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The brain basis of “hatred of sound:” Misophonia

“Munch, munch, munch.”

For most of us, the sounds of our lunch date chewing or a coworker clicking their pen are everyday components of an auditory landscape that go largely unnoticed. But for others, these seemingly mundane sounds are painfully unpleasant to the point of eliciting uncontrollable irritation or rage. There is ongoing disagreement as to whether this hatred of sound, termed misophonia, should be recognized as a legitimate psychiatric disorder, and many sufferers continue to shamefully hide their extreme emotional responses to common sounds. But a recent surge in interest in misophonia is encouraging many to acknowledge that they suffer from the condition, and some medical professionals to accept that this reaction to otherwise neutral auditory stimuli reflects a veritable disorder. A flurry of research, aimed to characterize its behavioral manifestations and outline diagnostic criteria, has appeared over the past decade, though few studies have sought to determine the neural underpinnings of misophonia.

Characterizing the “hatred of sound”

Since “misophonia” was first coined in the early 2000’s, efforts have been made to characterize its symptoms through patient interview. Although its prevalence remains uncertain due to its still relative obscurity, studies suggest that it typically strikes in adolescence, affects men and women equally, and may occur in much as 20% of the population. The most commonly reported trigger sounds include eating, breathing or repetitive behaviors like typing or pen clicking. Hearing such sounds often evokes uncontrollable irritation, disgust or anger, which the individual recognizes as socially inappropriate. Therefore, the misophonic may try to suppress any outward reaction, with few acting upon their urges with verbal or physical aggression. These aversive responses in fact manifest as measurable physiological arousal. Compared to healthy controls, misophonic individuals have excessive skin conductance responses to auditory stimuli, and the magnitude of these skin responses correlates with how distressing the participants perceive the sounds.

An undiagnosed disorder?

The symptoms of misophonia largely overlap with other clinically accepted psychiatric disorders, including obsessive compulsive disorder (OCD), post-traumatic stress disorder, and various phobias. Some individuals reporting misophonic symptoms also have comorbid psychiatric conditions such as attention-deficit hyperactivity disorder, hypochondria, OCD, or eating disorders. Although some experts advise that misophonia be identified as a unique psychiatric disorder, it has yet to be included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Miren Edelstein, a graduate student at the University of California San Diego who researches misophonia, explains that

“The uncertainty surrounding the official status of misophonia as a discrete disorder stems from the fact that it does indeed have some similarities with other existing conditions. However, while some misophonics definitely do suffer from some of these other existing conditions, many do not and report no other ailments whatsoever. Because of this variation, I don’t believe another existing disorder can completely account for the specific constellation of symptoms present in misophonia.”

The misophonic brain

Despite an advancing understanding of the psychological and behavioral manifestations of misophonia, little research has attempted to clarify its neurobiological bases. Researchers suspect that misophonia is not a primary auditory disorder, but rather stems from aberrant attentional or emotional processing later in the brain’s auditory system. There is preliminary support for this explanation from one small EEG study. In an oddball auditory paradigm, misophonic participants showed a smaller N1 evoked potential than controls elicited by unexpected auditory tones, whereas the “pre-attentive” P1 component showed no group difference. The N1 is involved in early attention and detecting sensory changes, suggesting that abnormal attentional signaling early in the auditory processing stream may contribute to misophonia. Interestingly, an altered N1 peak has also been associated with impulsivity, drug abuse and bipolar disorder.

Recently, researchers used fMRI to examine brain activity in misophonic individuals while they listened to sounds that were neutral, unpleasant or characteristic misophonia triggers. The misophonics rated the trigger sounds as more distressing than the unpleasant or neutral sounds, whereas normal controls rated trigger and unpleasant sounds as similarly annoying, confirming a selective intolerance for triggers by misophonics. Critically, the misophonics showed greater activation in the insula than controls during trigger sounds, and this activity increased with greater reported distress. Furthermore, functional connectivity between the insula and other brain regions involved in attention and emotion was altered in misophonics when listening to trigger sounds. Although the insula has been promiscuously implicated in a plethora of cognitive processes, its proposed functions include internal awareness of one’s body and emotional states. Though preliminary, these findings suggest that misophonia is associated with pathological activation of a brain network supporting interception. Edelstein, who was not involved in this study, comments “There was a huge gap in the literature until recently. I think this study was a triumphant effort towards gleaning neurophysiological insights on misophonia and its findings fit nicely into the narrative emerging from behavioral research on misophonia.”

It has also been proposed that altered brain connectivity underlying misophonia may be similar to that occurring in synesthesia, a condition in which one sensory stimulus evokes sensation in a different modality (e.g., the letter “A” is associated with the color red). Faulty enhanced neural connections could theoretically lead to abnormal associations amongst sensory and emotional brain regions in misophonia, although this hypothesis remains untested.

Pacifying sound distress

Given the novelty of misophonia, effective therapies have been inadequately assessed. However, there is some support for the use of cognitive behavioral therapy and conditioning retraining. Hopefully, with further research into both its psychological profile and neurobiological underpinnings, misophonia will gain both greater social acceptance and effective treatment options.

References

Bruxner G. (2016). ‘Mastication rage’: a review of misophonia – an under-recognised symptom of psychiatric relevance? Australas Psychiatry. 24(2):195-7. doi:10.1177/1039856215613010

Edelstein M, Brang D, Rouw R, Ramachandran V (2013). Misophonia: physiological investigations and case descriptions. Front Hum Neurosci. 7:296. doi: 10.3389/fnhum.2013.00296

Jastreboff MM, Jastreboff PJ. (2001). Components of decreased sound tolerance: hyperacusis, misophonia, phonophobia. ITHS Newsletter. 2:5-7

Kluckow H, Telfer J, Abraham S. (2014). Should we screen for misophonia in patients with eating disorders? A report of three cases. Int J Eat Disord. 47(5):558-61. doi:10.1002/eat.22245

Kumar S et al. (2017). The Brain Basis for Misophonia. Curr Biol. 27(4):527-33. doi:10.1016/j.cub.2016.12.048

Schroder A, Vulink N, Denys D. (2013). Misophonia: Diagnostic Criteria for a New Psychiatric Disorder. PLOS One. 8(1):e54706. doi:10.1371/journal.pone.0054706

Schroder A et al. (2014). Diminished N1 auditory evoked potentials to oddball stimuli in misophonia patients. Front Behav Neurosci. 8:123. doi:10.3389/fnbeh.2014.00123

Wu MS, Lewin AB, Murphy TK, Storch EA. Misophonia: Incidence, Phenomenology, and Clinical Correlates in an Undergraduate Student Sample. J Clin Psychol. 70(10):944-1007. doi: 10.1002/jclp.22098

Image credit https://www.flickr.com/photos/benhusmann


Any views expressed are those of the author, and do not necessarily reflect those of PLOS.

Emilie Reas received her PhD in Neuroscience from UC San Diego, where she used fMRI to study memory. As a postdoc at UCSD, she currently studies how the brain changes with aging and disease. In addition to her tweets for @PLOSNeuro she is @etreas.

Discussion
  1. Never seen so much rubbish in my life! It’s common knowledge that repetitive noise is ignored by the brain, especially ‘white noise’. It’s when the noise is not regular that the brain keeps noticing it and it’s registered as a ‘new’ noise. Pen-clickers are the problem, not those who have to put up with it IMHO

  2. Mike must have had the good fortune not to live with a person with misophonia. A person with misophonia experiences rage from simple things like someone eating crisps or the sound of children playing, clicking a pen may be fine for some misophonia suffers but this is a very real problem that can hurt suffers friends and family. A cure would be very welcome and articles like this help non-suffers understand friends or family with misophonia that they have a genuine problem for which a cure will hopefully be found.

  3. Our 16 year-old granddaughter suffers from the currently incurable but manageable Ehlers-Danlos Syndrome (EDS), of which misophonia is one of the many symptoms that afflict her. Hyperextended joints (arms and legs and hips cannot stay in): inability to reach for something as simple as a water glass, without a shoulder dislocation has forced her to spend months between two top national children’s hospitals. One hospital had no idea how to treat her indescribable 24-hour a day pain that turned her from a vibrant dancer to a crippled, contorted, wheelchair-bound child. The other, Cincinnati Children’s Hospital, admitted her, and in a matter of six weeks got her walking again, with the help of braces and a massive self-management program (and with the help of her parents) that allows her to live with the pain that will always be there. Misophonia caught us completely off guard, as an adjunct symptom of EDS… particularly with the normal, everyday sounds of chewing food… and other sounds we take for granted as part of our daily environment.

  4. I don’t agree its a problem with the brain(whatever that is). instead its a problem with the triggering mechanism for the memory.
    So certain sounds are triggered to be noticed more then normal. indeed a opposite coinside of the memory editing out noise(white noise). its simply a predictable thing on a probability curve of error in a normal functioning editing mechanism.

  5. I’m 15 years old and I am currently in year 9. I suffer from misophonia and have told some of my friends about it but they continuously do things at school that triggers my misophonia and they don’t stop and I’m not sure what I should do.

  6. I suffer from this condition, and have discovered that hearing filters, such as Hawkes Noise Busters, are very helpful and relatively inexpensive. Ask a local audiologist or hearing aid center near you!

  7. I was born with misophonia. Since I was a baby I had severe panic attacks due to sound triggers. I hide it pretty well since I’ve dealt with it my whole life
    I don’t become irritated instead I become panicked and start crying. I combat it by listening to music and distracting myself . I started taking medication for anxiety and have recently stopped taking it since it had adverse effects. But now my symptoms are getting out of hand . I cricket escaped in my room and I had a mental breakdown.until I found it and killed it. I didnt sleep for 3 days actually became irritated and angry because I couldn’t stop it. I don’t want to medicate I want to find a different coping skill that I can use during moments of distress

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