Information for clinicians
(& those seeking clinical help)
What is misophonia?
For adults and children with misophonia, everyday sounds such as chewing, crunching, or breathing can cause intense negative emotions such as anger, rage, fear or disgust. The condition can have a highly detrimental impact on daily life but is often poorly understood, largely because sounds that trigger it (chewing, crunching, etc.) are easily ignored by most people, although are highly aversive to misophonics. You can click here for general FAQs about misophonia, and you can read here the NHS website (UK National Health Service) on sound sensitivity conditions, which describes misophonia and the related condition of hyperacusis (where sounds feel unusually loud/intense).
Scientific basis of misophonia
Misophonia was first named and identified in 2001 within the clinical audiology science community (Jastreboff & Jastreboff, 2001) and has now been the focus of almost 100 science papers within the domains of audiology, neuropsychology, psychology, and neuroscience. For a full bibliography please click here. Misophonia is newly classified, so has not yet entered formal diagnostic manuals such as the DSM-V and ICD-10, although it is increasingly recognised by audiologists and psychologists.
Misophonia has a known neurological basis. Brain imaging shows increased functional and structural connectivity within the brains of misophonics, e.g., in regions related to threat and emotion, such as the amygdala (Kumar et al., 2017). Other studies show altered brain activity in the auditory cortex and the “salience network” of the brain (Schröder et al., 2019) meaning that sounds are more salient than they might be for most other people. These subtle organisational differences in the brain appear to arise during normal development, but lead to important variations in sound tolerance which impact profoundly on daily life.
What are common co-morbidities?
In one recent study by Jager et al. (2020), 26% of their misophonic sample had co-morbid conditions, the most common of which were Obsessive Compulsive Personality Disorder, Mood Disorders, Attention-deficit hyperactivity disorder, Autism spectrum conditions, Tinnitus and Hyperacusis.
What recommendations can GPs (family doctors) make for patients who have misophonia?
Misophonia has a clear neurological basis, and can sometimes have devastating effects on lives. But sensitivity and responsiveness from doctors can lead to positive outcomes. One course of action is to refer patients to an audiologist, who can rule out related conditions (e.g., hyperacusis), and make specific recommendations with regards to the available treatment and management options. If misophonia is confirmed, the patient may be referred to a psychologist for support. However, audiology referrals are most suitable for hearing difficulties such as tinnitus or hyperacusis (i.e., general rather than specific sound intolerance). Although misophonia appears to be a problem with sound, a direct referral to a knowledgeable and experienced Clinical Psychology practitioner may be the better option.
Like many neurodevelopmental and neurological problems, support from a clinical psychologist can often help with the intensity and impact of misophonia. If misophonia is having a significant impact on mental health, home life, and learning, but local psychology and child and adolescent mental health services do not have the necessary expertise in misophonia, GPs can also refer to specialist services. Specialist treatment options are available from a small but growing number of specialists NHS clinics for misophonia in the UK such as the Oxford Health Specialist Psychological Intervention Centre or the Brighton based Hashir Clinic for Tinnitus, Hyperacusis and Misophonia. There are also a number of misophonia treatment centres in the USA, such as those at Duke University and Baylor College of Medicine. We provide non-endorsing links and are independent of these clinics.
Since NHS audiology and psychology clinics regularly receive patients with misophonia, these options should always be explored first in the UK. However, similar support can also be accessed privately (using a recognized regulator such as https://www.cbtregisteruk.com/).
What are the immediate treatment/ management options?
People with misophonia often find that small changes can help their day-to-day functioning and ability to cope. These include wearing headphones, playing white noise, and using ear plugs. Although these options may help manage symptoms in the short-term, evidence suggests that the severity of misophonia can increase over time (Rouw & Erfanian, 2018), and one theoretical possibility is that avoiding sounds may increase sound sensitivity.
Since misophonia commonly emerges during childhood or adolescence, another important approach is to improve understanding in parents and teachers. We have child-focused advice on our parent webpage and teacher webpage, where we also offer downloadable factsheet and practical advice in supporting children with misophonia within the classroom. Since these resources are science-led, with accompanying citations, they can be appropriately recommended to parents. We also have a similar factsheet for adults.
What are the longer-term clinical treatment options?
Current treatments for misophonia include cognitive behavioral therapy (e.g., Jager, Vulink, Bergfeld, van Loon, Denys, 2020; Schröder, Vulink, van Loon, & Denys, 2017), tinnitus retraining therapy (Jastreboff & Jastreboff, 2014), and counter conditioning (Dozier, 2015a). These approaches aim to re-conceptualise the individual's relationship with sound, or re-pair unpleasant sounds with more pleasant responses. Some approaches combine therapy with gentle exposure to troublesome sounds. However, researchers have noted a resistant to exposure therapy from the misophonia community (Frank & McKay, 2019), and also suggested that the ubiquitousness of trigger sounds in the general environment (e.g., chewing) means that daily life offers ample exposure without any apparent amelioration. For these reasons, exposure therapy may perhaps be used only in specific circumstances (Frank & McKay, 2019) or used alongside CBT (e.g., Jager et al., 2020; Schröder et al., 2017) or supplementary re-mapping of the sound to a more positive response (Dozier, 2015a). In particular, one recent randomised clinical trial has shown significant improvements from CBT (Jager et al., 2020). More studies are needed to examine the effectiveness of the full range of treatments (Jastreboff & Jastreboff, 2014; Cavanna & Seri, 2015; Cavanna, 2014). An important first step is to recognise misophonia and we provide a full scientific bibliography and testing resources for clinicians here.
I still have more questions, who should I contact?
Our research lab at the University of Sussex offers multiple resources via this website (www.misophonia-hub-org). You can find more information from our FAQs, or download our misophonia factsheet for adults and factsheet for children (/parents). We also offer educational support resources, and have an auto-email service linking parents and their teachers to share information about misophonia. There are also a number of misophonia web communities, including an active reddit and facebook community, and well-established misophonia associations, examples of which we list below: