Misophonia

Misophonia, literally "hatred of sound", is a rarely diagnosed neuropsychiatric disorder in which negative emotions (anger, flight, hatred, disgust) are triggered by specific sounds.[1] The sounds can be loud or soft.[2] The term was coined by American neuroscientists Pawel Jastreboff and Margaret Jastreboff[3] and is sometimes referred to as selective sound sensitivity syndrome.[4]

Misophonia is not classified as a discrete disorder in DSM-5 or ICD-10; in 2013 three psychiatrists at the Academic Medical Center in Amsterdam formulated diagnostic criteria for it and suggested that it be classified as a separate psychiatric disorder.[5]

A 2013 review of neurological studies and fMRI studies of the brain as it relates to the disorder[6] postulated that abnormal or dysfunctional assessment of neural signals occurs in the anterior cingulate cortex and insular cortex. These cortices are also implicated in Tourette Syndrome, and are the hub for processing anger, pain, and sensory information. Other researchers concur that the dysfunction is in central nervous system structures.[7] It has been speculated that the anatomical location may be more central than that involved in hyperacusis.[8]

An alternative view is that misophonia is a Pavlovian conditioned reflex.[9][10] This view is based in part on observations of the responses of patients to treatments that exhibit active extinction and counterconditioning, two Pavlovian reflex processes. Another Pavlovian reflex process called "spontaneous recovery" has also been reported by patients during treatment.[11]

Figure 1. Misophonia as a one-step process. The trigger stimulus directly elicits extreme emotions and fight-or-flight responses.

The traditional view of misophonia, as an emotional reflex response to the trigger stimulus, is shown in Figure 1. As shown, the emotional response is directly elicited (involuntary response) by the trigger stimulus. In the Pavlovian model, misophonia is a physical (muscle) reflex elicited by the trigger stimulus, and the emotional response characteristic of misophonia is elicited by the physical jerk of the muscle in the body (see Figure 2).[11]

Figure 2. Misophonia as a two-step process. The trigger stimulus elicits a physical reflex. The physical reflex elicits the emotional response and fight-or-flight responses. In some individuals, a secondary path develops so that the trigger stimulus directly elicits emotions.

It was reported that over 95% of patients identified a physical (muscle) reflex directly elicited by the trigger, when they were tested in a clinical setting.[11] The reflexes are diverse. Patients have reported muscle contractions of shoulders, neck, whole arm, upper arm, only the left upper arm, legs (in many variations), toes, abdomen, chest, jaw, hands open, hands making a fist, face, squinting, gasping and more. Other patients reported internal reflexes including stomach constriction, nausea, intestine constriction, esophagus constriction, sexual arousal, urge to urinate, and unidentified movement sensations in the chest cavity.[11]

Symptoms

People who have misophonia are most commonly angered by specific sounds, such as slurping, throat-clearing, nail-clipping, chewing, drinking, tooth-brushing, breathing, sniffing, talking, sneezing, yawning, walking, gum-chewing or popping, laughing, snoring, swallowing, gulping, typing, coughing, humming, whistling, singing, certain consonants, or repetitive sounds.[12] Sufferers experience fight/flight symptoms such as sweating, muscle tension, and quickened heartbeat. Some even feel unwanted sexual arousal, caused by the over-activation of hormonal circuits.[13] Some are also affected by visual stimuli, such as repetitive foot or body movements, fidgeting, or movement they observe out of the corners of their eyes. Intense anxiety and avoidance behavior often develops, which can lead to decreased socialization. Some people feel the compulsion to mimic what they hear or see.[14] Mimicry is an automatic, non-conscious, and social phenomenon. It has a palliative aspect, making the sufferer feel better. The act of mimicry can elicit compassion and empathy, which ameliorates and lessens hostility, competition, and opposition. There is also a biological basis for how mimicry reduces the suffering from a trigger.[6]

Prevalence and comorbidity

The prevalence of misophonia is unknown, but groups of people identifying with the condition suggest it is more common than previously recognized.[14] Among patients with tinnitus, which is found at clinically significant levels in between 4 and 5% of the general population,[15] some surveys report prevalence as high as 60%,[14] while prevalence in a 2010 study was measured at 10%.[16] A 2014 study of students, conducted at the University of South Florida found that 20% of the almost 500 participants had misophonia-like symptoms.[17] Misophonia may be associated with OCD, anxiety and depressive disorders.[17]

The Dutch study published in 2013[5] of a sample of 42 patients with misophonia found a low incidence of psychiatric disorders, with the exception of obsessive–compulsive personality disorder (52.4%).

It has been suggested that there is a connection between misophonia and synesthesia, a neurological condition in which stimulation of one sensory or cognitive pathway leads to automatic, involuntary experiences in a second sensory or cognitive pathway.[18] The basic problem may be a pathological distortion of connections between various limbic structures and the auditory cortex, causing sound-emotion synesthesia.[19] There are people with both misophonia and synesthesia, and many people with synesthesia have more than one form of synesthesia (there are over 60 reported types).[20]

Treatment

There are a limited number of journal articles and conference reports on treatment for misophonia, none of which involve controlled studies. The most widely used treatment is to add noise to the patient’s environment.[21][22] With increased ambient noise, many misophonia sufferers have a greatly reduced response to triggers. Noise can be added to an environment with a sound generator or fan, or directly to the ear with a behind-the-ear sound generator that looks like a small hearing aid. There are two treatment protocols that use sound generators.

The Misophonia Management Protocol[23] uses the ear-level noise generator and recommends 6-12 weeks of cognitive behavior therapy or similar therapy for dealing with misophonia as a chronic condition. On average this treatment reduces the perceived severity of misophonia from severe to moderate or moderate to mild, according to patient report.

The second treatment that uses sound is Tinnitus Retraining Therapy.[24] This treatment uses ear-level noise generators, counseling, and gradual exposure to triggers. This was reported to have produced significant reduction in the severity of misophonia in 83% of the 182 patients treated.

There are two case-study journal articles that report successful reduction of misophonia using cognitive behavior therapy (CBT). One case was an adult woman whose symptoms were reduced so there was no impairment of social functioning at the end of treatment and for four months post-treatment.[25] Another was two adolescents who were successfully treated with CBT, but no follow-up data was provided.[26]

A case study of a counterconditioning treatment called the Neural Repatterning Technique reported a drastic reduction in the severity of misophonia in a middle-aged woman by individually counterconditioning three auditory triggers and a visual trigger.[27] This treatment used an intermittent, reduced-intensity (short and quiet) trigger stimulus while talking about positive life experiences, listening to music, and dancing. This treatment is effective only for people who have a small number of triggers from a single person or in a single setting.

There are anecdotal reports of reduction of misophonia symptoms with other treatment methods, but so far no peer-reviewed articles on other methods.

See also

References

  1. ↑ M. Edelstein, D. Brang, V. S. Ramachandran (2012). "Sensory modulation in misophonia" (PDF). Program No. 367.07. 2012 Neuroscience Meeting Planner. New Orleans, LA: Society for Neuroscience. p. 1042. Retrieved 27 January 2013.
  2. ↑ Jonathan Hazell. "Decreased Sound Tolerance: Hypersensitivity of Hearing". Tinnitus and Hyperacusis Centre, London UK. Retrieved February 5, 2012.
  3. ↑ Pawel J. Jastreboff, Margaret M. Jastreboff (April 2003). "Tinnitis retraining therapy for patients with tinnitus and decreased sound tolerance". Otolaryngologic Clinics of North America 36 (2): 321�36. doi:10.1016/s0030-6665(02)00172-x. PMID 12856300.
  4. ↑ Neal, M.; Cavanna, A. E. (2012). "P3 Selective sound sensitivity syndrome (misophonia) and Tourette syndrome". Journal of Neurology, Neurosurgery & Psychiatry 83 (10): e1. doi:10.1136/jnnp-2012-303538.20.
  5. ↑ 5.0 5.1 Schröder, A.; Vulink, N.; Denys, D. (2013). Fontenelle, Leonardo, ed. "Misophonia: Diagnostic Criteria for a New Psychiatric Disorder". PLoS ONE 8: e54706. doi:10.1371/journal.pone.0054706.
  6. ↑ 6.0 6.1 Judith T. Krauthamer (2013). Sound-Rage. A Primer of the Neurobiology and Psychology of a Little Known Anger Disorder. Chalcedony Press, 210 pgs.
  7. ↑ Aage R. Møller (2006). Hearing, Second Edition: Anatomy, Physiology, and Disorders of the Auditory System. Academic Press. ISBN 978-0-12-372519-6.
  8. ↑ Aage R. Møller (2001). Textbook of Tinnitis, part 1. pp. 25�27. doi:10.1007/978-1-60761-145-5_4. Retrieved February 5, 2012.
  9. ↑ Jastreboff, M. M., & Jastreboff, P. J. (2014). Treatments for Decreased Sound Tolerance (PDF) (Hyperacusis and Misophonia). Seminars in Hearing, 35(2). 105-120. doi: DOI: 10.1055/s-0034-1372527
  10. ↑ Dozier, T.H. (2015). Counterconditioning treatment for misophonia. Clinical Case Studies, first published on January 20, 2015 as doi:10.1177/1534650114566924
  11. ↑ 11.0 11.1 11.2 11.3 Dozier, T. H. (2015). Etiology, composition, development and maintenance of misophonia: A conditioned aversive reflex disorder. Psychological Thought, , Vol. 8(1), 114–129, doi:10.5964/psyct.v8i1.132
  12. ↑ Joyce Cohen (September 5, 2011). "When a Chomp or a Slurp is a Trigger for Outrage". The New York Times. Retrieved February 5, 2012.
  13. ↑ http://www.misophonia-uk.org/dealing-with-misophonia.html
  14. ↑ 14.0 14.1 14.2 George Hadjipavlou, MD, MA, Susan Baer, MD, PhD, Amanda Lau and Andrew Howard, MD (2008). "Selective Sound Intolerance and Emotional Distress: What Every Clinician Should Hear". Psychosomatic Medicine (American Psychosomatic Society) 70 (6): 739/40. doi:10.1097/psy.0b013e318180edc2. Retrieved February 2012.
  15. ↑ Jastreboff, P., Jastreboff, M. (July 2, 2001). "Components of decreased sound tolerance : hyperacusis, misophonia, phonophobia" (PDF). Archived from the original (PDF) on August 13, 2006.
  16. ↑ Sztuka A, Pospiech L, Gawron W, Dudek K. (2010). "DPOAE in estimation of the function of the cochlea in tinnitus patients with normal hearing.". Auris Nasus Larynx 37 (1): 55–60. doi:10.1016/j.anl.2009.05.001. PMID 19560298.
  17. ↑ 17.0 17.1 Wu, M. S., Lewin, A. B., Murphy, T. K. & Storch, E. A. (2014), Misophonia: Incidence, phenomenology, and clinical correlates in an undergraduate student ample. Journal of Clinical Psychology. Vol. 00(00), 1–14. doi: 10.1002/jclp.22098
  18. ↑ Cytowic, Richard E. (2002). Synesthesia: A Union of the Senses (2nd edition). Cambridge, Massachusetts: MIT Press. ISBN 0-262-03296-1. OCLC 49395033
  19. ↑ EDELSTEIN, M., D. BRANG, and V. S. RAMACHANDRAN. "Sensory Modulation in Misophonia." Poster. Neuroscience 2012 Conference of the Society for Neuroscience. New Orleans, LA. 15 Oct. 2012. Sensory Modulation in Misophonia: A Preliminary Examination via Galvanic Skin Response. UCLA. Web. 4 July 2013.
  20. ↑ Day, Sean, Types of synesthesia. (2009) Types of synesthesia. Online: http://home.comcast.net/~sean.day/html/types.htm, accessed 18 February 2009.
  21. ↑ Jastreboff, M.M., & Jastreboff, P.J. (2014). Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia). Seminars in Hearing 35(2), 105-120. doi: 10.1055/s-0034-1372527
  22. ↑ Johnson, M. (2014, February). 50 cases of misophonia using the MMP. Paper presented at the misophonia conference of the Tinnitus Practitioners Association, Atlanta, GA.
  23. ↑ Johnson, M. (2014, February). 50 cases of misophonia using the MMP. Paper presented at the misophonia conference of the Tinnitus Practitioners Association, Atlanta, GA.
  24. ↑ Jastreboff, M.M., & Jastreboff, P.J. (2014). Treatments for Decreased Sound Tolerance (Hyperacusis and Misophonia). Seminars in Hearing 35(2), 105-120. doi: 10.1055/s-0034-1372527
  25. ↑ Bernstein, R.E., Angell, K.L., & Dehle, C.M. (2013). A brief course of cognitive behavioural therapy for the treatment of misophonia: A case example. The Cognitive Behaviour Therapist, 6 (10), 1-13. doi:10.1017/S1754470X13000172
  26. ↑ McGuire, J.F., Wu, M.S., & Storch, E.A. (in press). Cognitive Behavioral Therapy for Two Youth with Misophonia. Journal of Clinical Psychiatry.
  27. ↑ Dozier, T. H. (2015). Counterconditioning treatment for misophonia. Clinical Case Studies. Published online before print January 20, 2015. doi:10.1177/1534650114566924