Misophonia: The Hatred of Sound

by: Sony Khemlani-Patel & Darius Muller

Imagine fingernails scraping on a chalkboard, a fork scraping on a plate, or a high-pitched piercing scream. If you are like most people, the image of these sounds makes you cringe. You may get goosebumps, change the topic, or even run out of the room to avoid the uncomfortable sensations. Fortunately for most of us, these experiences are fleeting and infrequent. But what if you felt high levels of discomfort to sounds around you on a daily basis?

What is Misophonia?

Misophonia, translated as a “hatred of sound,” is a disorder characterized by an extreme sensitivity to specific auditory stimuli often leading to avoidance, rage, and anger outbursts. Individuals with misophonia are triggered by specific sounds that commonly occur, such as paper being crinkled, chairs scraping on the floor, others chewing crunchy food, the sound of a family member’s breathing, or high heels clicking on a hard floor. Many of us may feel mildly irritated by these daily environmental triggers, but someone with misophonia experiences a significant amount of distress and avoidance causing disruption in daily life.

What are the Symptoms of Misophonia?

Studies show that physiological responses in misophonia include the sensation of pressure in the head and whole body, clenched/tightening muscles, sweaty palms, difficulty breathing, and increased blood pressure and heart rate. Emotional reactions can escalate quickly to anger and rage. Someone with misophonia anticipates scenarios in which specific sounds may occur and may think excessively about the negative experience. Avoidance in day-to-day life is common. We have seen patients who eat meals alone in the basement, avoid going to work, or sit in the school guidance office during certain classes. Family and social relationships can also be negatively impacted. The person with misophonia may avoid interacting with loved ones if they are the source of a sound. They may even mistakenly believe that the sounds are being made in a purposeful way to upset them.  

Some individuals with misophonia begin to self-injury in response to their feared sounds, such as scratching oneself with paper clips, digging fingernails into the palms, and banging one’s head on a hard surface. The self-injury becomes an alternate physical experience to distract from the high distress associated with the sounds.

Misophonia is not an official psychiatric disorder in the mental health diagnostic system (the DSM-5), but it may share features with the obsessive compulsive related disorders and Tourette Syndrome. Individuals with misophonia frequently exhibit characteristics of OCD.

How Common is Misophonia?

Studies show that despite the lack of extensive research in misophonia, it may be more common than we think. It’s estimated to occur in 3.2% of the general population and in one study, 20% of the undergraduate students surveyed self-reported clinically significant misophonia symptoms.

What is the Treatment for Misophonia?

Although it is not a well-known disorder, treatment options are promising. There is evidence that cognitive behavioral therapy with systematic exposure therapy can be a highly effective approach. Treatment is best conducted when accompanied by a thorough assessment to understand the individual’s specific symptoms, life history, interpersonal factors, and current functioning. A medical cause for the sound sensitivity should be ruled out as well. Commonly co-occuring disorders such as OCD, generalized anxiety, and Tourette’s Syndrome should also be evaluated.

The following are some of the techniques that are often beneficial in the treatment of misophonia:

• Cognitive therapy is a set of techniques to identify and challenge unhelpful thinking patterns. Often unhealthy thinking patterns contribute to an individual’s negative emotions and subsequent avoidance behaviors. Learning to replace the negative thoughts with more balanced and rational thoughts can lead to an increase in daily functioning and a decrease in emotional distress. The techniques are beneficial in a variety of conditions.
• Exposure therapy consists of systematically and gradually confronting the uncomfortable situations and sounds. This technique is a scientifically supported treatment for many OCD related and anxiety disorders. In the beginning stages, the therapy might consist of watching the avoided sound online on mute and gradually increasing the volume as the patient is able to tolerate. This may be followed by the patient himself or herself creating the sound during a session and then at home. With repeated exercises the patient learns to tolerate the sounds and may experience less and less distress.
• Strategies to manage and decrease the strong emotional reactions that accompany the sounds may also be very beneficial.
• Family involvement is incorporated to provide an understanding of the condition and learn ways to support and react to the symptoms.

Case Example

Cindy was a 14-year-old young woman who lived with an older brother and her parents. She was high achieving student and active in many extracurricular activities. Her mother reported that Cindy was always a very sensitive and caring child who was concerned for the needs and emotions of her loved ones. She experienced a brief period of separation anxiety upon her enrollment to preschool. During elementary school, Cindy would at times spend an unnecessarily long time completing homework in order to be “perfect” for fear of making mistakes and disappointing her teachers. She also had a brief episode of anxiety about being kidnapped at age 10. She had difficulty falling asleep and had to check the doors and windows repeatedly before bedtime.

Her symptoms of misophonia developed gradually during the first year of middle school. She first recalls being bothered by the sound of chairs scraping against the floor in Science class. This class was also less organized as the teacher was often absent leading to a generally louder and stimulating environment. As the year progressed, she experienced an increase in anxiety on school mornings. She became more aware and sensitive to other sounds throughout her school day, including the sound of notebook paper being crinkled. To cope, she would try to hold her ears and needed frequent breaks in the nurse or guidance office. At home, Cindy began aware of other sounds she described as “annoying.” She didn’t want to participate at meals when her brother was eating “crunchy foods,” such as raw vegetables or potato chips. She previously did homework at the kitchen table with him, but had recently isolated herself in her bedroom. She also refused to eat dinner with the family. Her parents reported a change in her usual positive mood. She had become more and more withdrawn, sad, and at times uncharacteristically hostile to her brother. Cindy described being distracted and unable to concentrate in school. Her parents sought therapy for her when her grades dropped and she became increasingly socially isolated.

After gathering a history of symptoms and educating Cindy and her parents about misophonia, a treatment plan was developed. Cindy was first taught cognitive therapy techniques. She was able to identify unhelpful thoughts contributing to her distress. These included thoughts such as “I won’t be able to tolerate the sounds,” “I have to get straight A’s to get into a good college,” and “people shouldn’t make annoying sounds.” Cindy recognized her low tolerance for discomfort as well as her perfectionistic thoughts, which created an unnecessary amount of pressure to succeed academically.

To help her “habituate” and tolerate the sounds, exposure therapy was soon incorporated into her sessions. Cindy and her therapist examined the details of her sound sensitivity for each type of sound. A plan was developed to systematically experience these sounds in a gradual and tolerable manner. In the case of the chair scraping against the floor, a rolling office chair on carpet was easiest to tolerate vs. a school metal chair against a tile floor. The same was done for her distress listening to her brother chewing crunchy foods (cooked vegetables were easiest, potato chips medium distress, and raw vegetables were most difficulty). A hierarchy list was made for her sensitivity to paper crinkling (paper napkins at meals were easier to tolerate than notebook paper). The therapist made a list of the situations Cindy avoided in anticipation of experiencing these sounds.

Cindy and her therapist collaboratively decided to confront her sensitivity to scraping chairs first as this was causing the most interference in her daily life. At first, Cindy watched videos on YouTube of chairs scarping with the volume on mute. She was gradually able to tolerate the volume increasing. She then moved on to sitting in chairs herself and creating a variety of sounds that were increasingly more distressing. Eventually she tolerated the therapist creating the sounds. The therapist recorded the sounds for her to listen to for homework. Similar exposures were designed for all of the other sounds on the list. She even invited her brother into a session to eat raw vegetables together.

After Cindy was better able to tolerate her misophonia, she sought help from her therapist to learn ways to manage her academic stress, tendency to expect perfectionism, and to decrease her need to seek approval from others. She was encouraged to manage her academic time with pleasurable activities and general self-care. Homework practice to maintain her progress was an important component as was family involvement to increase their understanding of Cindy’s changes in mood and anxiety. Treatment sessions were scheduled for 2-3 times a week in the beginning phases and gradually decreased as Cindy progressed. Eventually Cindy came in on a monthly basis to check in and maintain her therapeutic gains.

References

Edelstein, M., Brang, D., Rouw, R., & Ramachandran, V.S. (2013).  Misophonia: physiological investigations and case descriptions. Frontiers on Human Neuroscience, 7, 296. doi:10.3389/fnhum.2013.00296.

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

McGuire, J. F., Wu, M. S., & Storch, E. A. (2015). Cognitive-behavioral therapy for 2 youths with misophonia. Journal of Clinical Psychiatry. 76(5), 573-574.

Robinson, S., Hedderly, T., Conte, G., Malik, O., & Cardona, F. (2018). Misophonia in children with tic disorders: A case series. Journal of Developmental and Behavioral Pediatrics. doi: 10.1097/DBP.0000000000000563.

Schroder, A., Vulink, N., & Denys, D. (2013). Misophonia: Diagnostic criteria for a new psychiatric disorder. Plos One. doi: 10.1371/journal.pone.0054706.

Wu, M.S., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014). Misophonia: Incidence, phenomenology, and clinical correlates in an undergraduate student sample. Journal of Clinical Psychology. 70(10), 994-1006.