# Misophony

Misophony (from the Greek μῖσος misos 'hate' and φωνή phonḗ 'noise'), literally "hatred of noises", is a form of reduced noise tolerance towards certain noises . It is debated whether it is a neurological or psychological disorder , which is characterized by negative reactions to certain noises that are independent of the volume. There is no classification according to ICD-10 or DSM-5 .

The term "misophony" was coined at the beginning of the 21st century by the American neuroscientists Pawel and Margaret Jastreboff. A commonly used synonym is Selective Sound Sensitivity Syndrome , in German as "Selective Geräuschempfindlichkeits- syndrome ". Although this term appears to be the more scientifically accurate of the two, the term misophony caught on in research. Stimuli that cause the reactions described are called triggers (sounds).

Some researchers suggest that misophonia is caused by classical conditioning rather than an abnormality in the brain. Conditioning in this context means that those affected unconsciously associate noises with negative or traumatic events and therefore immediately show extreme reactions because they are unconsciously put back into these bad situations. Some sufferers reacted positively to treatment methods with counter-conditioning (in which they learn to combine the sounds with positive experiences), which is a process that dissolves conditioned reflexes . In the body, conditioned reflexes are controlled by the autonomic nervous system.

## Demarcation

Fig. 1. Classification of misophonia in connection with related constructs.

Noise intolerance is a heterogeneous construct that is defined in different ways. A typical subdivision between hyperacusis and misophonia occurs within noise intolerance. Often, however, other clinical symptoms are also defined as noise intolerance; the selectivity of the definitions has so far been poor and therefore there are sometimes inconsistent terms. One of the most important differentiations is therefore to be made within the noise intolerance between misophonia and hyperacusis. These differ fundamentally in terms of the physical properties, the meaning and the context of certain noises. In contrast to the pathological hypersensitivity to sound (hyperacusis), misophonia only affects certain noises that are perceived as stressful regardless of volume or physical constitution. Misophonia also includes aversive reactions, depending on the subjective meaning of the noise or the context.

Some researchers suggest that phonophobia (fear of sounds) is classified as misophonia, with the specification that fear is the predominant emotion in response to distinct sounds.

In addition, overlaps with disorders of sensory processing are seen. However, due to the still low validity of this concept, it is difficult to systematically prove this connection. In particular, researchers assume there is a connection with the subtype sensory overreactivity. The authors define this syndrome as experiencing naturally non-harmful sensory impressions more quickly and persistently than dangerous, painful, or distracting. Concerned, the habituation of sensory input and the ability to behave functionally in the presence missing.

The differentiation between misophonia and tinnitus is just as relevant. Additional, unilateral or bilateral noises in the ear are generally referred to as tinnitus. Scientists pointed to an overlap in terms of the neurological basis. The syndromes can be distinguished, however, from the fact that misophonia is triggered by external noises or situations, mostly produced by humans, and tinnitus, on the other hand, is characterized by abstract noises perceived internally.

It is also important to emphasize that neither hyperacusis nor misophonia are related to hearing thresholds , but can still be associated with normal or impaired hearing. However, the cause is not activation of the auditory system, but of the central nervous system.

## Symptoms

In 2014, both possible reactions and the underlying noises were characterized. The reactions observed include emotional reactions such as irritation, anger and anger, frustration, worry and fear, as well as conative reactions such as the need to remove yourself and cry and psycho-physiological reactions such as pain, discomfort, loss of concentration, arousal and stress. The list of corresponding noises is too long to report, but practically does not exclude any sound. Researchers demonstrated a number of noise classes and reactions using factor analysis . Accordingly, they describe the following classes:

• Eating people, repetitive typing, rustling, nasal noises, throat noises, consonants and vowels and environmental noises.

Extreme fear and avoidance behavior can arise, which can lead to social isolation or decreased sociability . Some people are forced to imitate what they see or hear.

The examination of the sensory information involved in the misophonic reaction also plays an important role in research. It is mostly assumed that other sensory perception modalities also play a role. However, it is questionable to what extent these are involved. It could be shown that both visual (e.g. foot or body movements) and tactile perceptions (e.g. textures of certain objects) are involved. However, whether these trigger the misophonic reactions alone or in combination with auditory information remains unclear. The fact that misophonic reactions are triggered by auditory information, however, is mostly proven. In 2013, researchers reported misophonic responses only to auditory, not visual, stimuli.

## Diagnosis

### Diagnostic criteria

There are no standardized diagnostic criteria for misophonia because it is not listed in the ICD-10 or DSM-5. In science, however, research criteria are proposed that are intended to provide an orientation framework for scientific investigations.

The diagnostic criteria for misophonia most cited in the literature were formulated in 2013 by three psychiatrists from the Medical Academic Center Amsterdam. In an interview study with 42 patients, the scientists suggested a discrete classification of the psychiatric disorder. Despite justified criticism of the criteria, they offer a systematic and comparable approach to the scientific investigation of diagnostic instruments.

Proposed diagnostic criteria for misophonia
Description of the criterion
1 The presence or anticipation of a specific noise produced by humans triggers an impulsive, aversive physical reaction that begins with irritation or disgust and immediately turns into anger.
2 This anger introduces a deep sense of loss of self-control with rare but potentially aggressive outbursts of anger.
3 The individual realizes that the anger or disgust is excessive, unfounded, or disproportionate to the circumstances or the triggering stressor.
4th The individual tends to avoid misophonic situations or, when inevitable, to endure them, which is accompanied by intense discomfort, anger or disgust.
5 The anger, disgust, or avoidance causes significant distress in the individual (i.e., it bothers the individual to feel that anger or disgust) or significantly interferes with the person's everyday life.
6th The anger, disgust, or avoidance cannot be better explained by another disorder, such as Obsessive Compulsive Disorder or Post Traumatic Stress Disorder.
(Table adapted and translated from English)

### Psychological survey methods

In the literature, there are some self-reporting procedures (questionnaires) and interviews that claim to measure misophony. With one exception, however, it must be stated that there are currently no procedures that have been scientifically investigated and the test quality of which has been systematically checked. Some test procedures from the specialist literature are described below.

#### Misophonia Questionnaire (MQ)

The questionnaire is divided into three parts, which measure the presence of misophonia symptoms (misophonia symptom scale), the resulting emotions and behaviors (misophonia emotion and behavior scale) and the general severity of the sensitivity to noise. People are asked to rate how strongly or often the statements apply to themselves on a scale from 0 (doesn't apply at all / never) to 4 (always applies / always).

The questionnaire was examined as part of a study of 483 students in Florida. The psychometric examination did not take place independently.

The reliability (measurement accuracy) of the method was estimated using internal consistencies ( Cronbach's α ). For the symptom scale, α = .86 and for the emotion and behavior scale, α = .86, which are considered to be good results.

The construct validity was examined by means of an exploratory factor analysis, which was able to show a three-factor solution. This is in line with the three proposed parts of the questionnaire. As evidence of the convergent validity , the authors list high correlations with auditory hypersensitivity in a sensory hypersensitivity questionnaire (r = .50, p <.001). The authors see the lower correlations with other sensory hypersensitivities (r = .28 - .34, p <.001) as an indication of the discriminant validity .

The following scales are translations of the original English version of the MQ.

##### Misophonia Symptom Scale

Compared to other people, I am sensitive to the following noises:

1. Eating people (e.g. chewing, swallowing, lips, smacking, slurping, etc.)
2. Repeated tapping (e.g. pen on table, foot on floor, etc.)
3. Rustling (e.g. plastic, paper, etc.)
4. People who make nasal noises (e.g. inhale, exhale, sniff, etc.)
5. People who make throat noises (e.g. clearing their throat , coughing, etc.)
6. Certain consonants and / or vowels (e.g. "k" sounds etc.)
7. Environmental noises (e.g. clock ticking, refrigerator hum, etc.)
8. Other
##### Misophony, emotion and behavior scale

If you are aware of the sound (s), how often do you do or experience the following because of the sound (s):

1. Leave the environment and go to a place where the noises can no longer be heard?
2. Actively avoid certain situations, places, things and / or people in anticipation of the noise (s)?
4. Get anxious or worried?
6. Get annoyed?
7. Have violent thoughts?
8. Get upset?
9. Get Physically Aggressive?
10. Get verbally aggressive?
11. Other:
##### General degree of misophonia

Please rate the severity of your noise sensitivity on the following scale from 1 (minimal) to 15 (very difficult). Please take into account the number of noises you are sensitive to, the level of stress and the limitations in your life due to your sensitivity to noise.

scale description
1

2

3

Minimally within normal or very weak noise sensitivity. I spend little time resisting or being influenced by my sensitivity to noise.
4th

5

6th

Weak sensitivity to noise. Weak noise sensitivities that are noticeable to me and observer, cause weak impairment in my life and which I can oppose or for a short time I am influenced by them. Easily endured by others.
7th

8th

9

Moderate noise sensitivity. Sound sensitivities that cause significant impairments in my life and that cost me a lot of conscious energy to oppose them or by which I am particularly influenced. I need some help from others to function in everyday activity.
10

11

12

Severe sensitivity to noise. Sensitivities to noise that are so overwhelming and influencing for me that my daily life is an "active struggle". I spend all of the time resisting or being influenced by my sensitivity to sounds. I need a lot of help from others to function.
13

14th

15th

Very heavy noise sensitivity. Noise sensitivities that overwhelm me completely, so that I need intensive care when eating, sleeping and so on. It is therefore difficult to function in everyday life.

#### Amsterdam Misophonia Scale (A-MISO-S)

This interview-based method was constructed on the basis of the Yale-Brown Obsessive-Compulsive Scale and consists of six items that purport to measure the severity of misophonic symptoms. The questions address the following subject areas:

• Time consumed by misophony; Influence on functionality; Level of distress ; Degree of resistance; perceived control over thoughts; Avoidance behavior

The items are assessed by an expert in an interview. The A-MISO-S has a maximum test value of 24, with a value of 15 and above assuming severe misophonia. Due to the small number of items, this is a very economical procedure, which, however, cannot provide any direct evidence of reliability and validity.

#### Misophonia Assessment Questionnaire (MAQ)

A less used questionnaire in the literature is the MAQ, which consists of 63 items. The questions focus on the emotional impact of misophonia and take into account possible social problems that may arise. No psychometric analyzes were reported.

#### Misophonia Activation Scale (MAS-1)

The purpose of this scale is to measure the physical and emotional reactions and to classify the degree of severity. However, there are no psychometric analyzes and therefore no evidence for the reliability or validity of the method.

## Epidemiology

Studies on the epidemiology of misophonia are limited by considerable limitations and should be interpreted and reported with caution, as no valid and systematic estimates of the parameters have been realized so far. Information on the prevalence (frequency), incidence (new disease) and comorbidity (concomitant disease) is reported below .

### Prevalence

Data on the prevalence (frequency) of misophonia are only available when significant limitations are taken into account, but some studies suggest that it occurs more frequently than previously assumed. Among patients with tinnitus , which affects 4-5% of the population, there are studies that assume a prevalence of misophonia of 60%. Researchers also calculated conservative prevalence figures of 3.2% of misophonia for the general population from data from tinnitus patients by estimating the prevalence of noise intolerance in tinnitus patients (60%) and the corresponding prevalence of 92% of noise intolerant patients with misophonia. The prevalence. A study from 2010 measured a prevalence of 10% among tinnitus patients. In a dissertation from 2015, 35% of 375 people were found to have general auditory hypersensitivity, of which 15–63% had symptoms of misophonia. In addition, a study with 483 students from Florida found an incidence of 19.9%, which, however, cannot be called a conservative measure and therefore under certain circumstances overestimates the true value.

### Comorbidity

One of the biggest discussions within the misophonia research is the question of whether misophonia a physiological response, a symptom of other mental disorders or a separate mental disorder is. The answer to this question can be realized by examining the comorbidity. For example, high comorbidities in large, systematic and representative studies would be an indication that misophonia is a symptom of another underlying mental disorder. It is not possible to answer this question at this time. However, some very limited information is already available in this regard.

Studies have shown evidence that misophonia could be assigned, or at least related to, other neuropsychiatric disorders. This has been shown for obsessive-compulsive disorder in a pediatric context. A Dutch study from 2013 with a group of 42 patients with misophonia found a low incidence (2.4-7.1%) of comorbid mental disorders, with the exception of compulsive personality disorder (52.4%). An overlap has also been shown for neurodevelopmental disorders such as autism . In 2014, researchers came to the conclusion that in a sample of 184 people with misophonia, around 5% were also affected by another mental disorder. This can show that the presence of mental disorders may not play a role in describing misophonic reactions.

A current study from 2018 with 826 participants examined to what extent the severity of misophonia can be explained by fear sensitivity and indirectly by obsessive-compulsive symptoms. The entire model explains 9% of the variance in the degree of misophonia ( = .09, p <.001). The direct effect of fear sensitivity on the degree of severity is small with = .06 and the indirect effect of fear sensitivity via obsessive- compulsive symptoms on the degree of severity is also small with · = .08. In addition, the authors report high correlations between obsessive-compulsive symptoms and symptoms of misophonia (r = .42, p <.001). Overall, the results suggest a connection with obsessive-compulsive symptoms. ${\ displaystyle {\ hat {\ beta}} _ {2}}$${\ displaystyle {\ hat {\ beta}} _ {1}}$${\ displaystyle {\ hat {\ beta}} _ {3}}$

However, since in most studies the term misophony is used rather poorly and is also interpreted in this way when there are disorders of sensory processing, the arguments are only partially valid. Therefore, additional, representative and larger samples have to be collected, in which the comorbidity is systematically examined. So far, a differentiation from other disorders and a low potential for explaining other psychological disorders in misophonia could be shown.

## etiology

The etiology (causes of development) and explanatory models of misophonia have not yet been studied very much. In addition to psychological approaches, the current focus is on neurophysiological explanatory models. It should be noted that the results must be interpreted with caution and only reflect the beginnings of the research.

### Psychological explanations

Some researchers suggest that there is a profound sense of disgust at the onset of symptoms that occurred during childhood when people overheard family members. The aversive reaction manifested itself through repeated associations of the noise with disgust .

A similar but more general approach was described in 2015. Misophonia therefore develops fundamentally through classical conditioning . Triggers set off a physiological (muscle) reflex, which in turn triggers an emotional response. The misophonic response is sustained by the physiological reflex. Further triggers come about through further associations with already existing triggers or the physiological reflex.

Researchers were also able to determine fear as a mediator of the connection between symptoms of misophonia and anger. Accordingly, higher symptom levels trigger higher levels of anxiety, which in turn trigger higher levels of anger. The indirect effect of the mediator fear on anger is small with · = .018. ${\ displaystyle {\ hat {\ beta}} _ {1}}$${\ displaystyle {\ hat {\ beta}} _ {3}}$

### Neurophysiological explanatory approaches

Some scientists cite neurological mechanisms as the underlying process of misophonia. According to this, the auditory system works normally, but the networking between the auditory system, the limbic system and the autonomic nervous system is increased for certain noises. Unconscious processes seem to play a dominant role in the overactivation of the nervous system. It is speculated that the anomaly is more central than that in hyperacusis .

However, the entire processing process has not been finally clarified and is therefore referred to as a potential mechanism. A sound triggers subcortical and therefore unconscious processing. Information is then passed on to the limbic system (emotional associations) as well as to auditory and other cortical areas in which the conscious perception and evaluation of the noise occurs. The perception and evaluation of the noise can then trigger emotional associations again and activate the autonomous system, which explains the autonomous reactions of the misophony.

A neurological EEG study from 2014 with 34 participants compared 20 people with misophonia with a control group with regard to event-related potentials , i.e. with regard to neurological markers or brain reactions that occur after certain stimuli. The scientists presented constant auditory stimuli, with an unexpected stimulus being presented in a random sequence with a lower probability. Meanwhile, the electrical activity of the brain was measured by an EEG. The result of the investigation was lower N1 activity in those affected by misophonia, which suggests that there is a neurological deficit in auditory processing. The results are limited to the extent that it cannot be clearly established whether this deficit occurs in general in psychiatric patients or only specifically in those affected by misophonia. It is also not clear whether the deficit is due to altered auditory perception, inadequate processing, or an overlying dysfunction of cortical control.

In 2017, researchers were able to uncover the neurological basis of misophonia for the first time using fMRI data. The two most important results from the functional brain anatomical examination are the increased networking in the ventromedial prefrontal cortex and the activation of the anterior insular cortex . The prefrontal cortex is primarily involved in processing sensory information in relation to misophonia on the one hand and influences the function of many other areas of the brain on the other; so z. B. Areas of memory processing and the amygdala, i.e. emotional processing (fight-flight reactions and the salience of sensory stimuli). The insular cortex is primarily involved in assessing salience and processing sensory information and emotions.

## treatment

Studies on the treatment of misophonia are mostly (individual) case studies . No conclusions can therefore be drawn about the generality of patients with misophonia regarding the effectiveness of the treatment or other variables in the studies. For this reason, these results are to be interpreted as orientational and generating hypotheses and are not reported here. Only a few studies examined treatment approaches on a sufficiently large sample. So far there has been no randomized controlled trial on the treatment of misophonia, which is an important prerequisite for the quality of a treatment study. Studies focus on behavioral and neurological approaches.

### Cognitive behavioral therapy

#### Exposure therapy

Some scientists suspect that misophonia on the one hand cannot be treated directly by habituation (getting used to) in confrontations with trigger noises or on the other hand is only effective in misophonia patients with symptoms of stress or anxiety instead of symptoms of anger. However, the effectiveness of direct exposure has not been systematically investigated with regard to misophonia and therefore requires more explicit scientific evidence.

A qualitative , randomized study with 18 patients who were already involved in the treatment process before the start of the study was able to show that some patients did not show any direct habituation within the treatment hour with simple exposure. For this reason, the authors adapted the confrontation and developed an inhibitory learning model through which the patients learn certain strategies that should bring about positive changes between the treatment hours. The strategies cover the following areas:

• Change in negative expectations (dissolving stable negative expectations)
• Extinction (extinction)
• Perception of stimulus variability (natural change in the sounds instead of stable negative perception)
• Elimination of safety signals that trigger avoidance behavior

Based on treatment protocols, the authors came to the conclusion that the patients could benefit from the strategies they had learned. Since the study has no quantitative evidence, subsequent studies should support the results in terms of the effectiveness of the inhibitory learning model.

#### Effectiveness of cognitive-behavioral therapy techniques

A Dutch study with 90 patients systematically examined the treatment as part of cognitive behavioral therapy for the first time . The study is designed as an open, quasi-experimental test plan with a control group and a pre-test-post-test (before-and-after comparison).

All patients were interviewed at the time prior to treatment with the Symptom Checklist-90 (SCL-90) and the A-MISO-S to ensure that the diagnostic criteria for misophonia were met. Following the treatment, the A-MISO-S and, in addition, the Clinical Global Impression-Improvement Scale (CGI-I; instrument for assessing the improvement) were carried out again.

The treatment was designed as a group session and included four techniques of cognitive behavioral therapy that were expected to have a positive impact on the symptoms of misophonia.

1. Concentration exercises
2. Counter conditioning
3. Stimulus manipulation
4. Relaxation exercises

48% of the patients achieved a very strong or strong improvement and a reduction of at least 30% in the symptoms of misophonia. On average, the patients' A-MISO-S values ​​decreased significantly from 13.6 (moderate misophonia) before treatment to 9.1 (mild misophonia) after treatment (t = −12,198, df = 89, p <. 001). The result suggests an improvement after treatment using cognitive behavioral therapy techniques.

Despite its large sample size and quasi-experimental design, the study has some limitations. The A-MISO-S has not yet been validated and is therefore questionable as a measurement. Since patients were also not randomly assigned to the groups, it cannot be strictly guaranteed that differences in the groups can be directly attributed to the treatment. Furthermore, no lasting effects on the success of the therapy were investigated as there was no follow-up survey. For these reasons, the results should be interpreted with caution, but also an indication of the effectiveness of some cognitive-behavioral interventions.

### Tinnitus Retraining Therapy (TRT)

The tinnitus retraining therapy is a treatment method that was originally used to treat patients with 1,990 tinnitus was developed. This treatment is based on a neurophysiological model that, as described above, can also be applied to misophonia. With more than 100 publications on this form of treatment and a randomized controlled study, the effectiveness in relation to patients with tinnitus is well documented. Some studies also show evidence of effectiveness in treating misophonia.

Since misophonia differs from tinnitus in that the triggering signal is external and not internal, the TRT was adapted by its founders.

The treatment of misophonia with TRT is based on the one hand on special advice and on the other hand on the weakening and elimination of dysfunctional neural connections between the auditory system, limbic system and autonomic nervous system. The principle of extinction (extinction) and systematic desensitization of a conditioned reflex are behind this method. This is mainly done by combining the noise perceived as stressful with positive noises.

## Society and culture

People affected by misophonia in Germany have set up online groups where people can share information about the syndrome. This is particularly popular on Facebook.

In 2016, an English language documentary by Jeffrey Scott Gould entitled " Quiet Please " about misophony was released.

The following misophony guides are known in German-speaking countries: "Understanding and overcoming misophonia: origin and course, diagnosis and treatment" and "I hate noises!".

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