Misophonia

What is misophonia? 

Almost everyone feels annoyed or irritated by certain sounds like chewing, lip-smacking, snoring, or pen-clicking. For people with misophonia, emotional and sensory reactions to certain sounds or visuals become so overwhelming that they begin to cause major problems.  Although misophonia is still not recognized as an official diagnosis in healthcare’s leading systems, a team of experts recently got together to create a definition of misophonia that leaders in the field could agree on as a starting point. According to this definition, misophonia is a disorder of decreased tolerance to certain sounds or visuals associated with these sounds, called “triggers.” When people with misophonia face their triggers, they feel very angry, disgusted, or upset, so much so that it is hard to focus on anything else. These triggers are less about the volume of the sound, and more about the sound’s pattern (“sniff, sniff, sniff”) or meaning (“This person is so rude!”). 

We’re still learning so much more about misophonia, and this definition will evolve as we do more research and the different theories about the disorder get tested out.

What types of sounds or visuals are usually triggers?

These triggers are usually (but not always) sounds caused by other people, and are often related to mouth or breathing sounds (like chewing, sniffing, crunching, sniffing, sneezing, etc.). The visuals that go along with these sounds are often triggers as well. Lots of other things can be triggers too, especially repetitive sounds or movements like pen-clicking or foot-tapping. Although human-made sounds seem to be most bothersome, people with misophonia can find other sounds more bothersome too, like water faucets dripping or bags rustling. 

How common is misophonia? 

Surveys have suggested that as many as one in five people experiences negative emotional reactions to misophonia triggers. It is still unclear how common misophonia is at the level where we would call it “clinically significant” or a “disorder,” which is when this sensitivity starts interfering with a person’s day to day life or causes a major level of distress that would warrant treatment. Scientists still needs to identify an accurate way to quickly screen for clinically significant misophonia - this work is ongoing, and once we figure that out, we’ll be able to conduct studies that estimate how common it is. 

What is the cause of misophonia?

As is the case with nearly all complicated conditions, there is not a single cause of misophonia. There is still a lot of research that needs to be done on this topic, but it seems like several interacting and overlapping factors contribute to a person developing misophonia, including brain-based, psychological, and social components. Each person's experience with misophonia is unique and the causing or maintaining factors are always at least in part unique to them, though there seem to be some common factors.

Neurologically, there seems to be quite a bit of overlap between misophonia and many psychiatric disorders. Specifically, there seems to be communication problems between parts of the brain responsible for emotional regulation, such as those between the prefrontal cortex (responsible for reasoning, directing attention, and cooling down emotional reactions) and the limbic system (the part of the brain responsible for emotional reactions to different situations). There quite a bit of recent research indicating that a part of the brain connected to the limbic system, the insula, is an area that is particularly over-reactive among people with misophonia.

Psychologically, it seems that the meaning people make of triggers often drives a big part of the reaction - for example, if you listen to someone sniffing, most people find that noise more irritating if it is paired with a visual of a nose breathing, and less irritating if it accompanies a pencil moving across a piece of paper (which actually can make a very similar sound). This difference might be particularly pronounced in people with misophonia. Expectations about how bad a sound will be also drives part of how strong the reaction is. People with misophonia also have trouble with emotion regulation, or the process of identifying and controlling emotional reactions. One specific facet of emotion regulation, or the ability to change the direction of your attention, appears to be one really prominent factor. People with misophonia may also have stronger general disgust reactions, inflexibility, and a high need for control.

Interpersonal dynamics can be critical to the meaning people make out of sounds - many people with misophonia describe being able to tolerate triggers in some situations (e.g., at lunch with friends), but are unable to cope in others (e.g., at dinner with family members). Many families end up having lots of conflict around misophonia, and these communication difficulties can often make dealing with this problem even harder.

How does misophonia affect someone’s day to day life? 

Although almost everyone is bothered by certain noises from time-to-time, the lives of people with misophonia can be completely disrupted by the disorder. Living with this condition often involves a never-ending cycle of being on-guard for triggers on the one hand, or recovering from reactions to triggers on the other. Triggers are found almost anywhere, so many people with misophonia miss out on family time, social opportunities, or other important parts of their life. Anxiety about hearing triggers can cause substantial challenges, and efforts to avoid triggers can lead people to feeling lonely and isolated. People with more severe misophonia may stop leaving the house, spending time with loved ones, working, or going to school because the reactions are so intense.  

Can kids have misophonia? 

Although most research has been done with adults, research suggests that it typically begins during childhood. There is now growing research on kids with misophonia too. My colleagues and I have pursued research that has shown kids with misophonia experience very similar triggers and reactions as those seen in adults.  Misophonia can create major challenges growing up, and kids often need academic accommodations to make it through the school day. In many cases, sound sensitivity, and children’s reactions to sounds, create lots of tension in the home as well and can lead to conflict among family members. My colleagues and I have done lots of research on this topic, which has highlighted that quality of life is highly impacted in misophonia and leads to family conflict, emotional exhaustion, social isolation, and academic issues. 

How can I manage misophonia?

We are still at the early stages of research studying treatments for misophonia. Unfortunately, few healthcare providers even know what misophonia is. The best advice we can give for now is to figure out whatever helps you or your child cope with misophonia on a day-to-day basis and accomplish your goals in life.

In my practice, I use cognitive behavioral therapy (CBT). Although research on this therapy for misophonia is still in its very early stages, CBT is the most tested therapy for this disorder, and has been shown to be more effective than no treatment in at least one study. CBT refers to a category of therapies that involves identifying patterns of thought (“cognitive”) and action (“behavioral”) that contribute to a mental or physical health problem, and practicing new, more effective ways to respond. As it applies to misophonia, CBT helps change your relationship with sound or visual triggers – how you think about them, the meaning you make of them, how you direct your attention when facing them, and how you cope with them. 

My philosophy to helping people with misophonia is to approach this topic collaboratively. If you or your child is struggling with misophonia, you are the expert on how it affects you and one of my most important jobs is to listen well so I can understand what your experience is like. On my end, I am up on the scientific literature in misophonia and have lots of experience in CBT, and can contribute that perspective. My goal in therapy is to form a strong partnership and find strategies that will help people manage or even overcome misophonia to the point where it is no longer an interfering problem. 

If you do find other healthcare providers, or even better, a team of healthcare professionals who know what misophonia is and provide help that makes sense to you, definitely take advantage of those resources. Clinicians who most often work with people with misophonia include therapists, psychologists, audiologists, psychiatrists, and occupational therapists.  But even within these professions, awareness about misophonia is still too low.

Isn’t misophonia a brain-based disorder? How is therapy supposed to help with something neurological?

It is is certainly true that there are neurobiological and physiological factors that are part of misophonia. It is also true that every time we learn anything or have a meaningful experience (both of which being a goal of therapy), our brains and bodies change in some way. An incredible thing about therapy is that it can change how the brain works as well. For example, the brain has been found to change following cognitive behavioral therapy focused on chronic pain and migraines, among many other physical and mental health problems. Similar studies still need to be conducted in misophonia, but it is hard to imagine the same would not be true for misophonia. 

Because intense reactions to misophonia triggers can occur nearly instantly, many people believe that finding new ways to respond to triggers can only change how we cope with them, rather than the "instant" reactions. Therapy has been shown to help some people even with problems related to other near-instant, seemingly automatic reactions. For example, people with PTSD can be completely free of intense reactions to trauma reminders following therapy when it goes well. Therapy can train the brain to understand these “false alarms” of danger are just that - false alarms. Because misophonia reactions also seem to be tied to this false alarm “fight or flight” response, I believe these reactions could also be tempered if the brain learns to associate them with safety rather than threat, at least for some people.