Like Nails on a Chalkboard: A Misophonia Overview

by Adam B. Lewin, PhD, ABPP; Eric A. Storch, PhD, & Tanya K. Murphy, MD, MS, University of South Florida

Misophonia, or “hatred or dislike of sound,”
is characterized by selective sensitivity to specific sounds accompanied by emotional distress, and even anger, as well as behavioral responses such as avoidance. Sound sensitivity can be common among individuals with OCD, anxiety disorders, and/or Tourette Syndrome. This co-occurrence has led clinicians and researchers to look into whether misophonia is related to these disorders, including potential overlaps in how the brain is affected (i.e, neurobiological overlaps).

Similar to OCD, misophonia presents differently in each individual. Misophonia may range from mild (for example, decreased tolerance of certain types of sounds) to severe, excessive sensitivity to specific auditory (sound) triggers. These sound triggers are often highly specific, including sounds emitted in the context of common human behavior such as sounds associated with: chewing, breathing, swallowing, stepping, lip smacking, tapping, and speaking (sometimes specific spoken sounds). In some cases, extreme sound sensitivity, a characteristic of misophonia, is associated with the behavior of a specific individual, such as “my brother chewing,” or “my mother’s voice.” In other cases, the presentation may be more generalized (e.g., all women’s voices, barking dogs) or may include environmental or engineered stimuli (e.g., “the hum of fluorescent lighting, clocks ticking, etc.”).

Individuals with misophonia describe encounters with triggering sounds resulting in discomfort, distress, or anger. Affected individuals liken experience of the sound trigger more closely to irritation, disgust, or even pain, rather than anxiety/fear. The magnitude of disturbance is not necessarily proportional to the duration or the volume of the sound trigger. For example, some children may exhibit an intense outburst when seemingly low-intensity sounds are encountered. The most common behavioral response is the avoidance of and/or withdrawal from sound triggers or situation/stimuli that
are likely to result in exposure to the sound. In some cases, situations or stimuli associated with specific sounds are also avoided (i.e., conditioned aversion), as just the possibility of encountering triggers may result in distress or discomfort. For example, an individual may avoid restaurants because of the high likelihood of encountering chewing sounds. Among youth with misophonia, rage or anger outbursts may occur in the presence of triggering sounds or stimuli associated with sounds (e.g. being in a room full of Halloween candy may trigger an outburst in a child with extreme sensitivity to the sound of opening a plastic wrapper).

Etiology and Prevalence 

The neurobiological mechanisms and etiological causes
of misophonia are still unknown; although it is thought
that it results from abnormal functioning within the limbic system (the part of the brain that regulates emotions), the autonomic nervous system (the part of the brain that controls our involuntary organ functions such as breathing and our hearts beating, and the “fight or flight response”), and the auditory cortex (the part of the brain that manages hearing
and interprets sounds). Respondent/classical conditioning also plays a role as previously neutral places and situations become associated with unpleasant sounds (for example, a young girl may be triggered by the sound of her brother chewing and may develop a conditioned reaction to the family’s dinner table regardless if anyone is eating at it).

As mentioned above, sensory over-responsivity (SOR), including heightened sensitivity to sounds is common among individuals with OCD, anxiety, and Tourette Syndrome. This suggests possible overlap in neuropathology. While the prevalence of misophonia is unknown, recent studies suggest high rates of SOR among youth with OCD and anxiety. The rate of misophonia among individuals with tinnitus (a condition that causes ringing in the ears) is also elevated.

Assessment

There are no official criteria for diagnosing misophonia in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5); however, it has been proposed that misophonia may be most appropriately categorized under “Obsessive Compulsive and Related Disorders.” In 2013, Schröder and colleagues proposed diagnostic criteria based
on their clinical observations. The proposed criteria may be
too restrictive, especially for youth (for example, these criteria require that the individual recognize the feeling of anger or disgust [associated with the sound trigger] to be excessive,
and specify that sound triggers must be produced by human beings, both of which may not necessarily apply in cases of misophonia in children and adolescents). We suggest the following considerations for identifying misophonia, simplifying Schröder’s proposed criteria:

  1. Hypersensitivity to the presence (or anticipation) of a specific sound that may be accompanied by hyper- arousal, irritation, anger/outbursts, or fear.
  2. Avoidance of sound triggers or stimuli associated with specific sounds.
  3. The individual’s sensitivity and autonomic/emotional experience and/or avoidance/behavioral response results in significant distress or impairment (e.g., tantrums, disrupted educational/occupational functioning, or significant family accommodation of symptoms).
  4. Symptoms are not better explained by another psychiatric disorder.

These criteria are offered as suggested guidelines for identifying probable occurrence of misophonia. Formal diagnostic criteria for misophonia will hopefully be developed though consensus panels of expert clinicians and scientists. At present, “Other Specified Obsessive-Compulsive and Related Disorder” (300.3) may be the most appropriate DSM-5 classification. Evaluation by a medical professional with audiological (such as an ear, nose, and throat [ENT] specialist or otorhinolaryngologist), or possibly neurological expertise is recommended as part of the assessment process to identify other possible conditions that affect the hearing or nervous system. For example, misophonia should be distinguished from hyperacusis (a hypersensitivity to sounds of a certain intensity/volume), which is more common among individuals with autism spectrum disorders.

Treatment

There are no evidence-based treatments for misophonia.
To date, we lack clinical trials (or treatment studies), and recommendations are currently based on clinical experience and case reports. Most psychological interventions focus on reducing distress or dysfunction associated with heightened sensitivity to sounds (e.g., anger, avoidance). Some preliminary reports have indicated treatments such as exposure and response prevention (ERP), psychoeducation, and habituation training may be helpful. Given the overlap with obsessive compulsive and related disorders, ERP may be an appropriate intervention for some patients. However, it is posited that exposure therapy may not be sufficient (or appropriate) for extinguishing the relationship between the sound trigger and the irritability/disgust reaction. In some cases, habituation to the auditory trigger (e.g., using graduated, real-life exposures) may reduce sensitivity and/or behavioral responses such as tantrums, anger, and irritability. Nevertheless, in other cases, even repetitive exposure to a target sound might not reduce the sensitivity or subjective distress.

Consequently, learning to “sit with” distress, as well as learning ways to reduce emotional and behavioral reactivity in the presence (or anticipation) of the triggering sounds may be
a core component of psychological treatment. Additionally, treatment can focus on breaking the associations between sound triggers and other stimuli (i.e., using extinction strategies to break the associations between locations where the sound may occur and the people/objects associated with the sound).

For children, it is recommended that distress tolerance skills be taught. Over time, prompting the use of these skills can become a replacement for rage outbursts, avoidance, or refusal when faced with triggering sounds. Child treatment is often focused on decreasing the rage outbursts and working extensively with parents to both (a) decrease accommodation around misophonia (e.g., such as setting special meal times to allow the child to avoid trigger sounds), and to (b) encourage/reward use of distress tolerance skills and managing discomfort/anger when triggers are encountered.

Until studied, the use of accommodations such as protective equipment (e.g., noise cancelling devices or ear protection)
or quiet-zones (e.g., quiet places in the home, school or workplace) should not be considered treatments of misophonia but might be helpful with managing symptoms while more adaptive strategies are implemented. In other words, accommodations (headphones, white noise, noise cancellation) alone, without cognitive behavioral strategies that develop new distress tolerance and other adaptive skills, is not recommended as a sole treatment strategy. Avoidance of sound triggers (e.g., homeschooling, eating in isolation) is strongly discouraged as a treatment strategy because of interference with the development of more adaptive strategies and possible negative social impacts.

In summary, there is no definitive psychological treatment
for misophonia. Until evidence-based treatment programs
are developed and tested, treatment should be individually tailored and based on research-supported techniques that address the targeted problems (e.g., avoidance, anger/rage, anxiety/fear, rituals/compulsions). In other words, knowledge of treating anxiety, OCD spectrum disorders, and anger/rage/ reactivity can be flexibly adapted.

There are no medications with specific indications for misophonia. Nevertheless, pharmacotherapy may be indicated for co-occurring problems such as severe anxiety or reactivity/anger/rage.


Dr. Lewin is an associate professor of pediatrics and director of the OCD, Anxiety, and Related Disorders Behavioral Treatment Program at the University of South Florida. Dr. Storch is the Guild Professor of Pediatrics at the University of South Florida, director of research in developmental pediatrics at All Children’s Hospital, and clinical director for Rogers Tampa Bay. Dr. Murphy is the Rothman Professor of Pediatrics, division chief of pediatric neuropsychiatry and vice chair of faculty affairs at the University of South Florida.

Suggested Reading

Jastreboff, P.J. and Jastreboff, M.M. (2014). Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia). Seminars in Hearing, 35, 105-120.

Lewin, A. B., Wu, M. S., Murphy, T. K., & Storch, E. A. (2015). Sensory Over-Responsivity in Pediatric Obsessive Compulsive Disorder. Journal of Psychopathology and Behavioral Assessment, 37, 134-143.

Schröder, A., Vulink, N., & Denys, D. (2013). Misophonia: Diagnostic criteria for a new psychiatric disorder. PLoS ONE, 8(1), e54706. doi:10.1371/journal.pone.0054706.t001.

Schneider, R.L., and Arch, J.J. (2015). Letter to the editor: Potential treatment targets for misophonia. Gen Hosp Psychiatry. doi:10.1016/j.genhosppsych.2015.03.020.

Webber, T.A., Johnson, P.L., Storch, E.A. (2014) Pediatric misophonia with comorbid obsessive–compulsive spectrum disorders. Gen Hosp Psychiatry, 36 (2), pp. 231.e1–231.e2.

Wu, M. S., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014).

Misophonia: Incidence, Phenomenology, and Clinical Correlates in an Undergraduate Student Sample. Journal of Clinical Psychology, 70(10), 994-1007.