Tuesday, April 2, 2013

Misophonia: Personality Quirk, Symptom, or Neurological Disorder?

When I first learned about misophonia, it was described as a severe annoyance by certain specific sounds, most commonly bodily sounds such as chewing, breathing and slurping, or repetitive sounds such as ceiling fans, beeping, etc.  A quick Wikipedia search described it as, “a form of decreased sound tolerance… believed to be a neurological disorder characterized by negative experiences resulting only from specific sounds, whether loud or soft.”

Immediately, I had a number of questions: if misophonia is just a hatred of certain sounds that leads to annoyance or anger, how is this classified as a neurological disorder?  Wouldn’t everyone have this disorder to some degree?  Everyone has their pet peeves as far as sound goes; I cannot stand the sound of people chewing, and while it is sometimes very irritating, I would by no means say that I have a neurological disorder.

The Wikipedia entry stated, “Intense anxiety and avoidant behavior may develop, which can lead to decreased socialization. Some people may feel the compulsion to mimic what they hear.”  If everyone has sounds that they hate, but some people get uncontrollably angry or anxious when they hear their hated sounds, then isn’t this disorder a behavioral issue?  I initially had two hypotheses about misophonia: 1) someone who cannot control their behavior in response to certain sounds probably has trouble controlling their behavior in response to other stimuli as well, and therefore misophonia is the side-effect of another neurological or psychiatric disease, not its own one.  And 2) misophonia is one of those “disorders” that just seems like a scheme to sell more drugs to hypochondriacs.  But this was Wikipedia, so I first looked to the DSM-IV to learn more about misophonia.

Misophonia is not classified in the DSM-IV, so even in the small pool of research available on the subject, there seems to be little agreement on what misophonia actually is and what causes it.  Some papers lump misophonia into the same category as tinnitus (hearing ringing sounds that are not there, usually due to cochlear damage or hearing loss) and hyperacusis (sensitivity to sound).  In a study of tinnitus patients, Sztuka et al [7] found that 10% of the patients they studied had misophonia.  However, other studies found that while hyperacusis, tinnitus, and misophonia are related, misophonia is not caused by auditory damage. Jastreboff and Jastreboff [3, 4], found that when a trigger sound is played to people with misophonia, it results in a larger activation of the limbic and autonomous nervous system, but not a larger activation of the auditory system.  The limbic system plays a part in other behavioral disorders such as OCD, so this suggests that misophonia could have an anatomical origin that may cause people with misophonia to react to sound differently.  Now that I had learned of an actual neurological difference in people with misophonia, I felt that my initial reaction - that misophonia is a ridiculous attempt to label something normal as a disorder - was false.  However, there is still evidence to support the position that misophonia is a symptom of a larger behavioral disorder, so I wondering about the legitimacy of misophonia as a stand-alone behavioral disorder.

A map of the misophonia activation pathway, from Tinnitus Retraining Therapy: Implementing the Neurophysiological Model [4]

Another study published in January of this year studied 42 patients with misophonia. [5]  The triggers for these patients were all human-generated noises; chewing, breathing, hand sounds, etc.  Some patients also reported visual triggers, simply referred to as “repetitive visual movements.”  This study conducted several personality tests and found that of their 42 patients, 35 had a comorbid disorder including mood disorders, panic disorders, ADHD, OCD, and OCPD, among others.  22 out of 42 patients were found to have Obsessive-Compulsive Personality Disorder (OCPD), a disorder characterized by “a chronic non-adaptive pattern of extreme perfectionism, preoccupation with neatness and detail, and a requirement or need for control or power over one’s environment.”  Since OCPD is estimated to occur in 7.88% the population [1], the extremely high comorbidity of misophonia and OCPD found in this study cannot be ignored.  Interestingly, in the discussion of this paper, Schröder et al. call to distinguish misophonia its own neurological disorder, explaining how misophonia is not a symptom of another disorder, but its own disorder [5].  They assert that misophonia, while similar to social phobia, is not a social phobia because patients do not feel anxiety, only anger and disgust.  Other studies [3, 4, 6]  found that misophonia patients do feel anxiety or fear as well as anger.  This paper also says that misophonia cannot be caused by OCD, because while they are both marked by obsession and avoidance, misophonia patients do not perform compulsions.  However, Hadjipavlou et al. found that misophonia patients will often mimic compulsively annoying sounds as a way to reduce the stress caused by them.

But to me it still remains unclear whether misophonia is a separate, distinct disorder.  Since misophonia is reported in people with auditory disorders as well as people with behavioral and mood disorders, it seems as though misophonia is a symptom, not its own disorder.  However, this begs the question, “How do we define a disorder?”  Many disorders are co-morbid with each other, yet we still classify them separately and we especially have difficulty with psychiatric disorders. These topics have also been discussed on this blog here, here, and here.

Right now, it seems that there are not many good treatment options for people suffering from misophonia.  Certain therapies including Cognitive Behavioral Therapy, and Tinnitus Retraining Therapy are options- while these options may improve symptoms, they are not a cure for the disorder.  In fact, in this blog submission, the patient’s therapist had not even heard of misophonia.  At this point it seems that whether it actually is its own disorder or caused by something else is less relevant than the problem that those suffering from the disorder are not getting the treatment they need.   However, it seems that providing misophonia with its own distinct identity might be part of the solution for helping these patients.  Hopefully the call to recognize misophonia as a disorder will spark interest in the subject, which will increase research on the neurological mechanisms of misophonia and innovation in treatment, so that patients will eventually be able to receive the treatment they need.

[1] Grant, Bridget F., et al., "Prevalence, Correlates, and Disability of Personality Disorders in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions." The Journal of Clinical Psychology 65 (2004): 948-58. Print.

[2] Hadjipavlou, G., S. Baer, A. Lau, and A. Howard. "Selective Sound Intolerance And Emotional Distress: What Every Clinician Should Hear." Psychosomatic Medicine70.6 (2008): 739-40. Print.

[3] Jastreboff, Margaret M. "Chapter 2: Decreased Sound Tolerance." Tinnitus: Theory and Management. By Pawel J. Jastreboff. Hamilton, Ont.: BC Decker, 2004. 8-15. Print.

[4] Jastreboff, Pawel J., and Jonathan J.P. Hazell. Figure 2.14. N.d. Tinnitus Retraining Therapy: Implementing the Neurophysiological Model. N.p.: Cambridge UP, 2004. 49. Print.

[5] Schröder, Arjan, Nienke Vulink, and Damiaan Denys. "Misophonia: Diagnostic Criteria for a New Psychiatric Disorder." PLoS One 8.1 (2013): n. pag. 23 Jan. 2013. Web.

[6] Schwartz, Paula, Jason Leyendecker, and Megan Conlon. "Hyperacusis and Misophonia The Lesser-Known Siblings of Tinnitus." Minnesota Medicine (2011): 42-43. Print.

[7] Sztuka, Aleksandra, Lucyna Pospiech, Wojciech Gawron, and Krzysztof Dudek. "DPOAE in Estimation of the Function of the Cochlea in Tinnitus Patients with Normal Hearing."Auris Nasus Larynx (2009): n. pag. Print.

About the author 
Emily Young is a third-year undergraduate Biology major at Georgia Tech.  She has participated in research at the Center for Advanced Brain Imaging at Georgia Tech, BRAIN, the United States Army Criminal Investigations Laboratory, and currently works in Dr. Maney’s lab at Emory University.  Emily is also the Vice President of marketing of GTNeuro, the neuroscience club at Georgia Tech.

Want to cite this post?
Young, E. (2013). Misophonia: Personality Quirk, Symptom, or Neurological Disorder? The Neuroethics Blog. Retrieved on , from http://www.theneuroethicsblog.com/2013/04/misophonia-personality-quirk-symptom-or.html


James Burkett said...

The fact that activation of limbic regions can be detected in misophonic patients is not particularly good evidence that misophonia is "real," distinct, or even neurological. It is more likely to be the physiological manifestation of their annoyance.

L'ecume said...

Very interesting blog entry
Keep going.

Anne Berryessa said...

Thank you so much for your article. There are so many of us that have suffered with Misophonia for decades and have just found out through the internet we are not alone. It's a debilitating and difficult disorder and robs many of us of a normal life. Everyday we are hit by a huge "flight or fight" response by normal everyday sounds most people can ignore. We need in depth research to find a solution. Thank you for helping the awareness of this disorder.

Mark Stevens said...

I am glad to see this post. This condition has a significant toll on those who suffer from it, and the "it's just in your head" reaction that most people have to it adds insult to injury.

I have a 15 year old son who experienced onset of MIsophonia (I think "Selective Sound Sensitivity Syndrome" is more accurate) at about 12 years old. I have 5 kids, all of whom are well adjusted and well behaved. When my son first began reacting to eating sounds it was very specific and unexpected. For over two years I assumed it was some kind of adolescent rebellion. We tried various approaches (from accommodation to strict discipline) and even took him to a psychologist who was puzzled but had us try to treat it as if it was OCD, even though he showed no other signs of that condition. Once we heard about Misophonia and heard other's stories it matched very closely. When we explained it to our son, it brought immediate relief as our son was starting to think he was "just crazy." By practicing avoidance of the triggers we are much closer and he is otherwise "back to normal" in the rest of life.

From my perspective, this seems very much to be some kind of sound processing "short circuit" with his "fight or flight" response so as to trigger instant rage. It is similar to the emotional response you might have if people kept slipping up behind you and blasting a horn in your ear...it is a reflexive response. While my son has no other disorders, I think he would have developed some psychological issues from the stress of dealing with it plus the pressure from others.

One other point about this is that there does appear to be a genetic link. In our case, my sister also suffers from a milder form of this. Her symptoms are similar but not as severe.

Carol said...

We were so lucky to find the Misophonia forums. Our daughter has been suffering for quite some time and we could not fathom why she was responding to normal noises with such intensity. Now I know that the trigger sounds sort of have different frequencies that most of us cannot hear (sort of like a dog whistle). It causes the sufferers different levels of discomfort. It results in spontaneous reactions- like a balloon being popped behind us causing us to jump. Hearing the sounds over and over does not help them "get used to it"; it actually intensifies the discomfort.

Courtney said...

Thank you for the blog entry. I recently discovered that my 'special corner of crazy' has a name, thanks to of all things a pin on Pinterest. I am in my mid 40's and have suffered in silence from this almost all my life. I have had decades of superb psychological care but it wasn't until I found out about misophonia that all the work I did came together. Misophonia is pervasive, touching every aspect of virtually every day. It is uncomfortable, it is private, and the biological urgency of the fight-or-flight/rage response is strong. Knowing that there are others makes a difference, thank you for being part of a growing awareness.

Sandra Green said...

I have had Misophonia, specifically 4-S, since childhood and it has affected every aspect of my life - work, relationships, education, social interactions, etc. I recently wrote an article for Yahoo Voices regarding Misophonia-4S. Please read my article and offer feedback.


Sandra Green

Winnie Smith said...

Thanks to Emily for bringing awareness of this disorder to the research community. Sandra: Your article is a must read for those that are interested in helping those affected by Misophonia. The You Tube Video ( http://www.youtube.com/watch?v=rlWHLx9PTE4) is
extremely effective, also.

a siganoff said...

"It is more likely to be the physiological manifestation of their annoyance." ??? Shame on you.
Now that that is out of my system (and it points clearly to the need for real research), thank you Emily for an interesting article about this distressing disorder. The biggest cringe-worthy aspect of any research we have now is the backgrounds and interests of the authors and the lack of consistency for success in treatment. The Jastreboffs likening it to Tinnitus or Hyperacusis, Arjan Schroder claiming success by having subjects be less upset about having Misophonia vs a reduction in stimulus/response . . . etc.
This disorder runs on a spectrum just like everything does, it is clearly genetic and quite disabling. So - thank you again for your attention and the publicity we so desperately need.

Lynn H said...

I am the mother of a beautiful smart sweet 21 year old and watch this horrible condition torture her. We have been to psychiatrists counselors neurologists etc. With no success. When she was 9 she couldnt understand why none of us were disgusted by the same noises. She would get up and sit alone at restaurants and look at us like...help me. I miss you. Im so lonely. She wears headphones a lot and when she takes them off i see red marks on her precious ears as she tries to tolerate sounds of people she loves. She watches her friends in love and thinks she will have to be alone forever in a bubble. She doesnt even want to expose them to her..bcus she will possibly be disgusted by their breathing at some point. Please keep searching for answers. Thank you for all the articles and understanding. Its a sad debilitating condition. One she did not want or deserve. The normal noises make her become a person she doesnt like. So she escapes. Walks on the beach are helpful. Until she sits down to rest...and someone next to her opens a bag of chips. We are grateful for support and research.

CatBar said...

I'm never sure if I 'qualify' as a true Misophonic or not, as my particular Trigger Sounds appear very different - but I know I DO share the same anger/startle reactions, and the same feelings of marginalization and alone-ness.

In brief, my Triggers are nearly all 'impact-type' sounds carelessly or imitatively caused by other people. (I also loathe dog barking and fireworks).

If of further interest I've copied in a Link (below) to my Post on the Misophonia.com Forums, listing my Triggers and avoidances and vigilances.


CatBar said...

Lynn H said: "When she was 9 she couldnt understand why none of us were disgusted by the same noises. She would get up and sit alone at restaurants and look at us like...help me. I miss you. Im so lonely."

Lynn, I just know that situation SO WELL. That feeling of desolation when one sees nobody else minding the same sounds, and the going off - alone - to avoid these.... whilst everyone else stays together, bonded by their own 'not minding-ness'.

CatBar said...

James Burkett said: "The fact that activation of limbic regions can be detected in misophonic patients is not particularly good evidence that misophonia is "real," distinct, or even neurological. It is more likely to be the physiological manifestation of their annoyance."

That's an interesting - if perhaps somewhat disillusioning - comment, as, sadly, it might just turn out to be true.... or, rather, in this world, it would be made out to be true.

That said, why are some of us so clearly sensitive to, and distressed by, certain otherwise harmless sounds - be these eating/breathing sounds, or, in my case, certain impact-type sounds carelessly/imitatively caused by other people.

James Burkett said...

I should qualify that I in no way meant that misophonia is not real, distinct, or neurological. However, brain activation in limbic regions is not good evidence of any of these things. Limbic regions are often activated during emotional responses, so this would be expected in any test where the subject is experiencing a negative reaction.

Sleepy said...

Dogs are my trigger too, hard to find people that take it seriously as most doctors only accept eating noises or breathing etc as possible triggers. Hearing dogs bark even once unleashes violent anger followed a little later by feelings of stomach in spasm, increased blood pressure, desire to hide and become deaf which lasts for days. I feel imprisoned if I have to wear ear plugs all day as well as all night. Dog owners don't seem to care, tell me to get over it or ignore it like that is even possible.

Have any of you found any benefit from cbt or hypnosis as nothing I've tried has worked?

Hen G said...

Hi Sleepy. I have the same exact trigger. Barking dogs is a huge issue for me. Hearing it once sets me off too. If it goes on and on (and it mostly does with dogs) I go into a spiral of rage, anxiety, and panic. I hate being this way. I feel trapped all the time with this.

Unknown said...

Agreed. If it's real, then I am considered under this category. I used to share a room with my younger sister and every single sound she made drove me nuts hearing her breathing loud or snoring or any sounds of that nature drove me bananas. I to this day have this pproblem with my boyfriend. And I start getting knots in my stomach and this anxious angry feeling I have to react. I wake them. I work myself up and can't fall asleep for a few hours and have to sleep elsewhere. Same goes for people chewing or making noises with their mouth like as if they're tasting something - that's the worst one for me. That's the best I can describe it.

Marwa Saleh said...

Well I'm really confused if I have misophonia. I don't really get irrated by common sounds such as breathing. When I hear sounds such as the school bell, door slam, floor creaks, etc. I react by feeling anger and I make a fist. Usually when I know I'm going to hear an annoying sound (even if it's not loud) I react quickly by putting my index finger near my ear. Does it seem like I have misophonia?

Mark Stevens said...

Marwa, the particular trigger sounds are different for different people. I think the question is if the same sounds consistently cause a reaction. If so, then that makes me think it is misophonia.

Kim Schilling, DDS said...

I can remember when it started with me... my little brother had allergies and sniffled a lot... drove me nuts! to this day sniffling drives me nuts as does chewing with your mouth open especially things like gum, repetitive and those same barking dogs plus of course snoring. I think snoring seems to be accepted as irritating but those other things... makes me leave, put on music loud enough that I cannot hear the trigger, put in ear plugs, I have found Macks to be the best.... Would be nice to have a treatment for this. It has been a lot of years... going on 50.

Anonymous said...

My theory about misophonia is that there are certain sounds that occur as you grow and when these sounds are occurring they often occur when another event is going on.
For example, my sister believes that I have misophonia because I can't stand it when I can hear people chew or breath. (There are plenty of other noises that anger me, but lets focus on these two). Anyways, my dad doesn't have the best health, and so he always chews with his mouth open and he is always breathing very hard, when coming up a small set of stairs or putting on his shoes. Anyways, now whenever my dad makes these noises I literally run out of the room because otherwise I feel this overwhelming urge to break things or just scream at him (which would make everything worse). Now when others breath loudly or are chewing loudly, I have to ask them to alter the way they chew because I can't handle it. I don't even like the sound of my chewing, but at least when I chew it makes me feel like I mocking someone or that I have the potential to make them angry.