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Understanding and Overcoming Misophonia, A Conditioned Aversive Reflex Disorder

Authors:
  • Misophonia Treatment Institute

Abstract

Does the sound of other people chewing fill you with rage? Do certain sights and sounds make you crazy when they don’t bother anyone else? If so, you are not alone. Although rarely known, misophonia is quite common, and there is hope. Misophonia is a neurological condition where a person has a strong emotional response of anger or disgust to specific sounds. For some, it might be hearing someone chewing. For others, it is the sound of sniffling or breathing. Many people also have the misophonic response to visual triggers such as seeing someone chew gum. With misophonia, a person has specific soft sounds (and sights) that they cannot tolerate. Misophonia can be upsetting and annoying, or it can be a debilitating condition. It may vary in intensity but generally gets worse with time. There are important management techniques that are helpful to almost everyone. Although there are no proven treatments that work for everyone, there are treatments that work for many. With proper management and treatment there is hope for reducing the horrible effects of this condition. This book will help you understand what this mysterious condition is doing to you, or help you understand what someone close to you is experiencing. It explains how misophonia develops and expands with time, and why those little sounds cause a person SO much distress. It also gives you many techniques that will help you manage this condition and explores the existing treatment options. With proper management and treatment, you can greatly reduce the effects of misophonia in your life. Developing misophonia has been a journey. Overcoming misophonia is also a journey, and it is a journey that can provide much relief for this horrible condition.
Understanding and Overcoming
Misophonia
A Conditioned Aversive Reflex Disorder
Thomas H. Dozier
Misophonia Treatment Institute, Livermore, CA
Understanding and Overcoming Misophonia: A
Conditioned Aversive Reflex Disorder
Published by Misophonia Treatment Institute
5801 Arlene Way
Livermore, CA 94550
Copyright  2015 Thomas H. Dozier
ISBN 978-0-692-49482-0
All rights reserved
No part of this book may be reproduced in any form or by any
electronic or mechanical means including information storage and
retrieval systems, without permission in writing from the author. The
only exception is by a reviewer, who may quote short excerpts in a
published review.
Disclaimer
The information presented herein represents the views of the
author as of the date of publication. This book is presented for
informational purposes only. Due to the rate at which conditions
change, the author reserves the right to alter and update his opinions
at any time. While every attempt has been made to verify the
information in this book, the author does not assume any
responsibility for errors, inaccuracies, or omissions.
This book does not offer medical advice nor is it intended as a
substitute for the medical advice of a physician. The reader should
regularly consult a physician in matters relating to his/her health and
particularly with respect to any symptoms that may require diagnosis
or medical attention.
The names of patients who have provided testimonials have been
changed to protect their privacy.
Contents
1. The Misophonia Experience
My Introduction to Misophonia
Friday, August 31, 2012. I was working as a parent coach when
a mother contacted me asking for help with her difficult daughter and
the disruption she was causing in their family. She explained the
extreme behavior and her daughter’s unusual hatred of the breathing
and eating sounds of her parents. She said it was called “misophonia”
and there was no treatment for it. It was like a lightbulb went on in
my head. All of a sudden, my daughters irrational complaining
about my loud chewing made sense. My daughter had misophonia
also. She was now an adult with her own children and one of them
had misophonia also.
My retirement income supported me and I had extra time, so I
decided to investigate misophonia. My training as a behavior
specialist taught me that there were two general classes of human
behavior. The first is purposeful behaviorthe things we do. The
second class of behavior is reflexes all the things that our body
does automatically, including emotions. Misophonia was clearly an
emotional response, so I decided to apply my training to this new and
mysterious condition. I love a challenge, and this was definitely a
challenge. I love to help people, and this seemed like a worthwhile
way to help my family and others.
I am also a very tenacious and determined person. When I set
my mind to accomplish something, I stay focused and keep moving
forward, despite surprises and roadblocks. Understanding
misophonia has been an exciting challenge with many surprises and
roadblocks. It has also been technically challenging developing
methods to treat misophonia, including developing smartphone apps,
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but the opportunity to help others has been very rewarding. We have
made great progress, but we still have much to do.
It is my hope that this book will help you understand
misophonia. You are not crazy, and you were not just born this way. I
hope this book will help you make immediate changes that can
reduce the agony and emotional upheaval of misophonia, and that
you will understand how you can start the process of overcoming this
condition. It took years to develop all of your triggers, and it will
take time to overcome them. I wish you well in your new journey to
overcome your misophonia. So let’s get started.
Misophonia is a condition where a person has an extreme
emotional response to commonly occurring soft sounds or visual
images. These are called “triggers” because they trigger the
emotional response of anger and disgust. The anger may be any form
such is irritation, anger, hatred, or rage. Triggers also demand your
attention, and when they are happening, they prevent you from
thinking about anything else. If you’re reading this book because you
think you have misophonia, you’re probably thinking, “How can
little noises have such an overpowering negative effect on me? How
(and why) do such noises cause me to feel such irrational anger or
disgust?”
If you’re reading the book because someone close to you has
misophonia, you have probably thought it inconceivable that the
misophonic person has such an extreme response to something as
harmless as the sound of a crunch from eating a chip or a sniffle.
This just doesn’t make sense. At least at some point, you probably
thought, this is all in their head. This can’t be real. But it is real
very real. And it is likely more horrible than you can imagine.
In this book, I’ll present stories of real people with misophonia.
Some are my patients, and others are those I have met along the way.
Each gave their permission to have their story included because they
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want to help others understand this condition. I’ve changed their
names for their privacy. Here are two typical stories from people just
like you who hope to find relief from this debilitating condition.
Ryan’s Story
“I’ve dealt with misophonia since I was a child. I think it started
around the age of six or seven. My parents would raise their voices
when reprimanding me and I would quickly cover my ears and beg
them to stop yelling at me. They weren’t even close to actually
yelling at me, but on top of having this disorder, I also have above
average hearing. I hear one pitch above and one pitch below the
normal hearing range. This was medically proven by an ear, nose and
throat doctor I went to because my mother talked through one of my
hearing tests at the doctor so they thought I was half deaf.
“I find my triggers have continued to grow over the years.
Chewing was really all that bothered me, but once I went to college
my triggers grew at a staggering rate. I’m now triggered by any kind
of chewing; even knowing someone is going to eat in the same room
as me makes me get up and leave before they start eating because I
have anxiety knowing what’s about to happen. Birds chirping (this
started during my freshmen year of college because birds chirped
nonstop outside of our dorm room window), pens clicking, nails
tapping, the text message clicking sound, heavy breathing, noise
through the wall of any kind, but especially the bass in music or
people’s voices, sniffling, someone clearing their throat the list
goes on and on. Basically my misophonia has gotten to the point that
any sound, if repetitive, will make me freak out. It’s like I’m
constantly alert and my ears are always searching for trigger sounds,
which is why I sleep with headphones and white noise and a box fan
on high every night.
“My friends and family have known something was up for so
long that the second I hear a trigger sound I turn and look at them
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with this ‘if you don’t stop making that noise I will kill you’ look,
and they instantly stop what they’re doing and apologize. Their
apology after they’ve stopped making a trigger sound makes me feel
bad because they shouldn’t have to apologize for doing normal
things like eating. Logically I know they shouldn’t have to alter their
behavior because they’re not doing it on purpose and the sounds that
bother me are normal everyday sounds, but in the moment all I can
think about is that sound, and if I can’t remove myself which I
most often do I will lose my mind and freak out. For example, I
used to live at college and I could hear my neighbors through the
wall of my room, and because I couldn’t get away from it I flipped
and started banging on the wall and screaming at the top of my lungs,
all while shaking with anger and rage flowing through my veins.
Afterwards I felt stupid for flipping out, but I couldn’t help it, I
couldn’t get away from the sound, and after about five minutes it
feels like people are making sounds to purposely piss me off.
Needless to say my dorm director called me a handful and I no
longer live at college.
“Since finding this website and showing the research to my
family, they are much more understanding, my mother more than my
father (his chewing is my biggest trigger in the entire world even
when he chews with his mouth closed – and he’s constantly biting his
nails or his lip or the skin inside his mouth). By the way, Tourette
syndrome runs in my family, and my sister and father have it, so you
can imagine how difficult it is to have misophonia and live with
people who can’t help but do things repetitively. Basically I’ve come
to the point that I spend the majority of my time in my bedroom,
alone. I don’t mind being alone, and frankly I feel less on edge when
I’m by myself because I know that I’m not going to hear a trigger
sound. On the other side of that coin is the fact that I live with my
family, but I rarely see them because I’m constantly in my room.
Additionally, sudden loud sounds make me jump out of my skin, so
at this point being deaf seems like the only way I would be able to
spend time around other people.
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“Does anyone know any tips or anything that may help me and
decrease my isolation? Any advice is helpful because I love my
family and I want to spend time with them, but I find it impossible to
do so.”
Bill’s Story
“I feel like I know everyone else’s story by heart and can relate
to all. After a recent crisis and diagnosis, I’ve been examining this
and other sites like it. Thank-you to all who have shared their stories.
I’ve struggled with the symptoms of this condition for as long as I
can remember. The first vivid memory I have is during a 2,600-mile-
long family road trip where I noticed my younger brother was
breathing loudly. I alerted my mother, who assured me he was OK.
In a short time this had escalated into yelling, and me positioning my
head against the window and my bicep in such a way that I couldn’t
hear him.
“This scene played out over and over in my family. Mealtimes
were anxiety-provoking, and filled with anger, hurt feelings,
abandonment and self-loathing. I rarely ate with my folks and
brother at mealtime. I rarely accompanied them on family outings.
Believing I liked nature, I remember searching for secluded places
outdoors. I wonder now if I wasn’t seeking some relief. University
was hell sniffles, gum chewing/popping, coughing, shuffling feet.
Towards the end of my program I did not go to class but studied on
my own or with a close friend. Miso has played a part in all my
significant relationships, contributing to a divorce.
“I developed an addiction at an early age but have been sober
for twenty-seven years (not always easy). It’s hard for me to
overlook how the possibility of using a substance to manage miso
could be problematic. I’m fifty-one years old now and feel like I’m
starting something new again. As I said earlier, this diagnosis puts
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my life in a new perspective. I had forgotten about the mealtime
anxieties and self-loathing, the look on my brothers face when I’d
look at him in rage and hatred. I hated myself for this; no one
deserves those looks. I thought my mother hated me and regretted
my birth. I can’t ignore how difficult life with me must have been. In
the end I became a loner, finding it easier to be alone than with
others. There have been significant people in my life, but miso has
always surfaced.
“The aspect of this diagnosis that I find hopeful is how it may
just be legitimate. I say that with respect to all that believe its
legitimacy. I’ve spent my whole life being told and believing ‘it’s all
in my head’ or ‘just ignore it,’ and believing that I was fundamentally
broken. I’m in a relationship now with a reasonably understanding
lady who says we can work this out. I hope we can, because I’m tired
of believing I’m broken.
“I want to acknowledge how difficult it is for those around me
and at the same time respect my struggles. I’ve never considered that
maybe there is a possibility that this thing is beyond my control and
that it is OK to ask for help. It sounds like a fairytale... thinking I can
ask for help. I’ve got a lot of respect for all those who have put
themselves on the line asking for help with this from those around
them.
“Thanks for giving me this opportunity to express this.”
Misophonia Triggers
For a person who suffers with misophonia, his or her personal
triggers are a central fact of life. A trigger is a sound or sight that
causes a misophonic response. It may be a sound someone makes
when chewing, a slight pop of the lips when speaking, or a person
whistling. For a person with misophonia, a trigger causes an
involuntary reaction of irritation, and if the trigger continues, the
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emotions quickly become extreme anger, rage, hatred, or disgust.
These emotions are jerked out of the person, and trying to stay calm
when being triggered is futile.
The immediate negative emotions to a trigger are the hallmark
of misophonia. Along with the emotions come physiological (bodily)
actions that go along with such emotions. These include increased
general muscle tension, increased heart rate, sweating, and feelings
of overwhelming distress. When the trigger ceases, the emotional
upheaval generally continues. Many people continue to hear the
sound in their mind and replay the experience in their mind. While it
may only take a few minutes for a person to become extremely
distraught from the triggers, it can take hours for the person to calm
down and resume normal life.
The impact of misophonia can vary from almost nothing to
debilitating. I met a man who has only one trigger, and it’s the sound
of a spoon stirring a glass of iced tea. The tinkle sound is intolerable
for him, but no one in his family drinks iced tea, so he rarely hears
that trigger. His misophonia has little to no impact on his life. On the
other hand, I met another person who also has only one trigger, and it
is ruining her life. Her trigger is the sound of two or more women
talking to each other. As a student in a mostly female discipline, she
is subjected to this trigger continually at school, making her school
experience hellacious.
Misdiagnoses
Many people with life-long misophonia have suffered because
of being misdiagnosed. Traditionally, because virtually no one in the
medical and psychological communities was aware of misophonia,
any examination of an individual with misophonia resulted in a
misdiagnosis. I asked members of an online misophonia support
group to tell me their diagnoses prior to realizing they had
misophonia. Here is a partial list: intermittent explosive disorder,
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oppositional defiant disorder, mood disorder, hyperacusis,
ADD/ADHD, bipolar, paranoid personality disorder, obsessive
compulsive disorder, anxiety, autism, nervous disorder, sensory
processing disorder, phobia, typical mother-daughter issues,
migraines, seizures, PTSD, and depression. Because any diagnosis
without knowing about misophonia is a misdiagnosis, the best
answer any professional can provide is, “I don’t know.”
Additionally, many people have been told that there was
nothing wrong with them. They were told they just needed to get on
with their lives, or that they were spoiled brats, crazy, too sensitive, a
prima donna, never happy, stuck up, or hypersensitive. Many were
also told they needed to ignore the sounds or that it was all in their
head. Misophonia causes extreme negative emotions and many
individuals engage in inappropriate overt behavior (actions) directed
against people they dearly love. Both the extreme emotions and
actions cause high levels of guilt and shame, which is only made
worse if the person is told it is their entire fault!
Here is a poem that expresses what it is like to have
misophonia.
“My Misophonia”
By Angela Muriel Inez Mackay
My misophonia is not a quirk.
It’s not what “makes her different”
It’s not something fresh air can fix, or a pill can subside.
My misophonia is not intolerance.
It’s not an excuse to be “bitchy,”
and it is most certainly NOT that time of the month.
These tears are not from sadness.
They are from anger, and being overwhelmed.
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They’re from the fear that it will be too much.
That it will push you away.
I do not wear headphones in defiance,
or in disrespect to your words.
I wear headphones for an ironic sense of quiet.
“It’s not you, it’s me” is my motto.
It’s what I repeat in my head while you chew,
Each bite slicing into my ears like knives,
Each scrape of the fork a flinch of my finger,
Each crumple of the bag a cringe.
It kills me when you take joy in my pain,
Your gum mocks me,
And instead of an apology, you say,
“It’s just a sound!”
To you, it IS just a sound.
But to me, it’s my worst nightmare.
To me,
It’s what makes me avoid people,
Avoid plans,
Avoid “grabbing a bite to eat” with friends.
It’s what makes me want to stay home,
It’s what makes me question why I even bother.
My misophonia is what fills me with fear
Every single day,
That I will be too much to handle,
That I’m too touchy,
That I’m too “intolerant”,
My misophonia is part of me,
And I’m sorry.
I’m sorry for every glare,
Every cringe,
Every snappy word.
I’m sorry,
I have misophonia.
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2. Diagnosing Misophonia
Misophonia is an extreme emotional reaction to typically
occurring sounds. “Miso” means dislike or hatred, “phonia” means
sounds, so “misophonia” means ‘’a dislike or hatred of sounds.” This
rather broad name was given to the disorder in 2001 by Drs. Pawel
and Margaret Jastreboff.1 I say “broad” because it’s not about hating
sounds in general; it’s about hating only specific sounds. We call
these trigger sounds. Additionally, the “hatred” of trigger sounds
applies more to your involuntary response to a sound than your
feelings about that sound.
This condition is also known as selective sound sensitivity
syndrome, or 4S. This is the name given to this condition by
audiologist Marsha Johnson, who first identified this condition in
1997.2 This is really a better name for the condition because there are
specific and selective sounds to which the person is extremely
sensitive. However, misophonia is the more popular name for this
condition now, and it also includes visual triggers.3
I have proposed that an even better name for this condition is
Conditioned Aversive Reflex Disorder or CARD, which I will
explain in a later chapter.
To define misophonia, let’s first describe what misophonia is
not.
Misophonia is not a sensitivity to the volume of the sound or to
how loud the sound is. That’s hyperacusis, and that’s common,
especially in small children. Hyperacusis can either develop in
adulthood or continue from childhood. It can be tested by an
audiologist by measuring the volume at which sound becomes
painful. There are specific treatments that have been shown to reduce
hyperacusis.
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It’s not a fear of a sound; that’s phonophobia. And that’s also
common in children. Both hyperacusis and phonophobia are
common with autism, for example, and in young children being
scared by the toilet or the vacuum cleaner sound. This is not
misophonia.
In children, Sensory Processing Disorder (SPD) can also cause
an intolerance of loud sounds. SPD is a condition where a person has
significant problems with multiple forms of sensory input such as
touch, taste, smell, sight, and sounds. SPD is a general heightened
sensitivity to sensory stimulation. It is not the same as misophonia,
and it is not related to misophonia.4 A child with SPD may appear to
have hyperacusis or phonophobia because of the way he or she reacts
to sounds.
Misophonia is not being irritated or upset by a continuous, loud,
intrusive, or an irritating sound. There are people who, when they are
in a situation where there’s a repeating sound, become very upset.
These people are generally considered a highly sensitive person
(HSP). Their level of tolerance for these obnoxious or irritating
situations is not as high as with most other people. And so they get
upset. For example, a person living near an airport says that they
have an extreme emotional reaction to the sound of airplanes flying
over. This may or may not be misophonia. Misophonia is being upset
(triggered) by a single occurrence of the trigger. Suppose they are
not upset by the sound of a single airplane, but are upset by the first
airplane in the morning, knowing that many more will follow. This is
more likely to be a case of HSP than misophonia; they are upset
because they know they will be hearing airplanes all day long. And
the airplane noise is going to be intrusive and irritating. This person
may be very, very, very distressed by the noise, and the extreme
emotions may be identical to the emotions from misophonia. The
level of distress does not determine whether a person does or does
not have misophonia. The determining factor for misophonia is that a
person triggers – has an immediate response of irritation or disgust –
to a single instance of the trigger stimulus.
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A person who is highly sensitive can also have misophonia.
There may be certain sounds to which they are sensitive to because
they are irritating sounds, but there are other sounds that are
misophonic triggers.
Finally, misophonia is not reaction to a sound like nails on the
chalkboard, a baby crying, a knife on a bottle, a disc grinder, or a
female scream. It is common to be irritated by these sounds. They are
part of the top ten most irritating sounds. It seems that we are
genetically wired to respond to these sounds because they are similar
in frequency to a baby crying, a sound which should make us take
action.
With misophonia there is an immediate reaction to the trigger
stimulus. The trigger stimulus generally takes the form of sounds or
sights, and the stimulus causes an immediate and involuntary
response. It’s a response that is jerked out of the person.
The triggers are generally soft sounds. If you don’t have
misophonia or if it’s not a trigger sound you may not even hear the
sound; but for a person with misophonia, if they are in a room and
someone across the room starts doing something that is a trigger to
them, such as popping their gum, they are going to hear it and feel it.
This is common with a misophonia trigger.
There are also strong emotions with misophonia, the most
universal being hate, anger, rage, disgust, resentment, and being
offended. People with misophonia want to get away from the sound
or make it stop, and in most cases are thinking of a verbal or a
physical assault on the other person. Although it is extreme to think
about physically hurting someone because of a sound they are
making, rarely do people with misophonia act out on these impulses.
How to Determine if You Have Misophonia or Not
Suppose a person is triggered by a baby crying. This could be
misophonia, but maybe not. The way to tell is to perform two tests.
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The general principle is that we need to rule out that the person is
responding to the volume of the trigger or to the meaning of the
trigger – in this case, a baby in distress. Both of these can be tested
using a recorded trigger. First, test to see if the person is triggered by
a low volume cry. The crying needs to be a real trigger with the
volume reduced by distance or by playing the recorded crying at
lower volumes. If the person is triggered regardless of volume, it is
probably misophonia. Next see if the person is upset by the meaning
of the trigger by making it obvious that you are using a recording.
Because it is a recording, there is no baby in distress who needs to be
helped, and the person knows the baby is not in distress. If the person
is triggered to a soft sound (low volume crying) where the meaning
(baby in distress) is not a factor, then the person has misophonia.
A person has misophonia if they have at least one trigger that
creates the extreme emotional response in one setting. Of course, a
clinical definition of misophonia will take into account the impact of
the triggers on a person’s life, but such a level has not been specified
by the Diagnostic and Statistical Manual of Mental Disorders (DSM)
which is used by psychologists and psychiatrists, or the International
Statistical Classification of Diseases and Related Health Problems
(ICD) which is used by health care providers.
Rating the Severity of Misophonia
There are three surveys I use to rate the severity of misophonia.
These are the Misophonia Activation Scale, the Amsterdam
Misophonia Scale, and the Misophonia Assessment Questionnaire.
The Misophonia Activation Scale was developed by Misophonia-
UK.org and is the simplest of the three.
Misophonia Activation Scale (MAS-1)
Please select the level that best describes what you experience.
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Level 0: Person with misophonia hears a known trigger sound but
feels no discomfort.
Level 1: Person with misophonia is aware of the presence of a
known trigger person but feels no, or minimal, anticipatory anxiety.
Level 2: Known trigger sound elicits minimal psychic discomfort,
irritation or annoyance. No symptoms of panic or fight or flight
response.
Level 3: Person with misophonia feels increasing levels of psychic
discomfort but does not engage in any physical response. Sufferer
may be hyper-vigilant to audio-visual stimuli.
Level 4: Person with misophonia engages in a minimal physical
response - non-confrontational coping behaviours, such as asking the
trigger person to stop making the noise, discreetly covering one ear,
or by calmly moving away from the noise. No panic or flight or
flight symptoms exhibited.
Level 5: Person with misophonia adopts more confrontational coping
mechanisms, such as overtly covering their ears, mimicking the
trigger person, engaging in other echolalia, or displaying overt
irritation.
Level 6: Person with misophonia experiences substantial psychic
discomfort. Symptoms of panic, and a fight or flight response, begin
to engage.
Level 7: Person with misophonia experiences substantial psychic
discomfort. Increasing use (louder, more frequent) of confrontational
coping mechanisms. There may be unwanted sexual arousal. Sufferer
may re-imagine the trigger sound and visual cues over and over
again, sometimes for weeks, months or even years after the event.
Level 8: Person with misophonia experiences substantial psychic
discomfort. Some violence ideation.
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Level 9: Panic/rage reaction in full swing. Conscious decision not to
use violence on trigger person. Actual flight from vicinity of noise
and/or use of physical violence on an inanimate object. Panic, anger
or severe irritation may be manifest in sufferer's demeanour.
Level 10: Actual use of physical violence on a person or animal
(e.g., a household pet). Violence may be inflicted on self (self-
harming).
Unwanted sexual arousal can occur with an intense misophonic
response, as listed at level seven, but only one of my patients has
ever mentioned this. I had several patients who reported an
unpleasant sexual arousal reflex occurring at all levels of misophonia
severity. This is explained later, but for now, I suggest you do not
consider sexual arousal as a primary factor in determining your
misophonia severity. Virtually everyone with misophonia has wide
variation in their response to triggers based on the situation, the
trigger, and how long it continues. I suggest you rate yourself at the
highest level you experience in a typical week.
Amsterdam Misophonia Scale (A-MISO-S)
The Amsterdam Misophonia Scale (A-MISO-S) is an
adaptation of the Yale-Brown Obsessive-Compulsive Scale (Y-
BOCS) and was developed by researchers in Amsterdam.5 The
severity of your misophonia is determined by the sum of the points
from these questions.
AMSTERDAM MISOPHONIA SCALE: Rate the characteristics
of each item during the prior week up until and including the
time you fill out this survey. Scores should reflect the average
(mean) occurrence of each item for the entire week.
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Q1. How much of your time is occupied by misophonic triggers?
How frequently do the (thoughts about the) misophonic triggers
occur?
0: None
1: Mild - less than 1 hr/day, or occasional (thoughts about) triggers
(no more than 5 times a day)
2: Moderate - 1 to 3 hrs/day, or frequent (thoughts about) triggers
(no more than 8 times a day, most of the hours are unaffected).
3: Severe - greater than 3 hrs and up to 8 hrs/day or very frequent
(thoughts about) triggers.
4: Extreme - greater than 8 hrs/day or near constant (thoughts about)
triggers.
Q2. How much do these misophonic triggers interfere with your
social, work or role functioning? (Is there anything that you don’t
do because of them? If currently not working, determine how much
performance would be affected if you were employed.)
0: None
1: Mild - slight interference with social or occupational/school
activities, but overall performance not impaired.
2: Moderate - definite interference with social or occupational
performance, but still manageable.
3: Severe - causes substantial impairment in social or occupational
performance.
4: Extreme - incapacitating.
Q3. How much distress do the misophonic triggers cause you? (In
most cases, distress is equated with irritation, anger, or disgust. Only
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rate the emotion that seems triggered by misophonic triggers, not
generalized irritation or irritation associated with other conditions.)
0: None
1: Mild - occasional irritation/distress.
2: Moderate - disturbing irritation / anger / disgust, but still
manageable.
3: Severe - very disturbing irritation/anger/disgust.
4: Extreme - near constant and disturbing anger/disgust.
Q4. How much effort do you make to resist the (thoughts about
the) misophonic triggers? (How often do you try to disregard or
turn your attention away from these triggers? Only rate effort made
to resist, not success or failure in actually controlling the thought or
sound.)
0: Makes an effort to always resist, or symptoms so minimal,
doesn’t need to actively resist.
1: Tries to resist most of the time.
2: Makes some effort to resist.
3: Yields to all (thoughts about) misophonic triggers without
attempting to control them, but does so with some reluctance.
4: Completely and willing yields to all obsessions.
Q5. How much control do you have over your thoughts about the
misophonic triggers? How successful are you in stopping or
diverting your thinking about the misophonic triggers? Can you
dismiss them?
0: Complete control.
1: Much control - usually able to stop or divert thoughts about
misophonic triggers.
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2: Moderate control - sometimes able to stop or divert thoughts
about misophonic triggers.
3: Little control - rarely successful in stopping or dismissing
thoughts about misophonic triggers, can only divert attention with
difficulty.
4: No control - experience thoughts as completely involuntary,
rarely able to alter thinking about misophonic triggers.
Q6. Have you been avoiding doing anything, going any place, or
being with anyone because of your misophonia? (How much do
you avoid, for example, by using other loud sounds, such as music?)
0: No deliberate avoidance.
1: Mild, minimal avoidance. Less than an hrs/day or occasional
avoidance.
2: Moderate, some avoidance. 1 to 3 hrs/day or frequent
avoidance.
3: Severe, much avoidance. Greater than 3 up to 8 hrs/day. Very
frequent avoidance.
4: Extreme very extensive avoidance. Greater than 8 hr/day.
Doing almost everything you can to avoid triggering symptoms.
Finally:
What would be the worst thing that could happen to you if you
were not able to avoid the misophonic triggers?
Describe:
_________________________________________________
The sum score of these questions determines the severity rating as
follows:
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– 0-4: Subclinical (meaning you do not need treatment)
– 5-9: Mild
– 10-14: Moderate
– 15-19: Severe
– 20-24: Extreme
Misophonia Assessment Questionnaire
Marsha Johnson developed a survey for use with her patients.
It’s called the Misophonia Assessment Questionnaire. The survey
consists of 21 questions that are scored from 0 to 3 points based on
how often the item applies to you. The severity of your misophonia is
determined by the sum of the points from these questions.
MISOPHONIA ASSESSMENT QUESTIONNAIRE
RATING SCALE:
0 = not at all, 1 = a little of the time, 2 = a good deal of the time, 3 =
almost all the time
Score
1. My sound issues currently make me unhappy
2. My sound issues currently create problems for me.
3. My sound issues have recently made me feel angry.
4. I feel that no one understands my problems with certain
sounds.
5. My sound issues do not seem to have a known cause.
6. My sound issues currently make me feel helpless.
7. My sound issues currently interfere with my social life.
8. My sound issues currently make me feel isolated.
9. My sound issues have recently created problems for me
in groups.
10. My sound issues negatively affect my work/school life
(currently or recently).
11. My sound issues currently make me feel frustrated.
12. My sound issues currently impact my entire life
negatively.
13. My sound issues have recently made me feel guilty.
14. My sound issues are classified as “crazy.”
15. I feel that no one can help me with my sound issues.
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16. My sound issues currently make me feel hopeless.
17. I feel that my sound issues will only get worse with
time.
18. My sound issues currently impact my family
relationships.
19. My sound issues have recently affected my ability to
be with other people.
20. My sound issues have not been recognized as
legitimate.
21. I am worried that my whole life will be affected by
sound issues.
Sum Score
Dr. Johnson divided the scale into thirds. The lower third (0-21)
is mild. The middle third (22-42) is moderate, and the upper third
(43-63) is severe.6 You can take this survey and rate your
misophonia. It would seem to make more sense to divide the scale
into five zones, as with the A-MISO-S survey. With five zones, the
ratings would be
– 0-11: Subclinical (meaning you do not need treatment)
– 12-24: Mild
– 25-37: Moderate
– 38-50: Severe
– 51-63: Extreme
These assessments can be a valuable way to track the progress
of your misophonia over time. Because change in misophonia
symptoms is often slow (whether increasing or decreasing in
severity) and treatment programs can take six months or more, it can
be beneficial to fill out these forms regularly to track your progress
when you are engaged in a treatment program.
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3. Triggers, Triggers, and More Triggers
Misophonia triggers generally start with a familiar person and a
familiar sound. It is something in the person’s life. I conducted a
survey of individuals with misophonia in 2013 in which two-thirds
said their worst trigger was an eating/chewing sound, and 10% were
breathing sounds. The remaining 25% had a variety of “worst
triggers” including bass through walls, a dog barking, coughing,
clicking sounds, whistling, parents talking, sibilance (the sound
produced when saying words such as sun or chip), and someone
typing on a keyboard. This is by no means a complete list of triggers.
In fact, it is virtually impossible to make a complete list because a
trigger can be virtually any repeating sound or sight. Although much
less common, triggers can also be touch, smell, and vibrations.
Triggers are sounds we hear in everyday life. Eating sounds and
dinner table sounds are very common in our lives, and are the most
common triggers for misophonia. The second most common triggers
are breathing or nose sounds, such as nose whistles, heavy breathing,
sighing, snoring, and anything associated with breathing. But really,
a trigger can be any repeating sound. And the list of known triggers
is like the list of all repeating sounds in the world.
It’s not that these sounds become triggers because of the sound
itself. They become triggers because the person hears the sound in a
specific situation and they develop a misophonic response to that
sound.
As mentioned, we find that triggers start with one sound or one
person making a particular noise, and then the trigger spreads to
similar sounds, other places, anyone making the already offensive
sound, and sights associated with those sounds. So with time these
triggers spread and spread. We will cover this in detail in the chapter
on Developing New Triggers.
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Misophonia can start with a visual trigger, but this is very rare.
In fact, I have seen only one report of misophonia starting with a
visual trigger. Generally it starts with an auditory trigger, and then
visual images that occur immediately before the trigger can become a
visual trigger. For example, if I trigger to chewing, then seeing
someone put food into their mouth could become a trigger. I could
also develop a trigger to seeing someone bring food toward their
mouth or to picking up a potato chip.
Images that occur with the trigger can also become trigger
stimuli. For example, jaw movement associated with chewing is very
commonly reported as a visual trigger by someone who triggers to
gum popping.
Visual triggers can even be images that occur repeatedly after
being triggered, although this is less common. Also, we find that
repetitive movements such as leg jiggling or hair twirling are
common trigger stimuli, but it’s not clear why. I had a patient suggest
it was because it was a nervous behavior.
Common Misophonic Triggers
Sound (Auditory) Triggers:
Sounds of people eating all forms of chewing, crunching,
smacking, swallowing, talking with food in mouth
Sounds made at the table – fork on plate, fork scraping teeth,
spoon on bowl, clinking of glasses
Sounds of people drinking sipping, slurping, saying “ah”
after a drink, swallowing, breathing after a drink
Other mouth sounds sucking teeth, lip popping, kissing,
flossing, brushing teeth
Associated sounds opening chip bags, water bottle
crinkling, setting a cup down
Breathing sounds sniffling, snorting, nasally breathing,
regular breathing, snoring, nose whistle, yawning, coughing,
throat clearing, hiccups
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Vocal triggers – consonant sounds (S and P especially), vowel
sounds (less common), lip pop, dry mouth voice, gravelly
voice, whispering, specific words, muffled talking, several
people talking at once, TV through walls, singing, humming,
whistling, “uh”
Home sounds bass through walls, door slamming,
refrigerator running, hair dryers, electric shavers, nail
clipping, foot shuffling, flip flops, heavy footsteps, walking
of people upstairs, joint cracking, scratching, ticking clocks,
pipes knocking, baby crying, toilet flushing
Work/school sounds typing, mouse clicks, page flipping,
pencil on paper, copier sound, pen clicking, pen tapping,
tapping on desk
Other - farm equipment, pumps, lawnmowers, bouncing
balls, back-up beepers, traffic noise, beep of car locking, car
door slamming
Animal sounds dogs/cat grooming, dogs barking, rooster
crowing, birds singing, crickets, frogs, animal scratching, dog
whimpering
Sight (Visual) Triggers jaw movement (chewing), hand touching
face, scrolling on smartphone, pointing, leg jiggling, hair twirling,
putting food into mouth, drumming fingers, blinking eyes
Odor (Olfactory) Triggers – certain scents (rare)
Touch (Tactile) Triggers touching a keyboard, touching certain
fabrics (rare)
Other Triggers vibration from anything such as bass, bumping
desk, kicking chair, heavy footsteps
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4. Oh, the Emotions!
An extreme emotional response is the trademark of misophonia.
Here is a comment someone with misophonia posted on
misophoniatreatment.com.
Judy’s Story
“I have only recently found out that there was a name for my
condition. I am fifty-four years old have suffered what seems like
forever with this problem. One particular person at work drives me
crazy sniffing and coughing all the time. At times I get so I angry I
think I could kill. I even get to the point of wishing this person would
drop dead (bad I know), but I’m sure other sufferers feel the same at
times. My poor lovely husband knows how I feel and tries his best
not to make the noises I detest. I sometimes don’t know how he lives
with me. I know I have passed this on to one of my girls, and my dad
had it, too. It’s making my social life a nightmare.”
Note that she wishes the person making the noise would drop
dead! It is hard for someone who does not have misophonia to
understand the extent of emotions that are caused by being
repeatedly triggered, especially in a situation where the misophonic
individual is trapped and cannot make the triggers stop.
Below is a twenty-six-question survey of emotional responses
to triggers. I use this survey for my new misophonia patients. As you
read through these, you will see that the list of emotions/reactions go
from mild to extreme. All of these emotions are often rated as “none
of the time,” “a little of the time,” “a good deal of the time,” or
“almost all the time.”
Misophonia Emotional Responses
0) None of the time, 1) A little of the time, 2) A good deal of the
time, 3) Almost all of the time
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1. You hear a known trigger sound. You may dislike the sound.
2. You hear a trigger sound and feel annoyed or upset.
3. You want the other person to know how upset you are.
4. You want the person to stop making the sound.
5. You want to force the other person to stop making the sound.
6. You feel you must see that the person is actually making the
sound or doing what you think they are doing. You want to keep
looking or stare.
7. You want to hear something else, so you don’t hear the sound.
8. You want to be physically far away from the sound.
9. You wish you were deaf.
10. You are afraid that if you do something you will hurt others’
feelings.
11. You want to get away from the sound but do not want to make a
scene.
12. You want to get away from the sound as quickly as possible, even
if it would be embarrassing.
13. You want to push, poke, shove, etc., the person making the
sound.
14. You want to verbally assault of the person making the noise.
15. You want to physically assault the person making the noise.
16. You want to physically hurt or harm the other person.
17. You want to scream or cry loudly.
18. You feel anger.
19. You feel rage.
20. You hate the person.
21. You feel disgust.
22. You feel resentment.
23. You feel you need to escape, flee, or run away.
24. You want to get revenge.
25. You feel offended by the person making the noise.
26. You feel despair or hopeless.
One person may respond withnot at all” to a few of these
questions, but most people with misophonia experience over 75% of
30
the feelings expressed on this list. In general, individuals will have
all of these emotions except for two or three, which are unique to
each individual. Misophonia causes extreme emotions in virtually
everyone.
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5. Oh, the Guilt!
Generally those suffering with misophonia feel guilty about the
way they think and act when being triggered. We typically reserve
the list of powerful emotions discussed in the previous chapter for
our worst enemies or times when we’re greatly offended, but people
with misophonia regularly direct these responses to those who are
closest to them. The ugly miso-emotions are literally jerked out of
the misophonic individual when they are being triggered.
Additionally, once the fight-or-flight response kicks in, the person
may scream, verbally assault, or even push, poke, and shove the
person who caused the trigger. If looks could kill, everyone around
the misophonic person would be dead!
Nearly everyone with misophonia feels a varying degree of
guilt after being triggered. Most feel a great deal of guilt because
they recognize that their response was out of proportion to what the
triggering person did. For example, children are often triggered by a
parent. One person reported that their trigger person was their
stepfather, whom they dearly loved. He was a great man, even his
hero. But when riding in the car, the stepdad would chew gum and
suddenly the child experienced nearly every emotion affiliated with
misophonia, including wanting to hurt his stepdad. Afterwards, the
person felt guilty for wanting to hurt someone, especially someone
he loved so dearly.
Guilt is also very common for a parent who has a child that
triggers them. The love of the parent for the child is inconsistent with
the rage felt toward that child for making an innocuous sound like
sniffling. Again, guilt follows.
Misophonia generally develops to sounds made by someone
who spends a lot of time with the misophonic individual. Except in
cases where there is an embroiled relationship that is full of conflict,
abuse, and contention, the strong miso-emotions are directed toward
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a loved one, and are inconsistent with the emotional bond with that
person. Guilt is common when we act differently than we think we
should act, which is why it is such a recurring emotion among
misophonics.
If you have misophonia, have empathy for yourself. Guilt is the
feeling a person has when they have intentionally done something
wrong. If a child steals candy from the store, then they should feel
guilty for doing that. If a sales clerk accidentally gives you five
dollars extra in change and you know it, you should feel guilty for
keeping the money because you chose to do something that was not
honest. But if you get the extra change, only to discover it later, you
should not feel guilty because you did not do choose to do something
that violates your moral values.
If you have misophonia, you may have horrible feelings toward
a loved one; but you are not choosing to have these feelings. These
feelings are literally yanked out of you, or imposed on you by your
misophonia. They are not really “your” feelings or feelings you have
decided to express toward that person. They are an emotional reflex.
As previously discussed, a reflex is an involuntary response to a
stimulus. In this case, the emotions simply happen as a direct result
of being triggered.
Because you are not choosing to have horrible feelings toward a
person you love, try replacing your guilt with regret. You don’t want
to have such ill feelings about someone after they trigger you, and
you regret that you have them. If you want to be tall, but your height
is only five feet, then you can regret that you are not taller; but
because it is not your choice, guilt is an inappropriate emotion. So be
good to yourself. Beating yourself up and feeling guilty about your
miso-emotions doesn’t help in any way. Anything that decreases your
feeling of well-being will increase your misophonia. So smile, and
realize that at this stage, the extreme miso-emotions are beyond your
control.
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However, there is hope! You do have a degree of control over
how you respond when you have misophonia triggers. These are your
coping behaviors. If your coping behaviors (fifth box on the drawing
below) are aggressive, then you can and should work to change
those.
Although difficult, you can (and should) manage them by
deciding what you want to do when you are triggered. One of the
easiest ways of reducing aggressive coping behaviors is to reduce the
number of triggers you experience, especially situations where you
cannot escape the triggers. I know it sounds like a lot for now, but
relax: we will talk more about how to do this in the chapter on
misophonia management techniques. For now, I just want you to stop
beating yourself up over the things you’ve felt and said as a result of
your misophonia, and instead take the time to regret some of your
misophonia-induced feelings and behaviors.
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6. Prevalence of Misophonia
How common is misophonia? Many consider it a rare disease,
and on rare disease day (the last day of February), many on the
Facebook misophonia group express a desire to speak out about
misophonia. In the United States, a rare disease has officially been
defined as one that affects less than 200,000 people in the US, which
is about one in 1,500 people (0.07%). By this definition misophonia
is not a rare disease. It is a “rarely known” disorder.
I did my first survey on misophonia in February of 2013 on
different characteristics of individuals with misophonia. I was trying
to determine how misophonia develops and if there were certain
characteristics people with misophonia have in common. I wanted to
have a control group to compare some of the personality traits and
characteristics, and so I sent the survey to my LinkedIn contacts.
Much to my surprise, 5% of my LinkedIn contacts had misophonic
reactions. And so I thought, wow, this is not some extremely unusual
phenomenon here. In fact, I had people with misophonia popping up
all over the place.
I paid for a survey using SurveyMonkey.com, where they
randomly solicited individuals who had no connection to
misophonia. These were just individuals who were willing to fill out
surveys to have fifty cents donated to the cause of their choice. I
purchased three hundred and I got ten extra for free. I made sure that
the title of the survey did not mention sound or sensitivities. I gave
the same survey to a group of people with misophonia to determine a
standard of reference for my SurveyMonkey group. Out of the 310
people surveyed (50% of them women, 50% men), I found that
15.2% had reactions suggesting misophonia. It was more common
among the women (18.6%) than it was among of the men (11.6%).7
Rather than being a rare disease, which is one in 1,500, it was a
rarely known but common disorder with about 225 in 1,500 having
misophonia.
35
That was actually a higher number that I expected. I was
expecting 5% to 10%, but it came in at 15%. In 2014, there was an
official published peer reviewed study that came out of the
University of South Florida’s College of Medicine and their
psychology department. They used undergraduate psychology
students. (This is very common in college research; they give
psychology students a little extra credit for taking a survey or
participating in some form of research for the graduate students.)
They had almost 500 participants in this study, and 84% were
women, so that would tend to raise the percentage of incidence of
misophonia. Their study was comprehensive enough to see how the
misophonia affected the individual’s life. What they found was that
20% had clinically significant misophonia,8 significant meaning they
had to alter their life in some regard in order to handle their triggers.
This finding surprised me since 20% is higher than what I had
previously observed.
However, since 84% of the participants were female, the
finding that 20% had misophonia is very similar to my survey that
found 18.6% of women had misophonia triggers.
A recent blog post on the family ancestry website
23andMe.com mentioned an internal study conducted with about
80,000 customers, in which people were asked “Does the sound of
other people chewing fill you with rage? (Yes/No/Not Sure).” About
20% replied yes. They also found that the affirmative response was
more common in women.9 Unfortunately they only reported the yes
and no numbers, and excluded the not sure. I am concerned that
those who were not sure probably don’t have misophonia so the
prevalence of misophonia is lower than their reported number, but at
least it provides general support for the prevalence of misophonia of
the other two studies.
The takeaway from this is that misophonia is really quite
common – perhaps affecting approximately 15% of adults. It is more
common in women than in men, but many, many people suffer in
36
silence, or they are written off as being grouchy, cranky, or irritable.
If this number is correct, and research is beginning to confirm it is,
there could be forty million people with misophonia in the United
States alone.
Considering these statistics and the fact that misophonia is not
widely studied, if you randomly selected a doctor or therapist and
then another individual, it is more likely that the random individual
would have misophonia than the doctor or therapist would know
about misophonia.
37
7. Diversity of Misophonia
Many people consider misophonia a condition that is the same
for everyone where everyone has the same symptoms. It is true that
there is a group of common triggers (such as eating sounds) and
common emotional reactions (anger, hatred, rage, and disgust). It
often starts during the late childhood years (six to twelve) and
becomes much worse in the teen years. But within this apparently
uniform condition there is much variation.
What are the differences from person to person that we see? We
can identify diversity in four areas:
1. The age of onset.
2. When it becomes severe.
3. Trigger sounds.
4. Initial physical reflexes.
The Age of Onset
I conducted a survey of 200 people with misophonia in March
of 2013. Seventy-five percent of those completing the survey were
women. The most common age for misophonia to begin was nine to
ten years. Twenty-five percent had their misophonia begin at this
age. Twenty-one percent had their misophonia begin at age seven to
eight, and 20% began at age eleven or twelve years. This seems to
demonstrate that misophonia begins at a typical age, but the survey
also showed that there is wide variation in the age of onset. In that
survey people started having misophonia from as young as age four
to as old as age fifty-five. It became severe from age four all the way
up to sixty-four. So there was really a wide range in the age when
misophonia begins.
In the graph below, the dark bars show the ages when people
started having misophonia, and the light bars are when their
38
misophonia became severe. Although we have a clear majority of the
people whose misophonia begins at ages seven to twelve years, and
became severe from age seven to sixteen, about half of the people
fell outside of these ages. If misophonia was a purely hereditary
condition like puberty, you would find that the age of onset and
severity would be more uniform. Also, you would not see a range in
age from four to fifty-five years for onset. You don’t find people
going into puberty at age thirty, but with misophonia we find a
scattering of ages for the start of misophonia.
We also find there’s quite a diversity of triggers. Although there
are common triggers such as mouth and breathing sounds, the list of
triggers comprises almost every repeating noise. No one has all of
these triggers; everyone has their own set of triggers. So even though
there are many common trigger sounds, there is a lot of variation in
the sounds from person to person.
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The first trigger that you get is specific to a single person or
thing that is part of the individual’s life in some way. It depends on
the sounds you are hearing. There are also particular sounds such as
bird chirps, crickets, pipes knocking, things that people say, oxygen
system noise, and many more. There are general triggers that will
affect many people popcorn, loud eating, gum popping (which
seems to be a very common trigger), but you may also have triggers
that are caused by a single person, at least that’s where they start.
Some people are triggered only when a certain individual makes
a specific sound. For example, I was working with a fifteen-year-old
young man who triggered to the sound of his mom eating crunchy
food. We had him face the wall. I popped a Frito in my mouth. I
crunched it. No response, nothing. His mom put a Frito in her mouth
and crunched it, and he said, “Ugh! That’s it.” For another person, it
didn’t matter who made the sound. Any crunch triggered him.
I worked with a person whose trigger was their husband saying,
“uh.” This monosyllabic utterance didn’t trigger anyone else, and
other people could make the same sound without it affecting her. It
was her unique trigger. Another person triggered when her husband
ate crunchy bread. We know of kids who trigger to a parent’s voice,
but not to other voices. I know a man who started triggering in
midlife when some birds built their nest outside of his window. It
seems like that would not be a big deal, but it was his bedroom
window and they were mockingbirds, which sing twenty-four hours a
day. He developed misophonia to those specific bird chirps.
Non-human sounds such as pipes knocking, clocks ticking, hair
dryers, electric shavers, and such are also triggers for some, but not
triggers for most people. Everybody has their own unique set of
triggers. So although there’s commonality, there’s still uniqueness,
and these particular triggers are based on your individual experience,
the ones that you have heard, and are not based on an automatic
biological time clock. It is based on your unique experiences with
those sounds.
40
It seems we have many common triggers because we have
fairly common experiences, such as eating together or being close
enough to hear another person breathe. It is customary to eat
together, during which time we hear others eating, and so many
people develop triggers to eating sounds. If you have someone in
your home with allergies, you hear lots of nasally breathing, so we
have lots of people who develop triggers to breathing sounds. Since
we have common life experiences, we develop some similar triggers,
but also unique triggers.
The Individual Physical Reflex
A trigger produces an involuntary response or reflex. Ninety-
five percent of the people I work with can identify a specific physical
reflex to a trigger. They hear the sound and have a particular physical
reflex. It may be the contraction of muscles in the neck, shoulders,
chest, arms, face, hands open, hands closed, feet, legs, toes, or butt. It
can be internal reflexes such as esophageal, intestinal, or stomach
constriction, nausea, sexual arousal, or the urge to urinate. There’s a
wide range of reflexes. Sometimes the reflexes are complex and
involve many muscles, such as a reflex feels that like catching a ball
that hits your chest. This was the trigger reflex for one person. The
uniqueness in the physical reflex of each individual is part of what
suggests that misophonia is not just a genetic condition that kicks in,
but is something that develops because of both the neurology and the
experience of the person.
Some physical reflexes are almost imperceptible, such as a
slight head jerk or a twitch of the eye. Others are very strong. One
person described how hers felt as having a shovel stabbed through
her chest and out her back. Another person said her reflex felt like
someone was pulling a string out of her spine. While there’s going to
be some repetition among thirty to forty million people who have
misophonia triggers, these are unique physical responses and very
few others would describe them in the same way.
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The reflex can be difficult to perceive because of the strong
emotions that you have. The overwhelming emotions that come
immediately after the trigger can make it difficult to perceive that
there was a physical reflex response. It is kind of a one-two punch –
the little physical reflex and then these strong emotions, or the little
physical reflex and then the fight-or-flight response. This makes the
physical reflex hard to notice.
If you want to know your physical reflex, you need a very small
trigger – short and quiet, maybe a half second or less, barely audible.
You can record the sound of your trigger and then play it back so that
you can adjust the volume. You can use a voice memo app on your
phone, although that app will not allow you to control the length of
the trigger. You can use the Misophonia Trigger Tamer app or the
Misophonia Reflex Finder app, both of which I developed, to record
the trigger and then control both the volume and the duration of the
trigger. Some people need to have a session on the Neural
Repatterning Technique, which I also developed. This treatment
method, which uses the Trigger Tamer app, plays the very small
trigger every thirty seconds or so, along with relaxing music. The
trigger is so weak that you do not experience the negative
misophonic emotions. You can recognize the reflex because you are
relaxed and experience the trigger many times during a thirty-minute
treatment.
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8. Prognosis for Misophonia
If a person has misophonia, what’s the prognosis?
I will provide hope later in the book, but first let me provide
you with an overall view of misophonia. For one thing, misophonia
doesn’t just go away with time or getting older. Generally the
severity of misophonia remains the same or gets progressively
worse10. It can be stable for years and then escalate. Sometimes it
will remain at that elevated state for years and then escalate even
more. It does seem to lessen at certain times. The upheaval
associated with misophonia tends to lessen as the teen matures into
adulthood, because they learn that they are going to be triggered and
there’s no other choice. They are just going to have to deal with this
unpleasant reaction, and many people learn to suffer in silence. A
child may scream and yell at her mom, but it doesn’t get any better.
She may scream and yell at her friends and be ostracized. Eventually
the child learns that acting out only makes it worse and that she must
cope. She learns to suffer in silence. One lady said that when she was
triggered too much, she would just go into another room and cry.
And people also learn to modify their life to cope with misophonia.
Many people with misophonia would never go to a movie
theater because the popcorn crunching is there and they would find it
intolerable. They also modify their work conditions. I know of one
case where a person couldn’t handle the trigger sounds in the
classroom so he dropped out of M.I.T and became a machinist.
Although the classroom noises triggered him, the sounds in the
machinery created a trigger-free environment for him.
Unfortunately, we find that misophonia can be very detrimental
to relationships. It really takes a caring, patient person to deal with a
spouse who is triggered by the sounds they make.
Another situation that heightens misophonia is that triggers
develop with prolonged experience with a particular person. A
43
spouse or significant other may not trigger you at first, but with time,
triggers develop. The same thing happens with children. It would be
most unusual for your baby to trigger you, no matter how loud they
ate. But with time, those cute little eating and breathing sounds
change into the lip smacking and sniffling of an elementary school
kid, and can become full strength triggers. We will talk about how to
reduce the risk of developing new triggers in a later chapter.
44
9. Perception Versus Reality
We are going to use several simple figures in this chapter to
show how you react to misophonic triggers. So let’s start with a
simple one about how it feels when you are triggered.
You hear or see a trigger, and ka-boom, there is an explosion.
You feel extreme emotions that may include anger, disgust, rage,
resentment, or that you’re offended or being attacked. Some people
have extreme feelings of helplessness or hopelessness. While all of
these feelings are valid, let’s take a more objective view of this
misophonic response to triggers.
Involuntary Emotional Response
The misophonic response is an involuntary reaction that’s
jerked out of the person. They are not choosing to react. If we look at
the brain in the figure below, there are three regions identified. Let’s
consider what is happening in each region.
45
At the top is the cerebrum, which is the thinking brain. With
your thinking brain, you can think, “Okay, I’m going to stay calm.”
But with misophonia, the person can’t stay calm when they are
triggered.
The part at the bottom of our brain, in the brain stem, is called
the autonomic nervous system. Many people call it the lizard brain.
The lizard brain controls our reflexes, and this is the heart of
misophonia.
The limbic system is what lights up when we have these strong
emotions. Misophonia is a combination between the reflex reaction
of the lizard brain and the emotional reaction of the limbic system
that’s just yanked out of the person. People with misophonia just
can’t stay calm when they are being triggered.
46
The popular view of this misophonic response or reflex is that
you hear or see a trigger, and you immediately experience extreme
emotions without intentionally doing so. This reaction is involuntary.
You didn’t have it at birth, so one would conclude that it’s acquired,
meaning you’ve developed it or it’s developed. So now you hear this
trigger and instantly feel the emotions. This is the popular view of
misophonia as shown in the figure.
This is also the way that misophonia is described in peer
reviewed journal articles, which report misophonia research studies.11
In fact, there is one article entitled, “Misophonia: A Disorder of
Emotion Processing of Sounds.” But I find that misophonia is
fundamentally not about the emotional processing of sounds. It is
about a physical sensation that happens when you hear a trigger. You
hear normal sounds, but you literally feel (physically) a trigger.
I’ve been told that a trigger is more like being slapped or being
poked in the ribs with a stick or being zapped with a cattle prod or
mini-Taser. I sometimes demonstrate to a non-misophonic person
what a trigger is like by taking a rubber band, putting it against my
chest, pulling back the center, and popping myself. Ouch! That hurts.
That’s the way I think of misophonia. It is an initial POW
response. And it has very extreme emotions that come with the
POW.”
There’s quite a bit of diversity in this physical reflex. In my
practice, I estimated that about 95% of those I had worked with had a
physical reflex. However, I had four clear cases where no matter how
hard we tried to identify a physical reflex, the only experience of the
47
person to a trigger was an emotional response of irritation. I worked
with one person a second time, and using a different test method, he
felt a muscle jerk in his legs. After working with another person for
over six months, one session she declared that she had identified her
physical reflex. She said a coworker had asked her why she was mad,
but she replied she was not. The coworker said, “Then why are you
frowning? You frown almost all the time.” My patient recognized
that she did frown a lot, and that the frown was caused by her
triggers. Every time she was triggered, her forehead muscles jerked,
which are one of two sets of muscles involved in frowning. That was
her reflex. The third person reported not having a physical reflex, but
the physical reflex in his face was visible. So with the people that I
have worked with, about 99% have a physical reflex.
A lot people with misophonia say, “I simply have rage. I don’t
have a physical reflex,” but when we get into a treatment setting or
we get calm and do a test with a weak trigger, then they can identify
the reflex. I worked with one girl who said she only had rage (no
physical reflex at all). Yet whenever we used a very, very small
trigger during treatment, you could see her shoulders jerk. She
identified the muscle jerk herself when we finished the treatment and
we talked about it. Incidentally, she did not feel the negative emotion
during the treatment. She felt the muscle jerk reflex. This is shown in
the figure below that the misophonic trigger elicits the physical
reflex, as shown in the next figure. (Note: Elicit is a technical term
that means to “cause a reflex to happen.”)
Now it’s time to add the emotional response to your misophonic
reflex response into our drawing. It appears that the emotional
48
response is jerked out of you (elicited) by the sensation of the
physical reflex as shown in the next figure.
As noted above, misophonic individuals all reported that it was
impossible for them to not become upset when exposed to trigger
stimuli, although they had repeatedly tried to remain calm. It is
commonly said that “anger is a choice,” or that “another person
cannot make you mad.” This may be true for verbal behavior because
the meaning of the words is determined by a person’s learning
experience with language and other social factors. A person’s
response to a statement such as “I hate you” is affected by their
evaluation of the context and social dynamics at that moment.
With misophonia, however, anger is not a choice. There are two
plausible constructs for emotional response being elicited by the
initial physical reflex. The first construct is as follows. The sound
elicits an intrusive, uncomfortable reflex response. I propose that this
physical reflex response is a form of physical assault on the person,
although the actual physical assault is performed by their autonomic
nervous system. The response to the repetitive physical reflex is the
array of the extreme emotions as shown above.
How about the emotional response? Well, you can’t feel
electricity, but if you’ve been shocked you felt something. What you
felt was muscle contraction. The electricity made you tighten your
muscles, and that was uncomfortable. We know that the reason our
muscles move is that our brain sends out electrical impulses, which
cause our muscles to constrict. So when the lizard brain perceives the
49
trigger, it sends out an electrical shock! The emotional response to
aversive events is consistent with research. The electric shock is an
assault on your body, and it’s that physical assault that produces the
strong emotions.
Research studies have shown that aversive stimuli cause fight-
or-flight emotions in humans.12 The strength of these emotions is
affected by a number of factors, and the urge to fight may not be
visible through outward behavior. This is consistent with the
emotions for misophonics, and the reported effort of misophonics to
resist aggressive impulses. Furthermore, activity in the limbic system
of humans in response to aversive odors and tastes has been
demonstrated.13 Evidence suggests that the aversive physical
misophonic reflex may cause the commonly reported emotions of
hate, anger, rage and disgust.
As I mentioned earlier, one woman reported feeling like a
shovel was run through her sternum and out her back when she was
being triggered, but said this was metaphorical, incorporating both
the physical and emotional feelings. She couldn’t describe which
muscle was contracting, but she sure felt it. Her reflex was a gasp for
breath. Do a quick exercise to gain an understanding of what that felt
like for her. Close off your windpipe and try to take a quick breath.
You may want to close your mouth and pinch your nose to do this.
That hurts around the sternum. The girl I mentioned earlier as having
a visible shoulder jerk to a tiny trigger during a treatment probably
had a very strong, physical jolt from a trigger. In treatment, under
controlled circumstances when her trigger was presented minimally,
we could see her shoulders jump almost an inch. I can only imagine
how strong her reflex was in real life.
The second construct is that the physical misophonic reflex
elicits a conditioned emotional response. The physical reflex is
intrusive and difficult to ignore; even when a person tries to use a
technique to avoid attending to the auditory stimulus, the physical
reflex is perceived and elicits the emotional response.
50
There is still one more connection to add to our drawing of
misophonia. The figure below shows the development of a direct
connection between the misophonic trigger and the emotional
response. This is a secondary process. In some cases, the patient has
both an emotional response and a physical response to the very weak
trigger used in the Neural Repatterning Technique (NRT) treatment
(to be discussed later). The directly elicited emotional response is a
secondary process because in most cases there is first a clear physical
reflex which occurs independently of the emotional response during
the NRT treatment.
.
Benefits of Understanding the Misophonic Physical
Reflex
Viewing misophonia as a physical reflex may help you manage
your emotions. People have told you to just stay calm. You tried, but
could not. People have told you that it’s all in your head. When you
have been angry at the person making your trigger sounds or sights,
you have probably had horrible thoughts directed toward that person.
You thought things that were completely inconsistent with your
character. Many people with misophonia think about physically
hurting the person making the triggers. You may have even said or
done things that you feel sorry for. Guilt (after you calm down) is a
common emotion for people with misophonia.
51
With misophonia, anger is not a choice. It is jerked out of you,
and the reason you cannot stay calm without proper treatment is that
this physical reflex is an assault on you. You are being physically
assaulted, but you’re being assaulted by your lizard brain. The sound
comes into the brain, is perceived by the lizard brain, which then
zaps you.
The misophonia anger and the urge to physically assault are
consistent with research done with mice in an electrical cage, where
you could electrify the floor and shock them. (I didn’t do this
research, so please don’t blame me for cruelty to animals.) When the
mice were shocked, they attacked the adjacent mouse even though
the other mouse had not done anything. This is called pain-induced
aggression.14 Essentially you’re getting zapped or whacked, and that
produces your anger response. The emotions are so enormous that
you may not recognize the shock itself, but it is there. It is what kicks
off your misophonic emotions.
So what can you do? First, be kind to yourself. Beating yourself
up because you had horrible feelings toward another person doesn’t
help your misophonia. If you become physically or verbally abusive
when triggered, you need to make a plan to avoid being triggered and
a plan for what you will do when you are triggered.
Second, try thinking of your misophonic reaction as coming
from your lizard brain, not from the person making the trigger.
Misophonia is all in your head and it is extremely real. Your lizard
brain is biting you. Look as the attack as coming from within. It is
your lizard brain reflex.
Third, identifying your physical reflex may allow you to
respond to triggers in a way that can lessen the agony of the trigger,
and slowly change your lizard brain so that future triggers are less
severe. This only applies to specific reflexes, but maybe you have an
easy reflex to work with. Also, recognizing your reflex can help you
with other treatments, such as the NRT treatment or SRT
hypnotherapy treatment. If nothing else, you will have a better
52
understanding of what is happening in your body when you are
triggered and why it makes you so darn mad.
Identifying Your Physical Reflex
Identifying your physical reflex is not something you can figure
out by thinking about the way you have reacted to triggers. Probably
nine out of ten of my patients cannot come close to identifying their
physical reflex from their own life experiences with triggers. The
emotional upheaval from triggers is too great and there are too many
physical responses that occur because of the extreme emotions and
the fight-or-flight responses. If you think your initial physical reflex
consists of all of your muscles tightening, then I respectfully suggest
that you are incorrect. Your reflex will be one or several specific
muscles or sensations in your body.
To determine this initial physical reflex, do a science
experiment. Get very relaxed and then listen to a very small trigger.
To make it a small trigger, typically it needs to be short and quiet. If
it is a visual trigger, then you would probably have to do that with a
video recording. With a sound trigger you might be able to have
someone make a single trigger sound from another room. You can
also use an audio or video recording and limit the length of time of
the trigger and the volume. The Misophonia Reflex Finder app is free
and is very good for doing this. You want the trigger to be very short
(less than a half second) and barely audible. Then you slowly
increase the volume until you start to trigger. At the point where you
first feel the trigger, you will probably be able to determine where in
your body you feel the reflex. Sometimes the reflex can’t be
described clearly. One person said their heart bumped. She didn’t
have an increased heart rate, just a single bump. She also had another
muscle jerk as her misophonia reflex.
Another person said, “It’s like something is growing in my
chest. I can’t describe it better than that.” Another person I worked
with, who didn’t think she had a physical reflex, tested her body
53
using electromyography (EMG) system which measures muscle
contraction and did not find any physical reflex. But when she used
the Misophonia Trigger Tamer, she felt the muscles behind her ears
jerking. Using the EMG system, she tested herself and verified that
when she heard a little trigger, those muscles behind her ears jerked.
That was her physical reflex, and it was barely noticeable.
I had another person who didn’t think she had a physical reflex,
but she went to a doctor whom I work with, and he saw the reflex.
During the treatment process the doctor had to trigger her, and he
could see a jerk in a muscle near her eye.
Some people cannot identify a physical reflex, even though they
physically feel the trigger. If you feel that a trigger jars your body,
then you have a physical reflex, even if you cannot identify the
specific muscle that moves when you are triggered.
All the Steps
We can expand our graph for the misophonia reaction a bit
more. The next figure shows the extreme emotional response and the
accompanying physiological response (stress response) as two
adjoining boxes. Anytime you are feeling emotions, the emotions
consist of two parts. One part is what is going on in your head – what
you perceive as the feeling, along with thoughts about it. The other
part is what is happening in your body. There are automatic
responses for emotions. If you are angry, you will have tense muscles
and increased heart rate. If you are happy, you will have more
relaxed muscles and positive sensations in your body (we will use
this to our advantage later). The last box, labeled Coping Behaviors,
comprises the things you do after you are triggered. This includes
things that will reduce the trigger, such as putting your hands over
your ears, mimicking the trigger noise, ordering the offending person
to stop, or running away from the trigger. We will talk more about
changing our behavior in each of these boxes later. For now, we just
54
want to recognize that they exist as different components of your
misophonic response to triggers.
Summary
What is happening when you are triggered? It is not as simple
as it seems to someone suffering with misophonia. Misophonia is
really a two-step process.
Step 1: You hear or see a trigger. You perceive a trigger and you
have an intrusive, physical reflex. This is an aversive, unpleasant,
unwanted physical reflex.
Step 2: You feel the sensation of the physical reflex and
instantly feel irritation or disgust. The physical sensation triggers
your extreme emotions, and general physiological (bodily) responses
associated with emotional arousal including pressure in chest, head,
and whole body; clenched/tightened muscles; sweaty palms;
difficulty breathing; and increased blood pressure and heart rate.
From my work with patients, I find that the way their physical
reflex responds to treatment and to different strength of triggers is
very consistent with the research on reflexes. This reflex is an
acquired aversive physical reflex. An acquired reflex is also called a
55
conditioned reflex or a Pavlovian reflex,15 which we shall discuss in
the next chapter.
56
Chapters 11-17 omitted. This book is available
on Amazon.com and other online book stores as
both paperback and ebook.
18. Misophonia or Conditioned Aversive Reflex
Disorder (CARD)
While the term “misophonia” is commonly used for this
condition and has a catchy ring to it, in the course of my experience
and research I have concluded it does not accurately describe this
disorder.
Firstly, “misophonia” literally, a hatred or dislike of sound
only refers to the emotional response to auditory triggers. Many
individuals have visual triggers, and there are anecdotal reports of
olfactory (smell) and tactile (touch) triggers. It has been proposed
that an extreme emotional response to visual triggers be named
misokinesia,16 which would be a second name for an aspect of the
same phenomenon.
Secondly, the term “misophonia” puts the focus on the
individual’s experience of a strong dislike of sound. Liking or hating
something is generally an evaluative process that can be altered by
thoughtful consideration, but this is generally not the case with this
condition. You can hate punk rock, but that’s not the same thing as
having an involuntary physical response to it.
Finally, a disorder that is fundamentally an emotional response
places the neurological emphasis on the limbic system, while a
disorder that is fundamentally a conditioned reflex response places
the neurological emphasis on the autonomic nervous system.
Misophonia is a conditioned reflex response. This distinction has
57
important implications for both research and the development of
treatments. Therefore, the term “misophonia” does not clearly
indicate the reflexive nature of the condition, which can also be a
source of misunderstanding when communicating to family
members, teachers, coworkers, and employers.
I propose that Conditioned Aversive Reflex Disorder (CARD) is
a more descriptive and appropriate name for this condition. It could
also be called Aversive Reflex Disorder (ARD). This name puts the
focus on the reflex nature of the disorder and on the etiology of the
reflex, which is classical conditioning. CARD easily incorporates all
modalities of trigger stimuli. Specifying it as a disorder requires a
diagnostic criteria to determine a clinical level versus subclinical
level of such reflexes. This disorder presents with great variety of
aversive reflexes, where one person may have a single aversive
reflex, as illustrated previously in the case of Paul (the middle aged
adult with only a trigger to a ringtone), while another individual may
suffer a debilitating condition that causes them to be unable to
tolerate a typical work environment.
I had one patient whose primary emotional response to the
trigger was fear. She had typical misophonic anticipatory anxiety of
being triggered, but felt no fear when discussing the trigger stimuli.
She had many of the common misophonic triggers, such as sniffling,
gum chewing, breathing, and coughing. Was this phonophobia (fear
of the sound)? No. It was CARD. Her physical reflex was a gasp.
When she heard the trigger stimulus, she gasped, which jerked her
body. She was easily startled, and the involuntary jerk of her muscles
startled her, causing the fear emotions. Clearly this was a conditioned
aversive reflex for her. The diagnosis of misophonia is confusing, but
she clearly fits the description for CARD.
There are other disorders that have similar symptoms to CARD
but appear more strongly influenced by genetics, such as sensory
processing disorder or being a highly sensitive person. These are
likely caused by inborn, genetic conditions rather that an acquired
58
reflex as CARD, and CARD rather than misophonia, makes this
distinction clear.
Additionally, the name CARD immediately helps others
understand that this is a real condition which happens to a person
rather than the person being overly emotional to something “they
should just ignore.”
59
Your Next Step
Thank you for reading this book. For more information, go to
the Misophonia Treatment Institute website at
MisophoniaTreatment.com. The Misophonia Treatment Institute is
committed to increasing misophonia awareness, providing helpful
information, and developing and disseminating misophonia
treatments. There is a list of treatment providers that is ever-
increasing. For some treatments, you will need to find someone in
your area, but others can be accessed using internet video-chat, so
help is available, regardless of where you live.
I hope this book has increased your understanding of
misophonia (or CARD). But more so, I hope that you will take the
ideas, tricks, treatments, and techniques described herein and take
action to improve your life or the life of someone close to you.
Overcoming misophonia is a process, not a single action. It will take
sustained, consistent work, such as doing Progressive Muscle
Relaxation every day. Developing misophonia, including all the
variations of triggers, has probably taken many years. Overcoming
misophonia is also a process, where you gradually reduce your
response to triggers and allow your lizard brain to learn a new way to
respond to them.
There is hope for you to overcome your misophonia. I also have
great hope that with a proper understanding of misophonia, many
other professionals and researchers will determine new ways that
will help you reduce and even eliminate your misophonia reflexes.
I wish you well!
60
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Citations
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1 Jastreboff & Jastreboff, 2002
2 Bernstein, Angell, & Dehle, 2013
3 Bernstein, Angell, & Dehle, 2013; Dozier, 2015a; Johnson et al., 2013; Schröder, Vulink, &
Denys, 2013
4 Schröder, Vulink, & Denys, 2013
5 Schröder, Vulink, & Denys, 2013. Note: This form has been modified by replacing “sounds” with
“triggers” to include visual and sound triggers.
6 Johnson, 2014
7 Dozier, 2014
8 Wu, Lewin, Murphy, & Storch, 2014
9 Accessed from http://blog.23andme.com/23andme-research/something-to-chew-on/ on June
7,2015
10 Wu, Lewin, Murphy, & Storch, 2014
11 Bernstein, Angell, & Dehle, 2013; Edelstein, Brang, Rouw, & Ramachandran, 2013; Jastreboff
& Jastreboff, 2014; Kumar et al., 2014; Schröder, Vulink, & Denys, 2013; Webber & Storch,
2015; Wu, Lewin, Murphy, & Storch, 2014
12 Berkowitz, Cochran, & Embree, 1981; Berkowitz, 1983
13 Zald & Pardo, 1997; Zald, Lee, Fluegel, & Pardo, 1998
14 Ulrich & Azrin, 1962
15 Lattal, 2012; Pavlov, 2003
16 Schröder, Vulink, & Denys, 2013
... Misophonia is viewed by many as an emotional response disorder (Brout et al., 2018;Edelstein et al., 2013;Ferrer-Torres & Giménez-Llort, 2021;McKay et al., 2018;Palumbo et al., 2018;Potgieter et al., 2019;Reid et al., 2016;Schröder et al., 2013;Swedo et al., 2021;Taylor, 2017;Wu et al., 2014) and by others as a physical and emotional reflex disorder (Claiborn et al., 2020;Dibb et al., 2021;Dozier, 2015aDozier, , 2015bDozier, , 2015cDozier, , 2017Dozier & Morrison, 2017;Dozier et al., 2020). In one study, 26 participants reported various physical sensations and emotions when exposed to very weak trigger stimuli (Dozier & Morrison, 2017). ...
... South-West University "Neofit Rilski" 2022, Vol. 15(1), 281-307 https://doi.org/10.37708/psyct.v15i1.622 Figure 1 shows the postulated response chain of misophonia as a conditioned aversive reflex disorder (Dozier, 2015c(Dozier, , 2017. Box (1) is the trigger stimulus, whether auditory, visual, or another sensory modality. ...
... This conditioning theory proposes that a muscle response that consistently follows a stimulus becomes a conditioned reflex elicited by that stimulus. stimulus-response conditioning include a muscle flinch in response to pagers by surgeons, ringtones by professionals, and chemo-therapy pump sound and vibration by a cancer patient (Dozier, 2017). The conditioned reflex intensifies over time through Pavlovian conditioning because the muscle flinch's sensation causes an immediate tightening of that muscle, thus strengthening the reflex rather than extinguishing it. ...
Article
Full-text available
Misophonia is an under-studied condition in which a person has intense emotional and physiological reactions to subtle stimuli (e.g., chewing sounds or hair twirling) which cannot be classified using DSM-5 criteria. This case illustrates the conceptualization of misophonia as a conditioned aversive reflex disorder consisting of a physical (e.g., muscle) reflex elicited by the misophonic trigger stimulus and subsequent emotional, physiological, and behavioral responses. This case describes a successful behavioral treatment of a middle-aged woman who was disabled by severe misophonia. The treatment included identifying the initial physical reflex, progressive muscle relaxation, and counterconditioning the initial physical reflex. Counterconditioning was accomplished by relaxing the initial physical reflex muscle during exposure to in vivo trigger stimuli, while using ambient sound as needed to reduce the severity of the misophonic response. The overall severity of misophonia reduced over the course of the 13-week treatment, based on client self-report. Data were analyzed using recovery percentage formula. The recovery percentage average of 3 scales was 82.1% at end of treatment and 93.1% at 1-year follow-up. In this case, when the initial physical reflex's muscle was held relaxed by the patient when exposed to trigger stimuli, the initial physical reflex and the emotional reflex diminished and extinguished. This theory of misophonia, as a conditioned physical reflex to subtle stimuli, should be an essential consideration for research of the etiology, expansion, maintenance, and treatment of misophonia.
... In this study, 80% reported symptom onset by age 15, and a majority with onset by age 11, consistent with age of onset reported elsewhere (Dozier, 2015d;Edelstein et al., 2013;Rouw & Erfanian, 2017;Schröder et al., 2013). However, 10% reported onset of misophonia at age 21 or older, with a maximum of 50 years in this sample. ...
... Onset of misophonia in adulthood has also been reported by other researchers (Dozier 2015b;Schröder et al., 2013), and these occurrences may indicate that misophonia is not a developmental disorder. Indeed, several researchers have proposed that misophonia develops through classical conditioning which could occur at any age (Dozier, 2015b(Dozier, , 2015c(Dozier, , 2015dDozier & Morrison, 2017;Jastreboff & Jastreboff, 2014;Schröder et al., 2013). Misophonia can be viewed as a conditioned emotional response (CER) to the trigger stimuli Jastreboff & Jastreboff, 2014;Schröder et al., 2013), or as a conditioned physical (muscle) response to the trigger stimuli and a CER to the combined sensation of the physical response and the trigger stimulus (Dozier, 2015b(Dozier, , 2015c(Dozier, , 2015dDozier & Morrison, 2017). ...
... Indeed, several researchers have proposed that misophonia develops through classical conditioning which could occur at any age (Dozier, 2015b(Dozier, , 2015c(Dozier, , 2015dDozier & Morrison, 2017;Jastreboff & Jastreboff, 2014;Schröder et al., 2013). Misophonia can be viewed as a conditioned emotional response (CER) to the trigger stimuli Jastreboff & Jastreboff, 2014;Schröder et al., 2013), or as a conditioned physical (muscle) response to the trigger stimuli and a CER to the combined sensation of the physical response and the trigger stimulus (Dozier, 2015b(Dozier, , 2015c(Dozier, , 2015dDozier & Morrison, 2017). ...
Article
Full-text available
Misophonia is a newly recognized condition involving adverse emotional reactions to environmental sounds, most often produced by other people. This study reports results of a survey describing the phenomenology of misophonia based on a large sample. Survey data were collected from individuals self-identified as having misophonia. A total of 1,061 individuals reported specific distressing reactions to sounds, and responses indicating severity of misophonia and perceived comorbidity. Over 82% of respondents were female. The average age of the study participants was 37.49 years (SD = 12.24; range from 18 to 72). Most respondents reported multiple triggers and adverse emotional reactions, as well as multiple coping responses. The majority of respondents reported comorbid diagnoses. Misophonia severity is described, as well as impact on quality of life. A minority of respondents had some experience with treatment and most reported no change in symptoms. Treatments reported for misophonia were typically ineffective, and once developed, misophonia symptoms persist. The results of the study showed that misophonia is a newly recognized condition that appears to have important impact on people’s lives. It typically develops in early life, and is associated with a reduced quality of life, substantial comorbidity, negative emotional experiences, and behaviors that are likely to impact interpersonal relationships.
... Misophonia is an underinvestigated condition often typified as an extreme sensitivity to specific, low volume sounds and images that elicit an intense physiological and emotional response Jastreboff, 2002, 2014;Edelstein et al., 2013;Schröder et al., 2013;Wu et al., 2014;Cavanna and Seri, 2015;Dozier, 2015aDozier, , 2017. While misophonia has been described as a distinct psychiatric disorder that should be delineated as such (Schröder et al., 2013), Taylor (2017) proposed that extensive research is needed before such a conclusion is warranted. ...
... 1. A misophonic stimulus can be produced by any source (i.e., human, animal, electronic, equipment, etc.; Edelstein et al., 2013;Wu et al., 2014;Cavanna and Seri, 2015;Dozier, 2015bDozier, , 2017Dozier and Morrison, 2017;Taylor, 2017) and not limited to stimuli from humans. 2. A misophonic stimulus can be virtually any sensory modality, with auditory and visual stimuli being the most common (Bernstein et al., 2013;Edelstein et al., 2013;Johnson et al., 2013;Schröder et al., 2013;Cavanna and Seri, 2015;Dozier, 2015aDozier, ,b,c, 2017Dozier and Morrison, 2017;Taylor, 2017) and not limited to auditory stimuli. ...
... 2. A misophonic stimulus can be virtually any sensory modality, with auditory and visual stimuli being the most common (Bernstein et al., 2013;Edelstein et al., 2013;Johnson et al., 2013;Schröder et al., 2013;Cavanna and Seri, 2015;Dozier, 2015aDozier, ,b,c, 2017Dozier and Morrison, 2017;Taylor, 2017) and not limited to auditory stimuli. 3. The eliciting stimulus is a conditioned stimulus and so excludes responses to innate sensitivities, such as those with sensory processing disorder or sensory over-responsiveness Jastreboff, 2002, 2014;Dozier, 2015bDozier, , 2017Dozier and Morrison, 2017). 4. The strength of the response is controlled by the context and experience with the stimulus and not the physical characteristics of the stimulus. ...
Article
Full-text available
Misophonia is an underinvestigated condition often typified as an extreme sensitivity to specific, low volume sounds and images that elicit an intense physiological and emotional response. Diagnostic criteria was proposed in 2013 by Schroder et al. specifying misophonia as a distinct auditory/psychiatric disorder. Subsequent research identifies several areas of clarification of misophonia which should be incorporated. These include trigger stimuli of all sensory modalities, stimuli from any source, exclusion of anger responses to unconditioned stimuli, dysregulation of thoughts and emotions, and the inclusion of an immediate physical conditioned reflex.
... Although sounds are most distressing, images and silent videos of eating and chewing can also cause distress. Trigger sounds in misophonia "automatically" elicit the emotional response (Dozier, 2015) without having any self-control, despite preserved insight into the disproportionate nature of the feelings and reactions evoked (Cavanna and Seri, 2015). Additionally, trigger sounds/actions can induce spontaneous mimicry of the triggering orofacial action in many misophonia sufferers (Edelstein et al., 2013). ...
... Misophonia as an aversive "reflex" has been argued previously by Dozier (2015). In this model, sound triggers a reflex-like bodily (physical) response, which is then followed by emotional response. ...
Article
Full-text available
Misophonia is a common disorder characterized by the experience of strong negative emotions of anger and anxiety in response to certain everyday sounds, such as those generated by other people eating, drinking and breathing. The commonplace nature of these ‘trigger’ sounds makes misophonia a devastating disorder for sufferers and their families. How such innocuous sounds trigger this response is unknown. Since most trigger sounds are generated by orofacial movements (e.g. chewing) in others, we hypothesized that the mirror neuron system related to orofacial movements could underlie misophonia. We analysed resting state fMRI (rs-fMRI) connectivity (N=33, 16 females) and sound-evoked fMRI responses (N=42, 29 females) in misophonia sufferers and controls. We demonstrate that, compared to controls, the misophonia group show no difference in auditory cortex responses to trigger sounds, but do show: (i) stronger rs-fMRI connectivity between both auditory and visual cortex and the ventral pre-motor cortex responsible for orofacial movements; (ii) stronger functional connectivity between the auditory cortex and orofacial motor area during sound perception in general; (iii) stronger activation of the orofacial motor area, specifically, in response to trigger sounds. Our results support a model of misophonia based on ‘hyper-mirroring’ of the orofacial actions of others with sounds being the ‘medium’ via which action of others is excessively mirrored. Misophonia is therefore not an abreaction to sounds, per se, but a manifestation of activity in parts of the motor system involved in producing those sounds. This new framework to understand misophonia can explain behavioural and emotional responses and has important consequences for devising effective therapies.
... Misophonia is considered by some to be uncommon and many members of misophonia Facebook groups engaged with awareness initiatives on Rare Disease Day (Rare Disease Day, 2017) at the end of February 2017. However, the condition may be present in at least 18% of the general population (Dozier 2015a). It is certainly not simply an issue of sound sensitivity. ...
Article
Full-text available
Misophonia can be modelled as a process of five components initiated by a sensory experience. It is typified by an initial physical reflex followed by an undesirable emotional response. It may be present in as much as 18% of the population and is not simply an issue of sound sensitivity; the process being initiated by visual and kinaesthetic sensation in many cases. A number of approaches to treatment may be listed, each having its own proponents. The process of sequent repatterning has been developed by recognising the neuroscience that underpins both the condition itself and the changes necessary to successfully treat misophonia. Pragmatic choices have been made by recognising simply 'what works' and setting aside paradigms that do not. The result is a person-centred and scientifically-based therapy model that has proved itself durable and effective working with clients both face-to-face and remotely (online). The results of cases treated to date are reviewed and potential next steps considered.
Article
Purpose Misophonia is a condition in which individuals experience negative reactions, including anger and disgust, to specific sounds in their environment. Individuals with misophonia often report feelings of anxiety and a reduced quality of life. While there is no cure for misophonia, there are management protocols supported by case studies in the literature, including tinnitus retraining therapy (TRT) and Misophonia Management Protocol (MMP), along with coping strategies. The purpose of this case study is to contribute to the field of clinical research on patients with misophonia. Method Case studies involving misophonia are limited, and further research in this area is needed to provide evidence-based treatment. This case details misophonia questionnaires and assessment, case formulation, and management of misophonia in an 11-year-old girl, using a variation of both the TRT and MMP, including ear-level sound generators and coping strategies. Conclusions This case serves as a contribution to the evidence base for the use of sound therapy and coping strategies in the treatment and management of misophonia, as well as tools that are available in diagnosing misophonia. Clinical implications reveal sound therapy and coping strategies as a means to manage misophonia symptoms. Further research is needed for large-scale data to be available.
Article
Misophonia is a common condition that causes significant distress and impairment for patients and families. Despite the growing body of literature, most treatment descriptions do not incorporate objective assessment measures or detail techniques to involve family members in addressing misophonia. This case report provides a step-by-step family-based cognitive-behavioral approach to treat youth with misophonia, uses objective rating scales to monitor therapeutic improvement, and elicits feedback on the therapeutic skills used between therapy sessions. It also provides guidance on implementing inhibitory learning exposures for youth with misophonia.
Conference Paper
Full-text available
Misophonia is generally viewed as a condition where a person has an extreme emotional response and accompanying visceral arousal. A recent fMRI study indicates that the emotional response is driven by the vmPFC and is a conditioned emotional response. Another study which focused on the initial physical response concluded that misophonia includes an immediate elicited physical response (most commonly a muscle flinch, but it can be almost any physical response). Stimulus-Response classical conditioning theory is described and applied to misophonia. Based on recent research, a proposed diagnostic criteria for misophonia is presented based on the proposed criteria of Misophonia: Diagnostic Criteria for a New Psychiatric Disorder by Schroder, Vulnik, and Denys (2013). Other data presented are age of onset of misophonia, frequency of auditory and visual triggers, and comorbidity.
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