Inge JagerpersName, Pelle de KoningpersName, Tim BostpersName, Damiaan DenyspersName, Nienke VulinkpersName (2020date). “Misophonia: Phenomenology, comorbidity and demographics in a large sample.” PLOS ONEtitle·j.
Object of study — the phenomenology, comorbidity, bodily status, and demographic profile of clinically assessed misophoniaterm·dom
Research question — whether misophoniaterm·dom is best understood as an audiological problem, another disorder, or a distinct psychiatric condition with revised diagnostic criteria
Contribution — the largest clinically examined misophoniaterm·dom sample and a revised diagnostic proposal grounded in psychiatric, somatic, audiological, and psychological assessment
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | specific socially situated sensory triggers elicit disproportionate irritation, anger, or disgust, hyper-focus, avoidance, and felt loss of control — “In conclusion, this analysis of a large sample confirms that misophonia is a distinct psychiatric disorder characterized by an intense emotional reaction of irritation, anger, and often disgust elicited by specific auditory, visual or sensory triggers predominantly induced by another person, resulting in preoccupation and avoidance. We suggest future studies to use the revised Amsterdam UMC proposed criteria and to conduct international multi-center studies. A multi-disciplinary approach, especially including psychiatry, audiology, and psychology, would be preferable. International confirmation of the Amsterdam UMC revised criteria is needed before next steps in research can be taken. Future research should also include more treatment studies (e.g., a RCT of CBT or a new intervention) and validation of misophonia questionnaires.” | |
| claim-type | existence — “Development and severity of misophonia symptoms in this large sample are consistent with findings in the 2013 AMC sample[ 2 ]. In our sample, however, a larger percentage is female. Specifically, age of onset, course, severity of symptoms, and a positive family history[ 49 , 6 , 7 ] supports misophonia as a distinct disorder[ 50 ]. Findings from psychiatric, medical, and psychological assessments substantiate this conclusion. Our findings result in a revision of the 2013 criteria, which are illustrated in the next paragraph and marked in Table 5 . We emphasize that to be diagnosed with misophonia, all criteria should be met. As in all psychiatric disorders a subclinical group probably exists, in most cases lacking criterion E-R.” | |
| method — evidence | — “This observational study of 779 subjects with suspected misophonia was conducted from January 2013 to May 2017 at the outpatient-clinic of the Amsterdam University Medical Centers, location AMC, the Netherlands. We examined DSM-IV diagnoses, results of somatic examination (general screening and hearing tests), and 17 psychological questionnaires (e.g., SCL-90-R, WHOQoL).” | |
| object of study — evidence | — “Analyze a large sample with detailed clinical data of misophonia subjects in order to determine the psychiatric, somatic and psychological nature of the condition.” | |
| research question — evidence | — “Therefore, we assessed a new sample of subjects with misophonia symptoms who were referred to the AMC by their general practitioner, which is both quantitatively and qualitatively superior to previous research. The first aim of this study was to determine whether referred subjects with misophonia-like symptoms actually suffered from misophonia using a psychiatric interview conducted by three experienced psychiatrists. The second aim was to determine phenomenology, comorbidity, and demographics of the misophonia sample to address three major issues: 1) whether misophonia should be approached from an audiological or psychiatric/psychological perspective; 2) whether specific psychological profiles, which have been associated with misophonia, such as disgust sensitivity[ 10 ], autism-like traits[ 11 , 12 ] and perfectionism[ 2 ] are still valid; and 3) whether misophonia is a distinct psychiatric disorder for which diagnostic criteria should be determined.” | |
| contribution — evidence | — “This study with 575 subjects is the largest misophonia sample ever described. Based on these results we propose a set of revised criteria useful to diagnose misophonia as a psychiatric disorder.” | |
| mechanism | Specific repetitive stimuli elicit an immediate aversive physical and emotional reaction. — “Misophonia is a recently recognized condition, characterized by an impulsive aversive physical reaction of irritation, anger, or disgust when confronted with specific, repetitive stimuli (for instance, eating sounds).” | mechanisms[0] |
| mechanism | Adding a matching visual cue can intensify an auditory-trigger response. — “Visual triggers were often reported, e.g., repetitive movements (68%). We found visual triggers were often directly associated with auditory triggers (e.g., grinding teeth) in clinical interviews. When visual triggers were reported, they occurred secondary to auditory triggers and had less impact than the auditory triggers. When visual and auditory stimuli occurred simultaneously (e.g., hearing and seeing someone chewing gum), subjects reported a more intense response. 59% were bothered by ambient sounds, particularly by sounds of neighbors.” | mechanisms[1] |
| mechanism | Anticipation of future trigger encounters produces anxiety and preoccupation. — “None of the subjects reported anxiety as a primary response, neither at psychiatric examination nor with questionnaires. Only five subjects (1%) reported secondary anxiety, following anger or disgust. The majority of the sample reported anticipatory anxiety, which was mild and related to thinking of future misophonic situations. In clinical interviews, all subjects reported confrontations with triggers as stressful events. Subjects worried about misophonic triggers and their capacity to cope. A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness. In clinical interviews, most subjects expressed shame or guilt. Anticipatory anxiety and preoccupation with misophonic triggers appeared simultaneously. Two different scales showed 86 to 91% experienced serious preoccupation.” | mechanisms[2] |
| mechanism | Social relationship and perceived responsibility modulate response intensity. — “Subjects often stated the emotional response to be far more intense towards loved ones inducing misophonia triggers. Context also influenced the emotional response; when misophonia trigger sounds were made by toddlers, mentally disabled adults, or elderly with dementia, an emotional response seldom occurred.” | mechanisms[3] |
| mechanism | Hyper-focus sustains preoccupation and is treated as a core symptom. — “We consider preoccupation an additional core symptom of misophonia, since approximately all subjects in our sample report hyper focusᵃ. Hyper focus was also reported in 82% of the sample of Edelstein et al[ 49 ] and an intervention targeting hyper focus has a clear effect on misophonia symptoms[ 59 ].” | mechanisms[4] |
| mechanism | Avoidance and masking behaviors reduce exposure to trigger sounds. — “Most used coping was turning on music (99%) and walking away (99%). Making noise or making noise in the same rhythm, e.g., chewing or typing, was also used frequently, 86% and 77%, respectively. Finally, 86% described using earplugs; the majority of these subjects used them in the last week (73%).” | mechanisms[5] |
| sense | emotion - irritation, anger, or disgust elicited by a socially contextualized sensory trigger — “Subjects reported extreme irritation, anger, and disgust as primary emotional responses (see Table 3 ). Aggressive outbursts were seldom reported at psychiatric interviews; verbal aggression was common, but physical aggression was rare. Frequency was not assessed with a questionnaire.” | senses[0] |
| sense | attention - hyper-focus and preoccupation directed toward trigger sounds — “We consider preoccupation an additional core symptom of misophonia, since approximately all subjects in our sample report hyper focusᵃ. Hyper focus was also reported in 82% of the sample of Edelstein et al[ 49 ] and an intervention targeting hyper focus has a clear effect on misophonia symptoms[ 59 ].” | senses[1] |
| sense | control - the subjectively diminished capacity to cope with a trigger response — “A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness.” | senses[2] |
| sense | bias - selection and diagnostic confirmation risk in a single specialist clinic — “This is the first large sample study of misophonia subjects in which we not only explored the dynamics of misophonia symptoms, but also examined the impact of symptoms on quality of life. However, this research also has its limitations. First, the Amsterdam UMC is the only center in the Netherlands with a specific treatment for misophonia, which could lead to a selection bias. Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias. However, we believe we limited confirmation bias, because we examined all patients who were referred with misophonia-like symptoms; using questionnaires with a broad scope, and we investigated alternative symptoms, e.g., anxiety, in our psychiatric evaluations. Finally, types or versions of questionnaires administered changed over time in this sample. Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available. Also, the A-MISO-S is not psychometrically validated and the AMISOS-R is in the process of validation.” | senses[3] |
| sense | salience - intensified response when visual and auditory trigger cues coincide — “Visual triggers were often reported, e.g., repetitive movements (68%). We found visual triggers were often directly associated with auditory triggers (e.g., grinding teeth) in clinical interviews. When visual triggers were reported, they occurred secondary to auditory triggers and had less impact than the auditory triggers. When visual and auditory stimuli occurred simultaneously (e.g., hearing and seeing someone chewing gum), subjects reported a more intense response. 59% were bothered by ambient sounds, particularly by sounds of neighbors.” | senses[4] |
| control | structured psychiatric interview — held — “This is the largest qualitative and quantitative description of a sample of misophonia subjects so far ( N = 575). Our study demonstrates that clinical examination from a medical-psychiatric perspective is invaluable for diagnosing misophonia, as one out of four referred subjects does not suffer from misophonia. Risk of misdiagnosis is high, because misophonia-like symptoms could be explained by comorbid conditions such as OCPD traits, mood disorders, AD(H)D, and ASC. From a somatic perspective, our misophonia subjects do not have specific somatic comorbid disorders. Furthermore, they have normal hearing, which is in contrast to hearing in tinnitus[ 44 ]. Prevalence of hearing loss found in our population is even less than expected based on the prevalence of disabling hearing loss in normal population for the Netherlands (PTA > 40 dB HL in better ear around 5% for adult population[ 45 ]). From a psychological perspective, misophonia can be seen as an independent construct. No association was found between misophonia symptoms and ASC, disgust sensitivity, or clinical perfectionism. Clinical perfectionism, however, was seen in 66 to 97% of the subjects. Severity of misophonia symptoms is negatively correlated with quality of life. Family relations especially suffer, but the influence on working life remains limited with only 5% on sick leave.” — rules out misophonia-like symptoms explained by another psychiatric diagnosis — “This is the largest qualitative and quantitative description of a sample of misophonia subjects so far ( N = 575). Our study demonstrates that clinical examination from a medical-psychiatric perspective is invaluable for diagnosing misophonia, as one out of four referred subjects does not suffer from misophonia. Risk of misdiagnosis is high, because misophonia-like symptoms could be explained by comorbid conditions such as OCPD traits, mood disorders, AD(H)D, and ASC. From a somatic perspective, our misophonia subjects do not have specific somatic comorbid disorders. Furthermore, they have normal hearing, which is in contrast to hearing in tinnitus[ 44 ]. Prevalence of hearing loss found in our population is even less than expected based on the prevalence of disabling hearing loss in normal population for the Netherlands (PTA > 40 dB HL in better ear around 5% for adult population[ 45 ]). From a psychological perspective, misophonia can be seen as an independent construct. No association was found between misophonia symptoms and ASC, disgust sensitivity, or clinical perfectionism. Clinical perfectionism, however, was seen in 66 to 97% of the subjects. Severity of misophonia symptoms is negatively correlated with quality of life. Family relations especially suffer, but the influence on working life remains limited with only 5% on sick leave.” | controls[0] |
| control | physical and neurological examination — held — “76% of the sample reported no diagnosis on Axis III, 20% reported one diagnosis, and 4% had multiple diagnoses. Most common diagnoses were: migraine, irritable bowel syndrome, asthma, and back pain. During physical examination, a primary neurological disorder was never determined, but a mild somatic comorbid disorder was regularly found (e.g., hypertension). Approximately 1% of blood tests results were abnormal (e.g., decreased Hb levels, thyroid abnormalities or increased liver functions).” — rules out a primary neurological disorder as the source of symptoms — “76% of the sample reported no diagnosis on Axis III, 20% reported one diagnosis, and 4% had multiple diagnoses. Most common diagnoses were: migraine, irritable bowel syndrome, asthma, and back pain. During physical examination, a primary neurological disorder was never determined, but a mild somatic comorbid disorder was regularly found (e.g., hypertension). Approximately 1% of blood tests results were abnormal (e.g., decreased Hb levels, thyroid abnormalities or increased liver functions).” | controls[1] |
| control | audiometry subgroup — held — “The subgroup performing an audiogram consisted of 109 subjects (69% female) with a mean age of 36.70 years ( SD = 12.08). 106 subjects had bilateral normal hearing (PTA < = 25 dB HL). The remaining three subjects had a unilateral hearing loss: one slight conductive hearing loss (25–40 dB HL), one moderate conductive hearing loss (40–60 dB HL), and one profound sensorineural hearing loss (80+ dB HL). This implies all participants had at least one ear with normal hearing.” — rules out hearing loss as the typical basis of the condition — “The subgroup performing an audiogram consisted of 109 subjects (69% female) with a mean age of 36.70 years ( SD = 12.08). 106 subjects had bilateral normal hearing (PTA < = 25 dB HL). The remaining three subjects had a unilateral hearing loss: one slight conductive hearing loss (25–40 dB HL), one moderate conductive hearing loss (40–60 dB HL), and one profound sensorineural hearing loss (80+ dB HL). This implies all participants had at least one ear with normal hearing.” | controls[2] |
| control | broad questionnaires and alternative-symptom evaluation — partial — “This is the first large sample study of misophonia subjects in which we not only explored the dynamics of misophonia symptoms, but also examined the impact of symptoms on quality of life. However, this research also has its limitations. First, the Amsterdam UMC is the only center in the Netherlands with a specific treatment for misophonia, which could lead to a selection bias. Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias. However, we believe we limited confirmation bias, because we examined all patients who were referred with misophonia-like symptoms; using questionnaires with a broad scope, and we investigated alternative symptoms, e.g., anxiety, in our psychiatric evaluations. Finally, types or versions of questionnaires administered changed over time in this sample. Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available. Also, the A-MISO-S is not psychometrically validated and the AMISOS-R is in the process of validation.” — rules out confirmation produced solely by narrow local criteria — “This is the first large sample study of misophonia subjects in which we not only explored the dynamics of misophonia symptoms, but also examined the impact of symptoms on quality of life. However, this research also has its limitations. First, the Amsterdam UMC is the only center in the Netherlands with a specific treatment for misophonia, which could lead to a selection bias. Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias. However, we believe we limited confirmation bias, because we examined all patients who were referred with misophonia-like symptoms; using questionnaires with a broad scope, and we investigated alternative symptoms, e.g., anxiety, in our psychiatric evaluations. Finally, types or versions of questionnaires administered changed over time in this sample. Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available. Also, the A-MISO-S is not psychometrically validated and the AMISOS-R is in the process of validation.” | controls[3] |
| control | comorbidity and trait regressions — held — “Using a standard multiple regression, perfectionism (CPQ: p = .487; FMPS: p = .651), autism traits (AQ: p = .270), and disgust sensitivity (DS-R: p = .628; DPSS-R: p = .961) showed no significant relation to the severity of the misophonia symptoms, measured by the AMISOS-R.” — rules out autism traits, disgust sensitivity, or perfectionism explaining severity — “Using a standard multiple regression, perfectionism (CPQ: p = .487; FMPS: p = .651), autism traits (AQ: p = .270), and disgust sensitivity (DS-R: p = .628; DPSS-R: p = .961) showed no significant relation to the severity of the misophonia symptoms, measured by the AMISOS-R.” | controls[4] |
| relation | trigger —causes→ emotional reaction — Combined sensory triggers cause a more intense emotional reaction. — “Our detailed investigation of triggers leads to new conclusions. Approximately all subjects in our sample report eating sounds as a trigger (96%) and the majority reports nasal or breathing sounds as a trigger (85%). Combined, all subjects report either oral or nasal sounds as a trigger. Therefore, we propose other triggers can be a part of the condition, but an emotional reaction to oral or nasal sounds is requiredᵇ. Visual triggers, like scratching, and non-human triggers, like animal sounds or air-conditioning sounds, were occasionally described[ 51 , 52 ]. We indeed found evidence for non-auditory triggers in 78% of our sample, but auditory triggers are primary triggers c . If combined, these triggers cause a more intense emotional reaction. In a mass experiment which was performed among the general population, adding a corresponding image to a disgusting sound had no effect[ 53 ]. This interaction effect is probably typical for misophonia subjects.” | concept_edges[0] |
| weight | trigger —causes→ emotional reaction — 0.95 — “Our detailed investigation of triggers leads to new conclusions. Approximately all subjects in our sample report eating sounds as a trigger (96%) and the majority reports nasal or breathing sounds as a trigger (85%). Combined, all subjects report either oral or nasal sounds as a trigger. Therefore, we propose other triggers can be a part of the condition, but an emotional reaction to oral or nasal sounds is requiredᵇ. Visual triggers, like scratching, and non-human triggers, like animal sounds or air-conditioning sounds, were occasionally described[ 51 , 52 ]. We indeed found evidence for non-auditory triggers in 78% of our sample, but auditory triggers are primary triggers c . If combined, these triggers cause a more intense emotional reaction. In a mass experiment which was performed among the general population, adding a corresponding image to a disgusting sound had no effect[ 53 ]. This interaction effect is probably typical for misophonia subjects.” | concept_edges[0] |
| outcome | control — held — “This is the largest qualitative and quantitative description of a sample of misophonia subjects so far ( N = 575). Our study demonstrates that clinical examination from a medical-psychiatric perspective is invaluable for diagnosing misophonia, as one out of four referred subjects does not suffer from misophonia. Risk of misdiagnosis is high, because misophonia-like symptoms could be explained by comorbid conditions such as OCPD traits, mood disorders, AD(H)D, and ASC. From a somatic perspective, our misophonia subjects do not have specific somatic comorbid disorders. Furthermore, they have normal hearing, which is in contrast to hearing in tinnitus[ 44 ]. Prevalence of hearing loss found in our population is even less than expected based on the prevalence of disabling hearing loss in normal population for the Netherlands (PTA > 40 dB HL in better ear around 5% for adult population[ 45 ]). From a psychological perspective, misophonia can be seen as an independent construct. No association was found between misophonia symptoms and ASC, disgust sensitivity, or clinical perfectionism. Clinical perfectionism, however, was seen in 66 to 97% of the subjects. Severity of misophonia symptoms is negatively correlated with quality of life. Family relations especially suffer, but the influence on working life remains limited with only 5% on sick leave.” | controls[0] |
| outcome | control — held — “76% of the sample reported no diagnosis on Axis III, 20% reported one diagnosis, and 4% had multiple diagnoses. Most common diagnoses were: migraine, irritable bowel syndrome, asthma, and back pain. During physical examination, a primary neurological disorder was never determined, but a mild somatic comorbid disorder was regularly found (e.g., hypertension). Approximately 1% of blood tests results were abnormal (e.g., decreased Hb levels, thyroid abnormalities or increased liver functions).” | controls[1] |
| outcome | control — held — “The subgroup performing an audiogram consisted of 109 subjects (69% female) with a mean age of 36.70 years ( SD = 12.08). 106 subjects had bilateral normal hearing (PTA < = 25 dB HL). The remaining three subjects had a unilateral hearing loss: one slight conductive hearing loss (25–40 dB HL), one moderate conductive hearing loss (40–60 dB HL), and one profound sensorineural hearing loss (80+ dB HL). This implies all participants had at least one ear with normal hearing.” | controls[2] |
| outcome | control — partial — “This is the first large sample study of misophonia subjects in which we not only explored the dynamics of misophonia symptoms, but also examined the impact of symptoms on quality of life. However, this research also has its limitations. First, the Amsterdam UMC is the only center in the Netherlands with a specific treatment for misophonia, which could lead to a selection bias. Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias. However, we believe we limited confirmation bias, because we examined all patients who were referred with misophonia-like symptoms; using questionnaires with a broad scope, and we investigated alternative symptoms, e.g., anxiety, in our psychiatric evaluations. Finally, types or versions of questionnaires administered changed over time in this sample. Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available. Also, the A-MISO-S is not psychometrically validated and the AMISOS-R is in the process of validation.” | controls[3] |
| outcome | control — held — “Using a standard multiple regression, perfectionism (CPQ: p = .487; FMPS: p = .651), autism traits (AQ: p = .270), and disgust sensitivity (DS-R: p = .628; DPSS-R: p = .961) showed no significant relation to the severity of the misophonia symptoms, measured by the AMISOS-R.” | controls[4] |
| limitation | Recruitment from the only specialized Dutch treatment center creates selection risk. — “This is the first large sample study of misophonia subjects in which we not only explored the dynamics of misophonia symptoms, but also examined the impact of symptoms on quality of life. However, this research also has its limitations. First, the Amsterdam UMC is the only center in the Netherlands with a specific treatment for misophonia, which could lead to a selection bias. Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias. However, we believe we limited confirmation bias, because we examined all patients who were referred with misophonia-like symptoms; using questionnaires with a broad scope, and we investigated alternative symptoms, e.g., anxiety, in our psychiatric evaluations. Finally, types or versions of questionnaires administered changed over time in this sample. Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available. Also, the A-MISO-S is not psychometrically validated and the AMISOS-R is in the process of validation.” | limitations[0] |
| limitation | Using the same local diagnostic criteria for selection creates confirmation risk. — “Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias.” | limitations[1] |
| limitation | Questionnaire types and versions changed over the study period. — “Finally, types or versions of questionnaires administered changed over time in this sample.” | limitations[2] |
| limitation | Some measures lacked Dutch validation, norm groups, or completed psychometric validation. — “Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available.” | limitations[3] |
| limitation | Independent international confirmation of the revised criteria is still required. — “In conclusion, this analysis of a large sample confirms that misophonia is a distinct psychiatric disorder characterized by an intense emotional reaction of irritation, anger, and often disgust elicited by specific auditory, visual or sensory triggers predominantly induced by another person, resulting in preoccupation and avoidance. We suggest future studies to use the revised Amsterdam UMC proposed criteria and to conduct international multi-center studies. A multi-disciplinary approach, especially including psychiatry, audiology, and psychology, would be preferable. International confirmation of the Amsterdam UMC revised criteria is needed before next steps in research can be taken. Future research should also include more treatment studies (e.g., a RCT of CBT or a new intervention) and validation of misophonia questionnaires.” | limitations[4] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | Three quarters of referred subjects met the Amsterdam misophonia criteria. — “The diagnosis of misophonia was confirmed in 575 of 779 referred subjects (74%). In the sample of misophonia subjects (mean age, 34.17 [ SD = 12.22] years; 399 women [69%]), 148 (26%) subjects had comorbid traits of obsessive-compulsive personality disorder, 58 (10%) mood disorders, 31 (5%) attention-deficit (hyperactivity) disorder, and 14 (3%) autism spectrum conditions. Two percent reported tinnitus and 1% hyperacusis. In a random subgroup of 109 subjects we performed audiometry, and found unilateral hearing loss in 3 of them (3%). Clinical neurological examination and additional blood test showed no abnormalities. Psychological tests revealed perfectionism (97% CPQ>25) and neuroticism (stanine 7 NEO-PI-R). Quality of life was heavily impaired and associated with misophonia severity (r s (184) = -.34 p = < .001, p = < .001).” | content_tags.findings[0] |
| finding | Most diagnosed subjects had no comorbid Axis I disorder. — “The comorbid DSM-IV disorders are shown in Table 2 . 72% of subjects diagnosed with misophonia had no comorbid Axis I psychiatric disorder, 22% had one comorbid disorder, and 6% had two or more comorbid disorders. Common comorbid disorders were major depressive disorder (6.8%) and obsessive-compulsive disorder (2.8%). Another 5% of the sample had comorbid AD(H)D and 3% was diagnosed with a comorbid ASC.” | content_tags.findings[1] |
| finding | Eating, nasal, and breathing sounds were the dominant reported triggers. — “Almost all subjects reported to be triggered by eating sounds (96%) followed by nasal and breathing sounds (85%). Subjects were also regularly disturbed by sounds of repetitive tapping or mouth/throat sounds. All triggers are shown in Fig 1 .” | content_tags.findings[2] |
| finding | Concurrent visual cues intensified responses to auditory triggers. — “Visual triggers were often reported, e.g., repetitive movements (68%). We found visual triggers were often directly associated with auditory triggers (e.g., grinding teeth) in clinical interviews. When visual triggers were reported, they occurred secondary to auditory triggers and had less impact than the auditory triggers. When visual and auditory stimuli occurred simultaneously (e.g., hearing and seeing someone chewing gum), subjects reported a more intense response. 59% were bothered by ambient sounds, particularly by sounds of neighbors.” | content_tags.findings[3] |
| finding | Irritation, anger, and disgust were the primary emotional responses. — “Subjects reported extreme irritation, anger, and disgust as primary emotional responses (see Table 3 ). Aggressive outbursts were seldom reported at psychiatric interviews; verbal aggression was common, but physical aggression was rare. Frequency was not assessed with a questionnaire.” | content_tags.findings[4] |
| finding | Primary anxiety was absent, while anticipatory anxiety, powerlessness, and loss of control were common. — “None of the subjects reported anxiety as a primary response, neither at psychiatric examination nor with questionnaires. Only five subjects (1%) reported secondary anxiety, following anger or disgust. The majority of the sample reported anticipatory anxiety, which was mild and related to thinking of future misophonic situations. In clinical interviews, all subjects reported confrontations with triggers as stressful events. Subjects worried about misophonic triggers and their capacity to cope. A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness. In clinical interviews, most subjects expressed shame or guilt. Anticipatory anxiety and preoccupation with misophonic triggers appeared simultaneously. Two different scales showed 86 to 91% experienced serious preoccupation.” | content_tags.findings[5] |
| finding | Nearly all audiometry participants retained normal bilateral hearing. — “The subgroup performing an audiogram consisted of 109 subjects (69% female) with a mean age of 36.70 years ( SD = 12.08). 106 subjects had bilateral normal hearing (PTA < = 25 dB HL). The remaining three subjects had a unilateral hearing loss: one slight conductive hearing loss (25–40 dB HL), one moderate conductive hearing loss (40–60 dB HL), and one profound sensorineural hearing loss (80+ dB HL). This implies all participants had at least one ear with normal hearing.” | content_tags.findings[6] |
| finding | Symptom severity was negatively associated with quality of life. — “Finally, non-parametric correlation (Spearman’s rho) was used to determine whether misophonia symptoms (A-MISO-S) correlated with a decreased quality of life (MANSA). The more severe the misophonia symptoms, the lower the satisfaction with quality of life, r s (184) = -.34 p = < .001.” | content_tags.findings[7] |
| quantity | 575 of 779 — referred subjects whose misophonia diagnosis was confirmed — “The diagnosis of misophonia was confirmed in 575 of 779 referred subjects (74%). In the sample of misophonia subjects (mean age, 34.17 [ SD = 12.22] years; 399 women [69%]), 148 (26%) subjects had comorbid traits of obsessive-compulsive personality disorder, 58 (10%) mood disorders, 31 (5%) attention-deficit (hyperactivity) disorder, and 14 (3%) autism spectrum conditions. Two percent reported tinnitus and 1% hyperacusis. In a random subgroup of 109 subjects we performed audiometry, and found unilateral hearing loss in 3 of them (3%). Clinical neurological examination and additional blood test showed no abnormalities. Psychological tests revealed perfectionism (97% CPQ>25) and neuroticism (stanine 7 NEO-PI-R). Quality of life was heavily impaired and associated with misophonia severity (r s (184) = -.34 p = < .001, p = < .001).” | content_tags.quantities[0] |
| quantity | 96% — subjects reporting eating sounds as triggers — “Almost all subjects reported to be triggered by eating sounds (96%) followed by nasal and breathing sounds (85%). Subjects were also regularly disturbed by sounds of repetitive tapping or mouth/throat sounds. All triggers are shown in Fig 1 .” | content_tags.quantities[1] |
| quantity | 81% — subjects reporting perceived loss of control — “None of the subjects reported anxiety as a primary response, neither at psychiatric examination nor with questionnaires. Only five subjects (1%) reported secondary anxiety, following anger or disgust. The majority of the sample reported anticipatory anxiety, which was mild and related to thinking of future misophonic situations. In clinical interviews, all subjects reported confrontations with triggers as stressful events. Subjects worried about misophonic triggers and their capacity to cope. A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness. In clinical interviews, most subjects expressed shame or guilt. Anticipatory anxiety and preoccupation with misophonic triggers appeared simultaneously. Two different scales showed 86 to 91% experienced serious preoccupation.” | content_tags.quantities[2] |
| quantity | 106 of 109 — audiometry subgroup with normal bilateral hearing — “The subgroup performing an audiogram consisted of 109 subjects (69% female) with a mean age of 36.70 years ( SD = 12.08). 106 subjects had bilateral normal hearing (PTA < = 25 dB HL). The remaining three subjects had a unilateral hearing loss: one slight conductive hearing loss (25–40 dB HL), one moderate conductive hearing loss (40–60 dB HL), and one profound sensorineural hearing loss (80+ dB HL). This implies all participants had at least one ear with normal hearing.” | content_tags.quantities[3] |
| quantity | 66% to 97% — range of observed clinical-perfectionism prevalence — “This is the largest qualitative and quantitative description of a sample of misophonia subjects so far ( N = 575). Our study demonstrates that clinical examination from a medical-psychiatric perspective is invaluable for diagnosing misophonia, as one out of four referred subjects does not suffer from misophonia. Risk of misdiagnosis is high, because misophonia-like symptoms could be explained by comorbid conditions such as OCPD traits, mood disorders, AD(H)D, and ASC. From a somatic perspective, our misophonia subjects do not have specific somatic comorbid disorders. Furthermore, they have normal hearing, which is in contrast to hearing in tinnitus[ 44 ]. Prevalence of hearing loss found in our population is even less than expected based on the prevalence of disabling hearing loss in normal population for the Netherlands (PTA > 40 dB HL in better ear around 5% for adult population[ 45 ]). From a psychological perspective, misophonia can be seen as an independent construct. No association was found between misophonia symptoms and ASC, disgust sensitivity, or clinical perfectionism. Clinical perfectionism, however, was seen in 66 to 97% of the subjects. Severity of misophonia symptoms is negatively correlated with quality of life. Family relations especially suffer, but the influence on working life remains limited with only 5% on sick leave.” | content_tags.quantities[4] |
| variable | misophonia severity (outcome measured with A-MISO-S or AMISOS-R) — “All statistical analyses were conducted with SPSS statistical package version 24. We report the sample descriptively in terms of means and standard deviations or percentage of the sample, where appropriate. We used independent-samples t-tests to explore whether males and females differed in age of onset and symptom severity (i.e. A-MISO-S or AMISOS-R score). We used multiple linear regression to explore whether certain features were associated with symptom severity. AMISOS-R scores were included as independent variables, and CPQ, FMPS, AQ, DS-R and DPSS-R were included as dependent variables. We confirmed normality of residuals by checking the QQ plot of the model. We treated the full Likert scales as numerical, since assumptions of linear regression were met (residuals were normally distributed) and results are much easier to interpret. Finally, a non-parametric correlation (Spearman’s rho) was calculated to determine whether misophonia symptoms (A-MISO-S) correlated with quality of life (MANSA). No missing scores were imputed and no outliers were removed. We considered P < 0.05 to be statistically significant.” | content_tags.variables[0] |
| variable | quality of life (correlate measured with MANSA and other functioning instruments) — “Subjects had moderate to moderate-severe symptoms according to the A-MISO-S and AMISOS-R. No significant sex differences were found (respectively p = .44 and p = .29). Subjects had mild symptoms on the HAS and HDRS and a high score on the SCL-90-R. Quality of life varied from a low satisfaction on the MANSA, to some impairment in day-to-day life on the SDS, particularly with family relations[ 40 ], to a slightly lower perceived quality of life on the WHOQoL-BREF[ 41 ]. Subjects all described to have made adjustments to their day-to-day life, such as avoiding public transport. Many subjects lost work or relationships because of misophonia. Rarely, subjects were desperate for help or expressed suicidal ideations in the clinical interviews.” | content_tags.variables[1] |
| variable | disgust sensitivity (candidate psychological correlate tested against symptom severity) — “Using a standard multiple regression, perfectionism (CPQ: p = .487; FMPS: p = .651), autism traits (AQ: p = .270), and disgust sensitivity (DS-R: p = .628; DPSS-R: p = .961) showed no significant relation to the severity of the misophonia symptoms, measured by the AMISOS-R.” | content_tags.variables[2] |
| definition | misophonia — “Misophonia is a recently recognized condition, characterized by an impulsive aversive physical reaction of irritation, anger, or disgust when confronted with specific, repetitive stimuli (for instance, eating sounds).” | content_tags.definitions[0] |
| definition | primary emotional response — “Subjects reported extreme irritation, anger, and disgust as primary emotional responses (see Table 3 ). Aggressive outbursts were seldom reported at psychiatric interviews; verbal aggression was common, but physical aggression was rare. Frequency was not assessed with a questionnaire.” | content_tags.definitions[1] |
| definition | anticipatory anxiety — “None of the subjects reported anxiety as a primary response, neither at psychiatric examination nor with questionnaires. Only five subjects (1%) reported secondary anxiety, following anger or disgust. The majority of the sample reported anticipatory anxiety, which was mild and related to thinking of future misophonic situations. In clinical interviews, all subjects reported confrontations with triggers as stressful events. Subjects worried about misophonic triggers and their capacity to cope. A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness. In clinical interviews, most subjects expressed shame or guilt. Anticipatory anxiety and preoccupation with misophonic triggers appeared simultaneously. Two different scales showed 86 to 91% experienced serious preoccupation.” | content_tags.definitions[2] |
| definition | auditory trigger — “Our detailed investigation of triggers leads to new conclusions. Approximately all subjects in our sample report eating sounds as a trigger (96%) and the majority reports nasal or breathing sounds as a trigger (85%). Combined, all subjects report either oral or nasal sounds as a trigger. Therefore, we propose other triggers can be a part of the condition, but an emotional reaction to oral or nasal sounds is requiredᵇ. Visual triggers, like scratching, and non-human triggers, like animal sounds or air-conditioning sounds, were occasionally described[ 51 , 52 ]. We indeed found evidence for non-auditory triggers in 78% of our sample, but auditory triggers are primary triggers c . If combined, these triggers cause a more intense emotional reaction. In a mass experiment which was performed among the general population, adding a corresponding image to a disgusting sound had no effect[ 53 ]. This interaction effect is probably typical for misophonia subjects.” | content_tags.definitions[3] |
| definition | hyper-focus — “We consider preoccupation an additional core symptom of misophonia, since approximately all subjects in our sample report hyper focusᵃ. Hyper focus was also reported in 82% of the sample of Edelstein et al[ 49 ] and an intervention targeting hyper focus has a clear effect on misophonia symptoms[ 59 ].” | content_tags.definitions[4] |
| definition | clinical perfectionism — “Subjects scored average on the AQ and ISS. Subjects scored low on the DS-R and on the DPSS-R[ 42 ]. There was a significant positive correlation between the DPSS-R and DS-R (r = .545, n = 442, p < .000). Further, subjects scored high on the CPQ (healthy controls in an unpublished AMC study have M = 23.82). A total of 97% had a score over 25, indicating clinical perfectionism. Subjects scored slightly higher on the FMPS (healthy controls in an unpublished AMC study have M = 92.70). A total of 66% had a score over 22 on the scale ‘Concern over mistakes’, indicating clinical perfectionism (cut off suggested by Egan & Hine[ 43 ]). There was no significant correlation between the CPQ and FMPS (r = .036, p = .571).” | content_tags.definitions[5] |
| concept | misophonia — not defined in this paper's own words; distinct psychiatric condition proposed from a trigger-response phenotype — “In conclusion, this analysis of a large sample confirms that misophonia is a distinct psychiatric disorder characterized by an intense emotional reaction of irritation, anger, and often disgust elicited by specific auditory, visual or sensory triggers predominantly induced by another person, resulting in preoccupation and avoidance. We suggest future studies to use the revised Amsterdam UMC proposed criteria and to conduct international multi-center studies. A multi-disciplinary approach, especially including psychiatry, audiology, and psychology, would be preferable. International confirmation of the Amsterdam UMC revised criteria is needed before next steps in research can be taken. Future research should also include more treatment studies (e.g., a RCT of CBT or a new intervention) and validation of misophonia questionnaires.” | concepts[0] |
| concept | trigger — not defined in this paper's own words; specific auditory, visual, or sensory event eliciting the response — “Our detailed investigation of triggers leads to new conclusions. Approximately all subjects in our sample report eating sounds as a trigger (96%) and the majority reports nasal or breathing sounds as a trigger (85%). Combined, all subjects report either oral or nasal sounds as a trigger. Therefore, we propose other triggers can be a part of the condition, but an emotional reaction to oral or nasal sounds is requiredᵇ. Visual triggers, like scratching, and non-human triggers, like animal sounds or air-conditioning sounds, were occasionally described[ 51 , 52 ]. We indeed found evidence for non-auditory triggers in 78% of our sample, but auditory triggers are primary triggers c . If combined, these triggers cause a more intense emotional reaction. In a mass experiment which was performed among the general population, adding a corresponding image to a disgusting sound had no effect[ 53 ]. This interaction effect is probably typical for misophonia subjects.” | concepts[1] |
| concept | hyper focus — not defined in this paper's own words; preoccupation with trigger stimuli — “We consider preoccupation an additional core symptom of misophonia, since approximately all subjects in our sample report hyper focusᵃ. Hyper focus was also reported in 82% of the sample of Edelstein et al[ 49 ] and an intervention targeting hyper focus has a clear effect on misophonia symptoms[ 59 ].” | concepts[2] |
| concept | emotional reaction — not defined in this paper's own words; irritation, anger, or disgust elicited by a trigger — “Our detailed investigation of triggers leads to new conclusions. Approximately all subjects in our sample report eating sounds as a trigger (96%) and the majority reports nasal or breathing sounds as a trigger (85%). Combined, all subjects report either oral or nasal sounds as a trigger. Therefore, we propose other triggers can be a part of the condition, but an emotional reaction to oral or nasal sounds is requiredᵇ. Visual triggers, like scratching, and non-human triggers, like animal sounds or air-conditioning sounds, were occasionally described[ 51 , 52 ]. We indeed found evidence for non-auditory triggers in 78% of our sample, but auditory triggers are primary triggers c . If combined, these triggers cause a more intense emotional reaction. In a mass experiment which was performed among the general population, adding a corresponding image to a disgusting sound had no effect[ 53 ]. This interaction effect is probably typical for misophonia subjects.” | concepts[3] |
| concept | anticipatory anxiety — not defined in this paper's own words; future-oriented worry about trigger encounters — “None of the subjects reported anxiety as a primary response, neither at psychiatric examination nor with questionnaires. Only five subjects (1%) reported secondary anxiety, following anger or disgust. The majority of the sample reported anticipatory anxiety, which was mild and related to thinking of future misophonic situations. In clinical interviews, all subjects reported confrontations with triggers as stressful events. Subjects worried about misophonic triggers and their capacity to cope. A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness. In clinical interviews, most subjects expressed shame or guilt. Anticipatory anxiety and preoccupation with misophonic triggers appeared simultaneously. Two different scales showed 86 to 91% experienced serious preoccupation.” | concepts[4] |
| concept | A-MISO-S — not defined in this paper's own words; Amsterdam scale for misophonia severity — “The following questionnaires were administered: Misophonia Screening List ( see S1 Appendix ), Misophonia Sound List (MSL; see S2 Appendix ), A msterdam Misophonia Scale [ 2 ] (A-MISO-S), AMISOS Revised (AMISOS-R; see S3 Appendix ), Hamilton Depression Rating Scale [ 18 , 19 ] (HDRS), Hamilton Anxiety Scale [ 20 , 21 ] (HAS), Symptom Checklist 90 Revised [ 22 , 23 ] (SCL-90-R), Manchester Short Assessment of Quality of life [ 24 , 25 ] (MANSA), Sheehan Disability Scale [ 26 ] (SDS), WHO Quality of Life-BREF [ 27 , 28 ] (WHOQoL-BREF), NEO-Personality Inventory-revised [ 29 , 30 ] (NEO-PI-R), Autism Spectrum Quotient [ 31 , 32 ] (AQ), Inventory of Interpersonal Situations [ 33 ] (IIS), Clinical Perfectionism Questionnaire [ 34 ] (CPQ), Frost Multidimensional Perfectionism Scale [ 35 ] (FMPS), Disgust Propensity and Sensitivity Scale Revised [ 36 , 37 ] (DPSS-R), Disgust Scale Revised [ 38 , 39 ] (DS-R). For more information, see S2 Table .” | concepts[5] |
| concept | AMISOS-R — not defined in this paper's own words; revised Amsterdam misophonia severity scale — “The following questionnaires were administered: Misophonia Screening List ( see S1 Appendix ), Misophonia Sound List (MSL; see S2 Appendix ), A msterdam Misophonia Scale [ 2 ] (A-MISO-S), AMISOS Revised (AMISOS-R; see S3 Appendix ), Hamilton Depression Rating Scale [ 18 , 19 ] (HDRS), Hamilton Anxiety Scale [ 20 , 21 ] (HAS), Symptom Checklist 90 Revised [ 22 , 23 ] (SCL-90-R), Manchester Short Assessment of Quality of life [ 24 , 25 ] (MANSA), Sheehan Disability Scale [ 26 ] (SDS), WHO Quality of Life-BREF [ 27 , 28 ] (WHOQoL-BREF), NEO-Personality Inventory-revised [ 29 , 30 ] (NEO-PI-R), Autism Spectrum Quotient [ 31 , 32 ] (AQ), Inventory of Interpersonal Situations [ 33 ] (IIS), Clinical Perfectionism Questionnaire [ 34 ] (CPQ), Frost Multidimensional Perfectionism Scale [ 35 ] (FMPS), Disgust Propensity and Sensitivity Scale Revised [ 36 , 37 ] (DPSS-R), Disgust Scale Revised [ 38 , 39 ] (DS-R). For more information, see S2 Table .” | concepts[6] |
| concept | audiometry — not defined in this paper's own words; hearing-threshold assessment used for differential diagnosis — “Somatic assessment consisted of a general physical and neurological examination and a general blood screening. Audiometry was performed with the Hughson-Westlake procedure[ 16 ] to obtain hearing thresholds in a random selection of participants (n = 109) in the first 300 subjects. Patients were randomly assigned to three psychiatrists. In a period of 20 months the assessment of one psychiatrist was extended with audiometry. Because the results were clear, we stopped performing audiometry in order not to unnecessarily burden subjects. Air conduction thresholds were measured at all octave frequencies from 0.25 to 8 kHz and bone conduction thresholds were measured at 0.25, 0.5, 1, and, 2 kHz, with adequate masking if necessary. The Pure Tone Average (PTA) was obtained by averaging air conduction thresholds 0.5, 1, 2, and, 4 kHz and hearing loss classification was defined according to WHO-classification[ 17 ].” | concepts[7] |
| concept | clinical perfectionism — not defined in this paper's own words; perfectionism above specified questionnaire thresholds — “Subjects scored average on the AQ and ISS. Subjects scored low on the DS-R and on the DPSS-R[ 42 ]. There was a significant positive correlation between the DPSS-R and DS-R (r = .545, n = 442, p < .000). Further, subjects scored high on the CPQ (healthy controls in an unpublished AMC study have M = 23.82). A total of 97% had a score over 25, indicating clinical perfectionism. Subjects scored slightly higher on the FMPS (healthy controls in an unpublished AMC study have M = 92.70). A total of 66% had a score over 22 on the scale ‘Concern over mistakes’, indicating clinical perfectionism (cut off suggested by Egan & Hine[ 43 ]). There was no significant correlation between the CPQ and FMPS (r = .036, p = .571).” | concepts[8] |
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Misophoniaterm·dom: Phenomenology, comorbidity and demographics in a large sample Abstract Analyze a large sample with detailed clinical data of misophoniaterm·dom subjects in order to determine the psychiatric, somatic and psychological nature of the condition.
This observational studyterm·mth of 779 subjects with suspected misophoniaterm·dom was conducted from January 2013 to May 2017 at the outpatient-clinic of the Amsterdam University Medical Centers, location AMC, the Netherlands. We examined DSM-IV diagnoses, results of somatic examination (general screening and hearing tests), and 17 psychological questionnaires (e.g., SCL-90-R, WHOQoL).
The diagnosis of misophoniaterm·dom was confirmed in 575 of 779 referred subjects (74%). In the sample of misophoniaterm·dom subjects (mean age, 34.17 [ SD = 12.22] years; 399 women [69%]), 148 (26%) subjects had comorbid traits of obsessive-compulsive personality disorder, 58 (10%) mood disorders, 31 (5%) attention-deficit (hyperactivity) disorder, and 14 (3%) autism spectrum conditions. Two percent reported tinnitus and 1% hyperacusis. In a random subgroup of 109 subjects we performed audiometryterm·mth, and found unilateral hearing loss in 3 of them (3%). Clinical neurological examination and additional blood test showed no abnormalities. Psychological tests revealed perfectionism (97% CPQ>25) and neuroticism (stanine 7 NEO-PI-R). Quality of lifeterm·var was heavily impaired and associated with misophonia severityterm·var (r s (184) = -.34 p = < .001, p = < .001).
This was a single site study, leading to possible selection–and confirmation bias, since AMC-criteria were used.
This study with 575 subjects is the largest misophoniaterm·dom sample ever described. Based on these results we propose a set of revised criteria useful to diagnose misophoniaterm·dom as a psychiatric disorder.
Introduction Misophoniaterm·dom is a recently recognized condition, characterized by an impulsive aversive physical reaction of irritation, anger, or disgust when confronted with specific, repetitive stimuli (for instance, eating sounds). The word was first used in audiology literature as a hatred of sounds[ 1 ]. In 2013 our research group at the Amsterdam University Medical Centers (Amsterdam UMC, location AMC) proposed the first diagnostic criteria for misophoniaterm·dom as a psychiatric disorder[ 2 ] ( Table 1 ). Thereafter, research on misophoniaterm·dom has increased vastly. The Amsterdam viewpoint is misophoniaterm·dom is definitely a psychiatric disorder, though there’s no agreement among different research teams. For a recent descriptive overview, we refer to Taylor[ 3 ] or Brout et al.[ 4 ].
AMC 2013 diagnostic criteria for misophoniaterm·dom.
Currently, a total of 797 misophoniaterm·dom subjects has been described in 26 clinical research papers, including five sample studies [ 2 , 5 , 6 , 7 , 8 ]. Only subjects included in the AMC sample[ 2 ] and a sample study published last year (Erfanian, Kartsonaki & Keshavarz[ 9 ]) had a systematic medical and psychiatric examination. All other samples (of the papers included in our 2018 search) merely used questionnaires to diagnose misophoniaterm·dom.
Without a systematic clinical interview, which is missing in almost three quarters of all described subjects, misophoniaterm·dom symptoms could possibly be better explained by another disorder or results could be influenced by self-report biases (references in S1 Table and S1 Fig ).
Therefore, we assessed a new sample of subjects with misophoniaterm·dom symptoms who were referred to the AMC by their general practitioner, which is both quantitatively and qualitatively superior to previous research. The first aim of this study was to determine whether referred subjects with misophonia-like symptoms actually suffered from misophoniaterm·dom using a psychiatric interview conducted by three experienced psychiatrists. The second aim was to determine phenomenology, comorbidity, and demographics of the misophoniaterm·dom sample to address three major issues: 1) whether misophoniaterm·dom should be approached from an audiological or psychiatric/psychological perspective; 2) whether specific psychological profiles, which have been associated with misophoniaterm·dom, such as disgust sensitivityterm·var[ 10 ], autism-like traits[ 11 , 12 ] and perfectionism[ 2 ] are still valid; and 3) whether misophoniaterm·dom is a distinct psychiatric disorder for which diagnostic criteria should be determined.
Methods Subjects In this sample study, we analyzed data collected from subjects who were referred with misophoniaterm·dom symptoms from 2013 through 2017 at the Department of Psychiatry at Amsterdam University Medical Center (Amsterdam UMC), the Netherlands. This study has been approved by the ethics committee of Amsterdam UMC and the need for informed consent was waived.
Of the 779 examined subjects, 575 subjects met criteria for misophoniaterm·dom. The 204 subjects excluded from this sample were: subjects with primary autism spectrum conditions (ASC), primary attention-deficit (hyperactivity) disorder (AD(H)D), a primary diagnosis on Axis II (varying from schizotypal personality disorder to obsessive compulsive personality disorder) and subjects without a DSM-IV diagnosis. Hearing impairments or audiologic disorders were no exclusion criterion.
Diagnostic procedures Assessment of current Axis I and Axis II disorders based on the DSM-IV criteria[ 13 ] was determined with the MINI-International Neuropsychiatric Interview Plus[ 14 ] (MINI-plus) and sections of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders[ 15 ] (SCID II). Based on information obtained from clinical interview, questionnaires or psychiatric history specific sections of the SCID-II relevant to each subject were selected and conducted. DSM-5 was not in use for clinical purposes at our department until 2018. Three psychiatrists, specialized in anxiety disorders and obsessive-compulsive and related disorders, carried out the clinical (medical and psychiatric) interviews.
Somatic assessment consisted of a general physical and neurological examination and a general blood screening. Audiometryterm·mth was performed with the Hughson-Westlake procedure[ 16 ] to obtain hearing thresholds in a random selection of participants (n = 109) in the first 300 subjects. Patients were randomly assigned to three psychiatrists. In a period of 20 months the assessment of one psychiatrist was extended with audiometryterm·mth. Because the results were clear, we stopped performing audiometryterm·mth in order not to unnecessarily burden subjects. Air conduction thresholds were measured at all octave frequencies from 0.25 to 8 kHz and bone conduction thresholds were measured at 0.25, 0.5, 1, and, 2 kHz, with adequate masking if necessary. The Pure Tone Average (PTA) was obtained by averaging air conduction thresholds 0.5, 1, 2, and, 4 kHz and hearing loss classification was defined according to WHO-classification[ 17 ].
Finally, a variety of self-report questionnaires examined the nature and severity of misophoniaterm·dom symptoms, quality of lifeterm·var, anxiety and depressive symptoms, and personality profile of the subjects. Given the naturalistic nature of the sample, the standard battery of questionnaires at our psychiatry outpatient clinic was used (seven questionnaires), with several additional questionnaires to understand the phenomenology of misophoniaterm·dom and the relation with possible correlated constructs. All questionnaires were administered during intake procedure. A random selection of subjects (n = 56) completed an additional personality questionnaire (see S2 Table ). During 4 months all intakes (60 subjects in total) were approached for this additional personality questionnaire, which was completed by 56 subjects.
Questionnaires The following questionnaires were administered: Misophoniaterm·dom Screening List ( see S1 Appendix ), Misophoniaterm·dom Sound List (MSL; see S2 Appendix ), A msterdam Misophoniaterm·dom Scale [ 2 ] (A-MISO-Sterm), AMISOSterm Revised (AMISOS-Rterm; see S3 Appendix ), Hamilton Depression Rating Scale [ 18 , 19 ] (HDRS), Hamilton Anxiety Scale [ 20 , 21 ] (HAS), Symptom Checklist 90 Revised [ 22 , 23 ] (SCL-90-R), Manchester Short Assessment of Quality of lifeterm·var [ 24 , 25 ] (MANSA), Sheehan Disability Scale [ 26 ] (SDS), WHO Quality of Life-BREF [ 27 , 28 ] (WHOQoL-BREF), NEO-Personality Inventory-revised [ 29 , 30 ] (NEO-PI-R), Autism Spectrum Quotient [ 31 , 32 ] (AQ), Inventory of Interpersonal Situations [ 33 ] (IIS), Clinical Perfectionismterm·dom Questionnaire [ 34 ] (CPQ), Frost Multidimensional Perfectionism Scale [ 35 ] (FMPS), Disgust Propensity and Sensitivity Scale Revised [ 36 , 37 ] (DPSS-R), Disgust Scale Revised [ 38 , 39 ] (DS-R). For more information, see S2 Table .
Statistical analysis All statistical analyses were conducted with SPSS statistical package version 24. We report the sample descriptively in terms of means and standard deviations or percentage of the sample, where appropriate. We used independent-samples t-tests to explore whether males and females differed in age of onset and symptom severity (i.e. A-MISO-Sterm or AMISOS-Rterm score). We used multiple linear regression to explore whether certain features were associated with symptom severity. AMISOS-Rterm scores were included as independent variables, and CPQ, FMPS, AQ, DS-R and DPSS-R were included as dependent variables. We confirmed normality of residuals by checking the QQ plot of the model. We treated the full Likert scales as numerical, since assumptions of linear regression were met (residuals were normally distributed) and results are much easier to interpret. Finally, a non-parametric correlation (Spearman’s rho) was calculated to determine whether misophoniaterm·dom symptoms (A-MISO-Sterm) correlated with quality of lifeterm·var (MANSA). No missing scores were imputed and no outliers were removed. We considered P < 0.05 to be statistically significant.
Results Demographics Our sample was predominantly Caucasian, 69% were female, and 64% had a relationship. Over 85% were employed or studying and 5% were on sick-leave. Mean age at admission was 34.17 years ( SD = 12.22) and mean age of onset was 13.17 years ( SD = 7.37). Onset in females was not significantly earlier than in males ( p = .076). Most subjects (93%) reported a gradual onset of the misophoniaterm·dom symptoms. Clinical interviews with older subjects indicated a chronic course and 33% reported a positive family history of misophoniaterm·dom.
Comorbidity The comorbid DSM-IV disorders are shown in Table 2 . 72% of subjects diagnosed with misophoniaterm·dom had no comorbid Axis I psychiatric disorder, 22% had one comorbid disorder, and 6% had two or more comorbid disorders. Common comorbid disorders were major depressive disorder (6.8%) and obsessive-compulsive disorder (2.8%). Another 5% of the sample had comorbid AD(H)D and 3% was diagnosed with a comorbid ASC.
Percentage and absolute frequencies of current DSM-IV Axis I & Axis II disorders in misophoniaterm·dom subjects.
The majority (59%) had no comorbidity on Axis II. Most prevalent were OCPD (2.4%) and borderline personality disorder (BPD, 1.7%). Obsessive-compulsive personality traits were found in 26%. Subjects exhibited especially high morality and clinical perfectionismterm·dom.
Misophoniaterm·dom triggersterm·dom Almost all subjects reported to be triggered by eating sounds (96%) followed by nasal and breathing sounds (85%). Subjects were also regularly disturbed by sounds of repetitive tapping or mouth/throat sounds. All triggersterm·dom are shown in Fig 1 .
Triggersterm·dom and provoked anger for misophoniaterm·dom subjects.
Visual triggersterm·dom were often reported, e.g., repetitive movements (68%). We found visual triggersterm·dom were often directly associated with auditory triggersterm·def (e.g., grinding teeth) in clinical interviews. When visual triggersterm·dom were reported, they occurred secondary to auditory triggersterm·def and had less impact than the auditory triggersterm·def. When visual and auditory stimuli occurred simultaneously (e.g., hearing and seeing someone chewing gum), subjects reported a more intense response. 59% were bothered by ambient sounds, particularly by sounds of neighbors.
Nature of the response Subjects reported extreme irritation, anger, and disgust as primary emotional responsesterm·def (see Table 3 ). Aggressive outbursts were seldom reported at psychiatric interviews; verbal aggression was common, but physical aggression was rare. Frequency was not assessed with a questionnaire.
Emotional response and hyper focusterm·dom to sounds in misophoniaterm·dom subjects.
None of the subjects reported anxiety as a primary response, neither at psychiatric examination nor with questionnaires. Only five subjects (1%) reported secondary anxiety, following anger or disgust. The majority of the sample reported anticipatory anxietyterm·dom, which was mild and related to thinking of future misophonic situations. In clinical interviews, all subjects reported confrontations with triggersterm·dom as stressful events. Subjects worried about misophonic triggersterm·dom and their capacity to cope. A perceived loss of control was seen in 81% of the subjects and 90% reported severe to extreme powerlessness. In clinical interviews, most subjects expressed shame or guilt. Anticipatory anxietyterm·dom and preoccupation with misophonic triggersterm·dom appeared simultaneously. Two different scales showed 86 to 91% experienced serious preoccupation.
Most used coping was turning on music (99%) and walking away (99%). Making noise or making noise in the same rhythm, e.g., chewing or typing, was also used frequently, 86% and 77%, respectively. Finally, 86% described using earplugs; the majority of these subjects used them in the last week (73%).
In general, subjects reported to spend a lot of time actively avoiding triggersterm·dom: 24% 0 to 1 hour each day, 24% 1 to 3 hours, 32% 3 to 8 hours, and 9% avoided over 8 hours each day.
General somatic 76% of the sample reported no diagnosis on Axis III, 20% reported one diagnosis, and 4% had multiple diagnoses. Most common diagnoses were: migraine, irritable bowel syndrome, asthma, and back pain. During physical examination, a primary neurological disorder was never determined, but a mild somatic comorbid disorder was regularly found (e.g., hypertension). Approximately 1% of blood tests results were abnormal (e.g., decreased Hb levels, thyroid abnormalities or increased liver functions).
Audiology Of the total sample, four subjects (0.7%) were previously diagnosed with hyperacusis only, ten subjects (1.7%) with tinnitus only, and one patient with both. Twenty subjects reported hearing loss or other hearing problems.
The subgroup performing an audiogram consisted of 109 subjects (69% female) with a mean age of 36.70 years ( SD = 12.08). 106 subjects had bilateral normal hearing (PTA < = 25 dB HL). The remaining three subjects had a unilateral hearing loss: one slight conductive hearing loss (25–40 dB HL), one moderate conductive hearing loss (40–60 dB HL), and one profound sensorineural hearing loss (80+ dB HL). This implies all participants had at least one ear with normal hearing.
Severity Subjects had moderate to moderate-severe symptoms according to the A-MISO-Sterm and AMISOS-Rterm. No significant sex differences were found (respectively p = .44 and p = .29). Subjects had mild symptoms on the HAS and HDRS and a high score on the SCL-90-R. Quality of lifeterm·var varied from a low satisfaction on the MANSA, to some impairment in day-to-day life on the SDS, particularly with family relations[ 40 ], to a slightly lower perceived quality of lifeterm·var on the WHOQoL-BREF[ 41 ]. Subjects all described to have made adjustments to their day-to-day life, such as avoiding public transport. Many subjects lost work or relationships because of misophoniaterm·dom. Rarely, subjects were desperate for help or expressed suicidal ideations in the clinical interviews.
Personality profile Subjects scored average on the AQ and ISS. Subjects scored low on the DS-R and on the DPSS-R[ 42 ]. There was a significant positive correlation between the DPSS-R and DS-R (r = .545, n = 442, p < .000). Further, subjects scored high on the CPQ (healthy controls in an unpublished AMC study have M = 23.82). A total of 97% had a score over 25, indicating clinical perfectionismterm·dom. Subjects scored slightly higher on the FMPS (healthy controls in an unpublished AMC study have M = 92.70). A total of 66% had a score over 22 on the scale ‘Concern over mistakes’, indicating clinical perfectionismterm·dom (cut off suggested by Egan & Hine[ 43 ]). There was no significant correlation between the CPQ and FMPS (r = .036, p = .571).
The NEO-PI-R sub-sample showed no sex differences and subjects scored above average (stanine 7) only on Neuroticism, with the facet Angry hostility (stanine 7). All characteristics are shown in Table 4 .
Characteristics of misophoniaterm·dom subjects.
Using a standard multiple regression, perfectionism (CPQ: p = .487; FMPS: p = .651), autism traits (AQ: p = .270), and disgust sensitivityterm·var (DS-R: p = .628; DPSS-R: p = .961) showed no significant relation to the severity of the misophoniaterm·dom symptoms, measured by the AMISOS-Rterm.
Finally, non-parametric correlation (Spearman’s rho) was used to determine whether misophoniaterm·dom symptoms (A-MISO-Sterm) correlated with a decreased quality of lifeterm·var (MANSA). The more severe the misophoniaterm·dom symptoms, the lower the satisfaction with quality of lifeterm·var, r s (184) = -.34 p = < .001.
Discussion This is the largest qualitative and quantitative description of a sample of misophoniaterm·dom subjects so far ( N = 575). Our study demonstrates that clinical examination from a medical-psychiatric perspective is invaluable for diagnosing misophoniaterm·dom, as one out of four referred subjects does not suffer from misophoniaterm·dom. Risk of misdiagnosis is high, because misophonia-like symptoms could be explained by comorbid conditions such as OCPD traits, mood disorders, AD(H)D, and ASC. From a somatic perspective, our misophoniaterm·dom subjects do not have specific somatic comorbid disorders. Furthermore, they have normal hearing, which is in contrast to hearing in tinnitus[ 44 ]. Prevalence of hearing loss found in our population is even less than expected based on the prevalence of disabling hearing loss in normal population for the Netherlands (PTA > 40 dB HL in better ear around 5% for adult population[ 45 ]). From a psychological perspective, misophoniaterm·dom can be seen as an independent construct. No association was found between misophoniaterm·dom symptoms and ASC, disgust sensitivityterm·var, or clinical perfectionismterm·dom. Clinical perfectionismterm·dom, however, was seen in 66 to 97% of the subjects. Severity of misophoniaterm·dom symptoms is negatively correlated with quality of lifeterm·var. Family relations especially suffer, but the influence on working life remains limited with only 5% on sick leave.
Overall prevalence rate of comorbid DSM-IV Axis I disorders is similar to general population in the Netherlands, except for mood disorders (twice as prevalent[ 46 ]), AD(H)D (two-and-a-half times more prevalent[ 46 ]) and the ASC (threefold the prevalence[ 47 ]). Some studies[ 6 , 48 ] suggest an association with affective disorders, particularly post-traumatic stress disorder. The preliminary results of a new sample study using psychiatric evaluation[ 9 ] even showed a prevalence of 15%. However, prevalence of PTSD in our sample is not higher. The prevalence rate of comorbid DSM-IV Axis II disorders is mildly higher and corresponds with findings of Rouw & Erfanian[ 6 ]. We found OCPD traits in one out of four subjects. Regardless, the exact prevalence of personality traits in community samples is unknown, we consider a 26% prevalence of OCPD traits high. 52% of the 2013 AMC sample[ 2 ] had a comorbid OCPD. This difference can be explained by a smaller sample size and selection bias in this previous sample.
Development and severity of misophoniaterm·dom symptoms in this large sample are consistent with findings in the 2013 AMC sample[ 2 ]. In our sample, however, a larger percentage is female. Specifically, age of onset, course, severity of symptoms, and a positive family history[ 49 , 6 , 7 ] supports misophoniaterm·dom as a distinct disorder[ 50 ]. Findings from psychiatric, medical, and psychological assessments substantiate this conclusion. Our findings result in a revision of the 2013 criteria, which are illustrated in the next paragraph and marked in Table 5 . We emphasize that to be diagnosed with misophoniaterm·dom, all criteria should be met. As in all psychiatric disorders a subclinical group probably exists, in most cases lacking criterion E-R.
Amsterdam UMC 2020 revised diagnostic criteria for misophoniaterm·dom.
Misophoniaterm·dom triggersterm·dom Our detailed investigation of triggersterm·dom leads to new conclusions. Approximately all subjects in our sample report eating sounds as a triggerterm·dom (96%) and the majority reports nasal or breathing sounds as a triggerterm·dom (85%). Combined, all subjects report either oral or nasal sounds as a triggerterm·dom. Therefore, we propose other triggersterm·dom can be a part of the condition, but an emotional reactionterm·dom to oral or nasal sounds is requiredᵇ. Visual triggersterm·dom, like scratching, and non-human triggersterm·dom, like animal sounds or air-conditioning sounds, were occasionally described[ 51 , 52 ]. We indeed found evidence for non-auditory triggersterm·dom in 78% of our sample, but auditory triggersterm·def are primary triggersterm·dom c . If combined, these triggersterm·dom cause a more intense emotional reactionterm·dom. In a mass experiment which was performed among the general population, adding a corresponding image to a disgusting sound had no effect[ 53 ]. This interaction effect is probably typical for misophoniaterm·dom subjects.
Ambient sounds are most often reported amongst other misophoniaterm·dom triggersterm·domᵈ (see S2 Table ). If subjects are bothered only by ambient sounds (e.g., sounds of neighbors), misophoniaterm·dom should not be diagnosed, even though subjects describe a similar response. Over 8% of the Dutch population reported serious nuisance by sounds of neighbors in the last year and 29% reported mild or moderate nuisance. A much higher percentage is bothered by various traffic sounds[ 54 ]. In these cases, symptoms can be seen as a more general disturbance of sounds, such as noise sensitivity or sensory over-responsivity, which also occurs in a normal population[ 55 ]. We used typical examples of avoidance from our psychiatric assessmentsᵉ.
Nature of the response As in other samples and case studies, we show misophoniaterm·dom is associated with considerable non-expressed aggression, but physical aggressive outbursts are rare[ 3 ]. Subjects with a comorbid affective instability, due to for instance comorbid BPD, sometimes reported aggressive outbursts in our clinical interviews. These outbursts were mild in comparison to the internal aggressive thoughts all misophoniaterm·dom subjects described. Anxiety is also frequently described as a response to misophoniaterm·dom triggersterm·dom[ 56 , 57 , 5 , 8 ]. In our sample, subjects do not report anxiety as a prompt reaction to a triggerterm·dom, but experience anticipatory anxietyterm·dom and physical stress. Possibly this anticipatory anxietyterm·dom is elsewhere mistaken for anxiety as a primary response. This emphasizes the value of a thorough psychiatric evaluation once more. We found all subjects consider their reaction to be out of proportion. Interestingly, only one case study describes a patient who perceived her reaction to sounds as inappropriate[ 58 ]. Subjects with a primary OCPD or ASC often do not consider their reaction to be out of proportion, and OCPD or ASC are possible differential diagnosesᶠ.
Subjects often stated the emotional response to be far more intense towards loved ones inducing misophoniaterm·dom triggersterm·dom. Context also influenced the emotional response; when misophoniaterm·dom triggerterm·dom sounds were made by toddlers, mentally disabled adults, or elderly with dementia, an emotional response seldom occurred.
We consider preoccupation an additional core symptom of misophoniaterm·dom, since approximately all subjects in our sample report hyper focusterm·domᵃ. Hyper focusterm·dom was also reported in 82% of the sample of Edelstein et al[ 49 ] and an intervention targeting hyper focusterm·dom has a clear effect on misophoniaterm·dom symptoms[ 59 ].
Limitations This is the first large sample study of misophoniaterm·dom subjects in which we not only explored the dynamics of misophoniaterm·dom symptoms, but also examined the impact of symptoms on quality of lifeterm·var. However, this research also has its limitations. First, the Amsterdam UMC is the only center in the Netherlands with a specific treatment for misophoniaterm·dom, which could lead to a selection bias. Furthermore, since no other criteria were available, AMC 2013 diagnostic criteria were used for selection of subjects, possibly leading to confirmation bias. However, we believe we limited confirmation bias, because we examined all patients who were referred with misophonia-like symptoms; using questionnaires with a broad scope, and we investigated alternative symptoms, e.g., anxiety, in our psychiatric evaluations. Finally, types or versions of questionnaires administered changed over time in this sample. Some of the questionnaires administered are not yet validated in Dutch translation or lack a norm group, but were the best available. Also, the A-MISO-Sterm is not psychometrically validated and the AMISOS-Rterm is in the process of validation.
Conclusions In conclusion, this analysis of a large sample confirms that misophoniaterm·dom is a distinct psychiatric disorder characterized by an intense emotional reactionterm·dom of irritation, anger, and often disgust elicited by specific auditory, visual or sensory triggersterm·dom predominantly induced by another person, resulting in preoccupation and avoidance. We suggest future studies to use the revised Amsterdam UMC proposed criteria and to conduct international multi-center studies. A multi-disciplinary approach, especially including psychiatry, audiology, and psychology, would be preferable. International confirmation of the Amsterdam UMC revised criteria is needed before next steps in research can be taken. Future research should also include more treatment studies (e.g., a RCT of CBT or a new intervention) and validation of misophoniaterm·dom questionnaires.
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