Misophonia
Misophonia is a disorder of decreased tolerance to specific sounds or their associated stimuli, or cues. These cues, known as "triggers", are experienced as unpleasant or distressing and tend to evoke strong negative emotional, physiological, and behavioral responses not seen in most other people. Misophonia and the behaviors that people with misophonia often use to cope with it can adversely affect the ability to achieve life goals, communicate effectively, and enjoy social situations. At present, misophonia is not listed as a diagnosable condition in the DSM-5-TR, ICD-11, or any similar manual, making it difficult for most people with the condition to receive official clinical diagnoses of misophonia or medical services. In 2022, an international panel of misophonia experts published a consensus definition of misophonia, and since then, clinicians and researchers studying the condition have widely adopted that definition.
When confronted with specific "trigger" stimuli, people with misophonia experience a range of negative emotions, most notably anger, extreme irritation, disgust, anxiety, and sometimes rage. The emotional response is often accompanied by a range of physical symptoms that may reflect activation of the fight-or-flight response. Unlike the discomfort seen in hyperacusis, misophonic reactions do not seem to be elicited by the sound's loudness but rather by the trigger's specific pattern or meaning to the hearer. Many people with misophonia cannot trigger themselves with self-produced sounds, or if such sounds do cause a misophonic reaction, it is substantially weaker than if another person produced the sound.
Misophonic reactions can be triggered by various auditory, visual, and audiovisual stimuli, most commonly mouth/nose/throat sounds, repetitive sounds produced by other people or objects, and sounds produced by animals. The term misokinesia has been proposed to refer specifically to misophonic reactions to visual stimuli, often repetitive movements made by others. Once a trigger stimulus is detected, people with misophonia may have difficulty distracting themselves from the stimulus and may experience suffering, distress, and/or impairment in social, occupational, or academic functioning. Many people with misophonia are aware that their reactions to misophonic triggers are disproportionate to the circumstances, and their inability to regulate their responses to triggers can lead to shame, guilt, isolation, and self-hatred, as well as worsening hypervigilance about triggers, anxiety, and depression. Studies have shown that misophonia can cause problems in school, work, social life, and family. In the United States, misophonia is not considered one of the 13 disabilities recognized under the Individuals with Disabilities Education Act as eligible for an individualized education plan, but children with misophonia can be granted school-based disability accommodations under a 504 plan.
The expression of misophonia symptoms varies, as does their severity, which can range from mild and sub-clinical to severe and highly disabling. The reported prevalence of clinically significant misophonia varies widely across studies due to the varied populations studied and methods used to determine whether a person meets diagnostic criteria for the condition. But three studies that used probability-based sampling methods estimated that 4.6–12.8% of adults may have misophonia that rises to the level of clinical significance. Misophonia symptoms are typically first observed in childhood or early adolescence, though the onset of the condition can be at any age. Treatment primarily consists of specialized cognitive-behavioral therapy, with limited evidence to support any one therapy modality or protocol over another and some studies demonstrating partial or full remission of symptoms with this or other treatment, such as psychotropic medication.
Terminology and origins of the concept
Pawel Jastreboff and Margaret M. Jastreboff coined the term "misophonia" in 2001 with the assistance of Guy Lee, introducing it in their article "Hyperacusis", with further explanation in the International Tinnitus and Hyperacusis Society's ITHS Newsletter."Misophonia" comes from the Ancient Greek words μῖσος, meaning "hate", and φωνή, meaning "voice" or "sound", loosely translating to "hate of sound", and was coined to differentiate the condition from other forms of decreased sound tolerance, such as hyperacusis and phonophobia.
The term "misophonia" was first used in a peer-reviewed journal in 2002. Before that, the disorder was more commonly called "selective sound sensitivity syndrome", or "4S", a term coined by audiologist Marsha Johnson. Other names formerly used for the condition include "soft sound sensitivity symptom", "select sound sensitivity syndrome", "decreased sound tolerance", and "sound-rage".
Even after the term "misophonia" was coined, the condition remained largely undescribed in the clinical and research literature until 2013, when a group of psychiatrists at Amsterdam University Medical Center published a detailed misophonia case series and proposed the condition as a "new psychiatric disorder" with defined diagnostic criteria. In this series, Schröder and colleagues coined the term "misokinesia" to describe misophonia-like reactions that occur when people are "triggered" by specific repetitive visual stimuli, such as another person's foot shaking, fingers tapping, or gum chewing. Other authors have proposed "Conditioned Aversive Response Disorder" as a more suitable name, which seeks to incorporate both the respective auditory and non-auditory aspects of misophonia and misokinesia into a single condition.
Adopting DSM-5-like terminology, some research groups have also advocated the term "misophonic disorder" to distinguish clinically significant and disabling misophonia from what they term "misophonic reactions".
Notably, of the above terms, only "misophonia" is widely used by researchers, clinicians, and sufferers of the condition. It is the primary term used for the condition in mainstream journalistic coverage and by the primary philanthropic agency funding research into it, The Misophonia Research Fund, and the term selected for use in an project to derive a field-wide consensus definition of the condition for clinical and research use.
Signs and symptoms
Misophonia is a disorder of sound tolerance characterized by extreme and disproportionate emotional reactions to specific sounds in one's environment, termed "triggers." Trigger stimuli are experienced as extremely unpleasant or distressing and tend to evoke a "misophonic reaction" that consists of both unpleasant negative emotions and increased sympathetic arousal.There may also be a feeling of unwanted sexual arousal, similar to the obsessive-compulsive complex known as groinal response, upon encountering the trigger stimulus. This symptom is often grossly misunderstood and misinterpreted, but not uncommon or unusual.
Trigger stimuli are highly varied and sometimes idiosyncratic. Certain stimuli, such as chewing and other oronasal sounds, are among the most commonly reported triggers in both clinically referred and population-based samples. The Duke Misophonia Questionnaire, a commonly used misophonia symptom measure, groups misophonia triggers into the following categories:
- People making mouth sounds while eating or drinking.
- People making nasal/throat sounds.
- People making mouth sounds when not eating.
- People making repetitive sounds.
- Rustling or tearing objects.
- Sounds produced during speech.
- Body or joint sounds.
- Rubbing sounds.
- Stomping or loud walking.
- Muffled sounds.
- People talking in the background.
- Repetitive or continuous sounds made by inanimate objects.
- Animals making repetitive sounds.
- Seeing someone making or about to make a specific sound that causes distress, even if the sound itself isn't audible.
Reactions to triggers can range from mild to severe. A number of physical symptoms may also accompany the misophonic response, including muscle tension, increased heart rate, sweating, and a feeling of pressure in one's body. Other idiosyncratic physical and cognitive symptoms are also possible.
The five dimensions of cognitive-behavioral responses to "triggers", as empirically derived from the "S-Five", are as follows:
- Internalizing appraisals such as self-critical thoughts, feeling guilty about one's reactions, and feeling ashamed for reacting to triggers
- Externalizing appraisals such as blaming others for making triggering sounds, feeling that others are being selfish or disrespectful, and believing that specific sounds are "just bad manners" and should never be made by anyone
- Anxiety/avoidance responses such as isolating oneself, moving away from the sound, or limiting opportunities to avoid potential trigger exposure
- Feeling threatened/overwhelmed such as feeling trapped, having thoughts of helplessness, or panicking when one can't escape a trigger
- Aggressive outbursts such as yelling, screaming, pushing, hitting, throwing things, or becoming physically violent
The first misophonic reaction typically occurs when a person is young, often between the ages of 9 and 13. But misophonia can have an onset at any age, with cases as young as two years old and a number of adult-onset cases reported in the literature. The initial misophonic reaction will often originate from someone in a close relationship or a pet.
Fear and anxiety associated with trigger sounds can cause people with this condition to avoid important social and other interactions that may expose them to these sounds. This avoidance and other behaviors can make it harder for them to achieve their goals and enjoy interpersonal interactions. It can also have a significant adverse effect on their careers and relationships. Many people with misophonia experience worsening mental health, and some develop psychopathology secondary to their misophonia, including depression, anxiety, phonophobia, self-harm behaviors, and suicidality.