International OCD Foundation | Like Nails to a Blackboard: An Overview of Misophonia (2023)

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

This article originally appeared in the Summer 2015 issue ofTOC-Bulletin.

Misophonia, or "hatred of or aversion to sounds," is characterized by selective sensitivity to certain sounds, accompanied by emotional distress and even anger, and behavioral responses such as avoidance. Sensitivity to noise can be common in people with OCD, anxiety disorders, and/or Tourette's syndrome. This co-occurrence has prompted clinicians and researchers to investigate whether misophonia is related to these disorders, including possible overlaps in affecting the brain (i.e., neurobiological overlaps).

Similar to OCD, misophonia presents itself differently in everyone. Misophonia can range from mild (eg, decreased tolerance to certain types of sounds) to severe and over-sensitivity to certain auditory triggers (sounds). These sound triggers are often very specific, including sounds that arise in the context of general human behavior, such as sounds associated with: chewing, breathing, swallowing, pounding, smacking, knocking, and speaking (sometimes specific spoken sounds). In some cases, the extreme sensitivity to noise characteristic of misophonia is associated with a particular person's behavior, such as B. "my brother is chewing" or "my mother's voice". In other cases, the presentation may be more generic (e.g., all female voices, dogs barking) or contain environmental or technical cues (e.g., "the hum of fluorescent lights, the ticking of clocks, etc.").

Individuals with misophonia describe encounters with provoking sounds that lead to discomfort, stress, or anger. Affected individuals are more likely to compare the noise trigger experience to irritation, disgust, or even pain than to anxiety/fear. The size of the disturbance is not necessarily proportional to the duration or volume of the sound burst. For example, some children may exhibit an intense outburst when faced with seemingly low-intensity sounds. The most common behavioral response is to avoid and/or withdraw from noise triggers or situations/stimuli that could lead to noise exposure. In some cases, situations or stimuli associated with certain sounds (e.g., conditioned aversion) are also avoided, since the mere ability to find triggers can lead to stress or discomfort. For example, a person may avoid restaurants due to the high likelihood of encountering chewing noises. In adolescents with misophonia, outbursts of anger or anger may occur in the presence of precipitating noises or noise-associated stimuli (e.g., being in a room full of Halloween candy may trigger an outburst in a child with extreme sensitivity to the opening noise). a plastic case).

Etiology and Prevalence

The neurobiological mechanisms and etiological causes of misophonia are still unknown; although it is believed to be due to abnormal functioning of 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 heartbeat and fight or flight). ") and the auditory cortex (the part of the brain that controls hearing and interprets sounds). Respondent/classical conditioning also plays a role, as previously neutral places and situations are associated with unpleasant sounds (e.g., a young woman can hear through be triggered by the sound of their sibling chewing and develop a conditioned response to the dinner table (dinner, regardless of whether someone eats in it).

As mentioned above, sensory hyperresponsiveness (SOR), including increased sensitivity to sounds, is common in individuals with OCD, anxiety, and Tourette's syndrome. This suggests a possible overlap in neuropathology. Although the prevalence of misophonia is unknown, recent studies suggest high rates of SOR in young people with OCD and anxiety. The rate of misophonia in people with tinnitus (a condition that causes ringing in the ears) is also high.

Evaluation

There are no official criteria for diagnosing misophonia in the latest edition ofDiagnostic and Statistical Manual of Mental Disorders(DSM-5); However, it has been suggested that misophonia should be better categorized under "Obsessive Compulsive Disorders and Related Disorders". In 2013, Schröder and colleagues proposed diagnostic criteria based on their clinical observations. The proposed criteria may be too restrictive, particularly for young people (e.g. these criteria require the person to recognize that the feeling of anger or disgust [associated with the sound trigger] is excessive and specify that the sound triggers of human beings must be created beings, which is not necessarily the case with misophonia in children and adolescents). We propose the following considerations to identify misophonia, simplifying the criteria proposed by Schröder:

1. Hypersensitivity to the presence (or anticipation) of a particular sound, which may be accompanied by over-excitement, irritation, anger/outbursts, or fear.
2. Avoiding noise triggers or stimuli associated with certain sounds.
3. The individual's autonomic/emotional sensitivity and experience and/or behavior avoidance/response results in significant distress or impairment (e.g., temper tantrums, impaired school/occupational functioning, or significant family adjustment of symptoms).
4. The symptoms are not better explained by another psychiatric disorder.

These criteria are offered as suggested guidelines for identifying the likely occurrence of misophonia. Formal diagnostic criteria for misophonia are expected to be developed by consensus panels of physicians and expert scientists. Currently, "Other specific obsessive-compulsive and related disorders" (300.3) may be the most appropriate DSM-5 classification. As part of the assessment process, an assessment by a medical professional with audiology (such as an otolaryngologist or otolaryngologist) or possibly a neurologist is recommended to identify other possible disorders affecting the hearing or nervous system. For example, misophonia needs to be distinguished from hyperacusis (an oversensitivity to sounds of a certain intensity/volume), which is more common in individuals with autism spectrum disorders.

treatment

There are no evidence-based treatments for misophonia. To date, clinical studies (or treatment studies) are lacking and recommendations are currently based on clinical experience and case reports. Most psychological interventions focus on reducing stress or dysfunction associated with increased sensitivity to sounds (e.g., anger, avoidance). Some preliminary reports have shown that treatments such as exposure and response prevention (ERP), psychoeducation, and habituation training may be helpful. Given the overlap with OCD and related disorders, ERP may be an appropriate intervention for some patients. However, it is postulated that exposure therapy may not be sufficient (or appropriate) to erase the relationship between the sound trigger and the irritability/disgust response. In some cases, habituation to auditory triggers (e.g., through real-life graded exposures) may reduce sensitivity and/or behavioral responses such as tantrums, anger, and irritability. In other cases, however, even repeated exposure to a target sound may not reduce sensitivity or subjective stress.

Consequently, learning how to sit with distress, as well as learning methods to reduce emotional and behavioral reactivity in the presence (or anticipation) of stimulating sounds, can be a central part of psychological treatment. In addition, treatment may focus on breaking associations between sound elicitors and other stimuli (i.e., using cancellation strategies to break associations between locations where the sound may occur and the people/objects associated with the sound).

Children are recommended to learn stress tolerance skills. Over time, asking to use these abilities can become a substitute for outbursts of anger, avoidance, or rejection when confronted with triggering sounds. Child care typically focuses on reducing temper tantrums and working extensively with parents to (a) reduce accommodation in misophonia (e.g., set specific mealtimes so the child cannot trigger triggering noises) and (b ) to encourage/reward the use of stress tolerance and discomfort/anger management skills when triggers are encountered.

Pending investigation, the use of precautions such as protective equipment (eg, noise-cancelling devices or hearing protection) or quiet areas (eg, quiet places at home, school, or work) should not be considered treatment for misophonia, but may be helpful with treating symptoms while implementing more adaptive strategies. In other words, adaptations (headphones, white noise, noise reduction) alone, without cognitive behavioral strategies that develop new stress tolerance and other adaptive skills, are not recommended as the sole treatment strategy. Avoidance of noise triggers (e.g., homeschooling, isolated eating) is strongly discouraged as a treatment strategy because it compromises the development of more adaptive strategies and potential 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 problems targeted (eg, avoidance, anger/anger, fear/anxiety, rituals/compulsions). In other words, knowledge about how to treat anxiety, OCD, and anger/anger/reactivity can be flexibly adapted.

There are no drugs with specific indications for misophonia. However, pharmacotherapy may be indicated for concomitant problems such as severe anxiety or reactivity/anger/anger.

The doctor. Lewin is Associate Professor of Pediatrics and Director of the Behavioral Treatment Program for OCD, Anxiety and Related Disorders at the University of South Florida. Dr. Storch is Professor of Pediatrics at the University of South Florida, Director of Research in Developmental Pediatrics at All Children's Hospital, and Clinical Director at Rogers Tampa Bay. DR. Murphy is Rothman Professor of Pediatrics, Chief of the Department of Pediatric Neuropsychiatry and Vice President of Faculty Affairs at the University of South Florida.

Suggested Literature

Jastreboff, P.J. and Jastreboff, M.M. (2014). Treatments for reduced sound tolerance (hyperacusis and misophonia).Auditory seminar, 35, 105-120.

Lewin AB, Wu MS, Murphy TK, and Storch EA. (2015). Sensory hypersensitivity in pediatric obsessive-compulsive disorder.Journal of Psychopathology and Behavior Assessment, 37, 134-143.

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

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

Webber TA, Johnson PL, Stork EA. (2014) Pediatric misophonia with comorbid obsessive-compulsive disorder.Psychiatrie General Hosp, 36 (2), S. 231.e1–231.e2.

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

Misophonia: incidence, phenomenology, and clinical correlates in a sample of undergraduate students.Journal of Clinical Psychology, 70(10), 994-1007.