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Misophonia in the UK: norms of the selective sound sensitivity five factor model (S-Five) for misophonia and prevalence of the disorder using a large sample representative of the UK population

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What is the reality of the misophonic experience in the general population? This is a study on misophonia in a large sample, representative of the UK general population. The study utilises a multidimensional psychometric tool, the S-Five, to study the intensity of the triggering misophonic sounds in everyday activities, the emotions/feelings related to them, and the norms of the key components of the misophonic experience: internalising and externalising appraisals, perceived threat and avoidance behaviours, outbursts, and the impact on functioning. Based on the S-Five scores and a semi-structured interview delivered by clinicians who specialise in misophonia, the estimated prevalence of people for whom symptoms of misophonia cause a significant burden in their life in the UK was estimated to be 18%. The psychometric properties of the S-Five in the UK general population were also evaluated and differences across gender and age were explored. Our results show that the five-factor structure is reproduced, and that the S-Five is a reliable and valid scale for the measurement of the severity of the misophonic experience in the general UK population.
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Misophonia in the UK: norms of the selective
sound sensitivity five factor model (S-Five) for
misophonia and prevalence of the disorder
using a large sample representative of the UK
population
Short title: The prevalence and norms of misophonia in the UK
Silia Vitoratou1, Chloe Hayes1, Nora Uglik-Marucha1, Oliver Pearson1, Tom Graham2, Jane
Gregory3,4
1 Psychometrics and Measurement Lab, Biostatistics and Health Informatics Department,
Institute of Psychiatry, Psychology and Neuroscience, King’s College London
2 Centre for Anxiety Disorders and Trauma, South London and Maudsley NHS Foundation
Trust
3 Department of Experimental Psychology, University of Oxford
4 Oxford Health Specialist Psychological Interventions Centre, Oxford Health NHS Foundation
Trust
*Corresponding author information: Silia Vitoratou, Biostatistics and Health Informatics
Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London,
SE58AF, Denmark Hill, London, UK, (e-mail: silia.vitoratou@kcl.ac.uk).
Abstract:
What is the reality of the misophonic experience in the general population? This is a study on
misophonia in a large sample, representative of the UK general population. The study utilises
a multidimensional psychometric tool, the S-Five, to study the intensity of the triggering
misophonic sounds in everyday activities, the emotions/feelings related to them, and the
norms of the key components of the misophonic experience: internalising and externalising
appraisals, perceived threat and avoidance behaviours, outbursts, and the impact on
functioning. Based on the S-Five scores and a semi-structured interview delivered by clinicians
who specialise in misophonia, the estimated prevalence of people for whom symptoms of
misophonia cause a significant burden in their life in the UK was estimated to be 18%. The
psychometric properties of the S-Five in the UK general population were also evaluated and
differences across gender and age were explored. Our results show that the five-factor
structure is reproduced, and that the S-Five is a reliable and valid scale for the measurement
of the severity of the misophonic experience in the general UK population.
Keywords:
misophonia, s-five, psychometric, selective sound sensitivity syndrome, general population
UK
Data availability statement:
The data presented in this study are available on request from the first author.
Acknowledgements:
SV, CH, OP and NUM were funded or partially funded by the Biomedical Research Centre for
Mental Health at South London and Maudsley NHS Foundation Trust and King’s College
London. This research was funded in whole, or in part, by the Wellcome Trust [JG; Grant
number 102176/B/13/Z]. For the purpose of open access, the author has applied a CC BY
public copyright licence to any Author Accepted Manuscript version arising from this
submission. The views expressed are those of the author(s) and not necessarily those of the
NHS, The Wellcome Trust, the NIHR or the Department of Health and Social Care.
Conflict of Interest:
The authors declare that the research was conducted in the absence of any commercial or
financial relationships that could be construed as a potential conflict of interest.
Introduction
Misophonia, by consensus (Swedo et al., 2021), is recognised as a disorder characterised by a
disproportionate emotional response to everyday sounds (Jastreboff et al., 2002). The
misophonic response can range from mild irritation to anger and distress and can result in
impairment to social and occupational functioning (Rouw et al., 2018; Schröder et al., 2013).
Common manifestations of misophonia include feelings of anger, disgust, and anxiety
(Edelstein et al., 2013; Jager et al., 2020; Johnson, 2013; Kumar et al., 2017; Schröder et al.,
2013); muscle tension (Cavanna et al., 2015; Rouw et al., 2018); avoidance of triggering stimuli
(Alekri et al., 2019; Rouw et al., 2018; Schneider et al., 2015; Singer, 2018), withdrawal from
social situations (Alekri et al., 2019; Hocaoglu, 2018; Johnson et al., 2013; Muller et al., 2018;
Schneider et al., 2015; Singer, 2018) and, in some cases, verbal and physical aggression (Alekri
et al., 2019; Hocaoglu, 2018; Jager et al., 2020; Reid et al., 2016). Secondary emotional
responses have also been reported, for example shame, guilt (Bernstein et al., 2013; Edelstein
et al., 2013) and anticipatory anxiety (Alekri et al., 2019).
To date, there is little research on the prevalence of misophonia, with reported estimates
varying between 5% and 20% in specific samples. A study of 483 American undergraduate
students, reported that nearly 20% of the sample experienced clinically significant symptoms
of misophonia (Wu et al., 2014). In a study of 415 Chinese university students reported that
20% of participants were either “often” or “always” sensitive to sounds of people eating, nasal
sounds and repetitive tapping, and 6% reported clinically significant misophonia (Zhou et al.,
2017). A study on the prevalence of misophonia in Turkey reported the prevalence of 12.8%
while 78% of the participants reported to experience aversion to at least one sound (Kılıç et
al., 2021). Naylor et al. (2020) found almost half of the undergraduate medical students of
their sample reported clinically significant symptoms of misophonia, with the majority (37%)
reporting mild symptoms of misophonia and a small number of students (0.3%) reporting
severe misophonia. The higher prevalence rate in this population may be explained by the
increased propensity of medical students to experience conditions which have been found to
co-occur with misophonia.
Research studies have used self-report questionnaires to study misophonia in the general
population (Naylor et al., 2020; Wu et al., 2014; Zhou et al., 2017) and in individuals identifying
with the condition (Jager et al., 2020; Rouw et al., 2018; Schröder et al., 2013). Vitoratou et
al. (2021b) used the responses of individuals who identified with having misophonia in four
waves of sampling to develop a robust psychometric tool that assesses the severity of the
misophonic experience. Their work resulted in the S-Five (Selective Sound Sensitivity
Syndrome Scale) which surfaced five dimensions of the misophonic experience: a sense of
emotional threat, internalising and externalising appraisals, outbursts and impact. In this
work we use this scale to assess misophonia in the UK general population.
To date, no study has investigated misophonia in a sample representative of the UK general
population. The S-Five was used to present estimates of the intensity of the emotions caused
by sounds which trigger misophonic reactions in everyday activities, and the norms related to
the five key components of the misophonic experience. A second aim of the study was to
estimate the prevalence of people in the UK for whom symptoms of misophonia cause a
significant burden in their life. We aimed to use the outcomes of semi-structured interviews
to determine the point on the S-Five at which someone can be considered likely to have
significant symptoms of misophonia, and to use that to estimate its prevalence in the UK
general population.
Methods
Recruitment
Participants constituted a representative sample of the UK general population, recruited via
Prolific.co, via an allocation algorithm to stratify sample size across sex, age, and ethnicity
using census data from the UK (Office for National Statistics, 2020). Participants read and
consented to participants’ information sheet (ethics approval reference RESCM-19/20-11826)
and were subsequently screened for their eligibility criteria, which included being aged 18
years or older, English fluency, and no diagnosis of a severe learning or intellectual disability.
Measures
An extended battery of 17 scales were considered within the S-Five study, described in
Vitoratou et al. (2021b) and reprinted here in the Appendix (Table A4). In this section we
present the tools used in the current validation.
Selective sound sensitivity syndrome scale (S-Five; Vitoratou et al., 2021b)
The S-Five consists of 25 items assessing the severity of misophonia. It is rated an interval
scale from 0: not at all true to 10: completely true. The severity scale is also complemented
by a trigger checklist (S-Five-T), to assess the trigger sounds, the response to them, and the
intensity of the response. The checklist currently uses 37 triggers suggested by research data,
but researchers can add or remove sounds. The type of reaction to the trigger can be recorded
and in this study were: no feeling, irritation, distress, disgust, anger, panic, other feeling:
negative, and other feeling: positive. Each trigger item also rates the intensity (henceforth
trigger intensity) of the reaction (from 0: doesn’t bother me at all to 10: unbearable/causes
suffering). This allows for the computation of four indices: 1) the trigger count (TC), which is
the total number of triggers endorsed by a participant from the list provided, 2) the reaction
count (RC), which is the number of times each particular reaction type is endorsed and can
be counted across triggers in a single participant, or across participants, 3) the
frequency/intensity of reactions score (FIRS) is the total value of the intensity items of all
endorsed triggers, and 4) the relative intensity of reactions score (RIRS) which gives an
estimate of the intensity of reactions to triggers, relative to the number of triggers reported.
The 25 statements and the trigger checklist used in this study are reprinted here in the
Appendix (Table A1) along with the details and examples for the computation of the five
factors and the four trigger indices, originally presented in Vitoratou et al. (2021a; 2021b).
Misophonia Questionnaire (MQ; Wu et al., 2014)
The MQ is a self-report measure consisting of three measures for misophonia: the Misophonia
Symptom Scale (MSYS) which assesses sensitivity to specific triggers in comparison to other
people, the Misophonia Emotions and Behaviours Scale (MEBS) which relates to an
individual’s reactions to triggering sounds. The MQ total score which is calculated by
combining the scores of both the MSYS and the MEBS. The third section of the MQ, is the
Misophonia Severity Scale (MSES). It is a single item which asks individuals to rate the severity
of their sound sensitivity on a scale from 1 (minimal) to 15 (very severe), with a score greater
than or equal to 7 indicating clinically significant symptoms.
Amsterdam Misophonia Scale (A-MISO-S; Schröder et al., 2013)
The A-MISO-S was adapted from the Yale-Brown Obsessive-Compulsive Scale (YBOCS;
Goodman et al., 1989). The A-MISO-S address different aspects of misophonia, including time
spent occupied by misophonia, impact on functioning, distress, attempts to resist, perceived
control over sounds and thoughts, and avoidance. An interviewer discusses the questions
with the patient and uses clinical judgement to rate each item (Schröder et al., 2013),
although it has also been used as a self-report tool (Quek et al., 2018).
Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001)
PHQ-9 has 9 items measuring the severity of depression with items scored on a 4-point ordinal
scale, and a total score range of 0 to 27.
General Anxiety Disorder-7 questionnaire (GAD-7; Spitzer et al., 2006)
GAD-7 is a 7-item scale measuring severity of anxiety symptoms, rated on a 4-point ordinal
scale and a total score ranging from 0 to 21.
The diagnostic interview
A preliminary version of the Oxford King’s Structured Clinical Interview for Misophonia (Pre-
OK-SCIM, in development by the authors) was used. The preliminary version used for the
present study contained a series of questions and prompts to determine whether six key
criteria were met, adapted from the Amsterdam UMC revised diagnostic criteria for
misophonia (Jager et al., 2020). The modifications were made based on outcomes from recent
research (Vitoratou et al., 2021a; Vitoratou et al., 2021b) and observations in clinical practice.
Notably, we did not require an oral or nasal sounds to be a trigger (A), intense reactions were
not limited to irritation, anger and disgust (B), the individual did not need to recognise the
excessive nature of the response (B), loss of control included experiencing panic and
helplessness (C), and coping strategies were included (D).
An outcome of “significant misophonia” on the Pre-OK-SCIM indicated that the individual was
significantly burdened by misophonia in their life at the time of the interview. It was not
intended to be a clinical diagnosis of misophonia at a disorder level, and therefore does not
assume levels of distress and impairment on par with, for instance, diagnoses such as
obsessive-compulsive disorder or posttraumatic stress disorder. The Pre-OK-SCIM was
administered by registered psychologists experienced with misophonia to allow for flexibility
and clinical judgement in the use of the protocol.
Statistical Analysis
The latent structure of the S-Five was assessed using exploratory (EFA) and confirmatory
factor analysis (CFA). The data were checked for their suitability for factor analysis using the
Kaiser-Meyer-Olkin (KMO) test for sampling adequacy (Kaiser, 1960; Kaiser et al., 1974) and
Bartlett (1951) test of sphericity. In EFA, the maximum likelihood estimator with robust
standard errors (MLR; Muthen et al., 1998-2017) was incorporated due to data being skewed,
with Oblimin rotation. To establish the number of factors, the Guttman-Kaiser criterion
(Guttman, 1954; Kaiser, 1960) and the parallel analysis criterion (Horn, 1965) were followed,
depicted using Cattell’s scree plot (1966). The percentage of variance explained was also
evaluated (see for instance Nunnally et al., 1994). Goodness of fit indices were computed to
to assess the relative and absolute fit of competing models. The measures of fit that are
reported include the relative chi-square (relative
𝜒
2: values close to 2 suggest an acceptable
fit; Hoelter, 1983), the Root Mean Square Error of Approximation (RMSEA: values <.06 are
required for adequate fit; Hu et al., 1999), the Taylor-Lewis Index (TLI: values >.95 suggest
close fit; Hu et al., 1999), the Comparative Fit Index (CFI: values >.95 are required for close fit;
Hu et al., 1999; West et al., 2012) and the Standardized Root Mean Residual (SRMR: values
<.08 are needed for good fit; Hu et al., 1999). The multiple indicator multiple causes model
(MIMIC; Joreskog et al., 1975; Muthén, 1979) was used to assess the measurement invariance
in relation to gender and age.
Internal consistency was computed within each factor using the Cronbach’s alpha coefficient
(Cronbach, 1951; α) and McDonald’s (1999) Omega (ω). Test-retest reliability was assessed at
item level by computing the Psi coefficient (Kuiper et al., 2019), to accommodate the
skewness of the data on item level, and at factor level using the (mixed effects, absolute
agreement) Intraclass Correlation Coefficient (ICC; Shrout et al., 1979). The latter was
evaluated according to interpretation guidelines outlined by Landis et al. (1977). The
assessment of convergent validity and hypothesis testing were conducted using parametric
(Pearson’s r, t-test) and non-parametric (Spearman’s rho, Mann-Whitney test) methods
depending on the distribution of the data.
To establish a cut-off score for significant misophonia from the S-Five, and subsequently
estimate of prevalence, receiver operating characteristic (ROC) curve analysis was carried out.
Using the outcome of the Pre-OK-SCIM, those with significant misophonia were classified as
cases and those without this outcome were classified as controls. The ROC (Altman et al.,
1994a, 1994b) curves were plotted for each of the S-Five subscales and total score and for the
S-Five-T variables, with the Pre-OK-SCIM caseness as the classification variable. First, the area
under the curve (AUC) values were considered, with good predictive ability achieved by an
AUC above or equal to 0.8. Where an adequate AUC was established, the optimal cut-off
scores were considered, for which a balance of sensitivity and specificity, close to 80%, and
the (Youden, 1950) J index. The ROC analysis was extended to test the presence of significant
covariates through ROC regression analysis (Janes et al., 2009; Janes et al., 2008; Pardo-
Fernandez et al., 2014).
The interview was conducted on a sample from the general population and a self-reporting
misophonia sample. Thirty individuals who identified with the condition were randomly
invited for the interview. A second sample of 30 individuals from the Prolific sample
(representative of the UK population) were invited, which included individuals from all 10th-
tiles of the total S-Five distribution, to ensure representation of the interviews of various
levels of severity and to ensure the presence of people with significant misophonia.
Data analyses were conducted using MPlus 8 (Muthen et al., 1998-2017), Stata 16 (StataCorp,
2019), and R (R Core Team, 2017) statistical packages.
Results
Descriptive indices
With respect to gender, 396 individuals identified as females (7 trans women), 372 as males
(1 trans man), and 4 identified as non-binary or other. The mean age was 46.4 years old
(standard deviation SD=15.5, min=19, max=83) and did not differ across genders (t=0.905,
df=758, p=0.366). Only 13.6% of the sample was aware of the term misophonia and 2.3%
identify as having the disorder.
S-Five statements
Statement responses
The norms of each of the S-Five item/statements for the UK population are presented in Table
1. More highly endorsed were the item statements which refer to ‘externalising appraisals’
(for example I06 ‘others should avoid making noises’). The least endorsed statements were
the statements related to being verbally aggressive (I04) and violent (I24), and impact (I01 ‘do
not meet friends’ and I20 ‘limited job opportunities’).
With respect to reported gender, females scored significantly lower than males in one of the
statements (I17 ‘physically aggressive’; Table 1). Almost all items had significant but weak,
negative correlations with age. The older the responder, the lower the endorsement of the
statements were, apart from I13 ‘others should not make sounds’ which was weakly related
to age.
EFA and CFA: dimensionality and measurement invariance
The data were suitable for factor analysis according to the diagnostic criteria (anti-image
correlations >0.88 in all statements, KMO=0.94, Bartlett’s test: χ2=13773,1, df=300, p<0.001).
The first random split half of the data was used in EFA. The sample correlation matrix with
five eigenvalues above 1 (10.3, 2.8, 1.7, 1.5, and 1.3) suggested a five-factor structure
according to Kaiser-Guttman criterion, explaining 73% of the total variance. Parallel analysis
also indicated that five factors should be extracted, as is depicted in the Scree plot in Figure
1. The goodness of fit examination suggested adequate to close fit indices for the five-factor
model (rel χ2=2.25; RMSEA=0.057 with 95% (0.050,0.065), TLI=0.90, CFI=0.93, SRMR=0.025).
We therefore accepted this solution (Table 2) and proceeded with CFA in the second split half
of the data which also indicated good fit to our data (rel χ2=2.38; RMSEA=0.066 with 95%
(0.060,0.072), TLI=0.88, CFI=0.89, SRMR=0.062). The model presented in Table 2 (EFA and CFA
loadings) coincides with the original model found by Vitoratou et al. (2021b) using responses
from people identifying with misophonia.
The complete sample was used in the evaluation of the measurement invariance of the tool
with respect to gender and age using a MIMIC model. At least one item per factor was found
to be non-invariant due to gender (six significant direct effects d.e. in total: I02 d.e.=0.22, I04
d.e.=0.23, I05 d.e.=0.35, I12 d.e.=0.48, I14 d.e. 0.12, I20 d.e=0.47, and I25 d.e.=-0.61).
However, the actual differences in the expected scores were remarkably low, as the
magnitude of all gender direct effects found significant was half a unit over eleven possible
units. For example, for the same levels of latent sound sensitivity, women are expected to
score significantly higher on the internalising statement I05 ‘respect myself less’ by 0.35 units,
on the 0-10 scale. When it comes to age, the effects were even less, with about 0.03 units
expected increase per year of age (I05 d.e.=0.03 and I08 d.e.=0.02). Therefore, we consider
the bias introduced in the measurement by gender and age minimal if not negligible and we
conclude that the assessment of structural invariance is attainable.
Norms for the UK population, reliability, and validity
The norms of the S-Five factor scores for the UK general population are presented in Table 2.
There were no significant differences in the total and factor scores with respect to gender.
All S-Five scores were significantly lower than those reported in the Vitoratou et al. (2021b)
sample of individuals who identify with the condition (p<0.001 in all cases; data available on
request).
With respect to internal consistency, alpha and omega were satisfactory for all factors (0.83
or higher; Table 2), while test-retest reliability was also satisfactory with ICC being larger than
0.86 for all S-Five scores. No significant differences occurred with respect to gender for each
factor of the S-Five, while negative low correlations emerged with age (-0.12 to -0.20), except
for the externalising factor (Table 2). The factor intercorrelations were moderate to
moderately strong and positive, as anticipated (Table 3).
Next, we follow Vitoratou et al. (2021b) and we present the correlations of the S-Five factor
and total scores with the two other misophonia scales (MQ and A-MISO-R), PHQ9
(depression) and GAD7 (anxiety; Table 3). All S-Five scores emerged moderately strong,
positive significant correlations with the MQ and A-MISO-R scores, thus providing evidence
of the concurrent, convergent validity of the measurements. Correlations between the S-Five
total scores and PHQ9 and GAD7 were weak to moderate with the lowest correlation between
the externalising factor and PHQ9, followed by correlations between GAD7 and externalising
factor, and PHQ9 and the impact factor.
S-Five trigger checklist (S-Five-T)
The scoring guide and the programming codes (SPSS, R project, Stata) to obtain factors and
indices are freely available upon request made to the first author.
Trigger count and reactions per trigger
On average, individuals reported a negative reaction to 17 triggers out of 37. Only 28
individuals selected no feeling to all sounds presented.
For each specific sound we computed the percentage of individuals who selected each
reaction. In this general population sample, the no feeling option was selected by most of the
participants across all sounds (see Figure 2 which presents the percentage of respondents
which selected each reaction for the 37 trigger items; for example, for the trigger sound
‘yawning’, 84% of the participants selected ‘no feeling’, 12% ‘irritation’, 1% selected ‘distress’,
etc).
For sounds such as ‘normal breathing’, ‘yawning’, ‘footsteps’, and ‘certain accents (letters)’,
more than 80% of the participants reported no feeling. On the contrary, there were sounds
where the percentages were reversed. For instance, less than 25% percent of the participants
reported no feeling when it came to the sounds ‘teeth sucking’, ‘[dog] barking’, slurping,
‘chewing gum’, ‘snoring’, ‘sniffing’, ‘coughing’, and ‘loud breathing’. The most frequently
reported negative reaction was irritation, for all trigger sounds except loud chewing, for which
disgust was more frequently reported (39%). The largest percentage of individuals reporting
distress was in relation to ‘baby crying’ (21%), reporting anger was in relation to ‘snoring’
(15%) and ‘barking’ (14%), and reporting panic was in relation to ‘footsteps’ (4%).
Reaction counts
For each specific reaction we computed the number of times (that is number of trigger
sounds) it was selected, over all triggers, to compute the corresponding reaction count (RC).
The norms for the UK population of the RC for each reaction to trigger sounds are
presented in Table 4. Women related more often than men to feelings of disgust and distress
to the triggers sounds, whereas men reported more often no feeling related to the triggers.
With respect to age, there were significant low negative correlations with all RC apart from
irritation where the correlation was positive (Table 4).
Table 5 presents the Intercorrelations of the S-Five, S-Five-T scores, and correlations
with other measures. There were significant positive moderate correlations between RCs and
the S-Five factors, A-MISO-S, and MQ, except for no feeling, which showed moderate negative
correlations (please see Table 5). Furthermore, the FIRS had moderate to strong correlations
with the S-Five factors, A-MISO-R, and MQ. Lower yet significant correlations emerged
between the RC scores and the measures of depression and anxiety.
Intensity of the emotional response. Table 6 presents the norms and reliability of the
intensity items for the 37 S-Five-T sounds. The highest mean intensity occurred in the ‘loud
chewing’, ‘repetitive barking’, ‘snoring’, and ‘chewing gum’ sounds (see also Figure 3).
Females reported higher intensity than males in all triggers, some were statistically
significant, with the largest differences occurring in ‘loud chewing’, ‘joint cracking’, and
‘slurping’. Very weak yet significant correlations with age emerged. The stability of the
intensity items was excellent (ICC>0.8).
Women had higher FIRS scores than men by 9 units on average (Table 6), while a very
low and negative correlation with age emerged. FIRS correlated very strongly and negatively
with the no feeling RC, indicating convergence validity of the scores. Moderate to strong
correlations emerged with other RC scores and had moderate to strong correlations with the
S-Five factor and total scores (Table 5). FIRS had low correlations with GAD7 and PHQ9, and
moderate with A-MISO-S and moderately strong correlations with the MQ symptom scale.
With respect to the total RIRS score (Table 6), no significant associations with age and
gender emerged. RIRS correlated negatively with the ‘no feeling’ RC, indicating convergence
validity of the scores. Moderate to strong correlations emerged with the other RC scores, the
S-Five factor and total scores, and the scores of the other measures (Table 5).
Prevalence of misophonia in the UK population. The Pre-OK-SCIM was implemented with 29
participants sampled from the general population and 26 from the misophonia population
(five individuals did not respond to our invitation). The two samples did not significantly differ
by age (t=0.55, df=53, p=0.59), with average age of 44 years old (mean=44.0, sd=13.7). Of the
general sample, 44.8% identified as women, compared to 84.6% women in the misophonia
sample (χ2 (1, N=55) =9.3786, p=0.002). The Pre-OK-SCIM classified 14% (4 participants) of the
general population sample and 81% (21 participants) of the misophonia sample as having
‘significant misophonia’.
The ROC analysis suggested a cut-off score for the S-Five total as 87 or above (out of 250) for
the presence of significant misophonia, where sensitivity and specificity were most balanced
(sensitivity 84%, specificity 72%, Youden’s J value 0.564, AUC=0.83). A large AUC was also
present for the impact (AUC=0.87) and threat scores (AUC=0.88), while the least
discriminative of the S-Five scores was the externalising factor (Figure 3). Moderately
discriminative were the S-Five-T scores (Figure A1).
With 87 as the cut-off point on the S-Five, we found that 142 individuals out of 772 met the
threshold for significant misophonia in our UK representative sample. Therefore, we
estimated that a percentage of 18.4% of the UK population experiences misophonia to an
extent that it causes significant burden. There were no significant differences in gender in the
prevalence of misophonia 2 (1, N=768) =0.06, p=0.80). The average age of those above the
threshold for misophonia (mean = 43.7 years; SD = 1.21) was lower than those below the
threshold for misophonia (mean = 47.0 years; SD = 0.63), and this difference was significant
(t=2.18, df=770, p=0.03). The age and gender of participants were not found to significantly
affect either the performance of the S-Five total score or the ability of the S-Five total score
to discriminate between cases and controls.
Discussion
The main purpose of this study was to evaluate the structure and psychometric properties of
the scale, present the S-Five and S-Five-T norms for the general UK population, and to
estimate the prevalence of misophonia in the UK.
Factor analyses supported the five-factor structure originally validated in a sample of
individuals identifying with misophonia (Vitoratou et al., 2021b), suggesting that this tool is
suitable for use in both clinical and community samples. Measurement invariance with
respect to age and gender was established. The scale showed satisfactory reliability indices
(internal consistency and stability) and concurrent (convergent and discriminant) validity. In
all assessments, the S-Five was found to have satisfactory psychometric properties for the UK
general population.
Average scores were highest for the externalising appraisals, and lowest in the impact factor.
This is in contrast to the pattern of findings found in the population of individuals identifying
with the condition (Vitoratou et al., 2021b), where the mean scores were the highest for the
threat factor while the lowest for the outburst factor. These results indicate that attributing
blame on others for making aversive sounds is a relatively common phenomenon, compared
with the other factors measured by the S-Five. This is supported by the finding that the
externalising factor showed to be the least discriminative of misophonia.
In relation to trigger sounds, we found that there were certain sounds that frequently elicited
a negative emotional response, such as loud chewing, slurping, snoring and loud breathing.
The most common reaction reported was irritation, except in the case of loud chewing, where
disgust was more frequent. This suggests that many of the sounds frequently reported as
triggers in misophonia are also aversive to the general population. However, there appear to
be two key differences in the pattern of trigger reactions in misophonia compared with the
general population. The first is in the types of triggers, for example, normal breathing being
indicative of higher levels of misophonia, and swallowing being a highly reliable indicator for
individuals with higher misophonia levels (Vitoratou et al., 2021a). Both these sounds were
reported as eliciting no feeling in most of the general population in the present study.
The second key difference is in the nature of the reaction, with anger and panic reported more
often in misophonia (Vitoratou et al., 2021b). We found that irritation was frequently
reported by the general population for a range of sounds, and that the irritation reaction
count had only a low correlation with the total S-Five and the A-MISO-S, providing further
evidence that responding with irritation is not a good indicator of the presence of misophonia
(Remmert et al., 2022; Vitoratou et al., 2021b). Additionally, irritation was not correlated with
any of the other negative emotion reaction counts (anger, disgust, distress and panic), nor
with symptoms of anxiety and depression, all of which were moderately correlated with each
other and with S-five total scores. This study estimated that almost one in five people (18.4%)
in the UK experience misophonia to a level where it causes significant burden in terms of
distress and impact. The prevalence and severity of misophonia appears to be similar in men
and women, which was surprising considering the disproportionate number of women in
previous misophonia research samples (see for instance Jager et al., 2021; Rouw et al., 2018;
Wu et al., 2014). Further, there was a small but significant difference in the average age for
those with significant and non-significant misophonia with those above the threshold for
misophonia being on average 3.3 years younger than those below the threshold. This is
consistent with the prevalence study in Ankara, Turkey (Kılıç et al., 2021), which indicated
younger age to be a predictor of misophonia. This could be due to improved coping strategies
and developing more effective organisation of everyday functioning to minimise the exposure
to sounds and their impact as the age progresses.
It is important to note that the preliminary version of the OK-SCIM was developed prior to
the consensus definition of misophonia as a disorder (Swedo et al., 2021). Our research team
have refined the OK-SCIM and are validating the tool’s capacity to distinguish clinical
misophonia (i.e. misophonia that causes current significant distress or impairment at a
“disordered” level) from subclinical misophonia (presence of misophonia symptoms without
current significant distress and impairment) and no misophonia. This will enable us to
estimate prevalence of misophonia as a disorder as well as significant symptoms of
misophonia. The present study should therefore be interpreted as the prevalence of
individuals who have misophonia symptoms to an extent that they consider it to cause a
significant burden in their lives.
The strength of the present study is that a large sample representative of the UK general
population was used, which contributed to the external validity of the results. Furthermore,
state-of-the-art psychometric techniques were used, including ROC curve regression analysis,
which allowed us to establish a meaningful cut-off score for significant misophonia, found not
to be affected by age or gender. We therefore present the best estimate available for
misophonia in the UK.
There were several limitations to this study. First, the sample was representative of the UK
population only; the results may differ across countries and cultures. Second, there were
limitations to the interview protocol, as described above. We attempted to minimise the
limitations of this tool by having it administered by qualified psychologists experienced in
working with misophonia, who were able to use the tool flexibly to determine the presence
or absence of significant misophonia. The OK-SCIM has since been refined by the research
team in line with the consensus definition of misophonia as a disorder (Swedo et al., 2021),
and subsequently tested for use by non-clinician interviewers, to validate its capacity to
identify subclinical and clinical misophonia (data currently being analysed). Finally, the
questionnaire should be tested in a treatment sample to assess its suitability for use as a
measure of clinical change.
In conclusion, our results show that the S-Five is a valid and reliable tool for measuring the
presence and severity of misophonia in the UK general population. The Vitoratou et al.
(2021b) five-factor solution was replicated in the general population data, with good
reliability and validity. By using semi-structured clinical interviews, we were able to establish
a cut-off score for significantly burdensome misophonia. This, in turn, allowed us to estimate
that the prevalence of misophonia in the UK is 18.4%. Our results show that misophonia is
relatively common condition and further research is needed to determine at what point this
condition becomes “disordered” in terms of distress, impact and need for treatment.
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Appendix
Table A1. The S-Five statements.
Please read each statement* carefully and base your answer on how true they feel to you based on your
current thoughts, experiences, and reactions.
Not at all true Completely true
0 1 2 3 4 5 6 7 8 9 10
Externalising
I13 People should not make certain sounds, even if they do not know about others’ sensitivities
I25 I get angry at other people because of how disrespectful they are with the noises they make
I06 People should do everything they can to avoid making noises that might bother others
I16 I react strongly to certain sounds because I cannot stand how selfish, thoughtless, or bad-mannered people can be
I21 Certain sounds are just bad manners, and it is not strange to feel intense anger about that
Internalising
I18 The way I react to certain sounds makes me wonder whether deep inside I am just a bad person
I08 The way I react to certain noises makes me feel like I must be an unlikable person deep down
I05 I respect myself less because of my responses to certain sounds
I12 I feel like I must be a very angry person inside because of the way I react to certain sounds
I19 I dislike myself in the moments of my reactions to sounds
Impact
I20 My job opportunities are limited because of my reaction to certain noises
I01 I do not meet friends as often as I would like to because of the noises they make
I14 There are places I would like to go but do not, because I am too worried about how the noises will impact me
I15 I can see future where I cannot do everyday things because of my reactions to noises
I09 The way I feel/react to certain sounds will eventually isolate me and prevent me from doing everyday things
Outburst
I17 I can get so angry at certain noises that I get physically aggressive towards people to make them stop
I22 Sometimes I get so distressed by noises that I use violence to try and make it stop
I23 Some sounds are so unbearable that I will shout at people to make them stop
I04 If people make certain sounds that I cannot bear, I become verbally aggressive
I24 I am afraid I will do something aggressive or violent because I cannot stand the noise someone is making
Threat
I11 I feel trapped if I cannot get away from certain noises
I07 I feel anxious if I cannot avoid listening to certain sounds
I02 If I cannot get away from certain noises, I am afraid I might panic or feel like I will explode
I03 If I cannot avoid certain sounds, I feel helpless
I10 I can experience distress as the result of some noises
* Items should be randomised before being administered and without enumeration.
Table A2. Scoring instructions for the S-Five.
Item number
Score calculation
Range
I13, I25, I06, I16, I21
I13 + I25 + I06 + I16 + I21
0-50
I18, I08, I05, I12, I19
I18 + I08 + I05 + I12 + I19
0-50
I20, I01, I14, I15, I09
I20 + I01 + I14 + I15 + I09
0-50
I17, I22, I23, I04, I24
I17 + I22 + I23 + I04 + I24
0-50
I11, I07, I02, I03, I10
I11 + I07 + I02 + I03 + I10
0-50
Total S-Five-E score
I01-I25
Σ
"(I01-I25)
0-250
*Each factor has 5 items rated on a 0-10 ordinal scale, thus the scores are directly
comparable in terms of statement endorsement.
The scoring guide and the programming codes (SPSS, R project, Stata) to obtain all factors
and indices are freely available upon request made to the first author.
The S-Five, © Copyright King’s College London, 2021. All Rights Reserved.
Table A3. The S-Five-t triggers checklist and scoring.
Trigger reaction items
Thinking about the past few weeks, what is the main feeling this sound* has caused you? (please choose the most
characteristic one)
No feeling Irritation Distress Disgust Anger Panic Other feeling: Negative Other feeling: Positive Other: Physiological reaction
Sound*
Trigger intensity items
Thinking about the past few weeks, please rate the intensity of your reaction to this sound* when made by another
person or object (from 0: doesn't bother me at all to 10: unbearable/causes suffering).
Doesn’t bother me at all Unbearable/causes suffering
0 1 2 3 4 5 6 7 8 9 10
Sound*
*List of triggers currently included in the S-Five-t: Normal eating sounds, Certain letter sounds, Mushy foods being eaten,
Sound of clipping nails, Swallowing, Keyboard tapping, Lip smacking, Normal breathing, Repetitive engine noises,
Loud/unusual breathing, Mobile phone sounds, Repetitive coughing, Humming noise, Repetitive sniffing, Snoring, Certain
accents, Whistling sound, Sound of tapping, Rustling, Chewing gum, Footsteps, Hiccups, Slurping, Cutlery noises, Sneezing,
Certain words, Kissing, Joint cracking, Muffled sounds, Throat clearing, Baby crying, Repetitive barking, Loud chewing,
Clock ticking, Crunching eating sounds, Teeth sucking, Yawning.
Scoring
Trigger Count (TC) for each participant over all triggers: the index is computed by counting the number of non-zero
responses in the trigger intensity items. The index takes values between 0 and the number of triggers considered, here
37, and provides information on the volume of triggers.
Example: if an individual selected ‘no feeling’ or, ‘other: positive’ reaction to a trigger to 32 out of 37 triggers, their TC
would be 5, that is, the number of triggers they experience.
Reaction Count (RC) for each trigger over all participants: the index is computed for each reaction type separately, by
counting over all participants the times a certain reaction was selected (using the trigger response items). The RC for each
reaction (i.e., RC-Anger, RC- Irritability etc) takes values between 0 and the number of triggers considered, here 37. The
index provides information on the frequency of endorsement of each specific reaction, across participants and triggers.
Example: if an individual selected anger as their main emotional reaction to three different triggers, and panic as their
main reaction to two triggers, then their RC-anger would be 3 and their RC-panic would be 2.
Frequency/Intensity of Reactions Score (FIRS): the index is computed by counting the trigger intensity items. FIRS takes
values between 0 and ten times the number of triggers considered, here between 0 and 370. The index provides a
combined information of the number of triggers and their intensity.
Example: if an individual reported 5 triggers and the highest possible intensity to each (that is 10), their FIRS value would
be 50. The same score would correspond to a participant who reported 10 triggers but of moderate intensity 5 to each.
Relative Intensity of Reactions Score (RIRS): the index is computed by dividing the FIRS index by the trigger
count TC, to derive an estimation of the intensity of the responses to triggers, relative to the number of
triggers reported. RIRS takes values between 0 and 100 and provides information on the intensity of the
response to triggers regardless of their number.
Example: if an individual with FIRS equal to 50 as before reported 5 triggers with intensity 10 each, their RIRS
would equal 10. But if an individual receives the same FIRS (50) by reporting 10 triggers of moderate intensity
(5), their RIRS would be 5.
The scoring guide and the programming codes (SPSS, R project, Stata) to obtain all factors and indices are freely available
upon request made to the first author.
The S-Five, © Copyright King’s College London, 2021. All Rights Reserved.
Table A4. Full list of administered questionnaires.
Bryant and Smith Aggression Questionnaire (BS-AQ; Bryant & Smith, 2001) is a shorter refined version of the
original AQ, with 12 items rather than 29 items, rated on a five-point Likert scale. The scale captures four aspects
of aggression: physical aggression, verbal aggression, anger and hostility. Higher scores are indicative of higher
levels of aggressive behaviour.
Generalized Anxiety Disorder-7 Questionnaire (GAD-7; Spitzer et al., 2006) screens for measures severity of
generalised anxiety disorder. The questionnaire asks the rater to consider the past two weeks and rate each
item on a four-point scale from ‘Not at all’ to ‘Nearly every day’. The scores for each item are totalled, with
higher scores suggesting higher levels of generalised anxiety.
The Patient Health Questionnaire-9 (PHQ-9), from Kroenke et al. (2001), is the brief assessment of depression
severity. The nine DSM-5 criteria are scored on a four-point scale, with higher scores indicating higher severity
of depression.
The Work and Social Adjustment Scale (WSAS; Mundt et al., 2002) is a simple measure of impairment in
functioning, consisting of five items rated on a nine-point scale from “Not at all” (0) to “Severely impaired” (8).
Higher scores on the WSAS indicate a greater level of impairment in work and social aspects of life.
The Beliefs about Emotions Scale (BES; Rimes & Chalder, 2010) is a 12-item questionnaire on beliefs regarding
the inability to accept negative emotions, and the adverse consequences of experiencing and expressing those
emotions. Items are rated on a seven-point Likert scale, specifying level of agreement or disagreement.
The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) assesses a receptive state of mind, which
is a core feature of mindfulness. MAAS contains 15 items measured on a six-point ordinal scale ranging from
‘almost always’ to ‘almost never’.
The Autonomous Sensory Meridian Response (ASMR-15; Roberts et al., 2019) is a questionnaire assessing
altered state of consciousness phenomena, namely autonomous sensory meridian response (ASMR), which is
characterised by pleasurable tingling sensation in response to certain audio-visual stimuli, causing relaxation
and euphoria. The 15-item scale is rated on a scale from 1, ‘completely untrue for me’ to 5, ‘completely true for
me’, and consists of four subscales: altered consciousness, sensation, relaxation and affect.
The reduced-item Disgust Propensity and Sensitivity Scale-Revised (DPSS-R; Fergus & Valentiner, 2009)
consists of 12 items on a five-point response scale that assess how easily one is disgusted, known as disgust
propensity, and how bothered a person is by their disgust, which is described as disgust sensitivity, both of
which contribute to disgust reactions.
The Anxiety Sensitivity Index (ASI-3; Taylor et al., 2007) is a shorter 18-item version of the original anxiety
sensitivity index (Peterson & Reiss, 1992). It assesses anxiety sensitivity conceptualised as one’s considerations
regarding misinterpretations of anxiety-related sensations. The scale measures anxiety sensitivity on physical,
cognitive, and social dimensions.
The Adult Eating Behaviour Questionnaire (AEBQ; Hunot et al., 2016) is a 35-item measure that assesses
appetitive traits in adulthood. AEBQ consists of eight subscales; however, for the purpose of this study only
‘food fussiness’ subscale was implemented, which consists of five items measured on a five-point Likert scale
ranging from ‘strongly disagree’ to ‘strongly agree’.
The Temperament Evaluation of Memphis, Pisa, Paris and San Diegoautoquestionnaire (TEMPS-A; Akiskal
et al., 2005) measures temperamental variations based on diagnostic classifications for affective
temperaments, namely cyclothymic, dysthymic, irritable, hyperthymic, and anxious, and has five subscales
named as such. The scale is a yes-or-no type questionnaire and consists of 39 items.
The Big Five Inventory (BFI; John & Srivastava, 1999) is a 44-item questionnaire with a five-point Likert
agreement scale, which measures one’s personality on the Big Five Factors of personality: extraversion vs.
introversion, agreeableness vs. antagonism, conscientiousness vs. lack of direction, neuroticism vs. emotional
stability, openness vs. closedness to experience. Those factors are further separated into personality
dimensions.
The Leahy Emotional Schema Scale II (LESS II; Leahy, 2012) is a 28-item measure with a six-point ordinal
response scale that determines beliefs and attributions about emotions. The scale is divided into fourteen
dimensions: invalidation, incomprehensibility, guilt, simplistic view of emotion, devalued, loss of control,
numbness, overly rational, duration, low consensus, non-acceptance of feelings, rumination, low expression,
and blame.
The Misophonia Questionnaire (MQ; Wu et al., 2014) is a 34-item scale consisting of three sections that
assesses misophonia regarding the presence of specific triggers, emotional and behavioural responses and its
severity. The first two sections, misophonia symptom scale and misophonia emotions and behaviours scale, are
rated on a five-point ordinal scale, whilst the third section, Misophonia Severity Scale, measures one’s severity
of sound sensitivity on a 1 to 15-point scale, with 1 suggesting minimal sound sensitivity and 15 indicating very
severe sensitivity.
The Amsterdam Misophonia Scale (A-MISO-S; Schröder et al., 2013) is a six-item scale that measures different
facets of misophonia, namely time consumed by the condition, its impact on one’s functioning, level of distress,
level of resistance, perceived control over thoughts, and avoidance behaviours.
Figure A 1: ROC curves and the estimated area under the curve (AUC) for each of the S-Five-T scores
Tables and Figures
Table 1: Descriptive indices, associations with age and gender, factor analysis loadings, and reliability indices of the 25 S-Five items (N=772)
S-Five-E
statements per factor
mean
(sd)
median
(Q1-Q3)
mode
(min-max)
Age
rho
Gender
difference
mean (se)
loadings
EFA (CFA) a
Psi
(95% CI)
ICC
Externalising
I06 Others avoid making noises
4.8 (3.3)
5 (2-8)
0 (0-10)
**0.11
0.40 (0.2)
0.67 (0.73)
0.81 (0.8,1)
0.86
I13 Others should not make sounds
4.1 (3.3)
4 (1-7)
0 (0-10)
0.06
0.35 (0.2)
0.82 (0.76)
0.80 (0.8,1)
0.86
I16 Others selfish
2.9 (3.0)
2 (0-5)
0 (0-10)
-0.04
0.36 (0.2)
0.69 (0.82)
0.80 (0.8,1)
0.86
I21 Others bad manners
4.9 (3.3)
5 (2-8)
10 (0-10)
-0.03
0.12 (0.2)
0.94 (0.76)
0.79 (0.8,1)
0.85
I25 Others disrespectful
2.7 (3.0)
1 (0-5)
0 (0-10)
-0.01
0.38 (0.2)
0.67 (0.73)
0.80 (0.8,1)
0.86
Internalising
I05 Respect myself less
0.9 (2.0)
0 (0-1)
0 (0-10)
**-0.12
-0.01 (0.1)
0.83 (0.79)
0.75 (0.7,1)
0.84
I08 Unlikeable person
1.2 (2.1)
0 (0-1)
0 (0-10)
**-0.22
-0.21 (0.2)
0.89 (0.85)
0.77 (0.7,1)
0.85
I12 Angry person inside
1.6 (2.5)
0 (0-2)
0 (0-10)
**-0.17
-0.21 (0.2)
0.82 (0.86)
0.78 (0.8,1)
0.85
I18 Bad person inside
1.2 (2.2)
0 (0-1)
0 (0-10)
**-0.24
-0.29 (0.2)
0.66 (0.87)
0.77 (0.7,1)
0.85
I19 Dislike self
1.4 (2.4)
0 (0-2)
0 (0-10)
**-0.20
-0.07 (0.2)
0.82 (0.83)
0.78 (0.8,1)
0.85
Impact
I01 Do not meet friends
0.6 (1.4)
0 (0-1)
0 (0-10)
**-0.12
0.05 (0.1)
0.55 (0.61)
0.75 (0.7,1)
0.84
I09 Eventually isolated
0.9 (1.9)
0 (0-1)
0 (0-10)
**-0.15
-0.09 (0.1)
0.71 (0.91)
0.76 (0.7,1)
0.84
I14 Avoid places
1.3 (2.3)
0 (0-1)
0 (0-10)
-0.05
-0.03 (0.2)
0.66 (0.67)
0.76 (0.7,1)
0.84
I15 Cannot do everyday things
0.8 (1.7)
0 (0-1)
0 (0-10)
**-0.10
-0.06 (0.1)
0.60 (0.91)
0.75 (0.7,1)
0.84
I20 Limited job opportunities
0.5 (1.4)
0 (0-0)
0 (0-10)
**-0.14
-0.13 (0.1)
0.38 (0.68)
0.74 (0.7,1)
0.84
Outburst
I04 Verbally aggressive
1.7 (2.4)
1 (0-2)
0 (0-10)
**-0.22
-0.12 (0.2)
0.55 (0.78)
0.78 (0.8,1)
0.85
I17 Physically aggressive
0.8 (1.6)
0 (0-1)
0 (0-10)
-0.07
*0.21 (0.1)
0.73 (0.77)
0.74 (0.7,1)
0.84
I22 Violence
0.5 (1.3)
0 (0-0)
0 (0-9)
**-0.14
0.13 (0.1)
0.56 (0.72)
0.71 (0.7,1)
0.83
I23 Shout at people
1.8 (2.6)
1 (0-3)
0 (0-10)
**-0.12
-0.01 (0.2)
0.65 (0.73)
0.79 (0.8,1)
0.85
I24 Afraid of outburst
0.6 (1.5)
0 (0-1)
0 (0-9)
**-0.13
0.13 (0.1)
0.56 (0.69)
0.73 (0.7,1)
0.83
Threat
I02 Panic or explode
2.3 (2.9)
1 (0-4)
0 (0-10)
**-0.18
-0.39 (0.2)
0.73 (0.82)
0.82 (0.8,1)
0.86
I03 Feel helpless
2.2 (2.9)
1 (0-4)
0 (0-10)
**-0.14
-0.26 (0.2)
0.80 (0.87)
0.82 (0.8,1)
0.86
I07 Feel anxious
3.0 (3.3)
2 (0-5)
0 (0-10)
**-0.14
-0.42 (0.2)
0.66 (0.88)
0.84 (0.8,1)
0.87
I10 Experience distress
4.0 (3.3)
3 (1-7)
0 (0-10)
**-0.14
-0.11 (0.2)
0.77 (0.79)
0.84 (0.8,1)
0.87
I11 Feel trapped
3.1 (3.3)
2 (0-6)
0 (0-10)
**-0.10
-0.40 (0.2)
0.60 (0.87)
0.83 (0.8,1)
0.87
Q1 Q3 first and third quartile; ICC intraclass correlation coefficient; Psi coefficient and 95% confidence intervals; rho: Spearman’s correlation
coefficient; *p<0.05; **p<0.01; ‡ mean difference (se) male vs female comparison, p-value via Mann Whitney test; aCFA loadings were standardised
(STDXY).
Table 2: Norms and reliability of the S-Five 5 factors and total scores (N=772)
Factor
descriptive indices
internal consistency
stability
mean
(sd)
median
(Q1-Q3)
mode
(min-max)
Gender
difference
mean (sd)
Age
rho
α / ω
ITC
Psi
(95% CI)
ICC
Externalising
19.38 (12.9)
18 (9 -29)
7 (0 - 50)
-1.6 (0.9)
0.02
0.87 / 0.87
0.66-0.73
0.84 (0.8,1)
0.87
Internalising
6.34 (9.7)
2 (0 -9)
0 (0 - 49)
0.8 (0.7)
**-0.23
0.91 / 0.92
0.70-0.84
0.82 (0.8,1)
0.86
Impact
4.05 (7.0)
1 (0 -5)
0 (0 - 48)
0.3 (0.5)
**-0.11
0.85 / 0.86
0.56-0.79
0.81 (0.8,1)
0.86
Outburst
5.28 (7.5)
2 (0 -7)
0 (0 - 44)
-0.3 (0.5)
**-0.17
0.83 / 0.84
0.61-0.71
0.81 (0.8,1)
0.86
Threat
14.58 (13.8)
10 (3 -23)
0 (0 - 50)
1.6 (1)
**-0.17
0.93 / 0.93
0.75-0.85
0.87 (0.8,1)
0.89
S-Five total
49.64 (40.1)
38 (18 -72)
0 (0 - 215)
0.7 (2.9)
**-0.13
0.94 / 0.94
0.43-0.75
0.87 (0.8,1)
0.88
mean difference (standard error) male vs female comparison, p-value via Mann Whitney test; sd: standard deviation; Q1 and Q3 first and third
quartile respectively; α: Cronbach’s alpha; ω: McDonald’s omega; ITC: item-total correlations; ICC: intraclass correlation coefficient (two-way mixed
effects, absolute agreement).
Table 3: Intercorrelations of the S-Five scores, and correlations with other measures (validity)
Externalising
Internalising
Impact
Outburst
Threat
Total
S-Five
S-Five (N=772)
Internalising
0.39
Impact
0.36
0.61
Outburst
0.48
0.61
0.56
Threat
0.54
0.62
0.60
0.60
Total
0.79
0.73
0.67
0.73
0.88
A-MISO-S (N=396)
Total
0.38
0.47
0.47
0.43
0.55
0.59
MQ (N=376)
MSYS (N=295)
0.38
0.41
0.30
0.39
0.44
0.49
MEBS (N=286)
0.50
0.53
0.51
0.62
0.68
0.72
MSES (N=376)
0.37
0.45
0.44
0.38
0.56
0.56
Total (N=295)
0.51
0.55
0.47
0.60
0.66
0.71
PHQ9 (N=761)
Total
0.19
0.34
0.27
0.29
0.40
0.37
GAD7 (N=772)
Total
0.25
0.37
0.31
0.30
0.45
0.43
Correlations are Spearman’s rho and p-value<0.01 in all cases; A-MISO-S: Amsterdam Misophonia
Scale; MQ: Misophonia Questionnaire; MSYS: Misophonia Symptoms Scale; MEBS: Misophonia
Emotions and Behaviours Scale; MSES: Misophonia Severity Scale; PHQ-9: Physical Health
Questionnaire; GAD-7: Generalised Anxiety Disorder Assessment.
Table 4: Norms and reliability of the S-Five-T scores
S-Five RC
(N=752)
mean
(sd)
median
(Q1-Q3)
mode
(min-max)
gender
difference
mean (se)‡
age
rho
Psi
(95% CI)
ICC
No feeling
18.7 (6.7)
18 (14-23)
17 (1-37)
*-1.4 (0.5)
0.06
0.85 (0.82,1)
0.87
Irritation
12 (5.0)
12 (9-15)
14 (0-29)
0.5 (0.4)
**0.19
0.82 (0.79,1)
0.86
Distress
1.2 (1.6)
1 (0-2)
0 (0-9)
**0.3 (0.1)
**-0.17
0.79 (0.76,1)
0.85
Disgust
2.2 (2.5)
1 (0-4)
0 (0-12)
**0.8 (0.2)
**-0.10
0.82 (0.8,1)
0.87
Anger
1.1 (1.7)
0 (0-2)
0 (0-16)
0 (0.1)
**-0.17
0.77 (0.75,1)
0.85
Panic
0.3 (0.8)
0 (0-0)
0 (0-7)
0 (0.1)
**-0.25
0.69 (0.67,1)
0.82
TC
17.5 (6.5)
18 (13-22)
17 (0-36)
*1.7 (0.5)
-0.01
0.85 (0.83,1)
0.88
FIRS
65 (41.6)
58 (32-88)
58 (1-241)
*9 (3.1)
**-0.15
0.85 (0.82,1)
0.87
RIRS
3.6 (1.5)
3 (2-5)
2 (0-10)
0.2 (0.1)
**-0.19
0.82 (0.79,1)
0.86
RC: response count; TC total count; FIRS frequency and intensity reaction count; RIRS relative intensity of
reactions score; sd standard deviation; Q1 Q3 first and third quartile; rho: Spearman’s correlation coefficient;
ICC intraclass correlation coefficient; Psi coefficient and 95% confidence intervals; *p<0.05; **p<0.01; ‡ mean
difference (se) male vs female comparison, p-value via Mann Whitney test.
Table 5: Intercorrelations of the S-Five, S-Five-T scores, and correlations with other measures
(validity assessment)
No feeling
Irritation
Distress
Disgust
Anger
Panic
TC
FITS
RIRS
S-Five RC (N=752)
No feeling
**-0.61
**-0.43
**-0.51
**-0.44
**-0.34
**-0.97
**-0.76
**-0.30
Irritation
0.05
-0.04
0.01
-0.06
**0.67
**0.33
*-0.09
Distress
**0.26
**0.16
**0.25
**0.41
**0.38
**0.21
Disgust
**0.39
**0.23
**0.50
**0.59
**0.42
Anger
**0.28
**0.43
**0.57
**0.47
Panic
**0.29
**0.35
**0.28
TC
**0.76
**0.28
FITS
**0.81
S-Five Factors (N=752)
Externalising
**-0.35
**0.11
**0.13
**0.35
**0.37
**0.16
**0.36
**0.48
**0.41
Internalising
**-0.36
**0.10
**0.26
**0.28
**0.33
**0.26
**0.37
**0.50
**0.43
Impact
**-0.31
*0.09
**0.26
**0.22
**0.26
**0.26
**0.31
**0.43
**0.38
Outburst
**-0.35
0.07
**0.25
**0.29
**0.40
**0.25
**0.35
**0.48
**0.41
Threat
**-0.40
*0.08
**0.36
**0.31
**0.37
**0.30
**0.39
**0.51
**0.43
Total
**-0.44
**0.10
**0.30
**0.38
**0.44
**0.30
**0.44
**0.60
**0.52
A-MISO-S (N=319)
Total
**-0.36
*0.13
**0.18
**0.32
**0.37
**0.21
**0.38
**0.44
**0.32
MQ (N=300)
MSYS (N=261)
**-0.52
**0.27
**0.18
**0.38
**0.37
**0.19
**0.54
**0.56
**0.33
MEBS (N=261)
**-0.39
0.05
**0.19
**0.27
**0.44
**0.33
**0.39
**0.49
**0.43
MSES (N=300)
**-0.33
0.08
**0.18
**0.23
**0.31
**0.27
**0.31
**0.38
**0.29
Total (N=261)
**-0.52
**0.16
**0.21
**0.37
**0.47
**0.31
**0.51
**0.60
**0.46
PHQ9 (N=726)
Total
**-0.29
0.07
**0.25
**0.22
**0.25
**0.24
**0.28
**0.31
**0.22
GAD7 (N=736)
Total
**-0.22
0.02
**0.22
**0.23
**0.20
**0.23
**0.22
**0.26
**0.19
RC: response count; TC total count; FIRS frequency and intensity reaction count; RIRS relative intensity of reactions score; rho:
Spearman’s correlation coefficient; A-MISO-S: Amsterdam Misophonia Scale; MQ: Misophonia Questionnaire; MSYS: Misophonia
Symptoms Scale; MEBS: Misophonia Emotions and Behaviours Scale; MSES: Misophonia Severity Scale; PHQ-9: Physical Health
Questionnaire; GAD-7: Generalised Anxiety Disorder Assessment.
Table 6: Norms and reliability of the intensity items for the 37 S-Five-T sounds
Trigger sounds
mean
(sd)
median
(Q1-Q3)
mode
(min-max)
Average
gender
difference
age
rho
Psi
(95% CI)
ICC
Normal eating
sounds
0.90 (1.8)
0 (0 -1)
0 (0 -10)
-0.2 (0.1)
-0.1
0.74 (0.72,1)
0.84
Certain letter
sounds
0.30 (1.1)
0 (0 -0)
0 (0 -10)
-0.1 (0.1)
-0.1
0.69 (0.67,1)
0.82
Mushy foods
1.27 (2.2)
0 (0 -2)
0 (0 -10)
-0.1 (0.2)
**-0.2
0.74 (0.71,1)
0.84
Sound of clipping
nails
1.16 (2.0)
0 (0 -2)
0 (0 -10)
*-0.6 (0.1)
0
0.77 (0.75,1)
0.85
Swallowing
0.71 (1.7)
0 (0 -0)
0 (0 -10)
-0.2 (0.1)
**-0.2
0.73 (0.71,1)
0.83
Keyboard tapping
0.88 (1.7)
0 (0 -1)
0 (0 -10)
-0.1 (0.1)
0
0.74 (0.72,1)
0.84
Lip smacking
1.66 (2.3)
0 (0 -3)
0 (0 -10)
**-0.5 (0.2)
**-0.2
0.78 (0.75,1)
0.85
Normal breathing
0.23 (1.0)
0 (0 -0)
0 (0 -9)
0 (0.1)
**-0.1
0.67 (0.67,1)
0.82
Repetitive engine
2.14 (2.3)
2 (0 -3)
0 (0 -10)
0 (0.2)
0
0.79 (0.76,1)
0.85
Blocked nose
2.67 (2.4)
2 (0 -4)
0 (0 -10)
**-0.5 (0.2)
**-0.2
0.8 (0.77,1)
0.86
Mobile phone
1.48 (2.0)
0 (0 -3)
0 (0 -10)
0 (0.2)
*0.1
0.76 (0.74,1)
0.84
Repetitive
coughing
2.84 (2.4)
2 (1 -5)
0 (0 -10)
-0.1 (0.2)
0
0.79 (0.77,1)
0.85
Humming
1.46 (2.1)
0 (0 -2)
0 (0 -9)
-0.2 (0.2)
0
0.77 (0.75,1)
0.85
Repetitive sniffing
3.28 (2.6)
3 (1 -5)
0 (0 -10)
**-0.6 (0.2)
0
0.83 (0.8,1)
0.87
Snoring
3.54 (3.0)
3 (0 -6)
0 (0 -10)
**-0.9 (0.2)
0
0.83 (0.81,1)
0.87
Certain accents
0.97 (1.9)
0 (0 -1)
0 (0 -10)
*0.3 (0.1)
0.1
0.73 (0.7,1)
0.83
Whistling sound
1.30 (2.1)
0 (0 -2)
0 (0 -10)
-0.2 (0.2)
0
0.76 (0.74,1)
0.84
Tapping
1.99 (2.4)
1 (0 -3)
0 (0 -10)
*-0.4 (0.2)
0
0.81 (0.79,1)
0.86
Rustling plastic or
paper
0.99 (1.9)
0 (0 -1)
0 (0 -10)
0 (0.1)
-0.1
0.76 (0.74,1)
0.84
Chewing gum
3.31 (2.8)
3 (1 -5)
0 (0 -10)
**-0.5 (0.2)
0
0.79 (0.77,1)
0.85
Footsteps
0.50 (1.5)
0 (0 -0)
0 (0 -10)
0.1 (0.1)
**-0.2
0.71 (0.69,1)
0.83
Hiccups
0.67 (1.5)
0 (0 -1)
0 (0 -9)
0.1 (0.1)
0
0.75 (0.72,1)
0.84
Slurping
2.99 (2.6)
3 (1 -5)
0 (0 -10)
**-0.8 (0.2)
0
0.8 (0.78,1)
0.86
Cutlery
2.87 (2.9)
2 (0 -5)
0 (0 -10)
**-0.6 (0.2)
**-0.2
0.81 (0.78,1)
0.86
Sneezing
0.99 (1.9)
0 (0 -1)
0 (0 -10)
0.1 (0.1)
0
0.74 (0.72,1)
0.84
Certain words
1.13 (2.1)
0 (0 -2)
0 (0 -10)
0 (0.2)
*0.1
0.75 (0.73,1)
0.84
Kissing
0.58 (1.6)
0 (0 -0)
0 (0 -10)
**-0.4 (0.1)
**-0.2
0.72 (0.7,1)
0.83
Joint cracking
1.83 (2.5)
0 (0 -3)
0 (0 -10)
**-0.9 (0.2)
*0.1
0.8 (0.77,1)
0.86
Muffled sounds
2.16 (2.5)
2 (0 -3)
0 (0 -10)
0.2 (0.2)
0
0.79 (0.76,1)
0.85
Throat clearing
1.89 (2.4)
1 (0 -3)
0 (0 -10)
*-0.4 (0.2)
0
0.78 (0.75,1)
0.85
Baby crying
2.78 (2.8)
2 (0 -5)
0 (0 -10)
0 (0.2)
**-0.2
0.83 (0.8,1)
0.87
Repetitive barking
3.63 (2.8)
3 (1 -6)
0 (0 -10)
-0.2 (0.2)
*0.1
0.81 (0.79,1)
0.86
Loud chewing
4.21 (3.0)
4 (2 -6)
0 (0 -10)
**-0.8 (0.2)
*-0.1
0.84 (0.82,1)
0.87
Clock ticking
1.02 (2.0)
0 (0 -1)
0 (0 -10)
-0.1 (0.2)
*-0.1
0.77 (0.74,1)
0.84
Crunching
1.29 (2.2)
0 (0 -2)
0 (0 -10)
-0.2 (0.2)
*-0.1
0.78 (0.75,1)
0.85
Teeth sucking
2.06 (2.5)
1 (0 -3)
0 (0 -10)
**-0.5 (0.2)
0
0.8 (0.78,1)
0.86
Yawning
0.44 (1.3)
0 (0 -0)
0 (0 -9)
-0.1 (0.1)
0
0.72 (0.7,1)
0.83
sd standard deviation; Q1 Q3 first and third quartile; rho: Spearman’s correlation coefficient; ICC intraclass correlation
coefficient; Psi coefficient and 95% confidence intervals; *p<0.05; **p<0.01; ‡ mean difference (se) male vs female
comparison, p-value via Mann Whitney test.
Figure 1: Scree plot and parallel analysis visualisation
Figure 2 Percentages of selection per feeling per trigger
Figure 2: ROC curves and the estimated area under the curve (AUC) for each of the S-Five scores
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Introduction People with misophonia experience strong negative emotional responses to sounds and associated stimuli—mostly human produced—to an extent that it may cause impairment in social functioning. The exact nature of the disorder remains a matter of ongoing research and debate. Here, we investigated the genetic etiology of misophonia to understand contributing genetic factors and shed light on individual differences in characteristics that are related to the disorder. Methods For misophonia, we used an unpublished genome-wide association study (GWAS) from genetic service provider 23andMe, Inc., on a self-report item probing a single common misophonic symptom: the occurrence of rage when others produce eating sounds. First, we used gene-based and functional annotation analyses to explore neurobiological determinants of the rage-related misophonia symptom. Next, we calculated genetic correlations (rG) of this rage-related misophonia symptom GWAS with a wide range of traits and disorders from audiology (tinnitus, hearing performance, and hearing trauma), psychiatry, neurology, and personality traits. Results The rage-related misophonia symptom was significantly correlated with tinnitus, major depression disorder (MDD), post-traumatic stress disorder (PTSD), and generalized anxiety disorder (GAD; 0.12 < rG < 0.22). Stronger genetic correlations (0.21 < rG < 0.42) were observed for two clusters of personality traits: a guilt/neuroticism and an irritability/sensitivity cluster. Our results showed no genetic correlation with attention deficit and hyperactivity disorder, obsessive-compulsive disorder, and psychotic disorders. A negative correlation with autism spectrum disorder (ASD) was found, which may be surprising given the previously reported comorbidities and the sensory sensitivity reported in ASD. Clustering algorithms showed that rage-related misophonia consistently clustered with MDD, generalized anxiety, PTSD, and related personality traits. Discussion We conclude that—based on the genetics of a common misophonia symptom—misophonia most strongly clusters with psychiatric disorders and a personality profile consistent with anxiety and PTSD.
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The Selective Sound Sensitivity Syndrome Scale (S-Five) is a contemporary and multidimensional self-report instrument measuring different aspects of misophonia. The five-factor scale consists of 25 items measuring the severity of the misophonic experience. The items capture misophonia in relation to internalising and externalising appraisals, perceived threat, aggressive behavior (outbursts), and adverse impact on individuals’ lives. It is complemented by a trigger checklist (S-Five-T), measuring the emotional nature and intensity of reactions to sensory triggers. In this work, we administered the S-Five in two German samples with a majority of individuals with significant misophonia. The S-Five and the supplementary S-Five-T were both translated into German using a rigorous translation procedure (i.e., TRAPD) and were separately tested in large German community samples. Psychometric analyses included the evaluation of the factor structure, measurement invariance with respect to age and gender, reliability (internal consistency and stability over time), and an extensive examination of the construct validity in a proposed nomological network. The nomological network we explore in this work consists of several constructs including different misophonic manifestations, anger and aggression, disgust propensity, anxiety sensitivity, depression, obsessive–compulsive traits, and functional impairment in different life domains. Results indicate evidence in line with the nomological network as demonstrated by strong correlations between the S-Five dimensions and convergent measures. All S-Five dimensions strongly correlated with overall misophonic symptoms (r ≥ 0.53). Internalising appraisals were highly associated with insight into excessive or disproportionate reactions to sounds (r ≥ 0.59), externalising appraisals with anger and irritability (r ≥ 0.46), threat with trait anxiety and dysregulation facets (r ≥ 0.62), aggressive behavior (outbursts) with anger and behavioral dysregulation (r ≥ 0.70), and impact with distress and functional impairment (r ≥ 0.64). The results demonstrate that the S-Five has a robust five-factor structure and allows to draw reliable and valid conclusions about misophonic experiences in German samples. The proposed nomological network gives an initial insight into the nature of misophonia and provides a formalized fundament to develop and test further hypotheses about misophonia in a more sophisticated and symptom-oriented way.
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Misophonia involves a strong emotional response to certain sounds and can cause signifi- cant distress and functional impairment. The aim of this study was to present and psychometrically evaluate a new, multidimensional measure of misophonia, the S-Five. The study also aimed to present and test a supplementary tool, a checklist of triggers that measure the nature and intensity of reactions. The stages of development for the measure are described. Psychometric testing on the final version of the tool was conducted using a sample of 828 individuals who identified with having misophonia. Analyses included factor structure assessment, measurement invariance testing, relia- bility (test–retest and internal consistency), and (concurrent) convergent validity assessment. Five factors emerged in the S-Five as dimensions of the experience of misophonia: internalising appraisals, externalising appraisals, sense of emotional threat, outbursts, and impact. No measurement bias was identified with respect to gender and age. All reliability and validity indices were satisfactory. The S-Five is a multidimensional measurement scale with satisfactory psychometric properties and will be a valuable tool for improving understanding of misophonia in research and clinical settings.
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Misophonia is characterised by a low tolerance for day-to-day sounds, causing intense negative affect. This study conducts an in-depth investigation of 35 misophonia triggers. A sample of 613 individuals who identify as experiencing misophonia and 202 individuals from the general population completed self-report measures. Using contemporary psychometric methods, we studied the triggers in terms of internal consistency, stability in time, precision, severity, discrimination ability, and information. Three dimensions of sensitivity were identified, namely, to eating sounds, to nose/throat sounds, and to general environmental sounds. The most informative and discriminative triggers belonged to the eating sounds. Participants identifying with having misophonia had also significantly increased odds to endorse eating sounds as auditory triggers than others. This study highlights the central role of eating sounds in this phenomenon and finds that different triggers are endorsed by those with more severe sound sensitivities than those with low sensitivity.
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Misophonia is a condition of abnormal emotional responses to specific auditory stimuli. There is limited information available on the prevalence of this condition. This study aimed to estimate the prevalence of misophonia in an undergraduate medical student population at the University of Nottingham. A secondary aim of this study was to assess the psychometric validity of the Amsterdam Misophonia Scale (A-Miso-S) questionnaire tool in this population. The A-Miso-S was administered online to medical students at the University of Nottingham. To assess the validity of the A-Miso-S, a factor analysis was conducted. To determine prevalence and severity the results of the questionnaire were quantitatively analysed using SPSS. Actor analysis was conducted. Free text responses to one questionnaire item were analysed using a thematic approach. Responses were obtained from 336 individuals. Clinically significant misophonic symptoms appear to be common, effecting 49.1% of the sample population. This is statistically significantly higher prevalence than previous studies have found (p < 0.00001). Using the classification of the A-Miso-S, mild symptoms were seen in 37%, moderate in 12%, severe in 0.3% of participants. No extreme cases were seen. The A-Miso-S was found to be a uni-factorial tool, with good internal consistency. This study has provided new information on misophonia and validity of the A-Miso-S questionnaire in a sample population of UK undergraduate medical students. The results indicate that misophonia is a phenomenon that a significant proportion of medical students experience though only a small subset experience it severely.
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Objective Analyze a large sample with detailed clinical data of misophonia subjects in order to determine the psychiatric, somatic and psychological nature of the condition. Methods This observational study of 779 subjects with suspected misophonia was conducted from January 2013 to May 2017 at the outpatient-clinic of the Amsterdam University Medical Centers, location AMC, the Netherlands. We examined DSM-IV diagnoses, results of somatic examination (general screening and hearing tests), and 17 psychological questionnaires (e.g., SCL-90-R, WHOQoL). Results The diagnosis of misophonia was confirmed in 575 of 779 referred subjects (74%). In the sample of misophonia subjects (mean age, 34.17 [SD = 12.22] years; 399 women [69%]), 148 (26%) subjects had comorbid traits of obsessive-compulsive personality disorder, 58 (10%) mood disorders, 31 (5%) attention-deficit (hyperactivity) disorder, and 14 (3%) autism spectrum conditions. Two percent reported tinnitus and 1% hyperacusis. In a random subgroup of 109 subjects we performed audiometry, and found unilateral hearing loss in 3 of them (3%). Clinical neurological examination and additional blood test showed no abnormalities. Psychological tests revealed perfectionism (97% CPQ>25) and neuroticism (stanine 7 NEO-PI-R). Quality of life was heavily impaired and associated with misophonia severity (rs (184) = -.34 p = < .001, p = < .001). Limitations This was a single site study, leading to possible selection–and confirmation bias, since AMC-criteria were used. Conclusions This study with 575 subjects is the largest misophonia sample ever described. Based on these results we propose a set of revised criteria useful to diagnose misophonia as a psychiatric disorder.
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Misophonia, also known as selective sound sensitivity syndrome, is a condition characterized by strong dislike of specific sounds with accompanying distressing reactions. To date, misophonia is still poorly understood. This study aimed to identify factors associated with severity of misophonic symptoms in Singaporean psychiatric patients. Ninety-two psychiatric patients were recruited from a large teaching hospital in Singapore in a cross-sectional study. Socio-demographics, severity of depression, anxiety and stress, and severity of misophonic symptoms were analyzed. Correlation analysis showed that anxiety, depression, and stress scores—as measured by the Depression, Anxiety and Stress Scales-21 (DASS-21)—were significantly positively correlated with the Amsterdam Misophonia Scale (A-MISO-S) scores. After adjustment for confounding factors, multivariate regression analysis showed that anxiety (β = 0.385, p = 0.029) remained significantly associated with A-MISO-S. Age, gender, depression, and stress were not significantly associated with the severity of misophonia. The findings showed that the severity of anxiety was associated with severity of misophonia in Singaporean psychiatric patients. Further research is needed to explore the nature of misophonia and its relationship with other psychiatric disorders.
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The case illustrates the effective assessment and treatment of misophonia in a 14-year-old adolescent female in which short-term cognitive-behavioral therapy (CBT) and exposure and response prevention (ERP) principles were utilized. Misophonia-related symptomology declined significantly during treatment, and partial gains were consolidated over time with the use of ongoing sporadic booster sessions to maintain reported improvements and to address the variable nature of the patient’s symptom expression. Significant tolerance of noise triggers occurred, both within and in between sessions, and the patient achieved concurrent behavioral changes and tolerated a marked reduction in relevant avoidance behaviors. Self-reported and observed psychological and physiological distress diminished when confronted with identified trigger noises, both during conducted in vivo exposures and, more broadly, in the patient’s home and school environments. The case serves as a contribution to the growing body of psychiatric literature recognizing misophonia as a distinct phenomenon, and offers anecdotal evidence regarding assessment treatment implications.
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Misophonia is defined as hate of sound. It is characterized with intense emotional reactions like anger, anxiety, or disgust to and avoidance behavior from special sounds such as mouth sounds while eating or chewing gum, nasal sounds like breathing, smelling or blowing or some other sounds done with fingers like playing with a pen, writing or drumming on the table, especially, made by other people. Misophonia has never been present in any of the psychiatric classification systems. Some authors suggest that misophonia should be regarded as a new mental disorder. There is limited information about misophonia. Only few cases of misophonia have been reported. The causes of misophonia, risk factors, the relationship between mental disorders and treatment of misophonia are not fully known. Misophonia is a recently described, poorly understood and neglected condition. Future studies will focus on investigating the epidemiology, phenomenology, neurophysiology, and treatment of the misophonia. Two cases of women who had complaints of misophonia are presented in this study. Principles of diagnosis and treatment in this kind of patients are discussed in our case report.