What doctors wish patients knew about misophonia

Tensions rise in the quiet corners of everyday life, where the gentle clinking of cutlery or the faint tapping of a keyboard can evoke a visceral reaction. This is misophonia, where seemingly innocuous sounds can trigger intense emotional responses in those living with the condition.

Misophonia can trigger a fight-or-flight response, causing those affected to avoid places or situations. And while misophonia does not yet have official recognition as a distinct disorder in the latest edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) or the International Classification of Diseases (ICD), experts still recognize it and patients affected deserve answers.

The Latin roots of the word “misophonia” translate to the “hatred of sound” and it is a chronic condition in which specific sounds provoke intense emotional experiences and autonomic arousal within a person. Such trigger sounds can include chewing, pen clicking, tapping, typing and lip smacking.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two physicians took time to discuss what they wish patients knew about misophonia. They are:

• Vijaya Appareddy, MD, a child, adolescent and adult psychiatrist in Chattanooga, Tennessee, and executive committee member of the AMA Council on Legislation. She is also a delegate in the AMA House of Delegates for the Tennessee Medical Association.
• John C. Goddard, MD, who specializes in otology, neurotology and skull base surgery at Northwest Permanente in Portland, Oregon. Northwest Permanente is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

Women are more likely to be affected by misophonia, but it is hard to say how common the condition may be because “literature on the exact incidence is lacking,” Dr. Goddard said. “ Many people may have experienced  some minor version of misophonia, but do not necessarily have a pathologic problem.”

For Dr. Goddard, who sees only patients with ear related problems, misophonia isn’t a commonly encountered condition.

Misophonia is “different from hearing loss, tinnitus and hyperacusis,” Dr. Goddard said, explaining that “hyperacusis is a reduced tolerance to sound where ordinary noises are too loud and can cause discomfort and pain.”

“Misophonia is when you’re intolerant of sounds that you wouldn’t think would cause such a strong reaction,” he said.

Dr. Appareddy treats many patients with post-traumatic stress disorder (PTSD) and what she has noticed is their “aversion to sounds, selected sounds. And these sounds can even be sounds that other people can’t even hear because they’re just so soft or so insignificant.”

“The sounds are amplified significantly, and they trigger an emotional reaction. It can be anger and irritability, but there is an overlap in symptoms when it happens with PTSD because the response is also an increased sensitivity to sound related to the trauma, especially when there’s complex PTSD,” Dr. Appareddy said. “There is a trigger to certain sounds that could be related to the chronic trauma or abuse in a very remote way. And that unleashes a lot of the symptoms.”

“Sometimes the trigger could be something that is remotely related to the trauma and sometimes there is no relationship. It’s almost like a conditioned response to something,” she said. “In PTSD, we’ll see much more of a cluster of symptoms like intrusive thoughts, flashbacks, nightmares and all this.”

“With misophonia, it’s a much more intense, narrowed-down symptom of increased aversion to sounds,” Dr. Appareddy noted. In such cases, it is “just normal day-to-day life sounds that they [patients] cannot sometimes link to a trigger or a trauma.”

In terms of co-prevalence with PTSD, Dr. Appareddy noted that of her patients who have PTSD, 15% also have misophonia.

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Misophonia can also “be accompanied by physical symptoms, which there may be an overlap because PTSD can also manifest in that way,” Dr. Appareddy said. She noted that such symptoms can include “sweating, increased blood pressure and chest pressure—but this can also happen with PTSD.”

Additionally, “it can be accompanied with avoidance,” she said, noting that while there is overlap with PTSD, “misophonia is more focused and more exaggerated, specifically with sound. So, it can cause anxiety, the fight-or-flight response, anger, rage.”

The common sounds that affect people with misophonia are “chewing or eating loudly,” Dr. Goddard said, noting that “water dripping or people tapping their nails can bother people. If people crinkle paper, that can really bother people too.”

Additionally, “specific keyboard sounds can really set some people off too. These are not sounds like airplanes taking off that would be damaging or bother people in terms of just discomfort,” he said. “These are just things that trigger some sort of reaction that otherwise wouldn’t do anything to other people.”

For patients with PTSD, “sometimes the nonspecific sounds could be somebody coughing or sneezing or yawning,” said Dr. Appareddy. “Sometimes it could be some specific sounds that are related to the complex trauma. For example, I had one patient who if I would ask her a question, she would say that I was shouting at her.

“And she would go into irritability, anger and panic. To her mother who was sitting next to her, it was very soft,” she added. “Even my breathing would make her extremely irritable and angry.”

Sometimes people may not even realize why it is happening.

“It may be the slightest thing that nobody notices, but when you go into great depths, you may find out over a period of time that somehow it is remotely associated with the chronic trauma,” Dr. Appareddy said, “especially with complex trauma PTSD patients.”

“Sometimes it’s just a regular sound that gets amplified and they develop an aversion to it,” she added.

“There’s usually a pretty strong overlap with some mental health condition,” Dr. Goddard said. “Whether it’s obsessive-compulsive disorder [OCD] or depression or all of the above, there’s definitely a component of that.”

This may be why misophonia has been gaining more attention in the media.

“In the last four or five years, there’s been more emphasis on mental health and there’s been more people suffering from mental health probably because of all the things that have been going on—at least in the states—in terms of the pandemic, our political turmoil, economy and all those things,” Dr. Goddard said. “So, to me, if there’s more of that going on and more awareness, maybe this is just another thing that is more visible.”

“In general, you don’t want people just wearing earplugs all the time, so they never hear anything,” said Dr. Goddard. “That’s not good for the brain and the ear.”

“They need to be aware of whatever triggers they have and try to avoid those and create spaces where they know they're not going to have those,” he added.

Overcoming misophonia may also mean “treating some underlying mental health issues,” said Dr. Goddard, noting “that can be through medication or various forms of therapy.”

For example, when “the neurotransmitters are out of line, you take Prozac [fluoxetine] for your anxiety. That’s because it actually is a physiologic issue,” he said. “If you treat some of those things medically, then it may lessen the chance of this being so severe. That’s the thought.”

“In PTSD, therapeutic intervention is multidisciplinary. So, medications depending on the symptoms they have, especially with complex PTSD patients,” Dr. Appareddy said, noting those include “depression, anxiety, flashback nightmares and dissociative episodes.”

Additionally, there is “cognitive behavior therapy, counseling, mindfulness and relaxation techniques,” she said.

If misophonia has contributed to anxiety or it is taking up a lot of your life, it is important to speak with your physician. However, Dr. Goddard would argue that patients should talk with their doctors before it becomes severe.

“If they are starting to notice that it’s impacting how they function, then I would definitely encourage them to talk to their doctor,” he said.

Patients should “definitely feel OK bringing it up,” Dr. Goddard said, noting that misophonia “is a physiologic issue. This is not somebody deciding they are just going to react this way.”

“Patients shouldn’t be embarrassed,” he added. “This has nothing to do with them making a decision as much as their physiology is driving why they respond this way, so they need help just like anybody else does with a condition that is based on physiology.”

“Do not feel ashamed. This is a symptom—especially the ones that arise from PTSD—so it has to be dealt with and treated,” Dr. Appareddy said.