observed similarities between misophonia and misokinesia, and suggested that it may be fruitful for future research to consider these disorders in the broader context of sensory over-responsivity. Additional support for such an approach comes from observations that patients with misophonia often exhibit over-responsivity in other sensory modalities as well (Efraim Kaufman et al. 2022).

After reviewing evidence from multiple studies of individual candidate biomarkers, Brout and colleagues (Brout et al. 2018) comment that seeking a single diagnostic biomarker is likely to fail, and that misophonia will probably be more productively studied as a network-level disorder.

Clinical presentation

Despite the absence of any consensus on diagnostic criteria, most clinical descriptions of misophonia are fairly similar. The following is an accessible example:

“Misophonia is a set of symptoms which some people experience when exposed to certain sounds. Strong emotions such as anger, irritation, disgust, or anxiety are evoked immediately when people with misophonia hear particular sounds. Somatic responses are also present – pressure in the chest, arms, head, or the whole body, as well as increased heart rate, increased body temperature, physical pain, or difficulties with breathing” (Siepsiak and Dragan 2019).

Physical examination

Physical examination should be normal in an individual with misophonia who is otherwise healthy.

Testing: auditory

At minimum, given the differential diagnosis (see below), when a diagnosis of misophonia is being considered, it is medically reasonable to check:

• Audiometry (with air and bone conduction, and loudness discomfort levels) and otoacoustic emissions (OAEs).
  • Hearing loss (detected on audiometry and/or otoacoustic emissions) can be associated with sound sensitivity through the mechanism of loudness recruitment.
  • Identification of conductive hyperacusis (on audiometry) may increase suspicion for superior semicircular canal dehiscence.
• Cervical and ocular vestibular evoked myogenic potentials (VEMPs). This helps evaluate for labyrinthine causes of sound sensitivity such as superior semicircular canal dehiscence.  Some patients with misophonia may be unable to tolerate VEMP testing.

Testing: other

Emerging evidence reviewed elsewhere (Brout et al. 2018; Ferrer-Torres and Gimenez-Llort 2022) reports that patients with misophonia may exhibit abnormalities on various tests such as electroencephalography, structural findings on MRI (Eijsker et al. 2021a), activation findings on functional magnetic resonance imaging (Eijsker et al. 2021b; Grossini et al. 2022; Schroder et al. 2019), galvanic (conductive) skin responses, and autonomic function. These are interesting candidate biomarkers for misophonia, but have not yet been incorporated into any widely-accepted diagnostic criteria.

Differential diagnosis

Each characteristic of misophonia can be found in other diseases as well, so the differential diagnosis is somewhat broad. The Table below, from Ferrer-Torres and Gimenez-Llort, provides a differential diagnosis of misophonia.

Treatment

There are not yet any randomized, prospective, double-blinded, placebo-controlled treatment trials for misophonia (Ferrer-Torres and Gimenez-Llort 2022). As Palumbo and colleagues bluntly note, “Currently there is no cure or pharmaceutical agent for misophonia” (Palumbo et al. 2018). Before such trials can be designed and their results scrutinized, considerable work remains to be done in terms of coming to some reasonably widely accepted set of diagnostic criteria, and some agreement on whether (and which) diagnostic testing should be part of the workup.

Until such research emerges, most patients with misophonia end up practicing trigger avoidance, though this may not always be practical. For patients who are receptive to the idea, consultation with psychiatry is appropriate to help manage the emotional burdens imposed by misophonia. There is modest evidence that cognitive-behavioral therapy may be helpful (Aazh et al. 2019; Jager et al. 2022; Jager et al. 2020; Kamody and Del Conte 2017; McGuire et al. 2015; Rappoldt et al. 2023; Roushani and Mehrabizadeh Honarmand 2021; Schroder et al. 2017). Consultation with an audiologist experienced in the management of hyperacusis is also sensible if such a specialist is available. Some audiologists may elect to employ strategies similar to those used in tinnitus retraining therapy (Ferrer-Torres and Gimenez-Llort 2022; Jastreboff and Jastreboff 2015).

Novel proposals regarding the possible application of neurostimulation (Neacsiu et al. 2022) are being explored.

We remain cautious about apparently favorable responses to pharmaceutical agents cited in the literature, as these are all case reports, such as for risperidone (Naguy et al. 2022; Pan et al. 2022), methylphenidate (Osuagwu et al. 2020), fluoxetine (Sarigedik and Yurteri 2021), beta blockers (Webb 2022), 3,4‑methelynedeoxy-methamphetamine (Webb and Keane 2022) and sertraline (Zuschlag and Leventhal 2021).

Prognosis

Given the lack of uniformity in diagnostic criteria for misophonia, very few longitudinal studies are available (Dibb and Golding 2022) to give a clear sense of the natural history of this disorder, so prognosis is uncertain (Rinaldi et al. 2022).

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