Disgust and Emotion Dysregulation in Misophonia: a Case for Mental Contamination?

Abstract

The aim of the present study was to investigate whether dispositional disgust sensitivity and affective styles are associated with features of misophonia and whether emotion dysregulation plays a role in this relationship. We anticipated disgust sensitivity and emotion dysregulation to be vulnerability factors for the emotional distress and behavioral reactions seen in misophonia. A sample of 334 adults (223 females, 104 males, and 7 non-binary individuals) ranging in age from 18 to 65 years were recruited through online social media websites and completed an online battery of scales that consisted of the Disgust Scale-Revised, the Difficulties in Emotion Regulation Scale-Short Form, the Affective Styles Questionnaire, and the New York Misophonia Scale. Significant correlations were obtained among the study variables. Results of mediation analysis indicated that disgust sensitivity has both direct and indirect effects on misophonic distress but only indirect effects on behavioral reactions in misophonia. The affective styles adjusting and tolerating had only indirect effects on misophonia symptomology. While emotion dysregulation partially mediated the relationship between disgust sensitivity and misophonic distress, it completely mediated the relationship between disgust sensitivity and misophonic behavioral reactions. These findings imply that the aggressive and avoidance reactions in misophonia may be a consequence of emotional dysregulation while misophonic distress may be a reflection of mental contamination associated with dispositional disgust sensitivity. Findings of the study have theoretical and clinical implications. Interventions focusing on disgust sensitivity reduction may benefit individuals with misophonia.

Full text

Vol.:(0123456789)
International Journal of Mental Health and Addiction
https://doi.org/10.1007/s11469-021-00677-x
1 3
ORIGINAL ARTICLE
Disgust andEmotion Dysregulation inMisophonia: aCase
forMental Contamination?
UshaBarahmand1 · MariaE.Stalias‑Mantzikos1,2 · EstherRotlevi1 ·
YingXiang1
Accepted: 8 October 2021
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021
Abstract
The aim of the present study was to investigate whether dispositional disgust sensitivity
and affective styles are associated with features of misophonia and whether emotion dys-
regulation plays a role in this relationship. We anticipated disgust sensitivity and emotion
dysregulation to be vulnerability factors for the emotional distress and behavioral reactions
seen in misophonia. A sample of 334 adults (223 females, 104 males, and 7 non-binary
individuals) ranging in age from 18 to 65years were recruited through online social media
websites and completed an online battery of scales that consisted of the Disgust Scale-
Revised, the Difficulties in Emotion Regulation Scale-Short Form, the Affective Styles
Questionnaire, and the New York Misophonia Scale. Significant correlations were obtained
among the study variables. Results of mediation analysis indicated that disgust sensitiv-
ity has both direct and indirect effects on misophonic distress but only indirect effects on
behavioral reactions in misophonia. The affective styles adjusting and tolerating had only
indirect effects on misophonia symptomology. While emotion dysregulation partially medi-
ated the relationship between disgust sensitivity and misophonic distress, it completely
mediated the relationship between disgust sensitivity and misophonic behavioral reactions.
These findings imply that the aggressive and avoidance reactions in misophonia may be
a consequence of emotional dysregulation while misophonic distress may be a reflection
of mental contamination associated with dispositional disgust sensitivity. Findings of the
study have theoretical and clinical implications. Interventions focusing on disgust sensitiv-
ity reduction may benefit individuals with misophonia.
Keywords Misophonia· Distress· Avoidance· Aggression· Disgust· Emotion
Regulation· Affective style
Misophonia is a recently recognized condition, characterized by abnormally strong and
negative reactions to the ordinary “patterned” oral, nasal, or repetitive sounds such as
* Usha Barahmand
usha.barahmand@qc.cuny.edu
1 Division ofMathematics andNatural Sciences, Department ofPsychology, Queens College, City
University ofNew York, 65-30 Kissena Blvd, Flushing, NY11367, USA
2 Westchester Community College, SUNY, Valhalla, USA

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slurping, breathing, or clicking a pen. Oral and nasal sounds, especially when produced by
familiar others, are most distressing (Taylor, 2017). Many misophonic people also find cer-
tain environmental sounds such as tap dripping or visual stimuli such as a person chewing
gum distressing. Reactions of individuals experiencing the condition may be emotional,
physiological, and behavioral. The emotional reactions are usually impulsive and can range
from mild annoyance and irritation to intense disgust and anger. Physiological responses
observed include clenched muscles, breathlessness, and increased heart rate, blood pres-
sure, and body temperature (Dozier, 2015; Dozier & Morrison, 2017; Edelstein et al.,
2013; Rouw & Erfanian, 2018; Schröder etal., 2017). While the most common behavioral
response to misophonia is an attempt to escape or avoid the disgust elicitors (Dozier &
Morrison, 2017; Rouw & Erfanian, 2018), approach behaviors such as impulses to con-
front or hurt others are not uncommon (Edelstein etal., 2013; Rouw & Erfanian, 2018).
Although not listed in the fifth edition of the Diagnostic Statistical Manual (DSM-5)
as a clinical entity, misophonia is believed to be a discrete psychiatric disorder with some
researchers (e.g., Jager etal., 2020; Schröder etal., 2017) even suggesting criteria for its
diagnosis. Recent studies have reported several psychiatric disorders as co-occurring with
misophonia, including anxiety, depression, and obsessive–compulsive personality disorder
(OCPD). The finding that the majority of patients with misophonia met criteria for OCPD
led Schröder etal., 2017 to propose that misophonia be categorized within the category of
obsessive–compulsive and related disorders. Misophonia is akin to obsessive–compulsive
disorders (OCD) because obsessions with triggers and compulsive avoidance are reported
by people with the condition. Another similarity may be the feelings of disgust experienced
by both people with obsessive–compulsive disorder (Olatunji etal., 2011a, 2011b; Whitton
etal., 2015) and misophonics.
Disgust is one of the basic emotions, culturally universal (Ekman, 1992). It is a feel-
ing of revulsion triggered by noxious stimuli resulting in a motivation to physically dis-
tance oneself from the disgust elicitors (Rozin etal., 2000). Disgust has been identified as
an evolved adaptive mechanism aimed at the avoidance of pathogens (Curtis etal., 2011;
Lieberman etal., 2014), thereby promoting survival. There are temporally stable individual
differences produced by both genetic differences (Schaller etal., 2011) and previous envi-
ronmental experiences (Tybur etal., 2013) in one’s responses to disgust eliciting stimuli,
suggesting that disgust sensitivity is a valid dispositional trait (McNally, 2002). A predis-
position to disgust has been reported as a common vulnerability factor for specific anxi-
ety-related conditions (Olatunji & Sawchuk, 2005), obsessive–compulsive disorder (Tolin
etal., 2006), and health anxiety (Olatunji, 2009). Disgust is further conceptualized as con-
sisting of two subconstructs, disgust propensity (DP), the likelihood an individual will feel
disgust for a range of disgust elicitors, and disgust sensitivity (DS), the degree to which an
individual will be distressed by the interpretation of a potential contaminant being present
and the experience of disgust (van Overveld etal., 2006). Disgust is conceived as being
part of the behavioral immune system (BIS; discussed in Taylor 2019). The BIS is a system
of psychological mechanisms that detect stimuli indicative of the presence of infectious
pathogens in the immediate environment and elicit emotional (e.g., fear, anxiety, disgust),
cognitive (obsessions, difficulty concentrating, worry), and behavioral (escape, avoidance,
aggression) reactions.
Disgust proneness has been suggested to confer risk for anxiety-based psychopatholo-
gies like OCD by reinforcing disease avoidance motives (Olatunji etal., 2011a, 2011b).
However, some studies have also found significant relationships between disgust and psy-
chopathologies that would not appear to be disgust relevant (e.g., height phobia and claus-
trophobia, Davey & Bond, 2006; and agoraphobia, Muris etal., 2000) as their features do

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not obviously relate the putative functions of the disgust response, such as disease avoid-
ance. Davey and Bond (2006) invoke the third variable explanation of neuroticism as a
mediator in such conditions, while Olatunji etal. (2017) propose a transdiagnostic frame-
work in which disgust proneness interacts with cognitions to lead to trajectories of various
kinds of psychopathology. Giner-Sorolla and Chapman, 2017; Giner-Sorolla etal., 2018)
believe that disgust may protect individuals not only from contracting disease, but also
from situations that may be in conflict with their morals or values. Rachman (2004) used
the term mental contamination to refer to the distress individuals experience when they
observe or think about something unclean, immoral, or undesirable. Mental contamina-
tion concerns originate as a result of disgust or anticipated exposure to stimuli that elicit
disgust (Olatunji etal., 2010). There is increasing evidence (e.g., Chapman etal., 2009;
Jones & Fitness, 2008) that disgust can be elicited by abstract stimuli such as perceived
transgressions by others (e.g., cheating, deceiving, injuring others, violating principle of
economic fairness) in the absence of concrete disgust triggers. Disgust can also be elicited
by abstract appraisals of oneself (“self-loathing”; Ille etal., 2014). An association between
disgust and mental contamination has been supported by prior studies (Badour etal., 2012;
Jacoby etal., 2018; Ojserkis et al., 2017; Rachman et al., 2011). We speculate that the
disgust experienced by misophonics may be a kind of mental contamination, sensations of
dirtiness experienced as an overall internal discomfort when exposed to triggering stimuli.
Although misophonia is comparable to some anxiety disorders and obsessive–com-
pulsive disorder (Wu etal., 2014) in terms of distress, avoidance, and functional impair-
ment, the pathophysiology of misophonia is inconclusive. Misophonia has been described
as a disorder of emotional processing of sounds (Kumar etal., 2014) that warrants fur-
ther investigation. Studies using autonomic (Edelstein et al., 2013), neurophysiological
(Schröder et al. 2014), and neurobiological (Kumar et al., 2017) measures have shown
that misophonic responses to triggers are accompanied by autonomic arousal and nega-
tive affective states, associated with atypical neuronal responses, and are different from
responses to non-misophonic aversive stimuli. Misophonia is believed to reflect connec-
tivity between sensory processing, emotional reactivity, and the regulation of emotional
arousal (Bruxner, 2016). In a recent study, Kumar etal. (2017) claimed that misophonia
is directly associated with a network of cortical and subcortical regions responsible for the
processing and regulation of emotions.
Emotion regulation refers to the control and management of emotions exerted through
changing the quality, intensity, and duration of an emotional response (Gross and Thomp-
son, 2007). Most emotion regulatory actions are aimed at fostering positive emotions and
reducing negative emotions (Tamir, 2009). Emotion regulation strategies that achieve these
goals are considered functional or adaptive, and those that do not, or exacerbate negative
emotions and are associated with psychological distress, functional impairment, and psy-
chopathology, are termed dysfunctional or maladaptive (Aldao and Dixon-Gordon, 2014).
Three emotion regulation strategies theoretically considered to be protective against psy-
chopathology are reappraisal, problem-solving, and acceptance, while those likely to put
an individual at risk for psychopathology are suppression (both expressive and thought
suppression), avoidance (both experiential and behavioral avoidance), and rumination
(Aldao etal., 2010). However, a meta-analysis revealed that the three maladaptive emotion
regulation strategies and problem-solving are more strongly related to psychopathology
than reappraisal or acceptance (Aldao etal., 2010).
Furthermore, individual differences in the habitual use of the various emotion regula-
tion strategies, each with discernible emotional experiences and psychosocial function-
ing, have been reported (Gross & John, 2003). Appraisal of emotions as intolerable may

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be followed by the use of avoidance or suppression of emotions (Hofmann and Kashdan,
2010) which decreases the experience and expression of both positive and negative emo-
tions (Gross and John, 2003), while readjusting or reappraisal and non-defensive tolerance
of negative emotions may decrease the experience and expression of negative emotions and
increase the experience or expression of positive emotions (Gross and John, 2003). Aldao
etal. (2010) found the absence of adaptive emotion regulation strategies to be less detri-
mental than the presence of maladaptive strategies. However, the authors did note that the
absence of problem-solving skills was an exception as that could contribute to the devel-
opment of maladaptive strategies. The broad range of individual sensitivity and respon-
siveness to emotions is referred to as affective style (Hofmann etal., 2012). Hofmann and
Kashdan, 2010 identify three affective styles for regulating emotions: concealing (which
includes suppression and avoidance), adjusting (which includes reappraisal and problem-
solving), and tolerating (which includes acceptance and a non-defensive response). Some
studies have described the individual’s affective style as a temperamental and trait-like
variable (e.g., Davidson, 1992; Wheeler etal., 1993), while others have reported not only
specific styles associated with anxiety and mood disorders but also therapeutic changes in
affective style associated with reductions in symptoms of psychopathology (e.g., Totzeck
etal., 2018, 2020).
Misophonia is a condition marked by the experience of a dominant negative emotional
reaction of anger, although other emotions such as irritation, stress and anxiety, aggrava-
tion, feeling trapped, and impatience may also be dominant (Rouw & Erfanian, 2018). We
speculate that the anger and other emotions may be associated with the habitual use of dys-
functional emotional regulation strategies. Studies on the regulation of anger have shown
that participants high in trait reappraisal show less anger in response to anger provocation
(Memedovic etal., 2010), while those who have low tolerance for frustration (Martin and
Dahlen, 2004, 2005) and those who ruminate (Ray etal., 2008) report greater anger. Anger,
when regulated using dysfunctional strategies such as expressive suppression or rumina-
tion, has also been associated with negative consequences such as loneliness (Karababa,
2020), depression (Besharat et al., 2012; Bujor & Turliuc, 2020), posttraumatic stress
(PTSD; Kulkarni etal., 2012), social anxiety (Erwin etal., 2003), and panic (PD) disor-
ders severity (Baker etal., 2004). The anger and other negative emotions seen in misopho-
nia may be a reflection of emotion dysregulation associated with low frustration tolerance
and reduced employment of reappraisal or increased reliance on suppression. Furthermore,
the transdiagnostic model of disgust proneness (Olatunji etal., 2017) contends that dis-
gust proneness may shape maladaptive coping strategies, predicting a possible association
between disgust proneness and affective styles.
Present Study
Based on the empirical findings described above, disgust sensitivity and emotion regulation
problems or reliance on dysfunctional regulatory strategies may play a role in misophonia.
The purpose of this study was to characterize the relationship between disgust, emotion
dysregulation, and misophonia features as they may have implications for the etiology,
maintenance, and treatment of misophonia. The following hypotheses were formulated.
H1. Disgust sensitivity will be positively associated with misophonia and its subscales,
misophonic distress and behavioral reactions.

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H2. The affective style concealing will be positively associated while adjusting and tol-
erating will be negatively associated with misophonia and its subscales, with adjusting
displaying a significantly greater correlation.
H3. Disgust sensitivity will be positively associated with concealing and negatively
with adjusting and tolerating.
H4. Disgust sensitivity and affective styles will be positively associated with emotion
dysregulation, with adjusting and tolerating affective styles displaying a significantly
greater correlation.
H5. Emotion dysregulation will be positively correlated with misophonia and its sub-
scales, misophonic distress and behavioral reactions.
H6. The relationship between disgust sensitivity and misophonic distress, behavioral
reactions to misophonic triggers, and misophonia, with affective styles as covariates,
will be mediated by emotion dysregulation.
Method
Ethics Statement
The study proposal received approval from the IRB of the City University of New York,
and all participants were provided with an informed consent form, endorsement of which
was required to gain access to the survey.
Participants
Using a non-experimental research design, data were collected from a large sample of vol-
unteers recruited through social media platforms such as Facebook, Instagram, Reddit,
and LinkedIn. The survey was promoted through these websites. No personal accounts of
the researchers were used. The survey was posted on misophonia support group pages as
well as on pages of other non-clinical public groups where research participants could be
recruited through survey exchange, sharing, and swap. A link directed participants to the
online information sheet, the consent form, and the battery of questionnaires. Participants
were fluent in English to be able to answer the survey questions and were not currently
experiencing a psychological disorder. Therefore, the following inclusion and exclusion
criteria were applied to select eligible participants. Participants were included in our sam-
ple if they (1) were between 18 and 65years of age, (2) were fluent in English, (3) had no
diagnosis of a medical or psychological condition, and (4) were not taking any psycho-
tropic drugs. Exclusion criteria included (1) not having completed at least 2years of edu-
cation in English, (2) having been diagnosed with a psychiatric disorder, and (3) currently
using psychotropic medication. Data collection commenced in November 2020 and contin-
ued through January 2021 using online questionnaires.
To determine the sample size necessary for this study, we used G*Power version
3.1.9.7. A series of calculations with power equal to 0.7, 0.8, and 0.9 for a multiple
regression model with two control variables, gender and socioeconomic status, and four
continuous predictor variables, an alpha of 0.05 for a medium effect size, yielded sam-
ple sizes ranging from 184 to 225. Based on the series of power analyses, we decided
to collect data on a sample of at least 225 individuals. The study sample comprised 334
individuals (223 females, 104 males, and 7 non-binary individuals), ranging in age from

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18 to 65years (M = 29.7years, SD = 11.4). Respondents varied in marital status (single
44.9%, married 26.6%, in a relationship 26.6%, divorced or separated 1.8%) and ethnic-
ity (67% White, 18.6% Asian, 3% Latino or Hispanic, 1.8% Middle Eastern, 1.2% Black
Americans, and 8.1% multiple races). The demographic characteristics of the sample
are presented in Table1. This being an international sample, representability of the pop-
ulation cannot be determined/may not be likely.
Measures
Sociodemographic Information Sheet
Participants completed a questionnaire inquiring about their age, sex, marital sta-
tus, education, number of years studied with English as their medium of instruction,
employment status, country of residence, ethnicity, perceived socioeconomic status,
religious and political orientation, medical/psychiatric condition, and medication use.
Table 1 Demographic
characteristics of the sample
(n = 334)s
Variable f %
Sex Male 104 31.14
Female 223 66.77
Non-binary 7 2.09
Marital status Single, never married 150 44.91
Married or in a relationship 178 53.29
Divorced or separated 6 1.80
Education Less than high school diploma 14 4.19
High school or equivalent 43 12.87
Some college but no degree 68 20.36
Associate degree 23 6.89
Bachelor’s degree 95 28.44
Graduate degree 91 27.24
Race White 224 67.06
Asian 62 18.56
Middle Eastern 6 1.80
Black or African American 4 1.20
Hispanic or Latino 10 2.99
From multiple races 27 8.08
Perceived SES Lower class 18 5.23
Lower middle class 73 21.86
Middle class 149 44.61
Upper middle class 83 24.85
Upper class 8 2.39
Refuse to answer 3 0.9

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The Disgust Scale‑Revised (DS‑R; Olatunji et al., 2007)
The DS-R is a 25-item self-report measure assessing an individual’s propensity to respond
with disgust across various domains of disgust elicitors. The first 13 items are rated as true
or false (scored 0 or 1; e.g., “It bothers me to hear someone clear a throat full of mucus.”),
and the remaining 12 items are rated on a 3-point scale (scored 0, 0.5, 1) and assess the
extent to which participants find a given experience “not disgusting at all,” “slightly dis-
gusting,” or “very disgusting.” Three of the true–false items are reverse scored. The scale
consists of three subscales: (a) core disgust scale with 12 items, (b) animal reminder scale
with 8 items, and (c) contamination disgust scale with 5 items. A total score for overall
disgust sensitivity is calculated by summing responses to the 25 items. The total scores
can range from 0 to 25. Internal consistency in the current study was 0.91. The DS is a
multidimensional instrument with three factors (core disgust, animal reminder disgust, and
contamination-based disgust) and predicts behavioral avoidance of disgusting objects/situ-
ations (Rozin etal., 1999). In the current study, internal consistency (Cronbach’s α) was
found to be 0.75.
Difficulties inEmotion Regulation‑Short Form (DERS‑SF; Kauffman et al., 2016)
Emotion dysregulation was measured using the DERS-SF which is a shortened version of
the 36-item self-report measure called Difficulties in Emotion Regulation Scale developed
by Gratz and Roemer (2004). The 18-item version yields a total score that serves as an
overall index of emotion dysregulation. Consistent with the original scale, this shortened
form also has six subscales, each with 3 items: nonacceptance of emotion (When I’m upset,
I feel ashamed with myself for feeling that way), difficulty engaging in goal directed behav-
ior (When I’m upset, I have difficulty focusing on other things), impulse control difficulties
(When I’m upset, I lose control over my behavior), lack of emotional awareness (I care
about what I am feeling, reverse scored), limited access to emotion regulation strategies
(When I’m upset, I believe that I will end up feeling depressed), and lack of emotional clar-
ity (I have difficulty making sense out of my feelings). Subscale scores are calculated by
adding the scores of individual items. Total scores range from 18 to 90 and are calculated
as the sum of subscale scores, with higher scores indicating poorer emotional regulation.
Adequate internal consistency and concurrent validity have been reported for the DERS-SF
in adolescent and adult samples (Kaufman etal., 2016). In this study, this internal consist-
ency (Cronbach’s α) of the scale was 0.89.
Aective Style Questionnaire (ASQ; Hofmann & Kashdan, 2010)
The ASQ is a 20-item scale, measuring an individual’s tendency to react to emotions. The
20 items are grouped into three subscales each measuring a specific affective style: con-
cealing (8 items), adjusting (7 items), and tolerating (5 items). Respondents indicate their
agreement with each item using a 5-point Likert scale ranging from 1 = not true of me at
all to 5 = extremely true of me. The scale is reported to have sound psychometric proper-
ties. The internal consistency values (Cronbach’s alpha) of the scores of the ASQ subscales
in the US student samples have been reported to be α = 0.84 for the concealing subscale,
α = 0.80 − 0.82 for the adjusting subscale, and α = 0.66 − 0.68 for the tolerating subscale. In

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this study Cronbach’s α for the full scale was observed to be as follows: full scale α = 0.87,
concealing subscale α = 0.88, the adjusting subscale α = 0.88, and the tolerating subscale
α = 0.73.
New York Misophonia Scale (NYMS; Barahmand etal., 2021)
The NYMS is a recently developed scale of misophonia. It includes two subscales, one
assessing severity of misophonic distress to various triggers and the other measuring miso-
phonic behavioral reactions to the distress elicitors. The misophonic distress component
consists of a list of 27 triggers (e.g., someone chewing loudly) that may elicit aversive
emotions. Participants indicate how aversive they find each trigger using a 5-point Likert
scale (0 = doesn’t bother me to 4 = disgusting). This component includes four categories
of triggers: mouth sounds (e.g., gum popping), repetitive actions of others (e.g., leg shak-
ing), ambient object sounds (e.g., tap dripping), and ambient people sounds (e.g., neigh-
bors talking). The second component includes a list of 13 behavioral reactions (e.g., I cover
my ears), and participants indicate how often they engage in those behaviors when exposed
to a trigger (0 = never to 4 = always). This component measures aggressive reactions (e.g.,
I become verbally aggressive) and nonaggressive avoidance (e.g., I distract myself). The
items of both components are summed to provide a total misophonia score which can range
from 0 to 160, and emotional arousal (distress) subscale score ranges from 0 to 108, and
the behavioral reactions subscale score ranges from 0 to 52. The scale has been found to
have good internal consistency (Cronbach’s α for the full scale = 0.94, for the emotional
reactions subscale = 0.94, and for the behavioral reactions subscale = 0.85; Barahmand
etal., 2021).
Procedure
All the scales assessing the study variables along with a consent form and a demographic
information sheet were put together into one package on Google Forms, and the link to
the survey was promoted through social media websites including Facebook, Instagram,
LinkedIn, and Reddit. The scales were administered in counterbalanced order and answers
selected from multiple options provided. The battery included 4 sections, which took
approximately 20min to complete in total. Data collection commenced in October 2020
and concluded in December 2020.
Preliminary analyses were conducted to eliminate cases with missing data and to ensure
no violation of assumptions. Descriptive statistics of all variables were computed, and rela-
tionships between the study variables were examined using Pearson’s correlation coeffi-
cients. The statistical significance of the mediation model tested in the current study was
studied using PROCESS, an SPSS macro developed by Hayes (2013).
Results
All hypotheses were assessed against an alpha level of 0.05. Hypotheses 1 to 4 were evalu-
ated with bivariate Pearson’s correlations and multiple regressions, with differences in cor-
relation coefficients evaluated through converting r values to z scores following the process
outlined by Lee and Preacher (2013). Hypothesis 6 was evaluated using three mediations.
Each analysis tested the indirect effect with a mediation performed using the PROCESS

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add-on in SPSS, selecting model 4 and stipulating the independent variable (IV), covari-
ates (CV), mediator, and dependent variable (DV) (detailed in Fig.1). An examination of
multivariate multicollinearity using the Mahalanobis distance, Cook’s distance, and the
Leverage statistic revealed five potential outliers resulting in a reduced sample size of 334
individuals. For all analyses, there were no violations of normality, linearity, homoscedas-
ticity, sequential dependence, or independence.
Hypotheses 1 to5
The zero-order correlations among variables are presented in Tables2 and 3 alongside the
means and standard deviations. Significant positive correlations were obtained between
disgust sensitivity scores and total misophonia and subscale scores, supporting H1. An
examination of disgust subscale score correlations revealed that while contamination-
based disgust failed to correlate with total misophonia, misophonic distress and miso-
phonic behavioral response scores, animal reminder disgust correlated only with miso-
phonic distress subscale scores, and core disgust correlated with both misophonic distress
and misophonic behavioral response scores as well as total misophonia scores. That is, the
behavioral reaction subscale of misophonia failed to correlate with animal reminder and
contamination-based disgust.
The affective styles, adjusting and tolerating, were negatively associated with misopho-
nia and its subscales, misophonic distress and misophonic behavioral response (p < 0.001),
while concealing showed no significant correlation. The negative correlation of adjusting
and tolerating was only seen with the “aggressive responses” component of the misophonic
behavioral reactions subscale. The associations of adjusting with misophonia (r = − 0.25,
p < 0.001) and with misophonic distress (r = − 0.23, p < 0.001) were not significantly
greater than the association of tolerating with misophonia (r = − 0.18, p < 0.01; z = − 0.9,
p = 0.184) and with misophonic distress (r = − 0.19, p < 0.001; z = − 0.358, p = 0.360).
However, adjusting did show a stronger association with the “aggressive reactions”
component than tolerating (r = − 0.29, p < 0.001; z = − 2.23, p < 0.013). No significant
Emoonal
Dysregulaon
Disgust Emoonal
Distress
Tolerang
Adjusng Behavioral
Reacons
Misophonia
Fig. 1 Path model displaying mediation of emotional dysregulation (EDys) in the relationship between
disgust sensitivity and misophonic distress. Behavioral reactions and misophonia with affective styles as
covariates

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Table 2 Correlations of disgust sensitivity, affective styles, and emotion dysregulation with misophonia
Variables Misophonia subscales and total score
Eating sounds Repetitive
move-
ments
Ambient
people
sounds
Ambient
object
sounds
Misophonic distress Aggressive reactions Avoidance Behavioral
reactions Misophonia
Core disgust .28*** .25*** .19*** .24*** .32*** .24*** .08 .22*** .31**
Animal reminder .07 .10 .05 .15** .11 .04 − .06 .02 .09
Contamination-based .03 .05 .08 .12* .07 .02 − .10 − .02 .05
Disgust sensitivity .20*** .21*** .16** .25*** .25*** .16** − .02 .13* .23***
Concealing − .03 − .05 − .01 − .04 − .01 − .04 .10 − .01 − .01
Adjusting − .16** − .17** − .30*** − .13* − .23*** − .29*** − .01 − .23*** − .25***
Tolerating − .15** − .17** − .15** − .12* − .19*** − .16** .04 − .12* − .18**
Lack of awareness − .02 .02 .03 .08 .01 − .07 − .13** − .11 − .03
Lack of emotional clarity .12* .16** .20** .15** .19** .22*** .10 .21*** .21***
Nonacceptance of emotions .27*** .19*** .20*** .19** .28*** .35*** .19*** .36*** .33***
Impulse control difficulties .14* .16** .24*** .17** .21*** .32*** − .08 .24*** .24***
Limited access to regulation
strategies
.24*** .18*** .29*** .15** .27*** .36*** .03 .31*** .31***
Difficulties with goal-
directed behavior
.25*** .25*** .32*** .19*** .32*** .37*** .17** .36*** .36***
Emotion dysregulation .26*** .25*** .31*** .24*** .33*** .40*** .08 .36*** .37***
Mean 15.57 7.46 5.94 4.88 33.86 15.77 11.50 27.27 61.13
SD 9.56 7.16 3.75 3.85 19.31 7.54 3.13 9.15 26.00

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Table 3 Correlations of disgust sensitivity and affective styles with emotion dysregulation indices
Variables Emotion dysregulation
Lack of awareness Lack of emo-
tional clarity
Nonacceptance
of emotions
Impulse control
difficulties
Limited access
to strategies
Difficulties with goal-
directed behavior
Emotion dys-
regulation
M SD
Core disgust − .10 .13* .22*** .26*** .30*** .29*** .29*** 7.89 1.12
Animal reminder − .05 .07 .16** .12* .14* .15** .16** 5.74 .83
Contamination-based .16** .13* .13* .17** .15** .08 .20*** 2.89 .73
Disgust sensitivity − .10 .15* .24*** .26*** .28*** .26*** .31*** 16.53 1.95
Concealing .24*** .13* − .07 − .21*** − .07 − .13* − .04 24.78 7.52
Adjusting .01 − .31*** − .39*** − .41*** − .66*** − .54*** − .59*** 18.93 6.26
Tolerating − .25*** − .29*** − .44*** − .28*** − .36*** − .28*** − .48*** 15.92 4.13
M6.78 6.91 7.93 6.18 7.78 10.66 46.25
SD 2.75 2.81 3.74 3.30 3.19 3.54 13.01

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correlations emerged between misophonia or its subscales and concealing. H2 was, there-
fore, only partially supported.
In support of H3, our findings revealed strong negative associations between disgust
sensitivity and adjusting (r = − 0.26, p < 0.001) and tolerating (r = − 0.25, p < 0.001) and
a nonsignificant correlation with concealing (r = − 0.10, p = 0.057). Adjusting showed sig-
nificant negative correlations with core disgust (r = − 0.27, p < 0.001), animal reminder
disgust (r = − 0.12, p < 0.05), and contamination-based disgust (r = − 0.14, p < 0.05).
Similarly tolerating correlated negatively with core disgust (r = − 0.21, p < 0.001), ani-
mal reminder disgust (r = − 0.14, p < 0.05), and contamination-based disgust (r = − 0.20,
p < 0.001). Concealing showed a significant negative correlation only with animal reminder
disgust (r = − 0.16, p < 0.01).
In accordance with H4, emotion dysregulation correlated positively with disgust sen-
sitivity (p < 0.001) and negatively with the affective styles, adjusting and tolerating
(p < 0.001), but failed to correlate with concealing. Furthermore, the strength of the asso-
ciation of both the affective styles, adjusting (z = 11.87, p < 0.001) and tolerating (z = 10.0,
p < 0.001), with emotion dysregulation was greater than that of disgust sensitivity. H3 was,
therefore, supported.
In confirmation of H5, significant positive correlations were also obtained between
misophonia and total and all subscale scores of emotion dysregulation except the lack of
awareness subscale.
Mediation Analyses
Hypothesis 6 To examine the mediating effect of emotion dysregulation between disposi-
tional disgust sensitivity and misophonia, Model 4 of the PROCESS macro (Hayes, 2013)
was used with the two affective styles, adjusting and tolerating as covariates. Disgust sensi-
tivity (a1 path; b = 0.86, t(330) = 2.92, p < 0.001 CI [0.28, 1.43]) and the covariates adjust-
ing affective style (a2 path; b = − 0.93, t(330) = − 9.31, p < 0.001, CI [− 1.12, − 0.73])
and tolerating affective style (a3 path; b = − 0.76, t(330) = − 5.06, p < 0.001, CI
[− 1.06, − 0.46]) significantly predicted emotion dysregulation.
Emotion dysregulation was also found to be significantly predictive of misophonic distress
(b1 path; b = 0.38, t(329) = 3.84, p < 0.001, CI [0.19, 0.58]), behavioral reactions to miso-
phonic triggers (b2 path; b = 0.26, t(329) = 5.41, p < 0.001, CI [0.16, 0.35]), and misopho-
nia (b3 path; b = 0.64, t(329) = 4.81, p < 0.001, CI [0.38, 0.90]). However, while disgust
sensitivity (b = 0.11, t(329) = 0.430, p = 0.667, CI [− 0.39, 0.61]) failed to have any direct
effects (c′ path) on misophonic behavioral reactions, it did have significant direct effects
on misophonic distress (b = 1.65, t(329) = 3.07, p < 0.01, CI [0.59, 2.71]) and misophonia
(b = 1.76, t(329) = 2.46, p < 0.05, CI [0.35, 3.17]).
The two affective styles, adjusting and tolerating, failed to have any direct effects (c′
path) on misophonic distress (adjusting b = − 0.09, t(329) = 0.428, p = 0.669, CI [− 0.48,
0.31]; tolerating b = − 0.05, t(329) = − 0.167, p = 0.867, CI [− 0.60, 0.51]), behavioral
reactions (adjusting b = − 0.07, t(329) = − 0.759, p = 0.448, CI [− 0.26, 0.12]; tolerating
b = 0.18, t(329) = 1.38, p = 0.167, CI [− 0.08, 0.45]), and misophonia (adjusting b = − 0.16,
t(329) = − 0.592, p = 0.554, CI [− 0.69, 0.37]; tolerating b = 0.14, t(329) = 0.367, p = 0.714,
CI [− 0.60, 0.88]).
These findings indicate that difficulties regulating emotions partially mediate the associ-
ation between dispositional disgust sensitivity and misophonic distress and misophonia but

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completely mediate the association between disgust sensitivity and behavioral reactions to
misophonic triggers. Calculated as the product of paths a and b, the indirect effects of emo-
tion dysregulation on misophonic distress (unstandardized indirect effect = 0.33, SE = 0.14,
CI [0.10, 0.63]), behavioral reactions (unstandardized indirect effect = 0.22, SE = 0.08, CI
[0.07, 0.40]), and misophonia (unstandardized indirect effect = 0.55, SE = 0.21, CI [0.19,
1.02]) were found to be significant as the confidence intervals do not contain zero. Results
of the three mediation analyses are displayed in Table4. These findings provide confirma-
tion of H6.
Discussion
This study explored the relationship between disgust sensitivity, emotion dysregulation,
and features of misophonia. In accordance with H1, disgust sensitivity was positively asso-
ciated with misophonia and its subscales, misophonic distress and behavioral reactions.
This study is the first, to our knowledge, to report the associations between dispositional
disgust sensitivity and misophonia and suggests that disgust sensitivity may be relevant to
understanding misophonia symptomatology. This finding provides support for the trans-
diagnostic model of disgust proneness proposed by Olatunji etal. (2017) in which dis-
gust proneness is conceptualized as a proximal risk factor that can lead to psychopathology
when it interacts with cognitions and emotions (moderators) to shape responses through
various learning pathways. In the case of misophonia, we speculate that disgust sensitivity
and mental contamination play a role in the trajectory to misophonia. Mental contamina-
tion occurs consequent to an individual’s interpretation of thoughts, images, and experi-
ences as dirty, immoral, or wrong (Radomsky etal., 2013). Triggers of misophonia likely
evoke mental contamination. Mental contamination and the mechanisms linking it to dis-
gust sensitivity require further research.
In a recent study, the presence of disgust was reported to be a positive predictor of
treatment response in individuals with misophonia (Schröder etal., 2017), implying that
there might be people with misophonia who do not experience disgust. Furthermore, the
Table 4 Path coefficients and indirect effects for the mediation models
Note: DIS disgust sensitivity, Adj adjusting, Tol tolerating, EDys emotion dysregulation, MisD misophonic
distress, BehRe behavioral reactions, Miso misophonia
To EDys To MisD To BehRe To Miso Indirect effects
Bias corrected
Estimate Bootstrap 95%
confidence
interval
Disgust sensitivity .86 (.29)** 1.65 (.54)** .11 (.25) 1.76 (.72)*
Adjusting − .93 (.10)*** − .09 (.20) − .07 (.10) − .16 (.27)
Tolerating − .76 (.15)*** − .05 (.28) .18 (.13) .14 (.38)
EDys .38 (.10)*** .25 (.05)*** .64 (.13)***
Total 1.98 (.54)*** .33 (.26) 2.31 (.73)**
DIS → EDys → MisD .33 (.14) 0.10, 0.63
DIS → EDys → BehRe .22 (.08) .07, .40
DIS → EDys → Miso .55 (.21) .19, 1.02

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authors speculated whether disgust may be associated only with mouth sounds. How-
ever, in our study, disgust sensitivity was associated with all the misophonic triggers
examined, mouth sounds, repetitive actions, and sounds and ambient sounds from peo-
ple and objects, indicating that dispositional disgust may in general predispose individu-
als to misophonia. In addition, contrary to the findings of Schröder etal., 2017, mouth
sounds correlated only with core disgust and failed to correlate with animal reminder
and contamination-based disgust, implying that the misophonic triggers may be per-
ceived as transgressions by others, behaviors seen as unclean, undesirable, and in con-
flict with morals or values and experienced as distressing mental contamination (Rach-
man etal., 2012).
The negative association of the affective styles adjusting and tolerating with aggres-
sive reactions in misophonia is consistent with findings of Memedovic etal. (2010) and
Martin and Dahlen (2004) who also pointed out that individuals with low reappraisal skills
and low frustration tolerance tend to display greater anger. In other words, individuals who
lack reappraisal skills or show reduced acceptance of negative emotions are more likely
to respond to misophonic triggers with aggressive responses. Adjusting showed a stronger
association. Parallel to the current findings, Totzeck etal. (2020) found remission from
anxiety disorders associated with higher scores on adjusting. It can be concluded that the
adjusting style (reframing one’s thoughts) is protective against psychopathology, and low
scores on this affective style may place an individual at risk for misophonia. The obtained
finding may have therapeutic implications. Although the positive effects of both reappraisal
and acceptance on psychological health have been confirmed (Shallcross et al., 2015),
it cannot be assumed that possession of these strategies will result in their employment
and result in a reduction of aggressive responses to misophonic triggers. As Gross and
Jazaieri (2014) have noted, the intensity of the emotion being experienced and the cogni-
tive demands of the current situation are also important considerations.
The negative association of disgust sensitivity with adjusting and tolerating implies
that disgust sensitivity may predispose a person to maladaptive affective styles preclud-
ing the use of adjusting (reappraisal) and tolerating (acceptance). Gross and Jazaieri
(2014) have pointed out that healthy emotional regulation entails clarity regarding
emotional intensity, knowledge of the differential efficacy of various strategies, and
accurate assessment of self-efficacy. Accordingly, disgust sensitivity may impact any
of these aspects directly or indirectly through distressing, vivid, involuntary images
and visual memories of real or imaginary events that are triggered by cues and result
in the individual experiencing or reexperiencing a negative event with various sensory
qualities Harvey etal. (2004) consider intrusive visual images and memories transdi-
agnostic. It is plausible that disgust sensitivity, also a transdiagnostic factor (Olatunji
etal., 2017), together with intrusive images contributes to the development of a mala-
daptive affective style.
The associations of disgust sensitivity, and deficits in adjusting and tolerating, with
emotion dysregulation provide support for the idea that disgust sensitivity is a latent
pathogenic trait that is activated by stress and associated with deficient coping strate-
gies as well as a vulnerability for psychophysiological strain (Rohrmann etal., 2009).
In the same vein, Olatunji etal. (2014) claimed that low disgust sensitivity may be
indicative of emotional hardiness, distress tolerance, or resilience. Furthermore,
the stronger correlation of the affective styles than disgust sensitivity with emotion
dysregulation may have therapeutic implications. It is likely that strengthening indi-
viduals’ abilities for adjusting and tolerating will have positive effects on well-being
by preventing the development of maladaptive emotion regulation strategies such as

International Journal of Mental Health and Addiction
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experiential avoidance which are risk factors for psychopathology (Aldao etal., 2010;
Troy etal., 2018).
As anticipated in support of our fifth hypothesis, difficulties regulating emotions were posi-
tively associated with both the misophonic distress and the behavioral reactions to distress
elicitors in misophonia. This is in harmony with robust literature (e.g., Gross & Jazaieri, 2014;
Kneeland etal., 2016; Sheppes et al., 2015) indicating the association of emotion regulation
problems with psychopathology.
More notably, evidence was obtained for the mediating role of emotion regulation in
the relationship between dispositional disgust sensitivity and misophonia. Specifically,
dispositional disgust sensitivity contributes both directly and indirectly through emotion
dysregulation, to misophonic distress and misophonia, but has no direct effects on the
behavioral reactions to the distress elicited by misophonic triggers. Furthermore, while
all the components of disgust correlated with misophonic distress, only core disgust
was significantly associated with all the aggressive responses to the distressing triggers.
These findings imply that while dispositional disgust may predispose an individual to
experience annoyance and distress when exposed to repetitive oral sounds or actions,
it does not predispose them to aggressive reactions. The aggressive reactions seen may
actually be the consequence of emotion regulation failures. The finding that the two
affective styles, adjusting and tolerating, failed to have any direct effects on misophonic
distress or behavioral reactions adds further credence to this implication. Along with the
observed associations among subscale scores, it is reasonable to assume that the aggres-
sive responses displayed by individuals with misophonia is due to lack of emotional clar-
ity, difficulty controlling impulses, presence of dysfunctional emotion-regulatory goals,
or lack of access to appropriate regulatory strategies (Gross & Jazaieri, 2014). Further-
more, the results also show that lack of adjusting, an adaptive emotion regulation strat-
egy which includes reappraisal, could be risk factor in the development of aggressive
responses in misophonia.
Limitations
This study has certain limitations that should be taken into consideration when interpret-
ing the findings. Firstly, the study gathered data using self-report scales, which preclude
any generalizations about individuals diagnosed with misophonia or sound sensitivity.
Also, the study sample included individuals not diagnosed with misophonia. Although
participants in the present study did span a wide range in age, ethnicity, and scale scores,
a comparison of the clinical population with non-clinical counterparts will clarify if the
obtained results generalize to a clinical population as well. Secondly, participants were
recruited through social media websites; therefore, individuals not using these websites
were automatically excluded from the study. Thirdly, our study samples all comprised a
greater number of female respondents. This is a trend reported by several other psycho-
logical studies utilizing online surveys, implying that the over-representation of females
in online research may not be related to the subject matter (Kalmijn & Liefbroer, 2011;
Slauson-Blevins & Johnson, 2016). Yet, caution is advised when generalizing the results
to males. Finally, the mediation model only implies causality, and confirmation requires
future validation through longitudinal research. Yet, the study findings do provide rea-
sonable direction regarding causal effects.

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Conclusions
The finding that disgust sensitivity has direct and indirect effects on misophonic distress
suggests that disgust proneness alone, or coupled with maladaptive coping strategies,
may predispose a person to misophonia. The results suggest that individuals with a dis-
position to disgust sensitivity and whose affective style is characterized by underutiliza-
tion of reappraisal and acceptance are at risk for experiencing emotion dysregulation
when confronted with sounds and sights that are interpreted as aversive, which can then
perpetuate misophonic distress and aggressive reactions. Concealing or suppression
does not seem to play an important role in misophonia.
Furthermore, the study shows that while disgust sensitivity and the maladaptive
affective styles (low reappraisal and acceptance) are associated with similar emotion
dysregulation and influence an individual’s experience of overall misophonic distress,
only core disgust was associated with every one of the triggers examined. The absence
of an association between animal reminder disgust and contamination-based disgust
with distress from mouth sounds implies that contagion concerns are less relevant in
misophonia. Also, only core disgust and the absence of an adaptive affective style con-
tributed to aggressive reactions in misophonia. These findings imply that disgust in mis-
ophonia is elicited rapidly and automatically as affective and cognitive processes inter-
act and stimulate behavioral and mental responses to the disgust elicitor (Izard, 2007).
Since in misophonia, the disgust is elicited by visual and auditory triggers, and since
contamination-based and animal reminder disgust were not associated with misophonia,
concerns about mental contamination (Elliott and Radomsky, 2013) may be more sali-
ent, and an investigation into the role of mental contamination in misophonia may be
warranted. Mental contamination is a feeling of internal dirtiness elicited by intangible
stimuli. Merely observing or thinking about something unclean, immoral, or undesir-
able can give rise to mental contamination (Rachman, 2004). There is evidence that a
predisposition to disgust may be a vulnerability factor for mental contamination (Fong
and Sündermann, 2020).
The disgust sensitivity-related associations found in the current study may be of clin-
ical value in the context of psychopathology. Although present findings do imply that
disgust sensitivity may be an important vulnerability factor for misophonia, it may not
have the same disease avoidance function as it does in many anxiety and fear-related
disorders. A critical next step would be to investigate whether clinical participants as a
group or specific subgroups of them show both increased disgust sensitivity and height-
ened mental contamination. Furthermore, interventions focused on reducing disgust
sensitivity may also be effective in treating misophonia.
The present study adds to the literature by providing a more informed understand-
ing of how individual differences in disgust sensitivity are linked to feelings of distress
and behavioral reactions seen in misophonia. Thus, it can be tentatively concluded that
dispositional disgust sensitivity may perpetuate the use of dysfunctional emotion regu-
lation strategies, resulting in heightened misophonia symptoms. Results emphasize the
need for future research to investigate other variables such as mental contamination that
may contribute to the relationship between disgust sensitivity and misophonia.
Data availability All data are available upon reasonable request.

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Declarations
Ethics Approval The study proposal received approval from the IRB of The City University of New York.
Consent to Participate All participants provided informed consent before gaining access to the survey ques-
tions used in this study.
Conflict of Interest The authors declare no competing interests.
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