Misophonia

What is misophonia?

Misophonia is defined as a strongly aversive response to certain specific trigger sounds. These trigger sounds are usually made by other people and typically include mouth/nasal sounds (eg eating/breathing sounds), repetitive sounds (eg keyboard tapping, crockery noise, rustling cellophane), intrusive sounds (eg neighbour’s music, noise from a nearby factory, dog barking).

Exposure to trigger sounds in people with misophonia involuntarily induces immediate and disproportionally high levels of anger or rage, along with strong reactions of irritation and/or disgust and distress.

Misophonia is a spectrum disorder and can range from mild through to severe to extreme.

Misokinesia is defined as a strongly aversive response to visually perceived movements, which may be associated with auditory trigger sounds, or be repetitive or involve excessive fidgeting, and can develop as a secondary reaction to misophonia (Jaswal et al 2021). Exposure to these visual triggers in people with misokinesia involuntarily induces a similar reaction to misophonia triggers - disproportionally high levels of anger or rage, along with strong reactions of irritation and annoyance.

Differentiating between Misophonia and Hyperacusis

Misophonia and hyperacusis are the terms used to explain significant and dysfunctional intolerance to everyday sounds.

While misophonia and hyperacusis can occur concurrently, they are distinctly separate conditions and differ as follows:

The sounds perceived as intolerable are different
The subconscious negative evaluation of these sounds is different. The misophonia evaluation is aversive, stemming from irritation, disgust and intrusion. The hyperacusis evaluation is of threat, stemming from a primal need to protect against tinnitus aggravation or the ear/hearing from damage.
The involuntary post-exposure symptoms are different. Following intolerable sound exposure, misophonia is typified by reactions of anger/rage, irritation, disgust. Hyperacusis patients will have reactions consistent with threat and fear. Hyperacusis patients generally experience sound-induced physical symptoms in their ears consistent with TTS; misophonia patients do not.

Misophonia has the potential to escalate into hyperacusis. Generally, misophonia precedes hyperacusis.

Factors underpinning misophonia

the sense of hearing in humans and animals evolved as a survival mechanism, providing warning of danger/loss of safety; our brain is hard wired to be vigilant towards the auditory environment
the ear is anatomically open to keep us safe (and alive) - we have not evolved an anatomical mechanism to ‘close our ears’ equivalent to closing our eyes
normal hearing is highly sensitive, allowing us to hear a huge range of sounds – through walls and the ground, from a distance etc.
sound is constant, pervasive, unavoidable, often unpredictable – and in the case of misophonia – often also too predictable and repetitive. Our subconscious brain, where sounds are evaluated for meaning and importance, is being flooded with sound. We have no ability to control incoming auditory stimuli other than blocking the ears and avoidance strategies.
generally, only a proportion of the sounds we are capable of hearing will be relayed to the conscious brain for our attention.

Misophonia is enhanced by trigger sounds often being perceived as an intolerable intrusion into one’s sense of personal space. Most commonly, the trigger sounds made by family members and heard in the home elicit the strongest reaction. This does not mean that people with misophonia can selectively control their misophonia reaction. It also does not imply that negative interpersonal relationships within the family are necessarily the basis for having induced this strong reaction.

This home-based reaction appears to be related to the combined effects of the pervasive nature of sound, sharing a common space, a sense of violation of the sanctuary of the home, the predictable inevitability of trigger sound exposure and involuntary auditory monitoring/hypervigilance influencing subconscious auditory processing.

Is neurodivergence a pre-disposing factor?

Research has shown that people with autism, ADHD (both inattentive and hyperactive) and sensory processing disorders have an increased risk of developing misophonia.

Ferrer-Torres et al, 2022 showed that 27% of participants with autism showed some degree of sensitivity to sounds greater than a control group. In children with autism, the risk of misophonia development can be enhanced by auditory processing difficulties filtering out unimportant sounds, being overwhelmed by multiple sounds heard simultaneously and difficulty with emotional regulation.

Misophonia has been found to occur with ADHD in 12% of cases (Ferrer-Torres et al, 2022). In children with ADHD, the risk of misophonia development can be enhanced by being strongly distracted when multiple sounds are heard simultaneously.

Sensory processing (integration) disorder is a neurological disorder which includes random and disorganized processing of external stimuli. Sensory processing sensitivity is not a disorder, but a neural trait in which certain stimuli are processed more thoroughly in comparison to others.

Misophonia in children and teenagers

With misophonia, exposure to trigger sounds involuntarily results in high levels of irritability, disgust, anger or rage. High levels of anxiety, panic, anger and distress can develop from the fear of being exposed to trigger sounds which induce this reaction. Children can readily become overwhelmed by this emotional maelstrom - they can resent being exposed to their trigger sounds and at the same time be frightened and embarrassed by the intensity of their reaction, fear their inability to control it, and guilty and ashamed by the effect this has on others.

For neuro-typical children and teenagers, the trigger sounds made by family members tend to elicit the strongest reaction. This can escalate into other familiar environments (eg the classroom) where trigger sounds become predictable and anticipated. For neurodivergent children, the home is often safer from trigger sound exposure – where sounds benefit from being more predictable and trigger sounds are (perhaps/somewhat) more controllable. For these children, being overwhelmed by multiple sounds, including trigger sounds, heard simultaneously away from home – often unexpectedly and inevitably – can make going to school or leaving the home an ordeal.

In children and teenagers with significant misophonia, auditory hypervigilance is likely to have developed, leading to high levels of environmental monitoring, increased alertness towards their trigger sounds, cognitive distraction and reduced concentration. The whole family can become involved in the monitoring and avoidance of trigger sounds.

As a result, misophonia can have a major impact on children/teenagers and their families, potentially affecting relationships within the family and resulting in severe lifestyle restrictions. Additionally, parents are faced with the challenge of trying to explain their child’s abnormal reaction to trigger sounds to others, including teachers and health professionals, and receive appropriate support.

How does misophonia develop?

In my experience, misophonia is an acquired disorder. Research carried out on patients with severe misophonia showed that the average age of onset of misophonia is 12 years (Schröder et al, 2013). Misophonia tends to develop earlier in childhood in those with neurodivergence.

Misophonia often stems from a specific instance in childhood where a sound made by a family member elicited a strongly negative reaction of irritation or disgust, particularly at a time of heightened stress or in a situation where the sound is unavoidable. Misophonia can stem from or be enhanced by auditory hypervigilance associated with trauma. In some cases, the initial trigger may stem from a strongly negative reaction to sounds intruding and violating the home environment.

Misophonia makes clinical sense and aligns with lived experience when viewed as a subconscious and involuntary mechanism, the result of a primal escalation stemming from this ‘seeding’ event strongly influencing auditory processing, triggered by unavoidable everyday sounds evaluated as ‘unsafe’.

The role of anxiety in misophonia

MISOPHONIA IS NOT AN ANXIETY DISORDER.

However, anticipatory anxiety and auditory vigilance are common in people experiencing severe misophonia because of the lack of control over the auditory environment, the intensity of their involuntary reaction to their trigger sounds and the distress caused.

It is important to distinguish between reasonable alertness and hypervigilance. Monitoring and vigilance towards the auditory environment is an intuitive, natural reaction, particularly in childhood. However, actively monitoring for trigger sounds brings them more strongly into conscious awareness and perpetuates their subconscious importance. As a result, the brain will continue to highlight these sounds creating a pathway towards misophonia escalation.

While misophonia overlaps with many features of obsessive-compulsive disorder (OCD), as the immediate involuntary post trigger sound exposure response is anger/rage, misophonia differs to OCD and anxiety disorders such as phobias. For this reason, a graded exposure approach is generally not effective and has been detrimental in a number of my patients.

With correct understanding of misophonia and effective support, anxiety and hypervigilance can be managed to minimise any ongoing contribution towards misophonia escalation.

Avoidance of trigger sounds

The considered and discretionary use of ear protection is reasonable in situations where people with misophonia feel particularly unsafe and highly vulnerable to trigger sound exposure.

This helps maintain reasonable lifestyle horizons, reduces vigilance and reinforces auditory safety to the subconscious brain.

Misophonia desensitisation therapy

Outcomes – what to expect?

The factors resulting in misophonia are complex and outside conscious control, so a guided desensitisation process is slow, requiring correct understanding, determination and belief in the prospect of change - in addition to commitment towards changing behavior and self-managing desentisation strategies.

Complete desensitisation is an unrealistic expectation if misophonia has been entrenched for many years. However, understanding, management and partial desensitisation in a supportive environment can make a big difference to the emotional impact and constraints of misophonia.

Once patients know how the brain processes sound subconsciously; have been helped to identify the initial event ‘seeding’ their misophonia onset; and understand their unique auditory and psychological neural pathways underpinning their misophonia development - there is potential for reversal. If a patient doesn’t know their pathways, they don’t know what/why/how they need to unravel.

So the first and most important step in a misophonia desentisation process has to be evaluation and analysis with an experienced clinician to explore, reveal, evaluate and explain. This provides insight, reassurance, a personalised and targeted framework for desentisation strategies and identifies the need for psychological treatment. Importantly, this understanding is of therapeutic benefit by limiting, and often halting, further escalation.

The therapeutic use of passive, portable, neutral, low volume sound enrichment without compromising communication can be used to provide withdrawal/detachment strategies, to support auditory refocusing and assist misophonia desensitisation.

Sequent repatterning hypnotherapy has been effective for a number of my patients.

Misokinesia is a more recently recognised condition and as yet there are no questionnaires designed to assess severity nor specific therapy programs to support desensitisation. Misophonia refocusing strategies can be adapted to support misokinesia desensitisation.