misophonia

misophonia, disorder marked by low tolerance of and unusually strong negative physiological, emotional, and behavioral reactions to specific sounds or to stimuli related to such sounds. In some persons with misophonia, the triggering stimulus may activate the fight-or-flight response, resulting in increased muscle tension and heart rate as well as sweating. The trigger may also elicit feelings of anxiety, disgust, irritation, anger, or even rage and may prompt strong behavioral reactions, such as aggression, toward the source of the trigger, especially if that source is another person.

Symptoms of misophonia vary from person to person and usually emerge in childhood or early adolescence. The disorder is more common in females than in males. It can occur in persons with normal hearing and in those who have other auditory conditions, such as tinnitus or hyperacusis (increased sound sensitivity). Misophonia can also occur with various other psychoneurological conditions, including anxiety disorders and obsessive-compulsive disorders. In general, onset of misophonia is not associated with a single event but rather develops over time through repeated exposure to a trigger that cannot be escaped.

Causes and neurological factors

The causes of misophonia are uncertain. Both mental and physical factors may contribute to the disorder. Some researchers suspect that it is related to abnormal functioning of mirror neurons in the orofacial motor cortex of the brain. Such neurons are sensory-motor cells that are activated when an individual performs an action or observes another individual performing the same action. According to brain-imaging studies, during sound perception, persons with misophonia exhibit unusually strong functional connectivity between the auditory cortex and the orofacial motor cortex. The latter is robustly activated in the presence of trigger sounds.

Individuals with misophonia also exhibit increased myelination of neurons in the brain’s ventromedial prefrontal cortex (vmPFC), which helps regulate emotions and decision making. Moreover, affected persons exhibit increased activity in the anterior insular cortex (AIC), which processes emotions and integrates sensory and emotional information, including internal sensations associated with emotions observed in others. Magnetic resonance imaging (MRI) has shown that the AIC of persons with misophonia has atypically strong functional connections to other brain areas, including the vmPFC, which may result in inaccurate perception of one’s own physical state, causing certain sounds to be misinterpreted as threatening.

In addition, misophonia appears to involve a learned reaction to a stimulus; that is, the physical reflex is thought to develop through classical conditioning to a trigger sound. Once the trigger is established, the brain simply reacts to it rather than processing the stimulus to produce a response appropriate to the situation. Misophonia may occur with other disorders, but no clear correlations with other disorders have been established.

Triggers

Specific kinds of sounds trigger misophonic reactions; in general, the volume of the sound is irrelevant. Trigger sounds can be categorized in several ways. For example, they may be produced by the human body, an inanimate object, or an animal. Some of the most common human-produced trigger sounds are related to the mouth or nose. Oral or nasal triggers include sniffling, coughing, throat clearing, snoring, and smacking of the lips or gums. Speech can be a trigger, especially sibilant sounds (e.g., s, ch, sh, and z). Even common oral and nasal sounds, such as breathing, chewing, and talking, can be triggers. Other human-produced sounds, such as the tapping of a pencil on a table or the clicking of a pen’s retractor mechanism, may cause a reaction in some individuals. Other such potential triggers include bass thumping through walls, heavy footsteps, people clipping their nails, and people typing. Potential trigger sounds produced by inanimate objects include clock ticking, water trickling, and reverse beeps from vehicles. Animal-related noises, such as barking, crowing, croaking, and scratching, may also be triggers.

Symptoms

Persons with misophonia complain of mild to severe reactions, which tend to centre on the fight-or-flight response. The fight impulse may produce discomfort, irritation, disgust, anger, or rage. The flight response may cause panic, fear, emotional distress, or anxiety. Triggering incidents can produce muscle tension, increased heart rate, and sweating. Although it may take only a few moments to become distressed, it may take hours to calm down. Misophonia can lead to social isolation, especially if individuals react to trigger sounds related to common social activities, such as eating. In addition to feeling distress while undergoing a strong aversive reaction, persons with misophonia may subsequently feel guilty about having reacted so strongly, may question their sense of reality, and may feel too embarrassed to discuss their experience.

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Management

Misophonia can greatly affect individuals’ quality of life. To mitigate negative reactions, individuals with misophonia may try to avoid or escape circumstances in which they encounter the trigger, may try to stop the production of the trigger, or may mimic the trigger. Having encountered a trigger, persons with misophonia may struggle to distract themselves from the stimulus and hence may suffer distress and impairment of social or occupational functioning.

Although there is no formal treatment for the disorder, a multidisciplinary approach that involves the development of coping skills can produce positive results. Health care providers can use a number of treatment modalities, including psychoeducation and cognitive behaviour therapy. Through such strategies, patients can learn about the brain and the rest of the nervous system, change their thought patterns and feelings about their misophonic reactions and about the sources of trigger sounds, develop new ways to respond and reduce emotional impacts, and calm the body when triggered. When patients apply such skills, they can redirect their attention and mitigate their reactions, improve their relationships with others, and become better at self-advocacy. Other potential treatments include white-noise devices or noise-canceling headphones, stress management, and sleep hygiene.