Misophonia: Diagnosis, Causes, And Treatment Options

Many people have sounds that they find annoying, whether it be the sound of a pen clicking, loud slurping, chewing sounds, or cracking knuckles. However, for some people, these sounds are more than just minor irritations – they can actually lead to intense physical and emotional responses, a reaction not widely understood or known by the general population.

This is a disorder called misophonia, and it affects the well being of millions of Americans. Those with misophonia perceive certain sounds far more intensely than most people, which can greatly impact their quality of life and relationships. While misophonia has no cure, there are effective methods available to help manage its symptoms.

What Is Misophonia?

Misophonia is an often under-diagnosed disorder, which is often confused with other hearing conditions. It wasn’t until the 1990s that a clear definition of the condition was put forth. Initially called Selective Sound Sensitivity Syndrome (or Sensitivity to Soft Sound), misophonia’s consensus definition includes extreme sensitivity to trigger sounds.

Misophonia is a combination of the Greek word ‘misos’, meaning ‘hate’, and ‘phon’, meaning ‘sound’, which translates to “hatred of sound”. In severe cases, these triggers, or misophonic sounds, can cause an intense fight or flight response of anger, aggression, or anxiety. The result of these responses can lead to further distress, and social or occupational impairment.

In reality, misophonia affects up to 20% of people, but few ever bother bringing it up to their doctor. This, plus a lack of adequate research on misophonia, makes it harder to diagnose the condition and develop appropriate treatment.

Misophonia vs Hyperacusis

Misophonia is a type of Decreased Sound Tolerance (DST), a condition where everyday sounds affect certain people in more severe ways than others. Decreased tolerance can present as misophonia, hyperacusis, or phonophobia.

Hyperacusis, the most common form of DST, is an increased sensitivity to everyday sounds at volumes that wouldn’t typically bother most people, leading to discomfort or even pain. Symptoms include discomfort or pain in response to sounds at normal volumes, often resulting in avoidance behaviors. It can be caused by ear damage from noise exposure, diseases, head injury, or as a side effect of certain medications, and is sometimes associated with conditions like migraine or PTSD.

Misophonia, on the other hand, involves intense emotional and physiological responses to specific sounds, especially repetitive or pattern-based noises such as chewing, breathing, or tapping. These responses are more emotional, such as anger, irritation, or disgust, and are triggered by the type of sound rather than its volume. The exact cause of misophonia is not fully understood, but it is believed to be a neurological condition linked to how sound affects emotional processing in the brain. Misophonia sometimes co-exists with hyperacusis, and they can have very similar symptoms.

Phonophobia is related to the fear certain sounds cause and the avoidance that results. People with phonophobia go as far as to withdraw from everyday activities to avoid the trigger sound. These negative reactions can impact work, school, relationships, and other aspects of daily life. Phonophobia is common in people with tinnitus as these patients fear the discomfort that can result from these sounds.

Misophonia Symptoms

Misophonia symptoms often present early in life, as soon as childhood or early adolescence. The most severe symptoms of misophonia can disrupt daily life, make it difficult to socialize, and even impact the one’s work life.

These symptoms can be split into three distinct categories:

• Emotional reactions: Strong emotional responses such as anger, irritation, and disgust are particularly common. These feelings can be so overwhelming that they present themselves verbally, causing unpleasant sounds like screams and groans, as well as insults, and verbal threats. Some patients experience anxiety and panic upon hearing triggering sounds, causing them to feel trapped or out of control. This can feel like a nightmare, and some people with misophonia spend every waking moment trying to control their environment.
• Physiological responses: Misophonia is strongly linked to the body’s fight or flight responses. This can cause muscle tension, increased heart rate, sweating, and tight feelings in the chest and rest of the body. misophonia can also cause increased awareness and an inability to relax in non-threatening situations. In other words, the body experiences involuntary reactions to the triggering sounds and visual stimuli.
• Behavioral responses: Behavioral responses to trigger sounds include agitation, aggression, and avoidance. In rare, more severe cases, misophonia can drive the afflicted to physically attack the source of the trigger sound. The distress caused is so overwhelming that affected persons may disregard their environment and personal relationships to escape and behave in a way they otherwise wouldn’t. For instance, making an outburst during an important career conference, or skipping school due to trigger sounds.

As if these symptoms aren’t bad enough, the social ostracization that may follow is enough to have an impact on mental health. The anticipation of social ostracization can even exacerbate or lead to social anxiety disorder.

Risk Factors For Misophonia

Misophonia researchers aren’t quite sure what causes people to have such intense reactions to specific sounds. For now, there are four running theories: related disorders, genetics, brain structure differences, and conditioning.

Related Disorders And Mental Health Conditions

Misophonia symptoms can exist alongside neurodivergence, particularly in patients with attention-deficit hyperactive disorder (ADHD), autism spectrum disorder (ASD), and tourette’s. In many cases, misophonia exists alongside other mental health conditions, such as anxiety disorders, obsessive-compulsive disorder (OCD), and major depressive disorder (MDD).

Other patients with misophonia have reported its symptoms along with some sort of hearing-related condition such as hearing loss, tinnitus, and hyperacusis. This suggests misophonia is caused by the same mechanisms that lead to the related conditions. 

Genetics

The link between misophonia, obsessive-compulsive disorder, and other disorders in the neuroticism/guilt cluster has led some experts to believe some patients have a genetic predisposition to misophonia. This could mean misophonia runs in families, but there is still a lot of research that needs to be done to substantiate this claim.

Brain Structure Differences

Researchers suggest misophonia could be due to differences in brain structure and activities. This altered brain activity occurs in the parts of the brain that are linked to emotions and perception of sound, namely the auditory and limbic systems. These systems become activated by the brain to protect itself in dangerous situations, manifesting in the form of fear, disgust, and anger.

In misophonia, the brain has associated non-threatening, otherwise ordinary sounds as a threat, which is what sends the body into fight or flight mode. This theory would also suggest addressing the issue with established treatments for abnormal brain activity, such as transcranial magnetic stimulation (TMS), could hold the key to misophonia treatment .

Conditioning

There are some in the field who look to the ‘conditioning hypothesis’. Food sounds and other triggering sounds are otherwise considered neutral stimuli, however, they can become associated, or confused with an adverse unconditioned stimulus in the brain. The unconditioned response, i.e. the angry outburst or panic will cause the patient to avoid situations involving the trigger sounds.

Over time, as the patient continues to avoid situations involving triggering sounds, the brain slowly trains itself to have that reaction whenever it happens. In simpler terms, the theory suggests the brain convinced itself that the triggering sounds are more devastating than they really are. The treatment plan would include tricking the brain back into interpreting triggering sounds as ordinary, non-threatening sounds.

Assessment Of Misophonia: How Is Misophonia Diagnosed?

Since misophonia isn’t listed in the DSM as an official mental health condition, there’s no consensus on diagnostic criteria. However, several authors have proposed questionnaires to assess the functional impairment of misophonia in patients’ lives. The most popular questionnaires include:

• Amsterdam Misophonia Scale (A-MISO-S)
• Misophonia Response Scale (MRS)
• Misophonia Assessment Questionnaire (MAQ)
• Misophonia Severity Scale (MSS)
• Berlin Misophonia Questionnaire (BMQ)
• MisoQuest
• Duke Misophonia Questionnaire (DMQ)

Some doctors may recommend hearing tests to rule out other hearing disorders. They will also require details about your medical and family history, and examinations to help diagnose the issue. In most cases, if another condition is discovered that has links to misophonia, doctors may focus treatment on that condition in conjunction with treatment of misophonia if both are considered to impact quality of life. Oftentimes, these are conditions like tinnitus and hearing loss with similar mechanisms and treatment options.

Common Trigger Sounds

Misophonia triggers are usually auditory and often include:

• Eating sounds: Certain eating sounds, particularly chewing, slurping, swallowing, throat clearing, lip smacking, and gulping are triggering sounds for some people with misophonia.
• Oral and breathing noises: Other people with misophonia have trigger sounds such as breathing, snoring, sniffling, nose blowing, kissing noises, and heavy breathing.
• Sounds made by objects and animals: These trigger sounds include clocks ticking, birds or crickets chirping,
• Other noises: These include pen clicking, keyboard typing, foot tapping, nail filing, paper rustling, writing sounds, etc.

Sometimes, misophonia triggers are visual, for example, seeing someone nearby crack their knuckles. Even though there is no sound, the sight of the action is enough to trigger the body’s fight or fight responses. Other visual triggers include swinging legs, watching someone eat, and hair twirling.

Interestingly, when the same triggering sounds are made by people with misophonia, they may not have the same reactions. Sometimes people with misophonia mimic the triggering sounds to minimize their distress, along with other coping strategies like noise canceling headphones, and listening to music.

It is important to note that misophonic sounds are not the same as tinnitus sounds – other people can hear misophonic sounds, while in most cases, tinnitus sounds can only be heard by the patient themselves. In other cases, it can be heard by the doctor during an examination. Loud misophonic sounds can be trigger sounds for a patient with tinnitus.

Treatment Options

While there is no cure for misophonia, luckily, experts in the field have recently begun to develop treatment and coping strategies for misophonia symptoms.

Tinnitus Retraining Therapy (TRT)

Tinnitus Retraining Therapy, or TRT, was initially developed to help manage tinnitus, a condition where phantom noises cause distress to people suffering from it. This approach is believed to decrease awareness of the tinnitus, thus reducing the impact on the patient.

Researchers suggest the use of ‘treatments in accordance with the neurophysiological model of tinnitus’ such as TRT to treat misophonia. The goals of these protocols are to help the patient create positive associations with sounds, gradually reduce control of the sounds they hear, and increase their tolerance for the loudness of environmental sounds.

Psychological Therapies

Mental health professionals can play an important role in helping people with misophonia develop appropriate coping strategies and relaxation techniques for their sound sensitivity. Some of these include:

Cognitive Behavioral Therapy (CBT)

Again, there aren’t any well-established treatment options available for people with misophonia, however, the same general principles still apply. While misophonia isn’t recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a mental health condition, a mental health professional can offer support, and help to treat the symptoms of misophonia. Anyone can benefit from cognitive behavioral therapy (commonly referred to as CBT) – not just patients with a mental health condition, and not people who are experiencing high-stress phases.

During a course of CBT treatment, a mental health professional will focus on identifying triggers as well as improving and developing appropriate coping skills. The purpose of this is to better equip their patients to deal with misophonic sounds and retake control of their lives.

Exposure Therapy is sometimes paired with CBT, which is where the patient is gradually forced to face the source of their fear. This happens in a safe and controlled environment following a treatment plan that is agreed upon by both the specialist and the patient. Much of this treatment takes place outside of a clinical setting, and the patient is expected to do ‘homework’ and use the coping strategies taught to overcome their misophonia symptoms.

One study revealed a 70% reduction in misophonic symptoms using a combination of traditional graded exposure habit reversal training, parent management training, and other CBT strategies. Researchers believe exposure-based CBT may be a useful treatment option for patients with different symptom profiles.

Dialectical Behavioral Therapy (DBT)

Dialectical behavior therapy, or DBT, is a treatment option based on CBT developed especially for patients with very strong emotional reactions to specific stimuli. This includes conditions under the anxiety and obsessive compulsive disorder spectrum such as social anxiety disorder, hypochondriasis, and certain phobias.

Physiological investigations are still ongoing, but at least one case shows promise, meaning there’s the potential for DBT to become a standard treatment option for people with misophonia. DBT has the potential to treat misophonia using techniques such as mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness

Counterconditioning Treatment

Counterconditioning works by using the identified potential underlying mechanisms against itself. Many believe misophonia is a result of an abnormality in the way the auditory cortex and other parts of the auditory system interact with the limbic system. It has been argued that the brain associates certain auditory stimuli with specific emotional and autonomic reactions. This puts it in a state of distress, even when simply anticipating certain sounds.

By combining reduced trigger sounds with positive stimuli, counterconditioning treatment retrains the brain to respond with less severe misophonia symptoms. This therapy has proven to be useful when treating conditions including phobias, obsessive compulsions, and anxiety disorders.

Mindfulness And Acceptance Based Therapy

Misophonia treatment may also involve mindfulness and acceptance-based therapy, involving opposite action, mindfulness, and acceptance. In one successful study, researchers were able to combine key components of existing treatments as an effective misophonia treatment for their patients.

Experiential Acceptance And Stimulus Engagement (EASE)

Experiential Acceptance and Stimulus Engagement, or EASE, is an emerging strategy that aims to end toxic hope, reduce avoidance of the stimulus, and eventually stimulus engagement. This model was proposed in 2022, as such, more research is needed to determine its effectiveness. It’s one of the few therapies designed especially for misophonia and should open the door to greater development in the field, so be on the lookout for developments.

Pharmacotherapy

Pharmacotherapy is a popular treatment approach to addiction. Addiction is a chronic and complex disorder that often requires medical intervention for successful recovery, and medication can often address the physical and psychological symptoms associated with withdrawal. In turn, this can curb the cravings for drugs and alcohol and minimize the risk of relapse. The objective of medication-assisted therapy is to enable the individual to achieve complete and long-lasting remission from addiction by teaching control.

Selective serotonin reuptake inhibitors (SSRIs) have also been suggested for treating misophonic symptoms. An analysis of three different studies with an adolescent female, an adult female with comorbid OCD, and an adult male with comorbid anxiety and depression demonstrated their potential. Daily treatments with popular SSRIs such as fluoxetine (brand name Prozac) and sertraline (brand name Zoloft) showed remission of symptoms after 3 months and 3 weeks respectively.

Researchers also found that when treating specific comorbidities, improving primary behavioral disorders can also improve secondary misophonia symptoms.

• A 4-year-old with autism saw an improvement in misophonia symptoms after taking low-dose risperidone.
• A 14-year-old with comorbid ADHD experienced improved distractibility and better tolerance to Misophonia triggers after receiving a combination of methylphenidate and CBT.
• Propranolol taken one hour before each meal reduced symptoms of autonomic responses to Misophonia from severe to subclinical levels on the A-MISO-S scale.

Popular Misophonia Coping Strategies

The most popular coping technique is leaving an area where certain sounds are known to be heard. But what happens when you can’t escape the triggering sounds in your daily life? If the sound is caused by a person, simply ask the person to stop. Otherwise, leaving the situation may be the best option.

If you have no control over the noise or the environment, bring noise canceling headphones with you, and/or listen to some music or calming sounds. Some find white noise, nature sounds, rain, and similar sounds helpful for soothing the mind. Use relaxation techniques such as breathing exercises and affirmations to overcome the effects of visual stimuli.

Takeaways

As time progresses, we expect more clarity in regards to finally establishing proven treatments for misophonia. Until then, patients engage in any number of experimental treatments including medications and supplements, lifestyle changes, relaxation strategies, psychological treatment, audiologic treatment, and neuromodulation.

Treatment for misophonia is typically a process of trial and error, but effective options do exist. It’s essential to approach treatment with a positive outlook, remembering that help is available. Patients experiencing symptoms of misophonia should consult an audiologist for tailored treatment recommendations. As we continue to anticipate further research developments, consulting a medical professional remains the best course of action, especially before trying any experimental methods.