Proposed Diagnostic Criteria for Misophonia: A Multisensory Conditioned Aversive Reflex Disorder

Brain circuits in autonomous sensory meridian response and related phenomena

Autonomous sensory meridian response (ASMR) is characterized by a tingling sensation with a feeling of relaxation and a state of flow. We explore the neural underpinnings and comorbidities of ASMR and related phenomena with altered sensory processing. These phenomena include sensory processing sensitivity (SPS), synaesthesia, Alice in Wonderland syndrome and misophonia. The objective of this article is to uncover the shared neural substrates and distinctive features of ASMR and its counterparts. ASMR, SPS and misophonia exhibit common activations in the brain regions associated with social cognition, emotion regulation and empathy. Nevertheless, ASMR responders display reduced connectivity in the salience network (SN), while individuals with SPS exhibit increased connectivity in the SN. Furthermore, ASMR induces relaxation and temporarily reduces symptoms of depression, in contrast to SPS and misophonia, which are linked to depression. These observations lead us to propose that ASMR is a distinct phenomenon owing to its attention dispatch mechanism and its connection with emotion regulation. We suggest that increased activations in the insula, along with reduction in connectivity within the salience and default mode networks in ASMR responders, may account for their experiences of relaxation and flow states. This article is part of the theme issue 'Sensing and feeling: an integrative approach to sensory processing and emotional experience'.

Sex-Specific Correlations Between Misophonia Symptoms and ADHD, OCD, and Autism-Related Traits in Adolescent Outpatients

Introduction

Misophonia, not yet classified within diagnostic manuals, triggers strong emotional, physiological, and behavioural reactions to specific sounds. This study examines its correlations with attention deficient/hyperactivity disorder (ADHD) traits, obsessive-compulsive traits, and autism-related traits in adolescent outpatients with non-psychotic disorders. We hypothesize a positive association between misophonic symptoms and these psychological traits.

Methods

This study was conducted at a Turkish psychiatric centre from January to July 2023 in adolescents aged 12-18. Parents completed the Autism Spectrum Quotient-Adolescent (AQ-Adolescent), and Conner's ADHD Parent Rating Scale-48 (CPRS-48), while the adolescent filled out the Misophonic Symptom Checklist (MCL) and Maudsley Obsessive-Compulsive Inventory (MOCI). Using non-parametric statistical tests, the research found associations between the scales, with a total sample size of 348.

Results

Females had higher scores on MCL. There is a negative correlation between AQ-Adolescent and MCL, positive correlations between MCL-MOCI and MCL-CPRS-48. In gender specific correlation analysis found that AQ-Adolescent and MCL were negatively correlated, MCL and MOCI were positively correlated in males. MCL, CPRS-48 and MOCI were positively correlated in females. In regression AQ-Adolescent, MOCI and CPRS-48 significantly predicted the levels of MCL.

Conclusions

Our study unveils a link between ADHD, obsessive-compulsive symptoms, autistic traits, and misophonic symptoms in adolescent psychiatric outpatients, highlighting sex differences.

Metacognitive Interpersonal Therapy for Misophonia: A Single-Case Study

BACKGROUND

Misophonia is a chronic condition in which the exposure to specific sounds increases the arousal and recurrence of specific intense negative emotions. We hypothesized that misophonia may be strongly related to maladaptive interpersonal schemas that create difficulties in interpersonal relationships. Subjects with maladaptive interpersonal schemas think that other people try to subjugate, criticize, dominate, exploit, deceive, disregard, and humiliate them. Furthermore, these patients typically endorse a representation of self as mistreated, constricted, harmed, damaged, humiliated, impotent, inadequate, or fragile.

METHODS

We describe the course of a treatment of Metacognitive Interpersonal Therapy (MIT) in a young man presenting misophonia and co-occurrent obsessive-compulsive personality disorder (OCPD) and avoidant personality disorder (AvPD), with narcissistic traits and normal hearing. We collected qualitative and quantitative data at the beginning of the intervention and at 2 years follow-up.

RESULTS

The therapy aimed at increasing awareness of maladaptive interpersonal schemas and promoting a healthy self. The results reported a significant decrease in misophonia; behavioural experiments were used to increase the quality of social relationships and tolerance to the trigger sounds.

CONCLUSIONS

MIT can be an effective therapy for the treatment of misophonia.

Background and Rationale for a Transitional Intervention for Debilitating Hyperacusis

PURPOSE

This report provides the experimental, clinical, theoretical, and historical background that motivated a patented transitional intervention and its implementation and evaluation in a field trial for mitigation of debilitating loudness-based hyperacusis (LH).

BACKGROUND AND RATIONALE

Barriers for ameliorating LH, which is differentiated here from other forms of hyperacusis, are delineated, including counterproductive management and treatment strategies that may exacerbate the condition. Evidence for hyper-gain central auditory processes as the bases for LH and the associated LH-induced distress and stress responses are presented. This presentation is followed by an overview of prior efforts to use counseling and therapeutic sound as interventional tools for recalibrating the hyper-gain LH response. We also consider previous efforts to use output-limiting sound-protection devices in the management of LH. This historical background lays the foundation for our transitional intervention protocol and its implementation and evaluation in a field trial.

CONCLUSIONS

The successful implementation and evaluation of a transitional intervention, which we document in the outcomes of a companion proof-of-concept field trial in this issue, build on our prior efforts and those of others to understand, manage, and treat hyperacusis. These efforts to overcome significant barriers and vexing long-standing challenges in the management and treatment of LH, as reviewed here, are the pillars of the transitional intervention and its primary components, namely, counseling combined with protective sound management and therapeutic sound, which we detail in separate reports in this issue.

Results of a 6-Month Field Trial of a Transitional Intervention for Debilitating Hyperacusis

PURPOSE

We present results from a 6-month field trial of a transitional intervention for debilitating primary hyperacusis, including a combination of structured counseling; promotion of safe, comfortable, and healthy sound exposure; and therapeutic broadband sound from sound generators. This intervention is designed to overcome barriers to successful delivery of therapeutic sound as a tool to downregulate neural hyperactivity in the central auditory pathways (i.e., the maladaptive mechanism believed to account for primary hyperacusis) and, together with the counseling, reduce the associated negative emotional and physiological reactions to debilitating hyperacusis.

METHOD

Twelve adults with normal or near-normal audiometric thresholds, complaints consistent with their pretreatment loudness discomfort levels ≤ 75 dB HL at multiple frequencies, and hearing questionnaire scores ≥ 24 completed the sound therapy-based intervention. The low-level broadband therapeutic sound was delivered by ear-level devices fitted bilaterally with either occluding earpieces and output-limiting loudness suppression (LS; to limit exposure to offensive sound levels) or open domes to maximize comfort and exposure to sound therapy. Thresholds for LS (primary outcome) were incrementally adjusted across six monthly visits based on treatment-driven change in loudness judgments for running speech in sound field. Secondary outcomes included categorical loudness judgments, speech understanding, and questionnaires to assess the hyperacusis problem, quality of life, and depression. An exit survey assessed satisfaction with and benefit from the intervention and the counseling, therapeutic sound, and LS components.

RESULTS

The mean change in LS (34.8 dB) was highly significant (effect size = 2.045). Eleven of 12 participants achieved ≥ 16-dB change in LS, consistent with highly significant change in sound-based questionnaire scores. Exit surveys indicated satisfaction with and benefit from the intervention.

CONCLUSION

The transitional intervention was successful in improving the hyperacusis conditions of 11 of 12 study participants while reducing their sound avoidance behaviors and reliance on sound protection.

The mediating role of anxiety in the relationship between misophonia and quality of life: findings from the validated Turkish version of MisoQuest

Introduction

Misophonia is a disorder characterized by decreased tolerance to certain sounds or their associated stimuli, and many measurement tools have been developed for its diagnosis and evaluation. The aims of the current study were to develop the Turkish version of MisoQuest, a fully validated misophonia questionnaire, to evaluate the relationships between misophonia, anxiety, and quality of life, and to examine the mediating role of anxiety in the relationship between misophonia and quality of life.

Methods

The reliability of the Turkish version of MisoQuest was conducted using data from 548 participants (Mean age = 28.06 ± 9.36). Then, the relationships between misophonia, anxiety, and quality of life were evaluated in a separate sample of 117 participants (Mean age = 25.50 ± 6.31) using the State-Trait Anxiety Inventory (STAI) and the Short Form 36 (SF-36) questionnaire.

Results

The results showed that the Turkish version of MisoQuest has good psychometric properties. Close-to-moderate positive correlations were found between misophonia and anxiety, and weak negative correlations were found between misophonia and quality of life. Anxiety mediated the relationships between misophonia and quality of life.

Discussion

These results emphasize that misophonia may be an important problem affecting people's quality of life and reveal the mediating role of anxiety on this effect.

Misophonia matters: A case study of the role of brain imaging in debates over new diagnoses

Misophonia has gained attention in scientific circles that utilise brain imaging to validate diagnoses. The condition is promoted as not merely a symptom of other psychiatric diagnoses but as a discrete clinical entity. We illustrate the social construction of the diagnostic category of misophonia through examining prominent claims in research studies that use brain imaging to substantiate the diagnosis. We show that brain images are insufficient to establish the 'brain basis for misophonia' due to both technical and logical limitations of imaging data. Often misunderstood as providing direct access to the matter of the body, brain images are mediated and manipulated numerical data (Joyce, 2005, Social Studies of Science 35(3), p. 437). Interpretations of brain scans are further shaped by social expectations and attributes considered salient to the data. Causal inferences drawn from these studies are problematic because 'misophonics' are clinically pre-diagnosed before participating. We argue that imaging cannot replace the social process of diagnosis in the case of misophonia, nor validate diagnostic measures or otherwise substantiate the condition. More broadly, we highlight both the cultural authority and inherent limitations of brain imaging in the social construction of contested diagnoses while also illustrating its role in the disaggregation of symptoms into new diagnoses.

Misophonia and Hearing Comorbidities in a Collegiate Population

OBJECTIVES

Misophonia is a little-understood disorder in which certain sounds cause a strong emotional response in those who experience it. People who are affected by misophonia may find that noises like loud chewing, pen clicking, and/or sniffing trigger intense frustration, anger, or discomfort. The relationship of misophonia with other auditory disorders including loudness hyperacusis, tinnitus, and hearing loss is largely underexplored. This project aimed to investigate the prevalence and hearing-health comorbidities of misophonia in a college-aged population by using an online survey.

DESIGN

A total of 12,131 undergraduate and graduate students between the ages of 18 and 25 were given the opportunity to answer an in-depth online survey. These students were sampled in a roughly 50 of 50 sex distribution. The survey was created using Qualtrics and included the following components: electronic consent, demographics questionnaire, Misophonia Questionnaire (MQ), Khalfa's Hyperacusis Questionnaire (HQ), Tinnitus and Hearing Survey, and Tinnitus Functional Index (TFI). To be eligible for compensation, answers for each of the above components were required, with the exception of the TFI, which was only presented to students who indicated that they experienced tinnitus. Respondents were determined to have high or possible likelihood of having misophonia if they gave specific answers to the MQ's Emotion and Behavior Scale or the MQ Severity Scale.

RESULTS

After excluding duplicate responses and age-related outliers, 1,084 responses were included in the analysis. Just over 20% (n = 217) of the sample was determined to have a high or probable likelihood of having misophonia. The sample was primarily White, female, and of mid-to-high socioeconomic status. There was a strong positive correlation between MQ total scores and HQ total scores. High likelihood misophonia status showed a significant relationship with self-reported hearing loss and tinnitus. No statistically significant relationship was found between misophonia and age, ethnicity, or socioeconomic status. MQ total scores differed significantly when separating respondents by sex, self-reported tinnitus, and loudness hyperacusis. White respondents had significantly higher MQ total scores than Asian/Asian American respondents.

CONCLUSIONS

The estimated prevalence of misophonia was about 8% to 20% of the sample, which agrees with most of the currently published research examining misophonia symptoms in collegiate populations. Results of data analysis suggest that misophonia severity may be related to loudness hyperacusis, sex, and possibly tinnitus. Future studies are needed to further examine the characteristics of these relationships, possibly in populations more optimized to reflect the general population or those with hearing-health disorders.

An Automated Online Measure for Misophonia: The Sussex Misophonia Scale for Adults

Misophonia is a sound sensitivity disorder characterized by a strong aversion to specific sounds (e.g., chewing). Here we present the Sussex Misophonia Scale for Adults (SMS-Adult), within an online open-access portal, with automated scoring and results that can be shared ethically with users and professionals. Receiver operator characteristics show our questionnaire to be "excellent" and "good-to-excellent" at classifying misophonia, both when dividing our n = 501 adult participants by recruitment stream (self-declared misophonics vs. general population), and again when dividing them with by a prior measure of misophonia (as misophonics vs. non-misophonics). Factor analyses identified a five-factor structure in our 39 Likert-type items, and these were Feelings/Isolation, Life consequences, Intersocial reactivity, Avoidance/Repulsion, and Pain. Our measure also elicits misophonia triggers, each rated for their commonness in misophonia. We offer our open-access online tool for wider use (www.misophonia-hub.org), embedded within a well-stocked library of resources for misophonics, researchers, and clinicians.

Novel five-phase model for understanding the nature of misophonia, a conditioned aversive reflex disorder

Background: Misophonia is a recently identified condition in which a person perceives a subtle stimulus (e.g., eating sounds, hair twirling) and has an intense, negative emotional response. Misophonia cannot be classified with established nosological systems. Methods: We present a novel five-phase model of misophonia from a cognitive-behavioral framework. This model identifies a learned reflex of the autonomic nervous system as the primary etiology and maintenance of misophonia. Phase one is anticipatory anxiety and avoidance. Phase two is a conditioned physical reflex (for example, the tensing of calf muscles) that develops through stimulus-response Pavlovian conditioning. Phase three includes intense negative emotional responses and accompanying physiological distress, thoughts, urges, and emotion-driven behavior. Phase four is the individual's coping responses to emotional distress, and phase five is the environmental response and resulting internal and external consequences of the coping behaviors. Each phase helps explain the maintenance of the response and the individual's impairment. Results: Anticipatory anxiety and avoidance of phase one contributes to an increased arousal and awareness of triggers, resulting in increased severity of the trigger experience. Both the Pavlovian-conditioned physical reflex of phase two and the emotion-driven behavior caused by the conditioned emotional response of phase three increase with in vivo exposure to triggers. Phase four includes internal and external coping behaviors to the intense emotions and distress, and phase five includes the consequences of those behaviors. Internal consequences include beliefs fiveand new emotions based on environmental responses to anger and panic. For example, the development of emotions such as shame and guilt, and beliefs regarding how 'intolerable' the trigger is. Conclusions: We assert misophonia is a multi-sensory condition and includes anticipatory anxiety, conditioned physical reflexes, intense emotional and physical distress, subsequent internal and external responses, and environmental consequences.

A symptom network model of misophonia: From heightened sensory sensitivity to clinical comorbidity

OBJECTIVES

Misophonia-an unusually strong intolerance of certain sounds-can cause significant distress and disruption to those who have it but is an enigma in terms of our scientific understanding. A key challenge for explaining misophonia is that, as with other disorders, it is likely to emerge from an interaction of traits that also occur in the general population (e.g., sensory sensitivity and anxiety) and that are transdiagnostic in nature (i.e., shared with other disorders).

METHODS

In this preregistered study with a large sample of participants (N = 1430), we performed a cluster analysis (based on responses to questions relating to misophonia) and identified two misophonia subgroups differing in severity, as well as a third group without misophonia. A subset of this sample (N = 419) then completed a battery of measures designed to assess sensory sensitivity and clinical comorbidities.

RESULTS

Clinical symptoms were limited to the most severe group of misophonics (including autistic traits, migraine with visual aura, anxiety sensitivity, obsessive-compulsive traits). Both the moderate and severe groups showed elevated attention-to-detail and hypersensitivity (across multiple senses). A novel symptom network model of the data shows the presence of a central hub linking misophonia to sensory sensitivity which, in turn, connects to other symptoms in the network (relating to autism, anxiety, etc.).

CONCLUSION

The core features of misophonia are sensory-attentional in nature with severity linked strongly to comorbidities.

Autistic traits, emotion regulation, and sensory sensitivities in children and adults with Misophonia

Misophonia is an unusually strong aversion to everyday sounds such as chewing, crunching, or breathing. Previous studies have suggested that rates of autism might be elevated in misophonia, and here we examine this claim in detail. We present a comprehensive review of the relevant literature, and two empirical studies examining children and adults with misophonia. We tested 142 children and 379 adults for traits associated with autism (i.e., attention-to-detail, attention-switching, social processing, communication, imagination, emotion regulation, and sensory sensitivity across multiple domains). Our data show that autistic traits are indeed elevated in misophonics compared to controls. We discuss our findings in relation to models of the interface between autism, sensory sensitivities, and the specific features of misophonia.

Auditory affective processing, musicality, and the development of misophonic reactions

Misophonia can be characterized both as a condition and as a negative affective experience. Misophonia is described as feeling irritation or disgust in response to hearing certain sounds, such as eating, drinking, gulping, and breathing. Although the earliest misophonic experiences are often described as occurring during childhood, relatively little is known about the developmental pathways that lead to individual variation in these experiences. This literature review discusses evidence of misophonic reactions during childhood and explores the possibility that early heightened sensitivities to both positive and negative sounds, such as to music, might indicate a vulnerability for misophonia and misophonic reactions. We will review when misophonia may develop, how it is distinguished from other auditory conditions (e.g., hyperacusis, phonophobia, or tinnitus), and how it relates to developmental disorders (e.g., autism spectrum disorder or Williams syndrome). Finally, we explore the possibility that children with heightened musicality could be more likely to experience misophonic reactions and develop misophonia.

Psychometric validation of a brief self-report measure of misophonia symptoms and functional impairment: The duke-vanderbilt misophonia screening questionnaire

Misophonia is a newly described disorder of sound tolerance characterized by strong negative emotional reactions to specific "trigger" sounds, resulting in significant distress, pathological avoidance, and impairment in daily life. Research on misophonia is still in its infancy, and most existing psychometric tools for assessing misophonia symptoms have not been extensively validated. The purpose of the current study was to introduce and psychometrically validate the duke-vanderbilt Misophonia Screening Questionnaire (DVMSQ), a novel self-report measure of misophonia symptoms that can be used to determine misophonia "caseness" in clinical and research settings. Employing large online samples of general population adults (n = 1403) and adults on the autism spectrum (n = 936), we rigorously evaluated the internal structure, reliability, validity, and measurement invariance of the DVMSQ. Results indicated that 17 of the 20 original DVMSQ items fit well to a bifactor structure with one "general misophonia" factor and four specific factors (anger/aggression, distress/avoidance, impairment, and global impact). DVMSQ total and subscale scores were highly reliable in both general population and autistic adult samples, and the measure was found to be approximately invariant across age, sex, education level, and autism status. DVMSQ total scores also correlated strongly with another measure of misophonia symptoms (Duke Misophonia Questionnaire-Symptom Scale), with correlations between these two measures being significantly stronger than correlations between the DVMSQ and scales measuring other types of sound intolerance (Inventory of Hyperacusis Symptoms [General Loudness subscale] and DSM-5 Severity Measure for Specific Phobia [modified for phonophobia]). Additionally, DVMSQ items were used to operationalize diagnostic criteria for misophonia derived from the Revised Amsterdam Criteria, which were further updated to reflect a recent consensus definition of misophonia (published after the development of the DVMSQ). Using the new DVMSQ algorithm, 7.3% of general population adults and 35.5% of autistic adults met criteria for clinically significant misophonia. Although additional work is needed to further investigate the psychometric properties of the DVMSQ and validate its theory-based screening algorithm using best-estimate clinical diagnoses, this novel measure represents a potentially useful tool to screen for misophonia and quantify symptom severity and impairment in both autistic adults and the general population.

A longitudinal investigation of quality of life and negative emotions in misophonia

Aims

This longitudinal study examined the role of anger, disgust, and anxiety in the experience of misophonia, the quality of life of those with self-reported misophonia in comparison to those without misophonia, and the association of misophonia and quality of life over time.

Methods

An online longitudinal survey was conducted, with misophonia, anger, disgust, anxiety, depression, self-esteem, and quality of life measured at two time points (6-months apart) in two groups of people (those with self-reported misophonia and those without misophonia).

Results

Anger and disgust emerged as the primary predictors of misophonic responses. Anxiety and depression were not significantly associated with misophonia over time. Differences in quality of life were observed between those with and without self-reported misophonia in the current study, with lower scores across the SF-36 domains of role limitations due to emotional problems, energy/fatigue, emotional wellbeing, social functioning, and general health for those with misophonia compared to those without misophonia. Compared with other studies, scores for those with self-reported misophonia were lower than those with long-term physical conditions, similar to those with tinnitus, but higher than those with obsessive compulsive disorder. Misophonia was predictive of quality of life over time but only on two domains: role limitations due to emotional problems (predictors: avoidance, emotional responses, and impact on participation in life) and pain (predictor: impact on participation in life). Depression remained a strong predictor of quality of life over time.

Conclusion

Anger and disgust are more strongly associated with the experience of misophonia than anxiety. Quality of life in people with self-reported misophonia is lower than in the general population and may be similar to those with tinnitus. Depression, avoiding triggers, the extent of the emotional response, and perceived impact on participation in life are associated with perceptions of lower quality of life over time for people with self-reported misophonia.

Misophonia: A Systematic Review of Current and Future Trends in This Emerging Clinical Field

Misophonia is a scarcely known disorder. This systematic review (1) offers a quantitative and qualitative analysis of the literature since 2001, (2) identifies the most relevant aspects but also controversies, (3) identifies the theoretical and methodological approaches, and (4) highlights the outstanding advances until May 2022 as well as aspects that remain unknown and deserve future research efforts. Misophonia is characterized by strong physiological, emotional, and behavioral reactions to auditory, visual, and/or kinesthetic stimuli of different nature regardless of their physical characteristics. These misophonic responses include anger, general discomfort, disgust, anxiety, and avoidance and escape behaviors, and decrease the quality of life of the people with the disorder and their relatives. There is no consensus on the diagnostic criteria yet. High comorbidity between misophonia and other psychiatric and auditory disorders is reported. Importantly, the confusion with other disorders contributes to its underdiagnosis. In recent years, assessment systems with good psychometric properties have increased considerably, as have treatment proposals. Although misophonia is not yet included in international classification systems, it is an emerging field of growing scientific and clinical interest.

Consensus Definition of Misophonia: A Delphi Study

Misophonia is a disorder of decreased tolerance to specific sounds or their associated stimuli that has been characterized using different language and methodologies. The absence of a common understanding or foundational definition of misophonia hinders progress in research to understand the disorder and develop effective treatments for individuals suffering from misophonia. From June 2020 through January 2021, the authors conducted a study to determine whether a committee of experts with diverse expertise related to misophonia could develop a consensus definition of misophonia. An expert committee used a modified Delphi method to evaluate candidate definitional statements that were identified through a systematic review of the published literature. Over four rounds of iterative voting, revision, and exclusion, the committee made decisions to include, exclude, or revise these statements in the definition based on the currently available scientific and clinical evidence. A definitional statement was included in the final definition only after reaching consensus at 80% or more of the committee agreeing with its premise and phrasing. The results of this rigorous consensus-building process were compiled into a final definition of misophonia that is presented here. This definition will serve as an important step to bring cohesion to the growing field of researchers and clinicians who seek to better understand and support individuals experiencing misophonia.

White matter abnormalities in misophonia

Misophonia is a condition in which specific ordinary sounds provoke disproportionately strong negative affect and physiological arousal. Evidence for neurobiological abnormalities underlying misophonia is scarce. Since many psychiatric disorders show white matter (WM) abnormalities, we tested for both macro and micro-structural WM differences between misophonia patients and healthy controls. We collected T1-weighted and diffusion-weighted magnetic resonance images from 24 patients and 25 matched controls. We tested for group differences in WM volume using whole-brain voxel-based morphometry and used the significant voxels from this analysis as seeds for probabilistic tractography. After calculation of diffusion tensors, we compared group means for fractional anisotropy, mean diffusivity, and directional diffusivities, and applied tract-based spatial statistics for voxel-wise comparison. Compared to controls, patients had greater left-hemispheric WM volumes in the inferior fronto-occipital fasciculus, anterior thalamic radiation, and body of the corpus callosum connecting bilateral superior frontal gyri. Patients also had lower averaged radial and mean diffusivities and voxel-wise comparison indicated large and widespread clusters of lower mean diffusivity. We found both macro and microstructural WM abnormalities in our misophonia sample, suggesting misophonia symptomatology is associated with WM alterations. These biological alterations may be related to differences in social-emotional processing, particularly recognition of facial affect, and to attention for affective information.

["Ear rage": misophonia : Review and current state of knowledge]

Misophonia is a devastating disorder. It is known as an affective sound-processing disorder characterized by the experience of strong negative emotions (e.g., anger, distress) in response to human sounds such as eating/swallowing/breathing. Other sounds produced by humans but not directly by human bodies can also be misophonic triggers (e.g. pen clicking) or environmental sounds (animal sounds/sounds of machines). The type of aversive triggers is individual. The reaction to trigger sounds can depend on many factors, such as assessment of the sound, personal experience, social context or psychological profile. However, there is currently no consensus in defining misophonia. Misophonia is also not yet classified by any official diagnostic system, although it seems to be a separate disorder. There are also associations with other disorders such as activity disorders, tinnitus, hyperacusis, and autism spectrum disorders. In 2013, the first definition criteria were published for the diagnosis of misophonia. Specifically, fMRI showed abnormal activation of the anterior insular cortex (AIC) and other brain areas responsible for the processing and regulation of emotions. To date, no randomized controlled trials evaluating treatments have been published. The use of cognitive and behavioral interventions have been reported as well as external sound systems and sound masking systems as known in the tinnitus retraining therapy. Sufferers try to minimize the trigger sounds by wearing ear plugs or music headphones. Otolaryngologists may also encounter patients with symptoms of misophonia, e.g., when hearing screening is requested or advice should be given on different therapeutic options. This report provides an overview of the current state of knowledge in misophonia and its diagnosis and treatment.

Structural and functional brain abnormalities in misophonia

Misophonia is a newly described condition in which specific ordinary sounds provoke disproportionately strong negative affect. Since evidence for neurobiological abnormalities underlying misophonia is scarce, we tested whether misophonia patients differed from healthy controls in grey matter volumes and resting-state functional connectivity. We collected structural magnetic resonance imaging and resting-state functional magnetic resonance imaging data from 24 misophonia patients and 25 matched controls. Compared to controls, voxel-based morphometry showed larger right amygdala volume in misophonia patients. Follow-up seed-based functional connectivity analysis of the amygdala showed a different pattern of connectivity with the cerebellum, driven by greater connectivity with the left amygdala. Additional data-driven independent component analysis showed greater connectivity within lateral occipital cortices and fusiform gyri in the ventral attention network. We propose that the amygdala enlargement may be associated with heightened emotional reactivity in misophonia. The higher connectivity between left amygdala and cerebellum might be linked to a tendency to exhibit reflex-like physical reactions to triggers. Higher attention network connectivity may reflect sensory enhancement of visual triggers or visual imagery related to trigger sounds. In sum, we found structural and functional abnormalities which implicate dysfunction of emotional and attentional systems in misophonia.

Development and Initial Validation of the Duke Misophonia Questionnaire

Misophonia is characterized by decreased tolerance and accompanying defensive motivational system responding to certain aversive sounds and contextual cues associated with such stimuli, typically repetitive oral (e. g., eating sounds) or nasal (e.g., breathing sounds) stimuli. Responses elicit significant psychological distress and impairment in functioning, and include acute increases in (a) negative affect (e.g., anger, anxiety, and disgust), (b) physiological arousal (e.g., sympathetic nervous system activation), and (c) overt behavior (e.g., escape behavior and verbal aggression toward individuals generating triggers). A major barrier to research and treatment of misophonia is the lack of rigorously validated assessment measures. As such, the primary purpose of this study was to develop and psychometrically validate a self-report measure of misophonia, the Duke Misophonia Questionnaire (DMQ). There were two phases of measure development. In Phase 1, items were generated and iteratively refined from a combination of the scientific literature and qualitative feedback from misophonia sufferers, their family members, and professional experts. In Phase 2, a large community sample of adults (n = 424) completed DMQ candidate items and other measures needed for psychometric analyses. A series of iterative analytic procedures (e.g., factor analyses and IRT) were used to derive final DMQ items and scales. The final DMQ has 86 items and includes subscales: (1) Trigger frequency (16 items), (2) Affective Responses (5 items), (3) Physiological Responses (8 items), (4) Cognitive Responses (10 items), (5) Coping Before (6 items), (6) Coping During (10 items), (7) Coping After (5 items), (8) Impairment (12 items), and Beliefs (14 items). Composite scales were derived for overall Symptom Severity (combined Affective, Physiological, and Cognitive subscales) and Coping (combined the three Coping subscales). Depending on the needs of researchers or clinicians, the DMQ may be use in full form, individual subscales, or with the derived composite scales.

The development and validation of the Misophonia response scale

OBJECTIVE

Most current Misophonia scales are not validated, do not include both emotional and physiological responses to triggers, and/or focus only on auditory triggers. This research aimed to develop and validate a measure of the magnitude of the Misophonic response that addressed these omissions.

METHOD

Three studies were carried out with individuals with self-diagnosed Misophonia. In study 1, expert opinion and participants commented on initial items to determine both face and content validity. In study 2, scale structure, reliability, and convergent and discriminant validity were determined using correlations, principal component analysis (PCA), and reliability analysis. In study 3, factor structure was confirmed in another sample of participants using confirmatory factor analysis (CFA).

RESULTS

The final 22-item scale assesses the magnitude of responses to triggers across any sensory modality. There are three subscales (emotional, physiological, and participation in life), with three additional items measuring frequency of triggers, avoidance of triggers, and time taken to recover from the triggers. The final scale showed suitable discriminant and convergent validity, with good internal consistency (Cronbach's alphas range 0.77 to 0.89). The three-component solution extracted using PCA explained 53.97% of variance, with all items loading between 0.45 and 0.84. The structure was confirmed with CFA (χ² = 269.01, p < .001; CFI = 0.96; TLI = 0.96 and RMSEA = 0.045 (CI 0.037-0.053).

CONCLUSION

The Misophonia Response Scale, which is valid and reliable, will facilitate understanding of Misophonia as it is short and easy to use for self-report in research.

The prevalence and characteristics of misophonia in Ankara, Turkey: population-based study

BACKGROUND

Misophonia is defined as significant distress (anger, distress or disgust) when exposed to certain sounds that would not affect most people, such as lip smacking or gum chewing. Although misophonia is common, the aetiology, prevalence and effective treatments are largely unknown.

AIMS

Based on our proposed diagnostic criteria, we examined the prevalence of misophonia and its relationship with clinical and demographic variables in a large representative population sample.

METHOD

We used a household sample (N = 541) of all residents aged >15 years, living in 300 homes randomly selected in Ankara city centre, Turkey. All participants were assessed at their homes by trained interviewers, for sociodemographic variables, misophonic sounds and related factors, using a semi-structured interview (the Misophonia Interview Schedule) developed for the current research.

RESULTS

The current misophonia diagnosis prevalence was 12.8% (n = 69 of 541), although 427 (78.9%) participants reported at least one sound that was distressing. The mean number of misophonic sounds was 8.6 (s.d. 8.9, range 0-44); the figure was 17.6 in those with misophonia compared with 7.3 in those without misophonia. Of those with misophonia, only 5.8% contacted services for their condition. Predictors of misophonia diagnosis included younger age, family history of misophonia and previous contact with mental health services.

CONCLUSIONS

Our study showed that misophonia is common in the general population, may cause significant disruption in daily life and is undertreated. Although more evidence is needed to classify misophonia as a psychiatric disorder, our findings support others who claim that the condition belongs to the group of mental disorders.

Evaluation and Management of Misophonia Using a Hybrid Telecare Approach: A Case Report

Decreased sound tolerance (DST) is a negative reaction to environmental sounds and is estimated to affect 3.5% of the population. This case report presents the evaluation and management of an adult female with severe, longstanding misophonia. Her evaluation included comprehensive audiometric testing (including uncomfortable loudness levels) and a detailed assessment of the impact of DST on her life. She enrolled in tinnitus retraining therapy and began receiving treatment aiming to facilitate habituation of bothersome environmental sounds. This case was complicated by the advent of the coronavirus disease 2019 (COVID-19) pandemic and a telemedicine hybrid approach was employed to increase access to audiologic care. Using this structure, some appointments occurred in person in the clinic and others occurred via a telemedicine video visit format. Telemedicine video visits facilitated in-depth discussions, afforded the opportunity to answer questions, and provided the option of cloud-based remote programming of on-ear devices. Future care will continue to employ a hybrid approach.

What sound sources trigger misophonia? Not just chewing and breathing

OBJECTIVES

Misophonia is a highly prevalent yet understudied condition characterized by aversion toward particular environmental sounds. Oral/nasal sounds (e.g., chewing, breathing) have been the focus of research, but variable experiences warrant an objective investigation. Experiment 1 asked whether human-produced oral/nasal sounds were more aversive than human-produced nonoral/nasal sounds and non-human/nature sounds. Experiment 2 additionally asked whether machine-learning algorithms could predict the presence and severity of misophonia.

METHOD

Sounds were presented to individuals with misophonia (Exp.1: N = 48, Exp.2: N = 45) and members of the general population (Exp.1: N = 39, Exp.2: N = 61). Aversiveness ratings to each sound were self-reported.

RESULTS

Sounds from all three source categories-not just oral/nasal sounds-were rated as significantly more aversive to individuals with misophonia than controls. Further, modeling all sources classified misophonia with 89% accuracy and significantly predicted misophonia severity (r = 0.75).

CONCLUSIONS

Misophonia should be conceptualized as more than an aversion to oral/nasal sounds, which has implications for future diagnostics and experimental consistency moving forward.

Confinement and the Hatred of Sound in Times of COVID-19: A Molotov Cocktail for People With Misophonia

Forced strict confinement to hamper the COVID-19 pandemic seriously affected people suffering from misophonia (M+) and those living with them. Misophonia is a complex neurophysiological and behavioral disorder of multifactorial origin, characterized by an intense physiological and emotional response produced by intolerance to auditory stimuli of the same pattern, regardless of physical properties. The present work studied the secondary impact that strict confinement caused in 342 adults (224 women: 118 men) regularly attending a medical psychological center in Barcelona. Misophonia, usually underdiagnosed, showed a prevalence of 35%, the same for women (37%) than men (31%). A retrospective analysis using a physical-psychological-social inventory of 10 variables evaluated the number of individuals that during confinement and self-confinement (March 11 - June 29, 2020) canceled (mostly M-) and/or requested a therapeutic intervention, the reasons for their request, and the strategies they used to self-manage the situation. Ten main variables indicated that the confinement exponentially increased the effects of misophonia compared with results from the same individuals during the last quarter of 2019. Most people diagnosed with misophonia continued with tele-assistance during the confinement because of this impact's self-concern. Besides the impacts as part of the general population, M+ also developed different symptoms causing significant personal, social, and job/occupational imbalance, as compared to M-. Health, fears, conflicts with neighbors, study-related difficulties were outstanding reasons for consultations. The LSB-50 test for 'Psychological and Psychosomatic Symptoms' applied to M+ revealed the increase of 8 of 9 items of this psychopathological test. Sleep disorders (coronasomnia), hostility, depression, and somatization were more severe than in previous assessments. Women presented the worst psychological and psychosomatic states (eight out of nine, as compared to one out of nine in males). The study unveiled the complex physical-psychological-social burden, the need for dissemination and a gender perspective to understand the secondary impact of COVID-19 pandemic on the mental health of the population with misophonia. The results also show that in this new COVID era people suffering from misophonia need to develop coping strategies addressing modifiable risk and protective factors. They deserve familial/social comprehension, stronger clinical support and a gender medicine perspective.

Cognitive behavioral therapy for misophonia: A randomized clinical trial

BACKGROUND

Patients with misophonia suffer from anger or disgust confronted with specific sounds such as smacking or breathing. Avoidance of cue-related situations results in social isolation and significant functional impairment. This is the first randomized, controlled cognitive behavioral therapy (CBT) trial for misophonia, evaluating the short- and long-term efficacy.

METHODS

The evaluator-blinded, randomized clinical trial was conducted from May 2017 until December 2018 at an academic outpatient clinic. Misophonia patients were randomly assigned to 3 months of weekly group-CBT or a waiting list and tested at baseline, 3 months (following CBT or waiting list), 6 months (after cross-over), and 15/18 months (1-year follow-up). CBT consisted of task concentration and arousal reduction, positive affect labeling, and stimulus manipulation. Co-primary outcomes were symptom severity assessed by the Amsterdam Misophonia Scale-Revised (AMISOS-R) and improvement on the Clinical Global Impression-Improvement (CGI-I). Secondary outcomes were self-assessed ratings of general psychopathology (Symptom Checklist-90-Revised [SCL-90-R]) and quality of life (five-dimensional EuroQol [EQ5-D], Sheehan Disability Scale [SDS], WHO Quality of Life-BREF [WHOQoL-BREF]).

RESULTS

In all, 54 out of 71 patients were included (mean age, 33.06 [SD, 14.13] years; 38 women [70.4%]) and 46 (85%) completed the study. In the randomized phase, CBT resulted in statistically significant less misophonia symptoms in the short-term (-9.7 AMISOS-R; 95% CI, -12.0 to -7.4; p < .001, d = 1.97). The CBT group had an observed clinical improvement (CGI-I < 3) in 37% compared to 0% in the waiting list group (p < .001). The effect of CBT was maintained at 1-year follow-up on primary and secondary outcomes.

CONCLUSIONS

This first randomized control trial shows both short-term and long-term efficacy of CBT for misophonia.

Misophonia: An Evidence-Based Case Report

Purpose Misophonia is a sound tolerance disorder condition in certain sounds that trigger intense emotional or physiological responses. While some persons may experience misophonia, a few patients suffer from misophonia. However, there is a dearth of literature on audiological assessment and management of persons with misophonia. The purpose of this report is to discuss the assessment of misophonia and highlight the management option that helped a patient with misophonia. Method A case study of a 26-year-old woman with the complaint of decreased tolerance to specific sounds affecting quality of life is reported. Audiological assessment differentiated misophonia from hyperacusis. Management included retraining counseling as well as desensitization and habituation therapy based on the principles described by P. J. Jastreboff and Jastreboff (2014). A misophonia questionnaire was administered at regular intervals to monitor the effectiveness of therapy. Results A detailed case history and audiological evaluations including pure-tone audiogram and Johnson Hyperacusis Index revealed the presence of misophonia. The patient benefitted from intervention, and the scores of the misophonia questionnaire indicated a decrease in the severity of the problem. Conclusions It is important to differentially diagnose misophonia and hyperacusis in persons with sound tolerance disorders. Retraining counseling as well as desensitization and habituation therapy can help patients who suffer from misophonia.

Development and Psychometric Properties of MisoQuest-A New Self-Report Questionnaire for Misophonia

Background: Misophonia is a condition related to experiencing psychophysiological sensations when exposed to specific sound triggers. In spite of progress in research on the subject, a fully validated questionnaire assessing misophonia has not been published yet. The goal of this study was to create and validate a new questionnaire to measure misophonia. Methods: MisoQuest is based on the diagnostic criteria proposed by Schröder et al. in 2013, with minor changes implemented by the authors of MisoQuest. A total of 705 participants took part in the study, completing the online questionnaires. Exploratory Factor Analysis (EFA) and analyses using the Item Response Theory (IRT) were performed. Internal consistency was evaluated with Cronbach's alpha. Results: The reliability of the MisoQuest was excellent (α = 0.955). The stability at five weeks was strong. There was a significant difference in results between people classified as those with misophonia and those without misophonia. Conclusions: MisoQuest has good psychometric values and can be helpful in the identification of misophonia. A deeper analysis showed that certain triggers might be more specific for people with misophonia. Consideration of violent behavior in response to misophonic triggers as a symptom of misophonia was undermined.

Inattention in misophonia: Difficulties achieving and maintaining alertness

Introduction: Misophonia is marked by abnormal negative reactions to specific and idiosyncratic sounds. Despite unclear etiology and diagnostic conceptualization, neuropsychology may be able to help characterize the syndrome. In the current study, we administered the Attention Network Test (ANT) under symptom provocation conditions, as well as secondary measures of concept formation, perseveration, processing speed, and frustration tolerance. We assessed treatment seeking individuals with misophonia and non-clinical controls. We hypothesized higher alerting, orienting, and conflict effects on the ANT suggesting overall poorer performance for the misophonia group.Methods: The sample consisted of symptomatic individuals recruited from a randomized treatment trial prior to the mandatory waitlist (n = 11) and age, gender matched controls (n = 11). Symptomatic individuals were screened with the Misophonia Questionnaire, as well as a number of additional self-report and diagnostic measures.Results: Robust Bayesian estimation in multi-level models suggested worse alerting attention for symptomatic individuals, β_Median = 2.766, β_SD = 1.253, 95% CI [0.322, 5.2876], Bayes factor = 31.41. There were no effects respective to block (i.e., blocks before versus during and after symptom provocation) or interaction effects. There were also no effects particular to executive functioning measures but some evidence this domain should be further explored (e.g., ANT conflict effects, perseveration, and serial math accuracy).Conclusions: We propose that symptom provocation alone does not explain the observed group difference in alerting attention, which could reflect a long-standing neuropsychological weakness. Future studies should attempt to characterize misophonia with more comprehensive neuropsychological batteries and larger samples.

Psychic euosmia and obsessive compulsive personality disorder

Patients with obsessive compulsive personality disorder (OCPD) often refer to a prompt mood improvement upon encountering good scents in general, or fresh laundry borax on their clothes, pillows or home settings. The Authors propose the new term psychic euosmia in the mean of an overstated psychological predisposition for a real pleasant smell that elicits an immediate sense of pleasure, order and calm. The prompt reactions to a pleasant odor might be explained by the involvement of rhinencephalon and its proximity to mood-related limbic circuits, which bypass the cognitive awareness. Cleanliness may not preclude a subject to enjoy a good smell, even if we are representing smells that resemble freshness, in other words order. A potentially even more important argument is given by the continuum of personality disorders and their variability. Not all personality characteristics led to disturbed behaviors. In evolutionary perspectives having the ability to differentiate between unpleasant and pleasant odors should have made the difference in surviving. On the other hand, psychic euosmia could be considered a normal reaction, but in our clinical experience it is over-represented among OCPD subjects with marked orderliness and disgust. Therefore, detecting psychic euosmia might vicariously confirm the relevance of disgust as a cognitive driver of OCPD. Hereby we support research to characterize psychic euosmia as a feature of orderliness and cleanliness for OCPD.

Misophonia in Singaporean Psychiatric Patients: A Cross-Sectional Study

Misophonia, also known as selective sound sensitivity syndrome, is a condition characterized by strong dislike of specific sounds with accompanying distressing reactions. To date, misophonia is still poorly understood. This study aimed to identify factors associated with severity of misophonic symptoms in Singaporean psychiatric patients. Ninety-two psychiatric patients were recruited from a large teaching hospital in Singapore in a cross-sectional study. Socio-demographics, severity of depression, anxiety and stress, and severity of misophonic symptoms were analyzed. Correlation analysis showed that anxiety, depression, and stress scores—as measured by the Depression, Anxiety and Stress Scales-21 (DASS-21)—were significantly positively correlated with the Amsterdam Misophonia Scale (A-MISO-S) scores. After adjustment for confounding factors, multivariate regression analysis showed that anxiety (β = 0.385, p = 0.029) remained significantly associated with A-MISO-S. Age, gender, depression, and stress were not significantly associated with the severity of misophonia. The findings showed that the severity of anxiety was associated with severity of misophonia in Singaporean psychiatric patients. Further research is needed to explore the nature of misophonia and its relationship with other psychiatric disorders.