Motivation and emotion/Book/2017/Misophonia

Overview


You've had a busy morning at work. It's lunchtime, and you've got an excellent lunch packed in your lunchbox, plus a nice strong cappuccino from the cafe next door. You head cheerfully to the staff tea-room, where one of your colleagues is happily chowing down on a delicious smelling casserole she's brought in from home. As you sit, you notice the SOUND! The seriously annoying, aggravating SOUND! She's CHEWING that food so LOUDLY! Is her mouth open? Surprisingly no, but you still want to throw your coffee at her and tell her to shush up. UGGGHHHHHH ..... You snatch up your own lunch and head outside to eat in privacy.

Sound familiar?

Most people aren't unduly bothered by regular eating sounds, but for people with misophonia, it's misery-making. Not just "I don't like that sound", more "OMG if that doesn't stop soon I'm going to smack someone upside the head" ... it produces actual anger or rage in the person listening. For someone with misophonia, family dinners can be hard to endure. Going out with friends, attending lectures, or working in the hospitality industry can all prove too challenging. Misophonia is more than mere dislike of a sound: it can be genuinely debilitating, leading to the person isolate themselves from situations where they may encounter the sound(s) they dread. Read on to learn more about this interesting condition, and if you suffer from misophonia, you may even learn some tips to help make mealtimes a bit easier.

Defining misophonia
Prince Kwaku - a YouTuber, (see link below) - inadvertently describes misophonia quite well. He's describing his pet peeve, which is people smacking their lips as they eat, and you can see he's quite irritated by the mere thought. But what *is* misophonia?

Jastreboff and Jastreboff (2001) coined the term Misophonia (Wikipedia page) in their work on decreased sound tolerance (DST). They describe it as an unusually strong reaction to a particular sound that has some meaning to the person. The sound does not need to be loud, nor do others necessarily find it annoying. It may be contextual - for instance, you might be annoyed by people chewing noisily in your staff tea-room or at the dinner table, but not even notice people chewing in a food mall. The response to the trigger is negative - it may be anger, rage, disgust, irritation or even anxiety.

 "I can't listen to that story recording. I can hear her wheezing and it's too distressing." a grandmother on her daughter's effort at making an audio-book for her after she went blind.



The kinds of sounds that induce misophonia are mostly sounds made by bodily functions. Bruxner (2016) says that sounds related to eating and breathing are the most common triggers, but notes many other sounds can have this effect, for example clicking a pen repetitively. Jastreboff and Jastreboff (2014) list a large number of trigger sounds, some of which are unexpected (a cat walking on a hardwood floor, for instance), and some of which it seems likely most people would dislike (warning sounds like sirens or car horns, for instance).

Taylor (2017) reports that some people with misophonia are also triggered by non-auditory stimuli, such as being able to see someone chew gum even though they can't hear it, or even actions that are normally silent like twirling hair or jiggling one's leg. People with misophonia can found some written phrases trigger them, because they visualise the action described, such as "she was munching an apple", or "they were enjoying dinner, feeding each other morsels".

Misophonia should not be confused with Hyperacusis. Jastreboff and Jastreboff (2014) made the point that the patients they studied when investigating DST fell into two categories – those with misophonia and those with hyperacusis. The people with hyperacusis reacted to sounds above a certain level, and their reactions were consistent across situations. For example, if you have hyperacusis and you always react badly to the sound of a balloon bursting, you'll probably also react to similar sounds such as firecrackers, loud hand claps, or doors slamming. The reaction is related to the type and intensity of the sound and is consistent across situations.

Misophonia has also been described as a type of synesthesia (Wikipedia page) – essentially feeling sounds (Edelstein, Brang, Rouw & Ramachandran, 2013). That is, you hear the sound but you react by feeling angry, anxious etc. So where a regular person might hear chewing sounds but not react because their brain regards it as background sound and thus unimportant, the misophonic will hear it, and react with varying degrees of negative emotion.

What kind of disorder is it?
People who do not experience misophonia often regard it as the type of thing experienced by Special Snowflakes, rather than an actual disorder. However, there is evidence that not only is misophonia genuine, the responses can be measured empirically. There is also evidence that the sounds misophonics react to are not simply sounds that most people find aversive.

Audiology and hearing
Misophonia was first reported under that name by Jastreboff and Jastreboff (2001). The Jastreboffs are audiologists who regard misophonia as essentially a hearing disorder under the DST umbrella. Their studies indicated that hyperacusis was a strong reaction to sound occurring within the auditory pathways, while misophonia involved negative responses to sounds that occur within the autonomic and limbic systems. That is, in misophonia, the physical characteristics of the sound are less important than the person's feelings about the sound. This is supported by Reuter and Oehler (2011, as cited by Spankovich and Hall, 2014), who found that people reported more aversion to a sound when they were told was nails on a blackboard than when they were told it was actually contemporary music.

 "I was really annoyed by this chewing sound, until I found the source – it was just my cat eating her dinner… the annoyed feeling stopped when I saw her."

- A misophonic alone with her cat.

Spankovich and Hall (2014) are also audiologists. They recommended that people with misophonic symptoms should be assessed for other conditions that might also include those symptoms – for example, a child on the autism spectrum might also experience distress reactions to certain sounds. They suggest a thorough audiological examination to exclude other hearing issues, and a multidisciplinary approach to establish a suitable treatment plan.

Most people with misophonia have normal hearing. Jastreboff and Jastreboff (2014) and Spankovich and Hall (2014) note that while misophonics may also have tinnitus (Wikipedia page), generally their hearing is completely normal.

Is it a disorder or just a variation of normal behaviour?
Sukhbinder et al. (2017) exposed misophonics and controls to sounds that act as triggers for misophonia and sounds that are generally regarded as unpleasant. They measured responses to sounds using fMRIs, galvanic skin responses and heart rate monitoring.

Functional MRIs show that misophonic people's brains are wired differently: there are changes in the myelination of the ventromedial prefrontal cortex. The anterior insular cortex, which is involved in processing incoming signals and emotions, does not function in the same way as a non-misophonic's does. Due to the abnormal response of the AIC, the misophonic experiences certain sounds differently to other people.

Misophonics also show greater galvanic skin responses (GSR) and increased heartrate (HR) when listening to trigger sounds compared with non-misophonic people. This is consistent with the feeling of needing to stop the sounds from happening, or to escape if it is not. Increased GSR and HR are both symptoms typical of the "fight or flight" response to stress.

Edelstein et al. (2013) conducted a similar study, and found that misophonics and controls had strong reactions to different kinds of sounds. The kind of sounds that most people find annoying, like babies crying or fingernails on a chalkboard, annoyed the control subjects more than the misophonics. Sounds that misophonics were triggered by, such as lips smacking or chewing gum, predictably enough annoyed the misophonics more than the controls. This is interesting because it shows that misophonics are not just more sensitive to sounds that annoy everyone. In fact, according to this study, they are less perturbed by sounds that "everyone" is annoyed by, than they are triggered by sounds that most people find only somewhat annoying.

Skin conductance responses (SCRs) measure electrical conductance across skin, which is enhanced when the person sweats. Testing via SCR is accepted as evidence of involuntary physical arousal, which is why Edelstein et al. (2013) used it in their experiment. It provided empirical evidence of the distress the misophonic people reported feeling in response to certain sounds.

 "It's funny, in stories or movies you see the girl watching her partner sleeping, gently snoring, and she's all "awww!". I watch (my partner) sleeping and gently snoring and I want to smother him with a pillow!"

- A woman who reacts badly to breathing sounds including snoring and asthma

Although there is some overlap between normally aversive sounds and misophonic triggers, it appears that misophonia is an actual disorder rather than a simple extension of a normal reaction. The evidence of a "fight or flight" type response being triggered by certain sounds indicates that it's not something the person can easily control.

Is it in the DSM?
Misophonia does not appear in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5 Wikipedia page), as it has not yet been classified as a psychiatric disorder. Some authors consider that a case could be made for inclusion as it can be argued to fulfil the criteria of a psychiatric disorder. However, others do not necessarily agree.

Taylor (2017) discusses whether misophonia should be a separate mental disorder. On the one hand, recognition of misophonia as a disorder can facilitate research into the condition, provide validation for the sufferer, raise public awareness, and hopefully facilitate treatment options. However, labelling also carries stigma as well as the risk of turning a "benign eccentricity" into a pathological model (Taylor, 2017). Given the involuntary nature of people's responses to trigger sounds, and the levels of distress that can be caused, it seems unlikely that misophonia is merely an eccentricity, or even simply a hearing disorder. It does seem logical to consider whether there is a psychiatric element to the disorder.

To be included in the DSM, a mental disorder needs to fulfil three criteria: there needs to be clinically significant signs and symptoms, these signs and symptoms should arise from some psychobiological dysfunction, and there needs to be significant distress or disability associated with the condition (American Psychiatric Association, 2013, as cited by Taylor, 2017). Misophonia can give rise to intense emotional reactions such as anger, rage, anxiety and disgust. The person can react by lashing out verbally or physically at the one making the sounds, although this is more common in younger sufferers. The person can feel physical symptoms such as their heart racing, or increased sweating. There can also be significant distress and/or disability experienced by the misophonic. Most sufferers recognise that their extreme feelings are in fact disproportionate. Some will refuse to eat with others, or to go places where they know they will be exposed to triggering sounds, which can make it challenging to study or hold down a job. The main difficulty seems to be that the origins of misophonia can't always be traced to a single starting point. People may be able to remember triggering sounds from a young age, but that might just mean they remember that incident, rather than that the incident sparked the misophonia.

 "Oh gross, I can’t believe he CHEWS HIS WINE!!!”

- A teenage misophonic, on hearing her father tasting a new wine he'd made.

Schroeder, Vulink, van Loon and Denys (2017) consider misophonia to be a psychiatric disorder. They discuss how the condition can have considerable impact on a person's ability to function in society, because they actively avoid situations where they will be likely to experience trigger sounds. They note that it has been associated with other psychiatric conditions such as obsessive-compulsive disorder and Tourette’s syndrome, which they say suggests a shared aetiology. Although people with certain psychiatric conditions were excluded from the study, there were still people with co-morbidities such as obsessive-compulsive disorder, ADHD, skin picking disorders and eating disorders. Jastreboff and Jastreboff (2014) criticised Schroeder et al.'s previous work in 2013 on the grounds that the subjects they examined were psychiatric patients, which might be why in this more recent study they excluded patients with more florid symptoms, for example, people with psychotic disorders. While Schroeder et al. (2017) do not actively discuss inclusion in the DSM, it appears likely they would support it based on their findings.

Psychology / Psychiatry
While misophonia might not yet have an actual classification as either a neurological or psychiatric condition, there is considerable support for the idea that misophonia has at least a psychological/psychiatric element. Although it can be a disorder on its own, it is often associated with other mental health disorders. Taylor (2017) and Schroeder et al. (2017) list some reasons why misophonia could be a psychiatric disorder.

Misophonia has also been associated with eating disorders, as a possible contributing factor. Kluckow (2014) studied three young women with eating disorders. Two of them developed misophonic symptoms before the eating disorder, and the other started being aware of her misophonia shortly after the onset of her eating disorder. Each woman reacted violently to the sound of eating, and their anorexia/bulimia was part of avoiding the situation where they’d have to hear the disagreeable sounds. Kluckow (2014) suggests that people with eating disorders should be screened for misophonia, as that may be helpful when it comes to treating the eating disorder.

Several authors note the possible connection with misophonia and OCD, including Kluckow (2014), Schroeder et al. (2017), Edelstein et al. (2013), Webber and Storch (2015), and Taylor (2017). Kluckow (2014) suggests this could be related to the regulation of serotonin and dopamine in the limbic system and basal ganglia. Failure to utilise these neurotransmitters effectively can contribute to compulsivity and aversive processing, which both misophonia and OCD have in common.

Wu, Lewin, Murphy and Storch (2014) conducted a large study of misophonia using 483 undergraduate students as participants. They found that misophonia showed some correlation with OCD, depression and anxiety. They note that anxiety has been less well studied, as most studies appear to focus more on anger rather than anxiety, and suggest that treating the anxiety can help with treating the misophonia. Wu et al. (2014) also note that more study is required to fully understand misophonia and its relationship with other conditions.

How can we deal with it?
There are various ways to deal with misophonia. People often come up with their own coping techniques, such as having background sounds like a television during meal times, or even chatty children present, to provide distraction. But for some it's overwhelming, and they may need professional help.

Can it be "healed"?
The difficulty with treating misophonia is that the cause is still not really understood. Although the condition was named back in 2001, most of the papers on the subject have only been published within the last ten years. There is some debate over what kind of condition misophonia is, and until this happens the best health professionals can do is offer advice and therapies that can help alleviate the symptoms.

Earbuds - effective or counterproductive?
It is not uncommon for people to use earbuds during stressful times such as mealtimes, to blot out the sound(s) they find triggering. Jastreboff and Jastreboff (2014) and Spankovich and Hall (2014) both recommend against doing this in the longer term, as it isolates the person, and doesn't actually help overcome the basic problem. However, Jastreboff and Jastreboff (2014) do suggest that earbuds can be a tool to help misophonics learn to deal with triggering sounds. The idea is that at first you use the earbuds with music loud enough to only just hear the triggering sounds. If this is tolerated, and the person becomes more able to cope, the sound level in the earbuds can be reduced. This way, mealtimes can become associated with music and the trigger sounds become less relevant. This does not work for everyone but it can help some people, especially if the music can then be played at ambient levels via an open sound system rather than earbuds. Spankovich and Hall (2014) also note that continuing to use earphones with loud music can decrease tolerance of a larger number of sounds if used continuously.

 "I listen to music in my tea break. That way I can't hear *them* and spoil my break."

- An employeee who hated to hear the sounds of people eating in the tea-room.

CBT
Several authors suggest CBT is a useful form of treatment, although it does not help everyone. Webber and Storch (2015) acknowledge that at the time of writing there was no evidence-based treatment available. They suggest however that there is not a "one size fits all" treatment – they recommend CBT for patients experiencing anxiety and misophonia but suggest that cognitive restructuring or stress inoculation are better for patients experiencing anger or rage with misophonia.

Schroeder et al. (2017) conducted a study using CBT to treat misophonics. They used the Amsterdam Misophonic Scale to assess severity of symptoms: a reduction in the score over time meant the condition was improving. This scale provided a more objective way to measure improvement, although it still involves the subject assessing themselves against a scale so there is the potential for bias. Interestingly, subjects who reported disgust rather than anger at trigger sounds generally found greater improvement in symptoms after the treatment offered. They also found that group therapy was a useful tool, as people in the groups reported that the recognition and support within the groups helped their symptoms improve. Unfortunately about half the participants did not improve, though. Schroeder et al. (2014) suggest this could be partly because of the limited number of treatment sessions, and partly because of the different triggers experienced by participants.

Bruxner (2016) also recommends CBT, and suggests that hypnosis could also be useful. On the other hand, he also suggests techniques such as mimicking the sounds made by the triggering person, or using other, pleasanter sounds to muffle the offensive sounds.

Mindfulness
Schneider and Arch (2017) conducted an interesting case study in which they made a logical case for using mindfulness techniques. They worked with a seventeen year old boy (Michael) who became angry on hearing trigger sounds – to the point where it was difficult for him to attend school or participate in family events including meals. They assessed Michael using the A-Miso-S : the Amsterdam misophonia scale. On a scale where the maximum score is 24, Michael scored 14.

Treatment consisted of a combination of acceptance and commitment therapy (ACT) and dialectical behavioural therapy (DBT). He had 10 sessions. Six months later he reported that he felt far less triggered now. His A-Miso-S score had gone down to 6. He still didn't like open-mouthed chewing but his feelings were no longer so aggressive. While a subject pool of one is very limited, this study does indicate that the techniques used could help others, in a relatively limited timeframe.

Neurophysiological model
Jastreboff and Jastreboff (2014) view misophonia as a neurophysiological problem, and treatment for this condition is similar to that of hyperacusis and tinnitus. They have a series of protocols they employ, aimed at increasing tolerance for annoying sounds by linking the negative sounds with positive experiences. This does not work for everyone but they do report good results – about 83% of patients learn to cope with their misophonia.

Conclusion
Although misophonia is a relatively recently reported phenomenon, and therefore is not yet well understood, it is a frustrating condition that can cause the sufferer to become isolated from family and friends. There are different schools of thought on what kind of condition it actually is, which makes it harder to establish a treatment that will work for most if not all. On the positive side, there are many different things to try including CBT, distraction, and replacing the annoying sounds with enjoyable ones.

If you think you may have misophonia, the Misophonia Online website (see link below in the "See also" section) may be worth a visit.