Being curious about misophonia

Misophonics have a chronic hatred of sound. The term misophonia has only been around since the new millennium, having been expressed as such by the neuroscientist Pawel Jastreboff. Before, it had been known as 'selective sound sensitivity'. The condition is understood to begin in late childhood/early adolescence, where aversion to family members' eating habits and the like worsens over time and extends beyond the family. Sufferers are thought to have a hyper-connectivity between the limbic and auditory regions of the brain. According to research, some of the typical sounds which could trigger misophonia include breathing, chewing, crunching, finger tapping, lip smacking, pen clicking, slurping, sniffing, swallowing, typing on a keyboard, and whistling. 

Misophonia elicits both affective and physiological responses at a disproportionate level, leading to avoidance behaviours and negative thinking patterns. Family mealtimes, eating out, trips to coffee shops, all manner of activities which we may perceive as being enjoyable are no longer so for someone suffering from misophonia. It can even impact upon students' ability to learn (Seaborne & Fiorella, 2018). 

Misophonic characteristics may run in the family, with one third of the participants in a large online study by Rouw and Erfanian in 2018 reporting this. It would also appear that for the majority, the symptoms begin in the childhood/adolescence years. Most people with misophonia reported moderate distress, whilst others experienced extreme levels of distress which devastated their lives. For sufferers at this end of the symptom spectrum,  there may be co-morbidity with PTSD. However, Rouw and Erfanian also found that some participants actually had pleasant experiences of sounds, which they found relaxing. This seems at odds with the negative aspects of misophonia and may be linked to a different phenomena, that of autonomous sensory meridian response (AMSR).

Other researchers have suggested a link with synaesthesia, where suffers experience 'a pathological distortion of connections between the auditory cortex and limbic structures' (Palumbo et al., 2018, p.6). Hearing appears to be normal, but the heightened sensitivity to sounds has been linked in fMRI studies to activation in the limbic and automatic nervous system. 

In terms of treatment, Schröder and colleagues (2017) carried out an open trial on 90 participants to test the effectiveness of CBT as an intervention. After receiving eight bi-weekly group sessions, just under half of the participants (48%) experienced a significant reduction in their symptoms. We'll come back to their treatment protocol later.

Potgieter et al. (2018) provide a useful scoping review of the research, consolidating what we know so far in terms of agreed definition of misophonia, the age at onset, symptom characteristics and CBT as the treatment option. 

'Gut wrenching'

Consider a trip to the cinema. We might see others happy, smiling and delighting in the crunchy texture of the popcorn as they munched and chewed (whilst continually scraping the box), excitedly grabbing a handful of the light, fluffy treats. Yet my client described how a visit to the cinema can become torturous and a source of dread. To misophonia sufferers, there can be a sinister undertone. This is how one person described it (Tinyurl.com/qmztqk9):

'A misophonic reaction is so strong and so instantaneous that, honestly, the only other emotion I can compare it to is that moment when someone tells you that a person you love has died. That gut wrenching, heart stopping, shortness of breath feeling, that you can not possibly control or stop from occurring. This is how intense the reaction to hearing a trigger sound can be. However, instead of that hollow grief that comes from such news, it is instead a burning anger, a completely alien level of rage. I am not a violent person… I would never dream of hitting a person or causing them harm, but a trigger will make me want to lash out, my cognitive processes go from perfectly normal to phrases such as 'I wish you'd just die' or 'why the hell are you making that noise, I'll make you stop'… along with some often very violent imagery.'

My client held a similarly distorted belief that others were being rude and making these sounds on purpose. This would instil anger, rage, and an intense desire to yell at these strangers to stop eating. The 'fight or flight' response would kick in: their heart would race, muscles would tighten and they would be forced to leave the cinema without having watched the film. 

With family outings such as these a no-go, misophonics may seek refuge in their own company, as it's the sounds that are created by other individuals, rather than sounds misophonics make themselves, which appear to provoke such negative feelings and reactions. They remove themselves from others and the social situations which they view as being the cause of their distress and urges to lash out. There's often a disconnect with family members, relationship breakdowns (as partners may fail to understand the behaviour of their loved one), loss of employment and a terrible sense of isolation. 

What we have here, then, is a serious condition that is often misunderstood/dismissed. In reality, it can have a devastating impact on an individual's life which can lead to self-harm. As one participant explained in Rouw and Erfaian (2018, p.465): '…I just long to die and escape the unbearable torture'.

The quest to understand more

To help my client, I reached out to my supervisor. Whilst they had no clinical experience of this client group, they did recall an article that would be a basis for me to grasp the concept and engage with the client. As I cast my net wider for support from other colleagues, I was often met with strange glances and quizzical looks. That drew my attention to the lack of awareness around this topic and its embryonic status as a possible psychological disorder. 

The next part of my journey to understanding involved my delving deeper into the research. This led me to the Netherlands and to Psychiatrists at the University of Amsterdam, working with individuals experiencing obsessive compulsive disorders. Their work identified similar patterns of symptoms and behaviours in patients being referred to the clinic for misophonia.  They realised that there was no recognised classification for the disorder. Whilst misophonia shares attributes associated with other disorders including obsessive compulsive disorder, post-traumatic stress disorder, autism spectrum disorder and sensory processing disorder, there was a lack of fit. 

As such, Schröder and colleagues embarked on their own research journey and assessed 43 Dutch patients over a period of three years, publishing diagnostic criteria in 2013. Alongside this, they developed a tool that helps to assess the level of symptom severity and how much it impacts upon the individual's emotions and fear response behaviours – the Amsterdam Misophonia Scale (A-MISO-S).  

As a therapist working with a client who is presenting with symptoms of misohponia, the A-MISO-S was an exciting discovery. It was one way of helping me formulate the extent of the problem with the client. It was also a way to measure symptom reduction following therapeutic intervention and to assess change. 

That presented my next challenge. What form should the intervention take? There are no clinical guidelines nor evidence-based treatments set out by ICD 10 nor NICE for either selective sound sensitivity or misophonia, although hyper-sensitivity to sound is recognised as a symptom of autism spectrum disorder. The closest guidelines I could find at that time that had some relevance to my client's experiences was perhaps social anxiety, where CBT is recommended. Whilst professional practice demands that clinicians follow evidence-based practice, this causes a dilemma where there is none.  

To resolve this predicament, I took a metaphorical 'hop over the pond' to the USA where, to my delight, I discovered an innovative CBT intervention for misophonia in the form of a case study (Bernstein et al., 2013). Interestingly, this study was published just a few months after the A-MISO-S in the Netherlands – hence there is no mention of using this to assess a baseline measurement. Instead, Bernstein's team used anxiety and depression scales. This study set out to test the efficacy of using a CBT anxiety protocol, designed to help the individual to manage their emotional and behavioural responses when they heard any offending human-made sounds, and subsequently to reduce distress. The outcome for the client was that auditory sounds made by others no longer triggered the same response, nor caused the client distress to a level which impaired their work or social functioning. Could I achieve similar success with my client?

The treatment

The treatment plan, to my mind, had a natural simplicity which brought together three components which fitted well within a familiar CBT framework:

1. cognitive: helping the client to challenge automatic thoughts that were dysfunctional in nature;
2. behavioural: changing the client's current maladaptive coping strategies and helping them to learn and implement new helpful ones; and
3. physiological: teaching the client how to reduce the affective responses they experienced.

The intervention was structured across six therapy sessions and, as expected from a CBT model, the therapy sessions also included homework for the client to work on in between sessions. Although I was inexperienced in working with misophonia itself, it was comforting to realise that I already possessed the skills to potentially help my client.  

I also considered more recent research to explore the efficacy of CBT in treating misophiona. Schröder et al. (2017) sought to tackle two particular symptoms that misophonia sufferers experience: hyper attentiveness to human sounds, and the negative affective response. Their intervention involved four specific elements:

1. task concentration: to shift the individual's focus of attention away from the trigger sound.
2. Counterconditioning: to change negative associations with triggers, to more positive ones.
3. Stimulus manipulation; and
4. Relaxation exercises.

By way of explanation, stimulus manipulation was created by Schröder et al (2017) by producing audio and video clips on the computer related to the client's own trigger sounds.  Positive images/videos which were unconditioned stimuli would then be paired with a negative conditioned stimulus (trigger sound) that was personal to the participant. The behavioural change for the participant would be to develop a positive association to the previously negative stimuli.

How helpful was the treatment?

Following the American CBT six session intervention and combing this with the A-MISO-S to assess the levels of distress before and after, my client and I were quickly able to identify the sounds which triggered the most irritation and anger. The A-MISO-S indicated the extent of the distress being experienced. The A-MISO-S is, as yet, a non-validated measure, so it had to be considered with caution and used alongside other measures (such as anxiety and depression scales).

We were also able to identify that the client's behaviours were all about escape (classic anxiety response) and trying to find ways to shorten conversations (nodding head, or giving short answers), eat quickly, or end the noise which was causing such an affront to their well-being. Interestingly, the client had developed a particular liking for using what could be best described as a 'Paddington Bear' style hard stare of disapproval. We spent time in session listing all the behaviours which had been tried, but failed, to reduce the anxieties. Instead we tried out and evaluated effective strategies such as distraction by other noises (music, TV), re-focusing on the person instead of the trigger sound, re-focusing on their own food, explaining sensitivity to others, and breathing/relaxation techniques. 

We also challenged the client's thought processes and assumptions that others were making noises on purpose, with my client coming to realise that others were in fact unaware that it bothered them. By the end of the intervention the client had learned new helpful strategies – and had even given up the Paddington Bear stare (reserving it instead for disciplining the children!). 

The end of my journey?

Someone appears at your door seeking an intervention; the world of psychology provides a fascinating backdrop for those with the curiosity to step inside and explore other's worlds. The misophonia trail of discovery which I embarked upon helped to increase my own knowledge and to view another's distress from a different perspective.

Being curious about misophonia led me to finding a workable intervention that proved useful for my client in lieu of evidence-based guidelines. However, individual case studies are only the beginning of exploration. There is still a lot we do not know and the concept remains in its infancy. We still don't really know how prevalent misophonia is, who might be particularly vulnerable, or how effective CBT interventions are. We need randomised control trials, and follow-up studies to assess long-term outcomes for this chronic condition.

Above all, I would encourage my fellow Psychologists to share their experiences (professional/personal); I'd love to hear more about this curious condition.

Dr Elaine Turtle, C.Psychol., AFHEA

Balanced Minds Psychology

[email protected]

References

BBC Radio 4. Word of Mouth. (2013). Misophonia and Me. [Blog]. Significant Science. 

Bernstein, R.E., Angell, K.J., & Dehle, C.M. (2013). A brief course of cognitive behavioural therapy for the treatment of misophonia: a case example. The Cognitive Behaviour Therapist 6, 1-13.

British Psychological Society (2017). Practice Guidelines (3rd ed.). Leicester: British Psychological Society: 

Edelstein, M., Brang, D., Rouw, R. & Ramachandran, V.S. (2013). Misophonia: physiological investigations and case descriptions. Frontiers in Human Neuroscience, 7, 1-11.

Hébert, S., & Lupien, S.J. (2006). The sound of stress: Blunted cortisol reactivity to psychosocial stress in tinnitus sufferers. Neuroscience Letters, 411, 138-142.

National Institute for Clinical Excellence (2012). Autism spectrum disorder in adults: diagnosis and management: NICE. 

National Institute for Clinical Excellence (2013). Social anxiety disorder: Recognition, assessment and treatment. 

Palumbo, D.B., Alsalman, O., de Ridder, D., Song, J-J., & Vanneste, S. (2018). Misophonia and potential underlying mechanisms: A perspective. Frontiers in Psychology, 9, 1-8.

Potgieter, I., MacDonald, C., Partridge, L., Cima, R., Sheldrake J., & Hoare, D.J. (2018). Misophonia: A scoping review of research. Journal of Clinical Psychology, 75, 1203-1218.

Rouw, R., & Erfanian, M. (2018). A large-scale study of misophonia. Journal of Clinical Psychology, 74(3), 453-479.

Schröder, A., Vulink, N. & Denys, D. (2013). Misophonia: Diagnostic criteria for a new psychiatric disorder. PLOS One 8(1), p1-5.

Schröder, A.E., Vulink, N.C., van Loon, A.J. & Denys, D.A. (2017). Cognitive behavioural therapy is effective in misophonia: An open trial. Journal of Affective Disorders, 217, 289-294.

Seaborne, A. & Fiorella, L. (2018). Effects of background chewing sounds on learning: the role of misophonia sensitivity. Applied Cognitive Psychology, 32(2), 264-269.

The Washington Post. (n.d.). Health and Science. Misophonia is a newly identified condition for people hypersensitive to sound.