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Objective: We aim to elucidate misophonia, a condition in which particular sounds elicit disproportionally strong aversive reactions. Method: A large online study extensively surveyed personal, developmental, and clinical characteristics of over 300 misophonics. Results: Most participants indicated that their symptoms started in childhood or early teenage years. Severity of misophonic responses increases over time. One third of participants reported having family members with similar symptoms. Half of our participants reported no comorbid clinical conditions, and the other half reported a variety of conditions. Only posttraumatic stress disorder (PTSD) was related to the severity of the misophonic symptoms. Remarkably, half of the participants reported experiencing euphoric, relaxing, and tingling sensations with particular sounds or sights, a relatively unfamiliar phenomenon called autonomous sensory meridian response (ASMR). Conclusion: It is unlikely that another "real" underlying clinical, psychiatric, or psychological disorder can explain away the misophonia. The possible relationship with PTSD and ASMR warrants further investigation.
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A Large-Scale Study of Misophonia
Romke Rouw 1and Mercede Erfanian2
1University of Amsterdam
2Maastricht University
Objective: We aim t o elu cid ate m iso pho nia , a condition in which particular sounds elicit di spr o-
portionally strong aversive reactions. Method: Alargeonlinestudyextensivelysurveyedpersonal,
developmental, and clinical characteristics of over 300 misophonics. Results: Most participants
indicated that their symptoms started in childhood or early teenage years. Severity of misophonic
responses increases over time. One third of participants reported having family members with similar
symptoms. Half of our participants reported no comorbid clinical conditions, and the other half reported
a variety of conditions. Only posttraumatic stress disorder (PTSD) was related to the severity of the
misophonic symptoms. Remarkably, half of the participants reported experiencing euphoric, relaxing,
and tingling sensations with particular sounds or sights, a relatively unfamiliar phenomenon called
autonomous sensory meridian response (ASMR). Conclusion: It is unlikely that another “real”
underlying clinical, psychiatric, or psychological disorder can explain away the misophonia. The possible
relationship with PTSD and ASMR warrants further investigation. C2017 Wiley Periodicals, Inc. J.
Clin. Psychol. 0:1–27, 2017.
Keywords: misophonia; ASMR; disorder; sound; synesthesia
Introduction
At the start of the new millennium, Jastreboff and Jastreboff (2001) coined the term misophonia
in a review paper on auditory disorders. These authors define misophonia as a condition in
which individuals react negatively to specific patterns of sound and/or to sounds that occur
in specific situations or settings, whereas they tolerate other sounds that are frequently much
louder (Jastreboff & Jastreboff, 2014). The small number of empirical studies that have been
conducted on misophonia showed common properties of the misophonic condition (Edelstein,
Brang, Rouw, & Ramachandran, 2013; Kumar, Hancock et al., 2014; Schr ¨
oder, Vulink, & Denys,
2013; Wu, Lewin, Murphy, & Storch, 2014). Common misophonic triggers are human-generated
sounds such as chewing and sniffing. However, each misophonic will have his or her own unique
set of triggers, which may also include different types of sounds or even particular visual stimuli,
such as leg swinging (Edelstein et al., 2013; Schr¨
oder et al., 2013; Johnson et al., 2013b).
Critical aspects of the condition are disproportional aversive responses to the trigger, aware-
ness that this response is disproportionate, and no clear physical feature (such as the loudness
of the sound) to explain the response (Jastreboff & Jastreboff, 2014). Instead, it seems that
the meaning, social context, or interpretation of the trigger influences the response to these
noises (Bruxner, 2015; Schr¨
oder et al., 2013). This definition distinguishes misophonia from
other auditory-related conditions (Møller, 2011; Jastreboff & Jastreboff, 2015), such as tin-
nitus (hearing an often ringing sound when no sound is present), hyperacusis (a generally in-
creased sensitivity to sound), and phonophobia (fear of a specific sound). Current treatments for
We thank all participants for their time, effort, and cooperation. Thanks to Jennifer Brout and Tom Dozier
for their useful suggestions, Marsha Johnson for her help in recruiting the participants, and Miren Edelstein
for her helpful comments on the manuscript.
Please address correspondence to: Romke Rouw, Brain and Cognition, Department of Psychology, Univer-
sity of Amsterdam, Amsterdam, The Netherlands, Postbus 15915, 1001 NK. E-mail: R.Rouw@uva.nl
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 0(0), 1–27 (2017) C2017 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22500
2 Journal of Clinical Psychology, xxxx 2017
misophonia include cognitive behavioral therapy (Bernstein, Angell, & Dehle, 2013; McGuire,
Wu, & Storch, 2015; Schr¨
oder, Vulink, van Loon, & Denys, 2017), tinnitus retraining therapy
(Jastreboff & Jastreboff, 2014), and counter conditioning (Dozier, 2015a). Although beneficial
effects have been reported, there is a general consensus that further evaluations and specific
quantitative studies are needed to examine the results and effectiveness of treatments (Jastreboff
& Jastreboff, 2014; Cavanna & Seri, 2015; Cavanna, 2014; Johnson et al., 2013b). Furthermore, a
better understanding of the condition and its behavioral and neurophysiological characteristics
are needed to improve effective treatment and management strategies.
On Web of Science, there are currently 37 publications on the topic of misophonia. Of these
publications, only nine are before 2013. In 2013, misophonia received an increased amount of
attention from both inside and outside the scientific community (see www.huffingtonpost.com;
metro.co.uk; www.nytimes.com; www.washingtonpost.com). As described above, scientific ef-
forts have succeeded in outlining the types of associations and responses that define misophonia.
Furthermore, findings that cannot be exaggerated or “faked” have helped in establish-
ing credibility of the condition. In particular, misophonia comprises a clear and distinct set
of characteristics and complaints (Schr¨
oder et al., 2013; Edelstein et al., 2013; Wu et al.,
2014). The reported disproportional aversive experience has been validated by finding an in-
creased autonomic response (as measured with GSR1)totriggersounds,butnottocorre-
sponding visual stimuli, in misophonic participants compared with nonmisophonic participants
(Edelstein et al., 2013). Furthermore, the reported sensory sensitivity has been corroborated
with an altered early physiological signal (auditory N100) measured in an oddball paradigm
with electroencephalogram (Schr¨
oder et al., 2014).
Despite these recent scientific advances, we know little about the causes and underlying
mechanisms of misophonia. At the theoretical level, different models have been proposed (see
Cavanna & Seri, 2015). However, very few experimental (neuroimaging, experimental psychol-
ogy, psychophysiology, large-scale behavioral) studies have been conducted. One neuroimaging
study came out very recently, relating the misophonic response to hyperactivity of the anterior
insula and abnormal functional connectivity of this region with medial frontal, medial parietal,
and temporal regions. Furthermore, it showed altered interoception in misophonics. These au-
thors concluded that abnormal salience attributed to certain sounds, combined with atypical
perception of internal body states underlies misophonia (Kumar et al., 2017; see also the Dis-
cussion section). Despite this important step forward, the limited number of (neuroimaging)
studies does not yet allow drawing firm conclusions on the explanatory power of the different
theoretical models. Although there are different viewpoints on misophonia, three fundamental
questions need to be answered when unraveling the mechanisms involved in it.
One question is whether misophonia could be induced in any person, perhaps following the
development of conditioned responses (Ferreira, Harrison, & Fontenelle, 2013; Jastreboff &
Jastreboff, 2002). Alternatively, there may be certain characteristics (e.g., genetic predisposition
or a neurological or psychological anomaly (Cavanna & Seri, 2015; Ferreira et al., 2013) that
make a person more receptive or even predisposed to misophonia. Because not all misophonics
report the same severity of symptoms, a related issue is whether certain individual characteristics
or other clinical, psychiatric or psychological conditions affect the severity of the misophonic
symptoms.
This brings us to the second question: What is the relationship of misophonia to other
clinical, psychological, or psychiatric conditions (see Cavanna & Seri, 2015)? Is misophonia an
idiopathic condition? Or is it related to (an)other condition(s)? Or is misophonia even perhaps
only a symptomatic manifestation of another underlying “real” disorder? Although comorbidity
with other conditions has been obtained (e.g., Ferreira et al., 2013; Kluckow, Telfer, & Abraham,
2014; Schr¨
oder et al., 2013), it is not yet clear if these co-occurrences are coincidental or not.
The third question pertains to the specificity of misophonia. Do misophonic complaints re-
late to a general cognitive and/or emotional divergence, for example, diverging processes in the
1Galvanic skin response.
ALarge-ScaleStudyofMisophonia 3
auditory domain or abnormal emotional processes? A mechanism proposed to underlie miso-
phonia is increased functional connectivity between the auditory and the limbic system (Jastre-
boff & Hazel, 2004; Johnson et al., 2013b). In the Jastreboff model, misophonia involves not only
conscious but also subconscious pathways, the latter governed by the principle of conditioned
reflexes and playing a role in overactivating the limbic and autonomic nervous systems (Jastre-
boff & Jastreboff, 2014). This could imply that a general mechanism is involved in several types
of conditions including tinnitus (Jastreboff, & Jastreboff, 2002) or obsessive-compulsive disor-
der (OCD) and Tourette syndrome (Webber, Johnson, & Storch, 2014). However, explanations
could also be on a more specific level, for example, if there are only highly specific trigger-to-
response associations without a more general underlying cognitive/emotional divergence (that
could relate misophonia to other conditions).
This latter characteristic reflects a similarity between misophonia and the autonomous sensory
meridian response (ASMR) and synesthesia conditions. The types of trigger (inducer) and
response (concurrent) differ between these conditions; they all share the characteristic of highly
specific and individually tailored trigger-to-response associations. ASMR is a phenomenon in
which particular audio and visual stimuli will evoke pleasant, relaxing, and euphoric experiences,
typically accompanied by tingling sensations on the scalp, neck, and spine.
As far as we know only one scientific study has investigated ASMR (Barratt & Davis, 2015).
It reports that common triggers in ASMR are whispering, personal attention, crisp sounds, and
slow movements, and that ASMR may provide temporary relief from pain or stress. Furthermore,
a high prevalence of synesthesia was observed in subjects in the ASMR group. These authors
suggest a possible link between ASMR, misophonia, and synesthesia. In synesthesia, a particular
sensory stimulus (known as an inducer) evokes another seemingly unrelated sensation (known
as a concurrent; Ramachandran & Hubbard, 2001; Rouw & Scholte, 2007). A common type
of synesthesia is grapheme-color synesthesia, in which a particular letter or number evokes a
particular color. The synesthetic experience is specific, consistent, and automatic (in the sense
that it does not take effort to evoke the experience), and people report to have had it for as long as
they can remember. There are clear parallels between these conditions because they all involve
strong sensations, which moreover tend to be experienced as pleasant or unpleasant, being
evoked by particular stimuli. Remarkably, the evoked additional sensations cannot be easily
explained by the stimulus properties alone. Moreover, the conditions all tend to be explained in
terms of increased cross-connections. Currently, the relationship between the three conditions
is not yet clarified.
In this study, we will explore characteristics of the misophonic condition. Using an online
study, we surveyed a large number of participants with misophonic complaints. This approach
allowed us to identify the factors or characteristics most clearly related to the presence or the
severity of the condition. The current study combined different approaches: it examined numer-
ical data and open-answer questions and used hypotheses testing and exploratory (hypothesis-
generating) analyses. Data collection methods were always structured; questionnaires were fixed
and evaluated in exactly the same way for each participant. Furthermore, the multiple choice
questions allowed for easy numerical comparison. In contrast, the open-ended questions allowed
for exploring the problems, sensations, and experiences of misophonia. Thus, the study combines
hypot heses testing and q uantitat ive data collectio n, with explorat ory re search to deve lop new
ideas and hypotheses. Furthermore, the current approach is not based on, or dependent on, clin-
ical diagnoses for each individual. Instead, we aimed to find patterns between the misophonic
complaints and other personal and psychological characteristics. We therefore recruited based
on reported complaints and did not draw conclusions on clinical implications.
First, we measured the severity of the misophonic symptoms. The large group of participants
allows for examining the distribution and overall range of misophonic complaints. Wu et al.
(2014) found that 20% of their entire sample of undergraduate students reported that misophonia
caused significant interference in their lives. In contrast, clinical studies such as Veale (2006) and
Schr¨
oder et al. (2013) stress that the severity and pattern of symptoms justify misophonia to be
considered a subgroup, or even a separate clinical (as defined in the Diagnostic and Statistical
Manual of Mental Disorders; 5th ed.; DSM-V; American Psychiatric Association [APA], 2013)
category. We included questionnaires about emotional and physical responses and the effect
4 Journal of Clinical Psychology, xxxx 2017
misophonia has on their life so that we can also examine if these different aspects of misophonia
correlate.
Next, we explored the etiology of misophonia by asking participants about the onset of
their symptoms and examining the relationship between misophonia and other environmental,
developmental, and familial traits. We explored how often misophonia is reported to run in
families. While currently there is little literature on the condition, we were able to formulate
hypotheses based on previous empirical findings or theoretical suggestions. This included the age
at which the first symptoms appeared. The specific hypotheses regarding onset of symptoms in
middle childhood was derived from a previous study (157 participants filled-in a questionnaire),
in which subjects reported a mean age of onset at 12 years (Kumar et al., 2014), and a study in
which subjects reported a mean age of onset at 13 years (Schr ¨
oder et al., 2013).
Another hypothesis was that the participants would report symptoms as getting worse over
time (Edelstein et al., 2013; Kluckow et al., 2014; Bernstein et al., 2013), supposedly caused
by the negative reinforcement provided by the reactions to the trigger (Jastreboff & Jastreboff,
2014). We also tested hypotheses related to environmental influences, in particular substance
abuse. Alcohol has been reported to alleviate the intensity (Edelstein et al., 2013), whereas
caffeine might have the reverse effect. This was found with a small group of subjects, but our
current study allows for testing these hypotheses in a larger misophonic population (Cavanna &
Seri, 2015).
Finally, we examined comorbidity with other clinical, psychological, or psychiatric conditions.
There have been reports of misophonics experiencing altered processing at the auditory/sensory
level (Wu et al., 2014; Schr ¨
oder et al., 2014; Edelstein et al., 2013) and comorbidity with other
hearing-related conditions (Cavanna & Seri, 2015; Møller, 2011). On the other hand, misophonia
has been defined as a separate condition, and standard hearing tests show normal hearing in
misophonic individuals (Schr¨
oder et al., 2013).
We also explored the relationship between misophonia and psychological, clinical or neuro-
logical conditions. Edelstein et al. (2013) found through interviews that some subjects described
symptoms related to OCD, attention deficit disorder (ADD), or posttraumatic stress disorder
(PTSD). A similarity between misophonic behavior and compulsive spectrum characteristics
has been noted by several authors (Johnson et al., 2013b; Ferreira et al., 2013; Schr¨
oder et al.,
2013; Webber et al., 2014). Schr¨
oder et al. (2013) reported that half of their subjects met the
criteria for OCPD, a condition we inquire about in our questionnaire.
We also included questions about eating disorders. Kluckow et al. (2014) reported cases of
individuals with a combination of misophonia and eating disorders, and they suggested testing
the prevalence of this combination. This is particularly interesting given that the most common
misophonic triggers are eating sounds. We test if reports on current or previous eating disorders
are present in misophonics, and if the presence or absence of eating conditions seems to interact
with misophonic mechanisms (as measured in severity of the misophonic symptoms). Although
this relationship is an interesting and important question, the large differences reported so far
in symptoms, proposed etiology, and theoretical explanations caused us to predict that eating
disorders do not provide an explanation for, and are not related to, the misophonic condition.
A connection between misophonia and tinnitus has been suggested (Neal & Cavanna, 2013),
given the phenomenological similarity between misophonia and the sensory phenomenon of
unpleasant sensations (Crossley & Cavanna, 2013), which provide involuntary urges to tic in
patients with tinnitus. In our questionnaire, we explore the relationship between misophonia
and hearing conditions.
Wu et al. (2014) studied a large group of undergraduate students and found an association
between misophonia and general conditions such as depression, OCD, and anxiety. Ferreira
et al. (2013) suggested that misophonia is better described as a symptom of OCD, generalized
anxiety disorder, or schizotypal personality disorder. While we can rely only on self-report, we do
ask participants about comorbidity with other conditions. The rationale is that if there is indeed
a condition or disease with a particularly strong relationship to misophonia, it should reveal
itself in this large participant group. It should show a stronger association with misophonia than
the other comorbid diseases (which are present only by coincidence). These relationships are
examined in our exploratory analyses.
ALarge-ScaleStudyofMisophonia 5
Finally, we include explanations and questions about ASMR and synesthesia. In this study, we
will test whether participants with misophonic complaints also experience these other conditions,
in which a particular stimulus evokes an unusual or disproportional response. Little is known
about misophonia, ASMR and synesthesia, yet a relationship between these conditions has been
predicted in literature (Edelstein et al, 2013; Barratt & Davis, 2015) and the shared characteristics
of the conditions invites further exploration.
Method
Participants received a link to an online test. The test was performed through a secure admin-
istration (Qualtrics software) and took between 20 and 30 minutes to complete. The study was
approved by the ethical committee of the University of Amsterdam.
After clicking the link, participants first received information about the aim of the study,
its procedures, confidentiality of research data, and on how to contact the experimenter or a
member of the ethical committee. An informed consent document was given to participants,
who declared to have read and understood the general information, take part voluntarily, and
have understood the fact that they can stop their participation and withdraw their consent,
anytime, and without any consequences. The experiment started if the participant gave his or her
consent.
The online experiment comprised 55 items, including yes/no questions, multiple answer
questions, and open-ended questions. Participants answered by clicking on the corresponding
answer with their mouse or typing in their answer (in the case of open-ended-answer questions).
Participants were asked about a variety of categories: demographic characteristics; the age of
onset of their misophonic responses; if (and when) the participant had received a misophonia
diagnosis; auditory triggers; possible changes, over time, of their misophonic responses; their
family history in misophonia and other conditions or disorders; coping strategies; effects of
substances on misophonic responses; emotional and physical properties of their misophonic
responses; visual triggers; possible presence of synesthesia; possible diagnoses with another
condition or disorder; possible presence of ASMR; the nature of their misophonic triggers;
provoked thoughts during a misophonic response; the effects misophonia had on their life; and
possible additional information they would like to share about their misophonia (an open-ended
question).
At the end of our test, we presented previously published misophonia tests: Misophonia
Activation Scale (MAS-1; Fitzmaurice, 2010, Kluckow et al., 2014, Dozier, 2015a), Misophonia
Physical Sensation Scale (MPRS; Bauman, 2015), and Amsterdam Misophonia Scale (A-MISO-
S; Schr¨
oder et al., 2013; 1. time, 2. interfere, 3. distress). In our test, the same types of questions
do not always succeed each other, to counter automatic answering or answer biases. At the
end of the experiment, participants had the opportunity to write down any additional ques-
tions or remarks, and we thanked them for their participation. Participants could leave their
e-mail address to receive more information about the research project and a general report
on the results of this study. The results of the experiment are presented below in four subsec-
tions: Participants, Severity of Symptoms, Developmental and Familial Traits, Prevalence and
Comorbidity.
Participants
A total of 385 participants were recruited, 84 of whom did not complete the questionnaires
and were thus excluded from further analyses. Participants were recruited online on vari-
ous websites and forums. We recruited participants from the “Selective Sound Sensitivity”
Yahoo group (see https://groups.yahoo.com/neo/groups/Soundsensitivity/info), which com-
prised patients from the Oregon Tinnitus and Hyperacusis Treatment Clinic. Recruiting this
group enabled us to reach out to a large group of misophonics, including those with a clinical
diagnosis.
There were few online groups when we first set up this study; however, since then there has
been a huge upswing in attention toward misophonia. We also recruited participants from two
6 Journal of Clinical Psychology, xxxx 2017
international Facebook misophonia support groups; one of the earliest and largest Face-
book group for people with misophonic complaints, and a group dedicated to ongoing in-
teraction between patients and clinicians or researchers. (https://www.facebook.com/groups/
misophoniasupport/, https://www.facebook.com/groups/misophoniatreatment/).
Because these online locations bring people together based on those very specific types of
complaints that we wished to examine, the websites and forums allowed us to recruit a very
large group of participants. Although this approach is necessary to recruit a large number of
this particular type of participants, it does imply that there is no random sample of participants,
and that all measurements are based on self-report. These limitations needed to be taken into
account in all our conclusions (see also the Limitations section).
Note that unbiased selection is extremely difficult for any study that aims to test a very large
(international) group. To be able to include over 300 subjects in our study, we had to recruit
specifically at a designated place that would allow us to get as many potential misophonics
as possible. Recruiting in a general (nontargeted) population would have meant testing several
thousands of individuals to find a sufficient number of people with misophonic complaints. The
current participant group furthermore already had an interest in the topic and their decision to
participate was based solely on their own motivation to contribute to misophonia studies. Thus,
our approach discouraged the participation of less motivated and less serious participants.
The recruitment procedure led to a large and international group of participants. Participants
were not paid and participation was completely voluntary. There is no complete consensus yet on
the exact diagnosis of misophonia, and no clear and agreed-upon clinical definitions (or DSM-V
criteria) exist. However, in this study, we are interested in the relationships with misophonic
complaints rather than setting a sharp cutoff (clinical) diagnosis. Therefore, we examined all
participants who self-report on suffering from misophonic complaints, and the range of severity
of complaints was a factor in our analyses.
Severity of Symptoms: Emotional, Physical responses, and Effect on Life
In this section, we describe the questionnaires that were used to measure the severity of miso-
phonic complaints. All these materials were designed by other researchers and have been reported
in previous studies. Relatively few studies have appeared on misophonia and much is still un-
known about the condition. Accordingly, it is not yet fully determined which questions or items
best predict or describe the misophonic condition. Questionnaires cannot lean on a tradition of
methodological research, and the validity and reliability of the questionnaires need to be further
studied. The current study is a step in this direction, which was set up to further our understand-
ing of the misophonic condition and advance the development of misophonic measurement
methods. We examined the misophonic measurements by including several questionnaires, from
different studies and different authors. We also measured different aspects of the misophonic
complaints. To further our understanding of the misophonic condition, we tested a large subject
group and added wide-ranging additional questions. This approach allowed us to retrieve a
broad perspective on the condition and further the development of misophonia measurement
methods.
Misophonic complaints: Emotional. The MAS-1 (Fitzmaurice, 2010; Kluckow et al.,
2014; Dozier, 2015a), retrieved from misophonia-UK.org, measures the severity of responses to
misophonic triggers, focusing on emotional responses. Participants are presented with 11 levels
of responses to misophonia, with higher levels reflecting increasingly severe effects. Participants
indicate which is the highest level they still recognize as their own responses. The last level, 12,
is the “other” category, created so that participants have the flexibility to put any alternative
choices or remarks here. Participants need to provide one answer only; the minimum score is 1
(for level 0) and the maximum score is 11 (for level 10), with other scored as missing (see the
Results sec tion for further explanation).
Misophonic complaints: Physical. On the MPRS (Bauman, 2015), participants indicated
physical sensations relating to their misophonia. The question of “PHYSICAL sensation to your
ALarge-ScaleStudyofMisophonia 7
misophonia (emotional response to certain sounds)” was followed by 11 scales, increasing in
reported intensity of the experiences (see the Results section for exact phrasing of scales).
Participants were allowed to indicate multiple answers because we felt these physical sensations
might be multifaceted. The 12th option was an open-ended question: “Please use space below if
you’d like to add any extra information about your misophonia.”
To avoid confusing a 0 score with a missing value, the lowest level (level 0) was scored with
1 point and the highest level (level 10) was scored with 11 points. A 12 indicated that the
participant had chosen “Other” (see the Results section). Using multiple answers allowed us to
compare relative frequency of certain physical sensations. If further analyses required a score
(see the Results section) that measured individual differences in physical intensity, then we took
the highest scale recognized by the participant as his or her score.
Misophonic complaints: Effect on life. The A-MISO-S (Schr ¨
oder et al., 2013) is based
on the Yale–Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989). Participants
indicated the severity of their symptoms by choosing one of five levels, with higher scores
reflecting more severe effects (0 =none to 4 =extreme). We presented three of the A-MISO-S
subscales.
The first subscale asks: “How much of your time is occupied by misophonic sounds? (How
frequently do the [thoughts about the] misophonic sounds occur?).” The second subscale asks:
“How much do these misophonic sounds interfere with your social or work (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 patient were employed).” The third subscale asks: “How
much distress do the misophonic sounds cause you? (In most cases, distress is equated with
irritation, anger, or disgust. Only rate the emotion that seems triggered by misophonic sounds,
not generalized irritation or irritation associated with other conditions).”
On each scale, the minimum score is 0 and the maximum score is 4. For further analyses, the
mean score of the three subscales is calculated per person.
Developmental and Familial Traits
We present participants with the following question: “How old were you since you started
experiencing the misophonic symptoms?” Participants could not only choose an answer from
one of five categories (as long as I can remember, childhood, 8–10 years old, early teenage years,
17) but also describe more specifically when the misophonia started (other, please explain).
The open-ended answers allowed participants to report answers that do not fit with any of
the categories, as well as providing information in addition to indicating one of the predefined
categories. As for further studies, it is useful to work with particular age categories; answers that
did clearly indicate a certain time in life were rated as belonging to a certain age category. Based
on the predefined categories and the 42 provided answers, five answer categories were created
(the boundaries that defined categories for answers to the open-ended questions are displayed
in italics).
1. as long as I can remember
(and answers referring to 2, 3, or 4 years of age).
2. childhood
(with age limits between 5 and 12)
3. early teenage years, 17
(with age limits between 13 and 17)
4. Adult
(18 years of age or older)
5. Don’t know/other
We furthermore presented the following question: “Do you think the results have worsened
over time?” Participants indicated yes, no, or stay the same. There was also an opportunity
to provide a written answer (other, please explain). The development or change over time of
8 Journal of Clinical Psychology, xxxx 2017
misophonic complaints was furthermore examined by analyzing the relationship between age of
the subject and the severity of misophonic symptoms.
Based on previous reports (Cavanna & Seri, 2015), we devised questions to examine if miso-
phonia runs in the family. Unfortunately, we could inquire about misophonia running in the
family only to the best of the participants·knowledge. We asked: “Do any family member(s)
have similar symptoms?” Participants indicated no, unknown, or yes. If a participant answered
affirmably, he or she was asked to elaborate and indicate exactly which family members.
Prevalence and Comorbidity
Other conditions. The question “Have you been diagnosed with any other psychiatric
conditions?” was followed by 10 different types of clinical items. Eight items, as well as no or
other (please explain), were chosen based on the misophonia literature at the moment of setting
up this study. The different items were as follows: tinnitus; obsessive compulsive personality dis-
order (OCPD); hyperacusis; auditory processing disorder; ADD; posttraumatic stress disorder
(PTSD); exploding head syndrome (EHS); phonophobia. We asked: “Have you ever experi-
enced or been diagnosed with any eating disorders?” Participants chose among four answers:
yes - anorexia nervosa; yes - bulimia nervosa; other (please explain); no.
Another question probing comorbidity was “Have you ever experienced or been diagnosed
with selective mutism? (an anxiety disorder in which a person who is capable of speech does not
speak in specific situations or to specific people. Children with selective mutism stay silent even
when the consequences of their silence include shame or even punishment.)” Participants chose
either yes or no, followed by “Please use space below to provide additional explanation.”
Synesthesia. We asked four questions on synesthesia and participants responded either
yes or no. Each question was followed by an open-ended question: “If you do recognize this,
please explain and give a few examples.”
!Have you ever experienced “Hearing color Synesthesia”? (in which sounds induce colors, or
visual images)
!Have you ever experienced colors with letters, numbers, days of the week?
!Have you ever experienced that letters, numbers, days of the week to you seem to have shape,
spatial location, or “mental map” that seems to appear when you think of them?
!Do you have other types of synesthesia: Do certain experiences (seeing or hearing a letter,
musical tone, name, person) trigger an additional sensation (color, personality, visual patterns,
tactile sensations)?
ASMR. We asked the question “Do you ever experience pleasurable tingling sensation in
the head, scalp, back, or peripheral regions of the body in respond to visual, auditory, tactile,
olfactory, or cognitive stimuli? (e.g., experiencing tingling strong desirable sensation when some-
one is whispering in your ear or rubbing fingers on a rough surface).” Participants chose either
no or yes, followed by the open-ended question “Please explain your experiences.”
In our contacts with misophonics while setting up this test, anecdotal reports had suggested
that some misophonics have another type of compulsion to listen to sound; therefore, we also
included this as a question: “Do you feel a compulsion to listen to some specific sounds on
regular basis which makes you feel better and help you to calm down? (e.g., calling random
numbers and listening to people on the phone).” Again, participants chose either no or yes and
the latter was followed by the open-ended question “Please explain your experiences.”
Family. The question “Do any family members (as far as you know) have other neurologi-
cal, psychological or psychiatric conditions, in particular OCD (obsessive-compulsive disorder),
eating disorders, synesthesia, ADD, ADHD, PTSD (post-traumatic stress disorder)” was fol-
lowed by 12 answer alternatives: tinnitus; obsessive compulsive personality disorder (OCPD);
hyperac usis; auditory processing d is order; attention d efi cit disorder (ADD); p ost-traumatic
stress disorder (PTSD); exploding head syndrome (EHS); phonophobia; eating disorder;
ALarge-ScaleStudyofMisophonia 9
Table 1
Nationalities of Participants (Ordered by Continent)
Belgian 3 American (USA) 93
Danish 1 Canadian 12
Dutch 9 Jamaican 1
English 38 Mexican 6
Finnish 2 Bolivian 1
French 2 Columbian 1
German 19 Afghan 1
Greek 10 Armenian 1
Hungarian 1 Chinese 2
Irish 1 Iranian 1
Italian 2 Korean 1
Moldovan 2 Malaysian 1
Polish 1 Aus tralian 8
Romanian 1 Indian 3
Rus sia n 1 New Zealander 3
Scottish 1 Moroccan 1
Spanish 4 South African 2
Swedish 2 Mixed 63
Turkish 1
synesthesia (letters always have colors/numbers have a spatial location/music tones have colors);
other (please explain); no. This question was followed by the open-ended question “Additional
space to describe conditions running in the family.” We furthermore asked: “Do any family mem-
bers have other types of perceptual dysfunctions? (in particular hearing issues or conditions that
evoke emotions in response to sounds).”
Results
Participants
The setup and procedures of this study allowed testing a large and diverse group of participants.
In this section, we display their characteristics, including both participant demographics and
characteristics and severity of their misophonic complaints as indicated by self-report question-
naires. A total of 301 (250 females) participants were included in the analyses (mean age 37
years; standard deviation [SD]=14). Participants were of diverse backgrounds including 36
different nationalities (see Table 1).
Severity of Symptoms
Misophonic complaints: Emotional. The emotional responses were measured with the
MAS-1 (Fitzmaurice, 2010; see also Kluckow et al., 2014; Dozier, 2015a). Responses ranged
from level 0 “Person with misophonia hears a known trigger sound but feels no discomfort” to
level 10 “Actual use of physical violence on a person or animal (i.e., a household pet). Violence
may be inflicted on self (self-harming).” Subjects indicate what is the highest level in this scale
that fits with their misophonic complaints.
We included an “other” option, which provided participants the opportunity to give further
descriptions of their complaints in case they felt the scales did not fit with their misophonic
complaints. A total of 43 participants used this opportunity to further explain their condition,
24 of whom clearly indicated what level (scale) their (severest) complaints belonged. Participants
were scored accordingly. If participants were not certain about their answer or if their answer
was not clear or did not clearly indicate which scale described their worst experiences, then the
response was categorized as other. For these 19 subjects, the MAS-1 scores were excluded from
further analyses, leaving a total of 282 participants included in the analyses.
10 Journal of Clinical Psychology, xxxx 2017
Figure 1. Severity of misophonic complaints, as measured with the Misophonia Activation Scale (MAS-1).
The answers to open-ended questions also allowed further insight in the kind of negative
personal experiences some of these participants have. An example of this is a comment made in
the MAS-1: “I have become a ‘hermit’ for the most part and only go out for groceries or to the
library to get books (not easy since people aren’t quiet in the library anymore).”
In our sample of 301 participants, the responses ranged from level 2 to level 10 (see Figure 1).
The most common level of emotional responses (see Table 2) was 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 demeanor.”
In addition to the MAS-1, we explored what types of emotional responses are common in
misophonia and which are less common in our participant sample. Subjects are allowed to
provide several answers and add their own answer in the other category. This showed that
almost all subjects recognized the feelings: “extreme annoyance/irritation,” “anger/rage,” but
also “stress/anxiety” (see Table 3). In the other category, the emotions reported (by more than
one participant) are guilt (5), frustration (4), rage (3), depression (3), sadness (3), cannot focus
(3), anger (2), want to die (2), feel trapped (2), overwhelmed (2), fear (of my own reactions) (2),
shame (2).
Misophonic complaints: Physical. On the MPRS, participants indicated their physical
sensations relating to their misophonia. There are 11 scales, increasing in reported intensity of
the experiences. Participants could indicate multiple answers. The chosen answers ranged from
level 0 to level 10, and several answers were recognized by at least one sixth of the participants.
The most common answer was level 8: “I feel physical sensation which can be best described as
emotional pain.” Using multiple answers allowed us to compare relative frequency of certain
physical sensations (see Table 4). If further analyses (see next results sections) required individual
differences in physical intensity, then we took the highest scale recognized by the participant as
his or her score.
ALarge-ScaleStudyofMisophonia 11
Table 2
Severity of Emotional Responses To Misophonic Triggers, As Measured With the Misophonia
Activation Scale (MAS-1)
MAS-1 No. %
Level 0
Person with misophonia hears a known trigger sound but feels no discomfort 0 0.0
Level 1
Person with misophonia is aware of the presence of a known trigger person
but feels no, or minimal, anticipatory anxiety
0 0.0
Level 2
Known trigger sound elicits minimal psychic discomfort, irritation or
annoyance. No symptoms of panic or fight or flight response
2 0.7
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
6 2.0
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 fight or flight symptoms exhibited
46 15.3
Level 5
Person with misophonia adopts more confrontational coping mechanisms,
such as overtly covering their ears, mimicking the trigger person, engaging
in other echolalias, or displaying overt irritation
31 10.3
Level 6
Person with misophonia experiences substantial psychic discomfort.
Symptoms of panic, and a fight or flight response, begin to engage
55 18.3
Level 7
Person with misophonia experiences substantial psychic discomfort.
Increasing use (louder, more frequent) use 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
25 8.3
Level 8
Person with misophonia experiences substantial psychic discomfort. Some
violence ideation
44 14.6
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 demeanor
60 19.9
Level 10
Actual use of physical violence on a person or animal (i.e., a household pet).
Violence may be inflicted on self (self-harming)
13 4.3
Other 19 6.3
To further explored how common or how uncommon particular physical responses are in our
participant group, we asked participants to indicate which physical responses from a list were
recognizable. See Table 5 for relative occurrences of reported physical discomfort. Results reveal
that a very common physical sensation in relation to their misophonia was increased muscle
tension.
In the “other” section, participants reported a wide variety of sensations, from “no physical
effect” to “sexual arousal” to “nausea.” Effects that were mentioned by at least three participants
were rage (8), pain/hurt (of which pain in ears 6), headache (5), anxiety (6), crying (7), panic
(3), and anger (3).
12 Journal of Clinical Psychology, xxxx 2017
Table 3
What Are the Feelings and Emotions Associated With the Trigger Sounds? (Multiple Answers
Possible)
Feelings and Emotions No. %
Extreme annoyance/Irritation 284 94.4
Anger/Rage 272 90.4
Stress/ Anxiety 269 89.4
Invasive, intrusive, insulting, violating, offensive, disgusting, rude 242 80.4
Aggravation 235 78.1
Feeling trapped 233 77.4
Impatience 221 73.4
Panic 168 55.8
Other (Please explain) 32 10.6
Table 4
Misophonia Physical Sensation Scale (MPRS)
Physical sensations, measured with the MPRS No. %
Level 0
Ifeelnophysicalsensation 23 7.6
Level 1
I feel minimal physical sensation and can ignore it 12 4.0
Level 2
I feel some physical sensation but can often/always ignore it 39 13.0
Level 3
I feel some physical sensation but have difficulty or cannot ignore it 61 20.3
Level 4
I feel elevated physical sensation and usually cannot ignore it 43 14.3
Level 5
I feel elevated physical sensation, definitely cannot ignore it 61 20.3
Level 6
I feel elevated physical sensation, cannot ignore it and each incidence
has an impact on my life
57 18.9
Level 7
Ifeelphysicalsensationasdescribedaboveandcannotcopewithit 46 15.3
Level 8
Ifeelphysicalsensationwhichcanbebestdescribedasemotionalpain 99 32.9
Level 9
Ifeelphysicalsensationwhichcanbebestdescribedasphysicalpain 32 10.6
Level 10
I feel physical sensation which is overpowering and is causing physical
pain
23 7.6
Misophonic complaints: Effect on life. On A-MISO-S (Schr ¨
oder et al., 2013), partici-
pants indicated the severity of their symptoms from one of 5 levels, with higher levels reflecting
more severe effects.
We presented three A-MISO-S subscales. The first asks, “How much of your time is occu-
pied by Misophonic sounds? (How frequently do the [thoughts about the] misophonic sounds
occur?).” Answers ranged from none to “extreme, greater than 8 hrs/day or near constant
(thoughts about) sounds.” Two participants indicated none and other answers ranged from
mild to extreme. The most common answer in our participant group was “moderate, 1 to 3
hrs/day, or frequent (thoughts about) sounds (more than 8 times a day, most of the hours are
unaffected).”
ALarge-ScaleStudyofMisophonia 13
Table 5
Reported Physical Discomfort
What is the physical discomfort? (multiple answers possible) No. %
Clenched/tightened/tense muscles 271 90.0
Increase in body temperature, blood pressure, or heart rate 180 59.8
Pressure in chest, arms, head or whole body 122 40.5
Sweaty palms 63 20.9
Hard to breathe 58 19.3
Pained by trigger sounds 39 13.0
Other (Please explain) 69 22.9
Table 6
Answers to Subscale 1–3 of the Amsterdam Misophonia Scale
How much time Interfere social or work life How much distress
None 2 None 7 None 0
Mild 65 Mild 59 Mild 13
Moderate 114 Moderate 148 Moderate 125
Severe 87 Severe 73 Severe 125
Extreme 33 Extreme 14 Extreme 38
The second subscale asks: “How much do these misophonic sounds interfere with your social
or work (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 patient were employed).”
Answers ranged from none to extreme. The most commonly chosen answer was “moderate,
definite interference with social or occupational performance, but still manageable.”
The third subscale asks: “How much distress do the misophonic sounds cause you? (In
most cases, distress is equated with irritation, anger or disgust. Only rate the emotion that
seems triggered by misophonic sounds, not generalized irritation or irritation associated with
other conditions).” Answers ranged from mild to extreme. No participants indicated none;
most commonly chosen answers were “moderate, disturbing irritation/anger/disgust, but still
manageable” and “severe, very disturbing irritation/anger/disgust.”
We explored what are common or uncommon effects of misophonia on the participant’s life,
by providing a list of complaints. Participants could indicate what complaints or effects they
recognized (multiple answers were possible) and could add their own answer in the “other”
category (see Table 7).
One fifth of the participants indicated that “thoughts of suicide” is one of the effects that
misophonia has on their life. The answers to the open-ended question also showed the severity of
feelings for a subgroup of the participants. Participants reported about misophonia interfering
with their work life to the degree of having to change/quit jobs, deteriorating relationships and
social life, interfering with normal daily life when triggers cause a lack of focus, and avoidance
or aggressive (e.g., self-harm) behavior. Other people not knowing or not believing the severity
of the misophonic complaints were felt to enhance their daily problems. Examples of answers to
the question “How do the trigger sounds effect on your life” are as follows:
!“Depression, sadness, failure and wanting to die and commit suicide.”
!“Fear of uncontrolled verbal and physical REACTIONS.”
!“I feel hatred towards the person making the sound sometimes. I say something to my family
when I can’t stand it, but my friends have no idea I have this problem. I’m embarrassed and
ashamed of being this way, but I don’t know how to stop.”
!“Suicidal thoughts I just long to die and escape the unbearable torture.”
14 Journal of Clinical Psychology, xxxx 2017
Table 7
Reported Effects of Misophonia on Participant’s Life (Multiple Answers Possible)
How do trigger sounds affect your life? No. %
Tried not to be around people if they make trigger sounds 267 88.7
Can’t pay attention at a movie or in class when people are
making trigger sounds
262 87.0
Realizes they are hyper focused on noises that should be in
the background and are unable to ignore them
224 74.4
Triggers are worse when tired 182 60.5
Can be triggered by sounds from television or video 176 58.5
Feels better when can locate source of sound 134 44.5
Stays away from certain foods/avoids making certain sounds 122 40.5
Thoughts of suicide 66 21.9
Other (Please explain) 63 20.9
At the end of the experiment, participants were provided with the opportunity to write any
general remark about the research. Examples are as follows:
!“I have no understanding of why I am like this, it’s very distressing when it happens & I get
very embarrassed at my reaction & I find it really hard to explain to others.”
!“I need to get help about this.”
!“Please help.”
Misophonic complaints: Covariates. In this section, we discuss characteristics of the
environment or of the misophonic individuals that may influence severity of the symptoms. We
examined influence of substance abuse as reported by male versus female participants. Further-
more, we examined how severity of symptoms are distributed and if different measurements of
symptom severity correlate.
Three questions probed effects of pharmacological agents on misophonia, including alcohol,
caffeine, and nicotine. The fourth question was “Do any other chemicals affect the symptoms?”
We included marijuana, ecstasy, and mushrooms as examples. Participants chose one of four
answer categories: “lessened symptoms,” “aggravated symptoms,” “no change,” or no use of
that particular substance.
Results are presented in Table 8. A relatively large percentage (36%) of the group mentioned
alcohol as lessening the symptoms. Some participants reported to have used alcohol with the
purpose of reducing the misophonic symptoms. Most misophonics indicated that caffeine does
not seem to affect the symptoms, and most misophonics do not use nicotine or other chemicals.
Of the participants indicating lessened symptoms with other chemicals, most (N=24) mentioned
marijuana/cannabis. Within this group, many participants indicated that they have used it only
rarely, and not anymore (e.g., by fear of losing their job).
We also contrasted the severity of complaints as reported by male versus female participants.
From each participant, we took (a) the score on MAS-1, (b) the highest indicated score on the
MPRS, and (c) the mean score on the three subscales on the A-MISO-S. Mean and standard
deviation are reported in Table 9. The reported severity of symptoms is somewhat increased in
females, compared with males.
A Kruskal-Wallis test evaluated the differences between two gender categories. The tests
showed no effect for MAS-1, a marginally significant effect for MPRS, X2(1, N=301) =
2.78, p=.095, and increased median for A-MISO-S, X2(1, N=301) =6.11, p=.013. The
increased severity reported by females, compared with males, might be a gender bias in (re-
ported) severity of symptoms; however, please note that with Bonferroni correction for multiple
comparisons (p<0.0167), only the effect measured with A-MISO-S is significant. Further-
more, the different sizes of the groups (51 males vs. 250 females) might influence the severity
differences.
ALarge-ScaleStudyofMisophonia 15
Table 8
Effects of Different Chemicals on Misophonic Complaints
No. %
1. How are symptoms affected by alcohol?
Lessened 107 36%
Aggravated 6 2 %
No change 61 20%
No alcohol use 128 43%
2. How are symptoms affected by caffeine?
Lessened 9 3 %
Aggravated 53 18%
No change 184 61%
No caffeine use 56 19%
3. How are symptoms affected by nicotine?
Lessened 19 6 %
Aggravated 3 1 %
No change 57 19%
No nicotine use 223 74%
4. Do any other chemical(s) affect the symptoms? (e.g., marijuana [THC], ecstasy [MDMA], mushroom
[psilocybin], etc.? (Please name the chemicals in the box below)
Yes- Lessened symptom 39 13%
Yes- Aggravated symptoms 11 4%
No 51 17 %
Unknown 201 67 %
Table 9
Reported Severity of Misophonic Complaints by Female Versus Male Participants
Female Male
Mean (SD) Mean (SD) p-value
MAS-1 7.77 (1.94) 7.34 (2.22) n.s.
MPRS 6.57 (2.97) 5.78 (3.15) .088
A-MISO-S 3.38 (0.71) 3.09 (0.71) .008
Note.SD=standard deviation; MAS-1 =Misophonia Activation Scale; MPRS =Misophonia Physical
Sensation Scale; A-MISO-S =Amsterdam Misophonia Scale.
Summary and the distribution of severity of symptoms. In summary, the measure-
ments show that our participants differ in nature and severity of misophonic complaints, with
a relatively high incidence of participants indicating their complaints as “moderate” on the
misophonia assessment scales. For another substantial group of participants, however, the miso-
phonic responses to sounds were experienced as extreme, severely disturbing, and even had a
devastating effect on their life.
None of the questionnaires were normally distributed (Shapiro-Wilk >.93; (N=282) p<
.001). As can be seen in Figure 1, the MAS-1 showed that the responses are diverse. Rather
than a normal distribution, the distribution includes a large group of subjects with relatively
mild complaints and another large group of subjects with severe complaints. Such distribution
does not seem to be in line with the notion that everybody has misophonia, but on a gradually
increasing scale of intensity. Perhaps more than one group of misophonics is represented here,
with more than one (causal) mechanism. It could also be related with our particularly large
group of participants, thereby including many different types of people reporting misophonic
complaints. Because the questionnaires were all non-normally distributed, in further analyses
nonparametric methods are chosen.
16 Journal of Clinical Psychology, xxxx 2017
The three measures show moderate to strong correlations, between MAS1 and A-MISO-S,
rs(282) =.67 p<.001, MAS-1 with MPRS, rs(282) =.53, p<.001, and MPRS with A-MISO-S,
rs( 301) =.47, p<.001.
Developmental and Familial Traits
Do the misophonic symptoms worsen over time?. More than three quarter of the par-
ticipants indicated that their symptoms had worsened over time (N=232, 77%), against a much
smaller number of participants indicating that it did not get worse (N=11, 4%) or stayed the same
(N=31, 10%). A total of 27 (9%) participants indicated “other,” a category that comprised very
diverse answers. Participants indicated that they have developed coping strategies/life changes
that make it easier to deal with their misophonia. Others indicated that the misophonic responses
have stayed the same but that the number of triggers has increased. A few participants chose the
“other” category to indicate that their misophonia got “a lot” worse.
Onset of symptoms. Participants provided diverse responses to the question “How old
were you since you started experiencing the misophonic symptoms?” Answers ranged from “as
long as I can remember” to “started around 2013, aged 57.” Yet a clear pattern emerged from
the results, with most of the participants indicating that the problems started in childhood
(N=136, 45%). Another large group indicated they had problems since teenage years (N=91,
30%); 44 (15%) participants answered “As long as I can remember.” It was also less common
to experience misophonia since adulthood (N=27, 9%), and three answers were in the “other”
category (1%).
As explained in the Method section, the participants used open-ended question for many
different purposes, and 39 participants in total provided a written answer. Most answers could
unambiguously be categorized in one of these age categories (only three participants did not
clearly indicate one of the four age categories). Several participants indicated that there were
early complaints and that only later in life these complaints increased in severity to become real
problems. For example, one participant indicated that as a child she probably had a weaker type
of misophonia, but that this problem became apparent only in adulthood. These reports are in
line with the notion that the severity of misophonic complaints increases over time. This latter
notion was examined by contrasting severity of misophonic symptoms across age groups. The
categories did not differ in terms of current age of the participants. Thus, someone answering
“all my life” has had misophonic complaints for a longer period of time than someone answering
“since adulthood.” As in the previous section, severity of symptoms is measured by (a) the score
on the MAS-1, (b) the highest indicated score on the MPRS, and (c) the mean score on the three
subscales on the A-MISO-S.
A Kruskal-Wallis test evaluated the differences among the four age of onset categories (always,
childhood, teenager, adult) on median change of symptom severity. Even without Bonferroni
correction, the tests showed only a marginally significant or no significant effect, for MAS-1,
X2(3, N=282) =7.63, p=.054; MPRIS, X2(3, N=301) =3.10, p=.376; A-MISO-S, X2(3,
N=301) =4.70, (3), p=.196.
An overview of severity of symptoms split out by age of onset (Table 10) revealed that the
indicated symptoms seem lowest for the group in which misophonia started in adulthood. We
therefore performed an exploratory analysis with Kruskal-Wallis split between all participants
answering that their symptoms started before adulthood, versus all participants answering that
their symptoms started as adults. It showed a difference on median change of symptom severity
in MAS-1, X2(1, N=282) =6.70, p=.01, a trend with A-MISO-S, X2(1, N=301) =3.40,
p=.065, and no significant effect with MPRIS, X2(1, N=301) =2.24, p=.135; therefore, with
Bonferroni correction (p<0.0167), there was only a significant effect on the MAS-1 but not on
the other measures.
Overall, these analyses did not show an overall effect between age of onset and severity of
symptoms in adulthood. There is, however, a small effect of less severe symptoms for participants
reporting that their symptoms started in adulthood.
ALarge-ScaleStudyofMisophonia 17
Table 10
Each of Five Answer Categories to the Question “How Old Were You Since You Started Experi-
encing the Misophonic Symptoms?”
No. % MAS-1 MPRS A-MISO-S
1. “As long as I can
remember” (2–4 years)
44 15% 7.63 (1.90) 6.86 (2.69) 3.36 (0.61)
2. “Childhood” (5–12 years)136 45% 7.90(2.02) 6.54 (3.10) 3.39 (0.70)
3. “Early teenage years”
“17” (13–17 years)
91 30% 7.73 (1.89) 6.30 (2.97) 3.30 (0.73)
4. Adult (18 years or older) 27 9% 6.61 (2.13) 5.59 (3.27) 3.10 (0.86)
5. Don’t know/other 3 1%
Note. Number and percentage of participants in each of the five answer categories, followed by mean
and standard deviation of the three measurements of severity of misophonic complaints. SD =stan-
dard deviation; MAS-1 =Misophonia Activation Scale; MPRS =Misophonia Physical Sensation Scale;
A-MISO-S =Amsterdam Misophonia Scale.
Figure 2. Severity of misophonic symptoms as measured with MAS-1, per participant age category. Note.
Age categories are per 10 years of age. The last two categories hold N=4andN=1 participant(s), respectively.
Current age and strength of symptoms?. Three subjects did not provide their age. There
is a significant small-sized negative correlation between age and strength of symptoms, obtained
with the MAS-1, rs(280) =.212, p<.001, and the A-MISO-S (mean subscales 1 to 3), rs(299)=
.15,p=.012; with Bonferroni correction, these effects are significant, p<.0167.
Figure 2 shows (in line with the negative correlations reported above) that the experienced
severity does not in general increase with age. Instead, reported severity is lowest for the middle-
aged participants. Although the reported severity increased in subsequent age categories, this
should be evaluated with care because there are only a few elderly participants (eight participants
are older than 65 years of age).
Running in the family. We asked the question, “Do any family member(s) have similar
symptoms?” Responses were as follows: 67 (22%) indicated that they did know family members
18 Journal of Clinical Psychology, xxxx 2017
with similar symptoms, 100 (33%) indicated no family members with similar symptoms, and 134
(45%) indicated “unknown.”
Contrasting the 100 participants reporting no family members with similar issues with the
67 participants who do know family members with similar issues shows a slightly increased
reported severity of the misophonic complaints if the participant knows family members with
similar symptoms (mean and SD), respectively: MAS-1 7.65 (1.9) versus 7.79 (2.0), MPRI 6.29
(3.1) versus 6.63(2.7), A-MISO-S 3.33 (.65) versus 3.37 (.74), but these effects are very small and
nonsignificant (in the Kruskal Wallis test, all three questionnaires, .2 <chi-square, .27, p=.6).
Describing the affected family members, the misophonics reported more female family mem-
bers than male family members with similar symptoms: more often mother (N=48) than father
(N=19), more often sister (N=37) than brother (N=10), more often daughter (N=29) than son
(N=17). Either misophonia is more common in females, or this particular participant group
(mainly comprising females) was biased in their responses.
Prevalence and Comorbidity
Other conditions. We asked participants if they had been diagnosed with other condi-
tions, to explore patterns of comorbidity. We also inquired about the presence of neurological,
psychological, or psychiatric conditions in their family members.
A total of 151 (50%) participants reported no other conditions or diagnoses. From the
list of conditions, the most commonly reported items were tinnitus (12%), PTSD (12%), and
ADD/ADHD (12%), followed by eating disorder (8%), OCPD (8%), selective mutism (6%), and
hyperac usis (4%). In the “ot he r” categ ory, most men tioned conditio ns were anxi ety disorders
(anxiety/panic/phobic conditions) (N=41, 13%) and depression/depressive disorders (N=40,
13%).
The mixed nationalities in our group, and particularly the fact that the data are based on self-
report, makes it difficult to contrast these prevalence rates with the prevalence rates as reported
in literature. We will therefore not perform such prevalence analyses. We instead aim to assess if
conditions are somehow related to misophonia or rather co-occur coincidentally. Our rationale
is that if conditions are related, then their mechanisms are not independent, and thus it is likely
that the presence of one condition will affect the nature and severity of the symptoms of the
other condition. However, if we find that the presence (vs. absence) of a condition shows no
effect on the severity of misophonic symptoms, then it indicates that these two conditions are
likely to coincide without reasons to assume interactions or shared mechanisms between the
conditions.
The relationship between the co-occurring conditions and misophonia was examined by
comparing severity of misophonic symptoms in participants with, versus participants without,
that other condition. For this analysis, we used the severity of misophonic symptoms in overall
effects on life (A-MISO-S). We excluded conditions reported by very few (less than N=15, or
5%) participants: These conditions were not related to misophonia for the great majority of our
participants, and the small subject number would make the analyses vulnerable for outliers. For
all other reported conditions, we correlated presence/absence of the condition with one specific
scale measuring severity of misophonic symptoms, the A-MISO-S scores.
There were nine tests in total (tinnitus, eating disorder, selective mutism, PTSD, OCSD,
ADD/ADHD, anxiety-related conditions, depression and no condition). With Bonferroni cor-
rection for multiple comparisons (α=.006), only two correlations survived. First, subjects report-
ing no comorbid disorder at all had less severe misophonic complaints rs(301) =.16 p=.006.
We found only one particular condition related to severity of misophonic symptoms measured
with A-MISO-S; increased severity of misophonic symptoms was related to reported presence
of PTSD, rs(301) =.19 p=.001. Concerning the conditions reported in the “other” sections,
presence of depressive (N=40) or anxiety-related (N=41) conditions did not matter for severity
of misophonic symptoms (all Kruskal-Wallis tests nonsignificant, with chi-square smaller or
equal to 1).
Further analyses showed that participants reporting PTSD indicate more severe misophonic
symptoms on all the Misophonic questionnaires. Kruskal-Wallis showed a difference on median
ALarge-ScaleStudyofMisophonia 19
change of symptom severity. These effects were significant after Bonferroni correction (p<
.0167) in all of the three questionnaires; in MAS-1, X2(1, N=282) =6.04, p=.01; in MPRIS,
X2(1, N=301) =7.18, p=.007; and in A-MISO-S, X2(1, N=301) =11.21, p=.001.
We examined if the presence of misophonia in the family and the presence or PTSD are
related (e.g., are these two different sources for misophonic complaints). However, whether or
not a participant reported family members with similar misophonic problems did not correlate
with any of the other factors of interest (PTSD, synesthesia, eating disorders, ASMR). Similarly,
whether or not a participant reported PTSD did not correlate to their reports on synesthesia,
ASMR, or eating disorders.
Synesthesia. The questions on synesthesia showed 9% to 17% prevalence, which is much
higher than the prevalence (2% to 4%) for these types of synesthesia as reported in the literature
(Simner et al., 2006). However, again the prevalence numbers are affected by how (stringent)
inclusion criteria are set (Simner et al., 2006; Johnson, Alison, & Baron-Cohen, 2013a), and in the
current study self-report is sufficient for inclusion. The (in)dependence of the two conditions was
therefore examined by analyzing the reported severity of misophonic complaints. For sequence-
color synesthesia and sequence-shape synesthesia, the Kruskal-Wallis test did not show increased
scores on the A-MISO-S (p>.1), and for hearing-color, there was a slight trend on the A-MISO-S,
X2(1, N=301) =3.30, p=.07.
Participants indicating “other synesthesia types” had increased scores on A-MISO-S, X2(1,
N=301) =9.34, p=.002. A total of 49 participants chose this “other” category. Participants gave
a description of their experiences, resulting in a wide range of their (“other”) types of synesthesia,
from people evoking colors, sounds evoking a particular taste, to particular emotions with touch
(e.g., rough or smooth surfaces). We listed these inducers and concurrents and tested if any of
the particular inducers (e.g., “sounds”) or any of the particular concurrents (e.g., “colors”
or “emotions”) were related to the reported severity of misophonic complaints. No effects or
relationships became apparent in these analyses; therefore, we currently have no explanation for
the effect of "other" categories on the A-MISO-S.
In line with current knowledge on synesthesia (Barnett et al., 2008), the presence of one type
of synesthesia correlated with the presence of other types of synesthesia. Participants reporting
sequence-shape synesthesia (days or letters have a spatial shape) were more likely to report
hearing-color synesthesia, rs(300) =.307, p<.001, or sequence-color, rs(299) =.318, p<.001.
And hearing-color correlated with sequence-color, rs(300) =.483, p<.001.
ASMR. A remarkable finding in our study was the high incidence of reports on particularly
pleasant responses to listening to sounds. The question described ASMR, a relatively unknown
condition in which particular sounds or sights elicit particular pleasant feelings, as euphoric,
relaxing, and involving tingling sensations on the skin. So far, only one scientific publication
has studied this phenomenon (Barrat & Davis, 2015). Despite this being an unknown condition,
almost half (49%) of the participants reported recognizing these phenomena. This shows that for
half of the participants, experiencing emotions in response to particular sounds extends beyond
their misophonia. This was also suggested by the finding that 30% of the participants reported
“compulsive listening to specific sounds.”
To further study these phenomena, we examined severity of misophonic symptoms for partici-
pants with versus without ASMR symptoms. This showed no significant relationship for MAS-1
and A-MISO-S and only a weak and nonsignificant relationship with MPRIS, X2(1, N=301) =
3.08, p=.079. Note that these questionnaires asked the severity of emotional responses in only
one direction–how negative or disturbing the symptoms are. It seems that ASMR adds positive
emotions to the scale of sound-induced emotions but does not significantly decrease the negative
effects of misophonia.
The conditions of ASMR, misophonia, and the “other” (sound) types of synesthesia might
be related to each other, as indicated by the high presence of ASMR and “other” (sound) types
of synesthesia in this group of misophonics. Furthermore, the presence of ASMR also correlates
with reporting “other” synesthesia, rs(301) =– .232, p<.001. Note, however, that given the
relative unfamiliarity of the conditions this needs to be further studied. Furthermore, the use of
20 Journal of Clinical Psychology, xxxx 2017
only one question to probe ASMR makes it more vulnerable for possible false positives or false
negatives in its measurement.
As a final note, all nonparametric tests were also performed as one-way analyses of variance
to see if this would change any of the conclusions. It did not change reported significance for
any of the results.
Discussion
Currently, much is still unknown about the features and underlying mechanisms of misophonia.
In the current project, we examined which patterns emerge when we examine the characteristics
of misophonic individuals and misophonic complaints in a large group of participants. We
examined the (severity of) misophonic symptoms and the reported comorbidity with other
clinical, psychological, or psychiatric conditions, and we also explored the relationship between
misophonia and other cognitive, auditory, or emotional characteristics.
Our participants differed in the nature and severity of their misophonic complaints, ranging
from minimal discomfort and no fight or flight response to full panic/rage response and violent
behavior toward others or self (self-harming). A large portion of the participants rated, on the
severity assessment scales, the level of their complaints as “moderate.” For a substantial group
of participants, however, the misophonic responses to sounds are experienced as extreme and
severely disturbing. These participants exemplify the significance (and thereby the relevance)
of understanding this condition. They reported misophonic responses that have a devastating
effect on their life. Our results thus showed a large range in misophonic complaints.
Furthermore, the reported severity of the complaints was not normally distributed. A study
of a large group of undergraduate students by Wu et al. (2014) showed that 20% of the students
had at least “moderate sound sensitivities” that cause “significant interference” (minimally 7
on a scale from 1 to 15). The group reported by Schr¨
oder et al. (2013) had an average score
of “severe” (15 out of 24). Jastreboff and Jastreboff (2014) note that Schr ¨
oder et al. (2013)
studied a population of psychiatric patients who happened to have misophonia as well, and
they noted that, in their own clinical work, it was very rare to find misophonic patients that
exhibit psychiatric problems. In our results, there is no normal distribution of the misophonic
complaints. Therefore, in terms of severity of symptoms our results show that misophonics are
not necessarily a unitary or homogeneous group.
Furthermore (see below), misophonics differed in terms of comorbidity with other conditions.
This suggests that there might be heterogeneity in the nature and in the mechanisms involved in
misophonia. Our study is particularly fit to find these individual differences within the group,
as we recruited a large and diverse group of participants (including different nationalities and
different age groups), because a large group of participants with different backgrounds were
recruited.
Much is still unknown about the developmental pattern, cause, and pathogenesis of miso-
phonia. We have learned, however, that there are patterns in the reported onset of misophonic
problems (similar findings were obtained in different groups of misophonics). The majority of
our participants, reported that the onset of their misophonic problems was in childhood or in
early teenage years. This is in accordance reports of misophonics found in a large group of un-
dergraduate students (mean age of onset 12: Kumar et al., 2014) and in a group of misophonics
recruited in a psychiatric setting (mean age of onset 13: Schr ¨
oder et al., 2013). While the results
rely on self-report and are an estimation rather than a precise indication, a consistent pattern of
results is obtained.
The misophonic reports also show a contrast with the condition synesthesia, where subjects
normally report that they have had their unusual (synesthetic) experiences for as long as they
can remember (Sagiv, Simner, Collins, Butterworth, & Ward, 2006; Dixon, Smilek, Cudahy, &
Merikle, 2000). In our study, a very large number of subjects have memories of misophonic
episodes in childhood, suggesting that misophonia typically is already present in childhood.
Participants often shared lively memories of misophonic episodes in childhood. This may sug-
gest that the characteristics of their family setting may be important in understanding the
development of misophonia (Johnson et al., 2013b).
ALarge-ScaleStudyofMisophonia 21
Future studies can inform us about misophonia “running in the family.” We found that one
third of the participants in our study knew of family members with similar symptoms. This might
suggest a genetic predisposition for misophonia; but given our dependence on self-report, this
needs to be further studied. A search for genetic links would be interesting and could also include
an examination of the gender bias obtained in this study. The gender bias might, however, also
merely reflect a gender difference in self-referral, as has previously been observed in synesthesia
(Simner et al., 2006; Rouw et al., 2016). Another question is why females, compared with males,
reported more severe misophonic symptoms.
Most (more than three-quarters) of the participants indicated that their misophonic symptoms
have worsened over time. Some participants indicate that their symptoms have worsened a lot.
Our findings are in line with the misophonic case studies, reporting a worsening of symptoms
over time (Kluckow et al., 2014). We did not test children, and therefore, cannot examine if this
implies that the symptoms are worse in adults than in children or if older children have worse
symptoms than younger children. It does indicate, however, that our participants do not have a
general effect of habituation to their trigger sounds.
Dozier (2015b) provides a theoretical framework for these reports of progressive worsening,
by pointing out that angry feelings typically increase tension in skeletal muscles. Such increased
tension would in turn enhance the physical response to the trigger stimulus. This way, prolonged
or repeated exposure to the trigger sounds would create a self-strengthening situation rather than
extinction of the misophonic response. It would be informative to examine the development of
misophonic symptoms in a longitudinal study. Furthermore, an interesting link is suggested with
aphysicalstressresponse;wewillreturntotherelationshipbetweenmisophoniccomplaintsand
physical (stress) response below.
Comorbidity with other conditions
Participants were asked about comorbidity with clinical, psychological, psychiatric, neurologi-
cal, or hearing conditions. The relationship can tell us something about the mechanisms involved
in misophonia: Is it an independent condition, completely unrelated to another disease or con-
dition? Is it associated with other conditions but only in a way of sharing symptoms? Is it
associated in terms of interactions in underlying pathology? Or can we find evidence for a more
extreme interpretation of comorbidity, stating that misophonia is actually only the symptomatic
manifestation of another, “real” disorder?
To start with the last of these viewpoints, our results do not support the presence of another
condition or disorder as the “real” underlying cause of the misophonic symptoms. No other
condition was sufficiently present in our group of misophonic participants to explain away
the misophonia. Half of the participant group did not report any of the inquired conditions,
reporting instead to have no additional condition at all. The other half of the participant group
did report other conditions, but they did not report one condition or disorder in particular;
instead, these misophonics were highly heterogeneous in their responses.
We examined if there is a relationship between (previous or current) eating disorder and
misophonia (Kluckow et al., 2014) because eating (slurping, smacking) noises are the most
common misophonic triggers (Wu et al., 2014; Schr¨
oder et al., 2013; Edelstein et al., 2013). Only
a small number of misophonics reported to have (had) eating disorders, and the presence of
an eating disorder (bulimia, anorexia nervosa or another eating disorder) did not significantly
increase the severity of misophonic complaints. Although eating disorders for some participants
might be a factor interacting with their misophonia, our results do not suggest that eating
disorder is a general underlying principle explaining the condition.
Is misophonia related to any other clinical, psychological, or psychiatric conditions? Because
it is difficult to make very precise calculations on prevalence in this study (see the Limitations
section), we did not base our conclusions on prevalence. Instead, as a first step we simply
examined if a condition was, or was not, present in this group of misophonic participants.
The possible relationship with misophonia was then further explored by examining if a con-
dition showed a relationship to the severity of misophonic complaints. This analysis gave two
results.
22 Journal of Clinical Psychology, xxxx 2017
First, participants without other conditions report less severe misophonic complaints. This in-
dicates that comorbidity with other conditions or diseases is related to an increase in the severity
of misophonic complaints. This finding is in line with previous studies noting shared pathol-
ogy between misophonia and other diseases, such as anorexia nervosa and OCD (Kluckow
et al., 2014); general sensory sensitivities, obsessive-compulsive symptoms, anxiety, and de-
pressive symptoms (Wu et al., 2014); or OCPD (Schr¨
oder et al., 2013). These findings of
comorbidity are however not necessarily pertaining specifically to the misophonic condition.
Shared pathology and comorbidity is often observed in medical conditions, but unfortu-
nately it is still poorly understood (Cramer, Waldorp, van der Maas, & Borsboom, 2010;
Kessler 1994; Krueger & Markon, 2006; Friborg, Martinussen, Kaiser, Øverg˚
ard, & Rosenvinge,
2013). Second, we found a relationship between severity of the misophonic symptoms, and
PTSD.
Relationship with PTSD. Participants with PTSD showed increased severity of miso-
phonic symptoms, on all misophonia measurement scales. This was not merely a general re-
sponse bias (subjects reporting one condition are also likely to report increased strength of
another condition) because the severity of misophonic symptoms was not found related to
any other relevant condition, such as depression, anxiety-related disorders, OCPD, or selective
mutism. A relationship between PTSD and misophonia has been described in a case study by
Dozier (2014), presenting a man with misophonia who was diagnosed with PTSD. He developed
misophonia while serving in the Marines in Afghanistan. The misophonic triggers did not elicit
PTSD responses, but instead the reverse was proposed (a causal relationship between PTSD and
the development of misophonia).
One of the diagnostic criteria of PTSD is alterations in arousal and reactivity (DSM-V).
This arousal characteristic of PTSD has similarities with the physical aspect of misophonia,
as misophonic sufferers often report physical tension as part of their misophonic response. In
our study, 90% of the participants recognized a physical response of “clenched/tightened/tense
muscles” as characteristic for their misophonia. In a previous skin conductance response study
(Edelstein et al., 2013), misophonic stimuli were found to be physiologically arousing. These
findings suggest that in order to understand misophonia, it is important to understand the role
of the physical stress response (as well as the emotional response; Dozier, 2015b).
The findings do not address the origin of this physical response, in particular whether or
not it is a conditioned response (Dozier, 2015a). Similarly, note that we do not suggest that
PTSD as a condition explains the existence of misophonic complaints. The great majority of our
participants do not report PTSD (in line with Schr¨
oder et al. 2013, who used clinical diagnostic
criteria). The results are, however, in line with the possible role of self-strengthening of the
misophonic response through increased physical (muscle) tension. We found reports of increase
in the severity of misophonic complaints in combination with PTSD as well as reports by almost
all misophonics of a physical (muscle) response as part of their misophonia. This is an important
topic for follow-up research.
Relationship with ASMR
Our findings are in line with the hypothesized relationship between misophonia and ASMR.
A remarkably large subgroup of misophonic participants recognized the description of ASMR
(Barratt & Davis, 2015). Currently, there are no clear “diagnostic” criteria, and very little is
known about the condition of ASMR. Still, half of our participants recognized the description
of pleasurable, tingling sensations, indicating that for them, unusual emotional responses to
particular (sound) sensations extends beyond their misophonia. An important question for
follow-up studies is whether the mechanisms involved in the abnormal negative emotional
responses with particular trigger sounds (the fight-or-flight response typical for misophonia)
also make misophonics more susceptible to abnormal positive emotional responses to sounds
(the relaxing and tingling sensations typical for ASMR).
This suggestion is particularly interesting in light of the recent findings by Kumar et al.
(2017). This study showed that the abnormal salience attributed to particular sounds is related
ALarge-ScaleStudyofMisophonia 23
to abnormal activation and functional connectivity patterns of the anterior insula cortex (AIC).
The hyperactivation of this brain region was moreover found to mediate the autonomic responses
in misophonia. Furthermore, questionnaire scores showed higher interoceptive sensibility in
misophonics than in controls, consistent with abnormal functioning of the AIC. Overall, these
obtained mechanisms could help explain the abnormal interactions between sensory processes
(abnormal salience attributed to particular sounds) and emotional processes.
The unusual responses to particular stimuli as obtained in ASMR and misophonia is akin to
synesthesia. In all of these conditions, a certain stimulus will evoke a particular and additional
response that cannot clearly be traced back to the stimulus properties. While the relationships be-
tween these conditions are still elusive, the similarity in symptoms allows to generate hypotheses
about the misophonic condition. A decade of research has provided knowledge on the mecha-
nisms involved in the unusual cross-sensations in synesthesia as well as its underlying functional
and structural brain properties (Rouw, Scholte, & Colizoli, 2011). This knowledge can be used
in formulating hypotheses about the neurological mechanisms involved in misophonia.
In particular, can increased structural connectivity be obtained between inducer and con-
current structures (in the case of misophonia, particular limbic and sensory structures), as has
been previously obtained in synesthetes (Rouw & Scholte, 2007)? Second, in synesthesia, a role
of “higher” brain areas, in particular the parietal cortex, is crucially involved in synesthesia.
The explanation is that parietal mechanisms underlie the general tendency to “bind” the dif-
ferent sensations together. Just as new models of synesthesia integrate these two main findings
into “two-stage” models (Hubbard, Brang, & Ramachandran, 2011), a model on misopho-
nia needs to integrate both the specific sensory characteristics of the (“triggers”-to-response)
associations, and the general or “higher order” processes underlying the tendency for unusual
“binding” between different sensory and emotional modalities. The latter higher order processes
are furthermore relevant in explaining how the interpretation and context of trigger sounds will
influence the misophonic responses.
Finally, we did not find that the obtained influences and relevant characteristics of misophonia
themselves correlate. For example, we did not find a correlation indicating that in one group of
participants the misophonia might have been caused by trauma (as indicated by the presence
of PTSD), while another group has misophonia “running in the family.” Similarly, the presence
of ASMR is independent on the participant’s reports on PTSD. This divergence of influencing
factors is in line with the findings of Wu et al. (2014). Moderate relationships led these authors
to conclude that misophonia may be related to multiple forms of psychopathology, through
either direct or associative relationships. Webber and Storch (2015) point to the relevance of
understanding such heterogeneity for the treatment of misophonia because variation (e.g., in
symptom presentation) suggests that there may not be a “one size fits all” treatment.
Limitations. While the online test has succeeded in recruiting a large sample of misophonic
participants, the approach does entail limitations. The most important is that the data rely on
self-report. Subjects were recruited online, and they participated based on their own interest in
helping out in a study on this topic. Self-report is not a reliable diagnostic measure, and none
of our results should be interpreted or perceived as clinical reports. In particular, asking about
comorbidity will likely lead to overrepresentation of conditions if participants are asked which
diagnosis they have received, compared with diagnosing the participants during the experiment
and in a clinical setting. In our method, the diagnostic criteria are less strict, plus diagnoses from
the past will also be reported in the self-report. Perhaps (but this seems less likely in a group that
voluntarily came forward to talk about their misophonic disease) there is also a tendency to not
report diseases. For these reasons, we treat the current study as an examination of associations,
but not as a prevalence study.
Rather than analyzing absolute measures of prevalence, we looked at the reported symptoms,
characteristics, and conditions as they compared with each other within this group. The ratio-
nale is that it is not likely that the participants would selectively remain completely silent on one
condition while reporting on other conditions. Furthermore, even if participants tend to under-
report a particular condition, only a small number of subjects reporting a condition is sufficient
to include in our analyses. Next, we performed a separate analysis that is independent of this
24 Journal of Clinical Psychology, xxxx 2017
issue, namely, correlating the comorbid condition to the reported severity of misophonic con-
ditions. Further investigations on prevalence numbers would be an interesting topic for future
studies, but preferably these should take place in a clinical setting. Furthermore, any prevalence
study still needs a large number of participants.
The use of self-report is also a limitation for all other collected responses. It is likely that
not all answers are complete or sufficiently specific, and perhaps some answers are simply not
true. This means that in our study, any single answer cannot be given a lot of weight. Instead,
the large number of participants should balance these types of effects out, as “noise” in the
measurements. This method of dealing with incorrect or imprecise responses does not hold,
however, when there is a particular direction or bias in the responses. Whenever we thought this
could influence the results, the effects were presented and the implications were discussed. An
important example is the possibility that female overrepresentation is in fact a female bias in
self-report. Female overrepresentation may disappear in studies avoiding self-report bias, as has
been previously found in synesthesia research (Simner & Carmichael, 2015; Rouw & Scholte,
2016).
Currently, little is known about mechanisms involved in misophonia. This study has generated
new hypotheses about the underlying mechanisms and explored patterns of influences on the
condition. As in all psychological research, only replication in other studies will provide more
definite answers. As a final note, this is not a developmental study or a longitudinal study.
The results do not allow conclusions about causality. While it is possible to speculate about
underlying mechanisms in the discussion, the results themselves are presented as “associations”
and thus without any causal connotation.
Conclusion
We started this article with three fundamental questions about the mechanisms of misophonia:
Can everybody develop misophonia or are there particular vulnerabilities or predispositions?
How is misophonia related to other diseases or conditions (is misophonia a separate and in-
dependent disorder)? And, third, how specific are the mechanisms involved in misophonia; are
misophonics different only in their trigger-to-response reactions, or do misophonics diverge in
general (e.g., cognitive or emotional) mechanisms as well? First, our results suggest that cer-
tain personal and environmental characteristics can influence the susceptibility to misophonia
as well as the severity of the misophonic response. These characteristics include current age,
gender, family characteristics during development, and the capacity to avoid the misophonia
getting worse over time (e.g., avoid repeated exposure to the trigger sounds). Most misophonics
reported knowing family members with similar complaints. This suggestion that misophonia
might be “running in the family” warrants further investigation.
As for the second fundamental question, current findings support the view that misophonia
is a separate and independent condition. While we found less severe misophonic complaints
in the absence of any other psychiatric, clinical or psychological condition, the pattern of
co-occurrences with other diseases or conditions showed that not one of the psychological,
clinical, or psychiatric conditions could serve as an alternative explanation for the misophonic
complaints. Furthermore, the reported presence or absence of another condition did not affect
the (severity of) misophonic symptoms. There was only one exception to this rule, as the severity
of the misophonic symptoms was found related to PTSD. Misophonics also tend to indicate
abnormal physical stress responses in relation to their misophonia. These findings provide
interesting suggestions for future research; in particular, how an anomaly in the physical stress
response system could be related to (the severity of) misophonic complaints.
In terms of the third question, the misophonia is specific in that no general cognitive or
emotional effects were found to underlie or explain the condition. Yet the mechanisms at play in
misophonia are larger than just the specific trigger-to-response associations. A recently published
neuroimaging study explains misophonia as an abnormal salience attributed to sounds coupled
with atypical perception of internal body states (Kumar et al., 2017). Interestingly, we found that
half of our misophonics recognize a description of ASMR, in which particular stimuli (often
man-made sounds such as whispering) evoke disproportionately pleasant, relaxing, or tingling
ALarge-ScaleStudyofMisophonia 25
sensations. This raises an interesting question on the proposed misophonic mechanisms: Does
the abnormal salience to stimuli and altered perception of body states also allow strongly
enhanced positive emotional and physical responses to particular sounds?
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... However, compared to a general population prevalence rate of 4.4% (Simner et al., 2006), the prevalence of synesthesia in their ASMR sample was only marginally higher (p = 0.06). Rouw and Erfanian (2018) found a significant correlation between ASMR and reporting "other" self-described types of synesthesia, but no relationship between ASMR and reporting sequence-color, sequence-shape, or hearing-color subtypes. The existing evidence, therefore, appears to show only a weak link between ASMR and (some types of) synesthesia. ...
... Such a comparison will produce different conclusions depending on the comparison rate chosen. Synesthesia prevalence rates are highly variable with some far higher than 4.4% (Chun and Hupé, 2013;Rouw and Scholte, 2016;Rouw and Erfanian, 2018) and others much lower (Baron-Cohen et al., 1996). Direct comparisons to previous prevalence rates are also challenging because they may differ from the study in the types of synesthesia captured, the assessment methods used, and how inclusion criteria are set and applied [see Table 1 in Johnson et al. (2013)]. ...
... ASMR has been likened to synesthesia, with parallels between the two inferred by their similar phenomenology and neurocognitive profiles. However, empirical evidence directly linking ASMR with synesthesia is sparse and appears to show only a weak link between ASMR and some types of synesthesia (Barratt and Davis, 2015;Rouw and Erfanian, 2018). In this study, we examined, for the first time, whether the prevalence of synesthesia is indeed significantly higher in ASMR-responders compared to non-responders. ...
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Autonomous sensory meridian response (ASMR) is a complex sensory-emotional experience characterized by pleasant tingling sensations initiating at the scalp. ASMR is triggered in some people (called ASMR-responders) by stimuli including whispering, personal attention, and crisp sounds (termed ASMR triggers). Since its inception, ASMR has been likened to synesthesia, but convincing empirical data directly linking ASMR with synesthesia is lacking. In this study, we examined whether the prevalence of synesthesia is indeed significantly higher in ASMR-responders than non-responders. A sample of working adults and students ( N = 648) were surveyed about their experience with ASMR and common types of synesthesia. The proportion of synesthetes who were classified as ASMR-responders was 52%, whereas 22% of ASMR-responders were also synesthetes. These results suggest that: (1) over half of those identifying as synesthetes also experience ASMR, and (2) that synesthesia is up to four times as common among ASMR-responders as among non-responders (22% vs. 5%). Findings also suggest a prevalence rate for ASMR of approximately 20%. Overall, the co-occurrence of ASMR and synesthesia lends empirical support to the idea that ASMR may be driven by synesthetic mechanisms, but future research would benefit from examining how ASMR and synesthesia are different, as well as similar.
... In contrast, though one of the criteria for post-traumatic stress disorder is the experience of an exaggerated startle reflex, larger psychophysiologically assessed startle reflex magnitude is not uniquely associated with post-traumatic stress disorder diagnoses (Pole, 2007) and could be associated with other diagnoses instead, like misophonia. The extent to which these disorders-along with such other disorders as obsessive compulsive disorders, personality disorders, and anxiety disorders-are comorbid with misophonia is unclear (Ferreira et al., 2013;Brout et al., 2018;Rouw and Erfanian, 2018;Erfanian et al., 2019). ...
... Individuals who experience misophonia typically report symptoms starting from a very young age and/or for as long as they can remember. In a sample of 301 misophonic patients above the age of 18, Rouw and Erfanian (2018) found that 45% of these patients reported onset of misophonic experiences during childhood, 30% during adolescence, and 15% for "as long as I can remember." In retrospective studies, most individuals reported that their misophonia symptoms emerged during childhood or adolescence (for a review, see Potgieter et al., 2019), with some reported symptoms not emerging until young adulthood (Boyce, 2015;Tunç and Başbug, 2017), or emerging at any point throughout the life span (Zhou et al., 2017;Sanchez and Silva, 2018). ...
... How misophonia develops is currently unclear (Schröder et al., 2017;Rouw and Erfanian, 2018;Lewin et al., 2021). One study found that 77% of participants self-reported symptoms worsening with age , whereas another study found a negative association between age and misophonia severity (Vitoratou et al., 2021). ...
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Misophonia can be characterized both as a condition and as a negative affective experience. Misophonia is described as feeling irritation or disgust in response to hearing certain sounds, such as eating, drinking, gulping, and breathing. Although the earliest misophonic experiences are often described as occurring during childhood, relatively little is known about the developmental pathways that lead to individual variation in these experiences. This literature review discusses evidence of misophonic reactions during childhood and explores the possibility that early heightened sensitivities to both positive and negative sounds, such as to music, might indicate a vulnerability for misophonia and misophonic reactions. We will review when misophonia may develop, how it is distinguished from other auditory conditions (e.g., hyperacusis, phonophobia, or tinnitus), and how it relates to developmental disorders (e.g., autism spectrum disorder or Williams syndrome). Finally, we explore the possibility that children with heightened musicality could be more likely to experience misophonic reactions and develop misophonia.
... Misophonia may overlap with other auditory conditions such as tinnitus, hyperacusis (Aazh et al., 2019), autonomous sensory meridian response (ASMR; McErlean and Banissy, 2018;Palumbo et al., 2018;Rouw and Erfanian, 2018), or with psychiatric conditions (Quek et al., 2018;Swedo et al., 2021). One study found a 52.4% overlap with obsessive compulsive personality disorder (OCPD; Cavanna and Seri, 2015) while in other samples this overlap was lower (26%; Jager et al., 2020). ...
... One study found a 52.4% overlap with obsessive compulsive personality disorder (OCPD; Cavanna and Seri, 2015) while in other samples this overlap was lower (26%; Jager et al., 2020). Other typical comorbidities are mood disorders (10-48%; Erfanian et al., 2019;Claiborn et al., 2020;Jager et al., 2020), attention deficit and hyperactivity disorder (ADHD; 12%), post-traumatic stress disorder (PTSD; 12-15%; Rouw and Erfanian, 2018;Erfanian et al., 2019;Claiborn et al., 2020), and obsessive compulsive disorder (OCD; 15-21%; Erfanian et al., 2019;Claiborn et al., 2020). Comorbidities with eating disorders have also been reported (10% in one study; Erfanian et al., 2019). ...
... Our review is restricted to psychiatric comorbidities because the solutions proposed for neuroscience-based interventions were primarily developed for psychiatric conditions. We focus on OCPD/OCD, mood disorders, ADHD, and PTSD because several papers have supported their co-occurrence with misophonia, and the rates of overlap appear to be over 10% (Cavanna and Seri, 2015;Quek et al., 2018;Rouw and Erfanian, 2018;Erfanian et al., 2019;Claiborn et al., 2020;Jager et al., 2020;Swedo et al., 2021). Other comorbidities may also occur and have relevance to the neurobiology of misophonia. ...
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Decreased tolerance in response to specific every-day sounds (misophonia) is a serious, debilitating disorder that is gaining rapid recognition within the mental health community. Emerging research findings suggest that misophonia may have a unique neural signature. Specifically, when examining responses to misophonic trigger sounds, differences emerge at a physiological and neural level from potentially overlapping psychopathologies. While these findings are preliminary and in need of replication, they support the hypothesis that misophonia is a unique disorder. In this theoretical paper, we begin by reviewing the candidate networks that may be at play in this complex disorder (e.g., regulatory, sensory, and auditory). We then summarize current neuroimaging findings in misophonia and present areas of overlap and divergence from other mental health disorders that are hypothesized to co-occur with misophonia (e.g., obsessive compulsive disorder). Future studies needed to further our understanding of the neuroscience of misophonia will also be discussed. Next, we introduce the potential of neurostimulation as a tool to treat neural dysfunction in misophonia. We describe how neurostimulation research has led to novel interventions in psychiatric disorders, targeting regions that may also be relevant to misophonia. The paper is concluded by presenting several options for how neurostimulation interventions for misophonia could be crafted.
... Anger has also been reported in both qualitative and quantitative studies of misophonia (Edelstein et al., 2013;Schröder et al., 2013;Wu et al., 2014;McKay et al., 2018;Rouw and Erfanian, 2018;Jager et al., 2020) and has been shown to be experienced to a larger degree in those who score higher in comparison to those who score lower on the Sound Sensitivity subscale of the MQ (McKay et al., 2018). This suggests there is more consistent evidence for the role of anger in the experience of misophonia. ...
... This suggests there is more consistent evidence for the role of anger in the experience of misophonia. Disgust is another emotion reported by some studies to be associated with misophonia (Edelstein et al., 2013;Schröder et al., 2013;Rouw and Erfanian, 2018); however, one study found that disgust was not associated with misophonia (Jager et al., 2020). Further research is therefore needed to examine this lack of clarity around the emotions that are important in the experience of misophonia, to contribute to our understanding of misophonia and to inform treatment options. ...
... Finally, our sample reported no change in misophonic scores over time, which contradicts findings from other studies where participants have reported perceived changes over time (Bernstein et al., 2013;Edelstein et al., 2013;Kluckow et al., 2014;Rouw and Erfanian, 2018). However, this may be due to differences in measurement as some studies ask participants about their perceptions of change, whereas in this study we did not ask about perceived change, but instead measured the misophonic response at two different time points. ...
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Aims This longitudinal study examined the role of anger, disgust, and anxiety in the experience of misophonia, the quality of life of those with self-reported misophonia in comparison to those without misophonia, and the association of misophonia and quality of life over time. Methods An online longitudinal survey was conducted, with misophonia, anger, disgust, anxiety, depression, self-esteem, and quality of life measured at two time points (6-months apart) in two groups of people (those with self-reported misophonia and those without misophonia). Results Anger and disgust emerged as the primary predictors of misophonic responses. Anxiety and depression were not significantly associated with misophonia over time. Differences in quality of life were observed between those with and without self-reported misophonia in the current study, with lower scores across the SF-36 domains of role limitations due to emotional problems, energy/fatigue, emotional wellbeing, social functioning, and general health for those with misophonia compared to those without misophonia. Compared with other studies, scores for those with self-reported misophonia were lower than those with long-term physical conditions, similar to those with tinnitus, but higher than those with obsessive compulsive disorder. Misophonia was predictive of quality of life over time but only on two domains: role limitations due to emotional problems (predictors: avoidance, emotional responses, and impact on participation in life) and pain (predictor: impact on participation in life). Depression remained a strong predictor of quality of life over time. Conclusion Anger and disgust are more strongly associated with the experience of misophonia than anxiety. Quality of life in people with self-reported misophonia is lower than in the general population and may be similar to those with tinnitus. Depression, avoiding triggers, the extent of the emotional response, and perceived impact on participation in life are associated with perceptions of lower quality of life over time for people with self-reported misophonia.
... It has been commonly reported that primary feelings such as anger and disgust are experienced (Edelstein et al., 2013;Schröder et al., 2013;Kumar et al., 2017;Jager et al., 2020), alongside unpleasant physiological changes, including an increased heart rate, muscle tension, pain and sweating (Edelstein et al., 2013;Johnson et al., 2013). Misophonia can have a significant impact on a person's social and occupational functioning (Schröder et al., 2013;Rouw and Erfanian, 2018). Avoidance behaviours, social withdrawal (Johnson et al., 2013;Schneider and Arch, 2015;Hocaoglu, 2018;Muller et al., 2018;Singer, 2018;Alekri and Al Saif, 2019) and, for some, aggression (Reid et al., 2016;Hocaoglu, 2018;Alekri and Al Saif, 2019;Jager et al., 2020) are also frequently reported. ...
... The MQ contains two factors: sensitivity to sounds compared to other people, as well as emotional and behavioural responses to those sounds. It does not capture some of the other aspects of misophonia reported in the literature, such as loss of control (Jager et al., 2020) and appraisals of oneself (Rouw and Erfanian, 2018) and of others (Edelstein et al., 2013). ...
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Misophonia is a disorder generally characterised by a decreased tolerance to everyday sounds. Although research is increasing in misophonia, a cross-cultural validation of a psychometric tool for measuring misophonia has not been evaluated. This study investigated the validity of the S-Five multidimensional model of the misophonic experience in a sample of Chinese participants. The S-Five was translated in a forward-backward method to Mandarin to establish a satisfactory translation. The translation was also independently back translated to English, with no significant differences when compared to the original S-Five. Through exploratory factor analysis, using responses from 256 Chinese individuals, the five dimensions (internalising appraisals, externalising appraisals, perceived threat and avoidance behaviour, outbursts, and impact on functioning) were replicated, indicating the cross-cultural uniformity of the experience of misophonia as captured by the S-Five. That is, current results point to the stability of the manifestation of misophonia across cultures, seen here for the first time in the literature. By design, the S-Five items were developed to reflect sound sensitivities in a manner that is not specific or matching to individuals of a certain age, gender, ethnicity, nationality, socio-economic status, and educational level. Testimonial to this fact is not only the replication of the five factors, but also the replication of the evidence towards satisfactory psychometric properties (reliability and validity) of the scale. Based on the results of this study, the S-Five is a psychometrically robust tool to be used within the Chinese population.
... Even with these comorbidities, it is unlikely misophonia can be fully explained by an underlying psychological disorder (Schröder et al., 2013;Rouw and Erfanian, 2018). However, the emotional regulation and dysregulation associated with psychiatric disorders have been found to mediate trigger responses (Cassiello-Robbins et al., 2020). ...
... Existing research suggests that misophonic trigger responses are susceptible to contextual factors, such as the meaning tied to the sound, social control, or social relationships (Schröder et al., 2013;Rouw and Erfanian, 2018). Our stimuli lacked social contexts and, more specifically, any necessary or imposed interactions between the participant and the producer of the sound. ...
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Misophonia has been characterized as intense negative reactions to specific trigger sounds (often orofacial sounds like chewing, sniffling, or slurping). However, recent research suggests high-level, contextual, and multisensory factors are also involved. We recently demonstrated that neurotypicals’ negative reactions to aversive sounds (e.g., nails scratching a chalkboard) are attenuated when the sounds are synced with positive attributable video sources (PAVS; e.g., tearing a piece of paper). To assess whether this effect generalizes to misophonic triggers, we developed a Sound-Swapped Video (SSV) database for use in misophonia research. In Study 1, we created a set of 39 video clips depicting common trigger sounds (original video sources, OVS) and a corresponding set of 39 PAVS temporally synchronized with the OVS videos. In Study 2, participants (N = 34) rated the 39 PAVS videos for their audiovisual match and pleasantness. We selected the 20 PAVS videos with best match scores for use in Study 3. In Study 3, a new group of participants (n = 102) observed the 20 selected PAVS and 20 corresponding OVS and judged the pleasantness or unpleasantness of each sound in the two contexts accompanying each video. Afterward, participants completed the Misophonia Questionnaire (MQ). The results of Study 3 show a robust attenuating effect of PAVS videos on the reported unpleasantness of trigger sounds: trigger sounds were rated as significantly less unpleasant when paired with PAVS with than OVS. Moreover, this attenuating effect was present in nearly every participant (99 out of 102) regardless of their score on the MQ. In fact, we found a moderate positive correlation between the PAVS-OVS difference and misophonia severity scores. Overall our results provide validation that the SSV database is a useful stimulus database to study how misophonic responses can be modulated by visual contexts. Here, we release the SSV database with the best 18 PAVS and 18 OVS videos used in Study 3 along with aggregate ratings of audio-video match and pleasantness (https://osf.io/3ysfh/). We also provide detailed instructions on how to produce these videos, with the hope that this database grows and improves through collaborations with the community of misophonia researchers.
... The emotion primarily associated with misophonia is anger, as opposed to the fear seen in phonophobia. Along with anger, feelings of irritation, stress, anxiety, aggravation, being trapped, and impatience can also occur [9,10]. The specific sound cue is believed to activate the right insula, right anterior cingulate cortex, and the right superior temporal cortex, resulting in the intense negative reaction experienced by the individual [11]. ...
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We report the case of a 32-year-old male with autism spectrum disorder (ASD) suffering from severe misophonia. After titrating risperidone to 2 mg twice a day, the patient reported a significant reduction in his symptoms and his Amsterdam misophonia scale-revised (AMISOS-R) score dropped by from 31 to 5. Upon discharge, the patient was noted to have decreased irritability and overall improved behavior and effect. This significant symptomatic improvement was likely not explained by inpatient admission alone or other simultaneous pharmacologic treatments, as the effect was seen during an isolated titration of risperidone with other treatments remaining constant. Although, unfortunately, follow-up findings indicated that the treatment was not curative for the patient, risperidone’s potential for treating misophonia may warrant systematic investigation.
... A consensus definition describes misophonia as a decreased sound tolerance to specific sounds or stimuli associated with the sounds, resulting in strong negative emotional, physiological, and behavioral responses not seen in other people (Swedo et al., 2021). Anecdotal reports from sufferers reveal serious daily impairments attributable to misophonia-job instability, deteriorating relationships, suicidal thoughts (Edelstein et al., 2013;Rouw and Erfanian, 2017;Swedo et al., 2021)-yet the condition is severely understudied with mechanisms vastly unknown. ...
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Misophonia, an extreme aversion to certain environmental sounds, is a highly prevalent yet understudied condition plaguing roughly 20% of the general population. Although neuroimaging research on misophonia is scant, recent work showing higher resting-state functional connectivity (rs-fMRI) between auditory cortex and orofacial motor cortex in misophonia vs. controls has led researchers to speculate that misophonia is caused by orofacial mirror neurons. Since orofacial motor cortex was defined using rs-fMRI, we attempted to theoretically replicate these findings using orofacial cortex defined by task-based fMRI instead. Further, given our recent work showing that a wide variety of sounds can be triggering (i.e., not just oral/nasal sounds), we investigated whether there is any neural evidence for misophonic aversion to non-orofacial stimuli. Sampling 19 adults with varying misophonia from the community, we collected resting state data and an fMRI task involving phoneme articulation and finger-tapping. We first defined “orofacial” cortex in each participant using rs-fMRI as done previously, producing what we call resting-state regions of interest (rsROIs). Additionally, we functionally defined regions (fROIs) representing “orofacial” or “finger” cortex using phoneme or finger-tapping activation from the fMRI task, respectively. To investigate the motor specificity of connectivity differences, we subdivided the rsROIs and fROIs into separate sensorimotor areas based on their overlap with two common atlases. We then calculated rs-fMRI between each rsROI/fROI and a priori non-sensorimotor ROIs. We found increased connectivity in mild misophonia between rsROIs and both auditory cortex and insula, theoretically replicating previous results, with differences extending across multiple sensorimotor regions. However, the orofacial task-based fROIs did not show this pattern, suggesting the “orofacial” cortex described previously was not capturing true orofacial cortex; in fact, using task-based fMRI evidence, we find no selectivity to orofacial action in these previously described “orofacial” regions. Instead, we observed higher connectivity between finger fROIs and insula in mild misophonia, demonstrating neural evidence for non-orofacial triggers. These results provide support for a neural representation of misophonia beyond merely an orofacial/motor origin, leading to important implications for the conceptualization and treatment of misophonia.
... These aversive sensory stimuli, commonly named misophonia triggers, are expressed physiologically (Edelstein et al., 2013;Johnson et al., 2013;Brout et al., 2018), severely impact daily function and social participation (Edelstein et al., 2013;Wu et al., 2014;Zhou et al., 2017;Kumar et al., 2021;Swedo et al., 2021), and are suggested to contribute to mental health difficulties (Schröder et al., 2013;Erfanian et al., 2019;Swedo et al., 2021). Indeed, misophonia has been reported to co-occur with psychiatric or neurological conditions (e.g., mental health disorders, attention deficit hyperactive disorder) (Cusack et al., 2018;McKay et al., 2018;Rouw and Erfanian, 2018;Erfanian et al., 2019;Swedo et al., 2021;Siepsiak et al., 2022), indicating that whether or not misophonia is a disorder in its own right is yet to be determined empirically (Swedo et al., 2021). Thus, research examining the nature and features of misophonia is needed to better characterize and differentiate this disorder (Swedo et al., 2021). ...
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Introduction Misophonia and sensory over-responsiveness (SOR) share physiological and psychological symptoms. While individuals with SOR demonstrate pain perception alterations, these were not explored in misophonia. Methods This exploratory study comprised thirty healthy adults with ( n = 15; based on the Misophonia Questionnaire) and without misophonia. The Sensory Responsiveness Questionnaire (SRQ) was used for evaluating sensory responsiveness. In addition, psychophysical tests were applied for quantification of: (i) stimulus-response function of painful stimuli, (ii) the individual perceived pain intensity, (iii) pain modulation efficiency, (iv) auditory intensity discrimination capability, and (v) painful and unpleasantness responses to six ecological daily sounds using the Battery of Aversiveness to Sounds (BAS). Results Individuals with misophonia reported higher scores in the SRQ-Aversive ( p = 0.022) and SRQ-Hedonic ( p = 0.029) scales as well as in auditory ( p = 0.042) and smell ( p = 0.006) sub-scales, indicating higher sensory responsiveness. Yet they were not identified with the SOR type of sensory modulation dysfunction. Groups did not differ in the pain psychophysical tests, and in auditory discrimination test scores ( p > 0.05). However, in the misophonia group the BAS evoked higher pain intensity ( p = 0.046) and unpleasantness ( p <0.001) ratings in the apple biting sound, and higher unpleasantness rating in the scraping a dish sound ( p = 0.007), compared to the comparison group. Conclusion Findings indicate increased sensory responsiveness in individuals with misophonia, yet not defined as SOR. Thus, this suggests that misophonia and SOR are two distinct conditions, differing in their behavioral responses to painful and non-painful stimuli.
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Autonomous sensory meridian response (ASMR) is a phenomenon characterised by a static-like tingling sensation spreading from the scalp and neck to the periphery in response to a variety of audio, visual, and tactile triggers resulting in a highly relaxed state and boosted positive affect. The limited literature on this phenomenon points to a potential of ASMR to alleviate pain. Emerging evidence also suggests that ASMR may be linked to increased sensory sensitivity more broadly. This study aimed to objectively address these claims by administering an algometer (measure of pain tolerance), and a visual analog scale (VAS) (measure of subjective pain sensitivity) to ASMR experiencers and controls at baseline, following an ASMR video, and a control video. Findings indicate that ASMR experiencers have a higher pain sensitivity than controls; however, there was no difference between the two groups in terms of pain tolerance. In addition, any potential analgesic properties associated with experiencing ASMR may reflect protective properties of ASMR buffering against the increased pain sensitivity among ASMR experiencers relative to controls.
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Misophonia is an affective sound-processing disorder characterized by the experience of strong negative emotions (anger and anxiety) in response to everyday sounds, such as those generated by other people eating, drinking, chewing, and breathing [1–8]. The commonplace nature of these sounds (often referred to as “trigger sounds”) makes misophonia a devastating disorder for sufferers and their families, and yet nothing is known about the underlying mechanism. Using functional and structural MRI coupled with physiological measurements, we demonstrate that misophonic subjects show specific trigger-sound-related responses in brain and body. Specifically, fMRI showed that in misophonic subjects, trigger sounds elicit greatly exaggerated blood-oxygen-level-dependent (BOLD) responses in the anterior insular cortex (AIC), a core hub of the “salience network” that is critical for perception of interoceptive signals and emotion processing. Trigger sounds in misophonics were associated with abnormal functional connectivity between AIC and a network of regions responsible for the processing and regulation of emotions, including ventromedial prefrontal cortex (vmPFC), posteromedial cortex (PMC), hippocampus, and amygdala. Trigger sounds elicited heightened heart rate (HR) and galvanic skin response (GSR) in misophonic subjects, which were mediated by AIC activity. Questionnaire analysis showed that misophonic subjects perceived their bodies differently: they scored higher on interoceptive sensibility than controls, consistent with abnormal functioning of AIC. Finally, brain structural measurements implied greater myelination within vmPFC in misophonic individuals. Overall, our results show that misophonia is a disorder in which abnormal salience is attributed to particular sounds based on the abnormal activation and functional connectivity of AIC.
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Misophonia is a condition in which a person has an acute emotional response of anger or disgust to a commonly occurring innocuous auditory or visual stimulus referred to as a trigger. This case details the effective treatment of misophonia in a young woman that included a counterconditioning treatment called the Neural Repatterning Technique (NRT), which combines a continuous positive stimulus and a reduced intensity, intermittent trigger. The treatment was delivered via the Misophonia Trigger Tamer smartphone app and all treatments were conducted independently by the patient. In this patient, the trigger elicited a physical reflex of contraction of the flexor digitorum profundus, which caused her to clench her fist. To enhance the effect of the NRT treatment, Progressive Muscle Relaxation was incorporated to increase her ability to deliberately relax the affected muscle during treatment. During NRT treatment sessions, the patient experienced a weak physical reflex to the reduced trigger stimulus but no emotional response. Her emotional response of misophonia was not treated, but when the physical reflex extinguished, the emotional response also extinguished. This case indicates that the misophonic response includes a Pavlovian-conditioned physical reflex. It is proposed that the trigger elicited the physical reflex and the physical reflex then elicited the conditioned emotional response that is characteristic of misophonia. Because of the conditioned reflex nature of misophonia, it is proposed that a more appropriate name for this disorder would be Conditioned Aversive Reflex Disorder.
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Objective: To explore the condition of misophonia, its definition, possible neurological correlates, its associated morbidity, its possible psychiatric relevance and potential treatment. Method: Provision of an illustrative case vignette and a review of the limited literature. Results: Misophonia is a symptom associated with obsessive-compulsive disorder and anxiety disorders and may be a syndrome in itself associated with significant distress and avoidance. Treatments are not well validated. Conclusion: Misophonia may be an under-recognised condition of psychiatric relevance.
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Misophonia is characterized by a negative reaction to a sound with a specific pattern and meaning to a given individual. In this paper, we review the clinical features of this relatively common yet underinvestigated condition, with focus on co-occurring neurodevelopmental disorders. Currently available data on the putative pathophysiology of the condition can inform our understanding and guide the diagnostic process and treatment approach. Tinnitus retraining therapy and cognitive behavior therapy have been proposed as the most effective treatment strategies for reducing symptoms; however, current treatment algorithms should be validated in large population studies. At the present stage, competing paradigms see misophonia as a physiological state potentially inducible in any subject, an idiopathic condition (which can present with comorbid psychiatric disorders), or a symptomatic manifestation of an underlying psychiatric disorder. Agreement on the use of standardized diagnostic criteria would be an important step forward in terms of both clinical practice and scientific inquiry. Areas for future research include phenomenology, epidemiology, modulating factors, neurophysiological underpinnings, and treatment trials.
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Misophonia is an impairing syndrome with typical onset during childhood and is characterized by extreme sound sensitivities to selective auditory stimuli that elicit avoidance, anxiety, irritability, and/or outbursts. To date, there exists only 1 case report of cognitive-behavioral therapy (CBT) and no published information on pharmacologic intervention for misophonia. Although Bernstein et al demonstrated that misophonia-related symptoms could be managed with CBT when triggers are encountered, they did not objectively measure misophonia symptom improvement. © Copyright 2015 Physicians Postgraduate Press, Inc.