The neurophysiological approach to misophonia: Theory and treatment

Abstract

Clinical observations of hundreds of patients who exhibited decreased tolerance to sound showed that many of them could not be diagnosed as having hyperacusis when negative reactions to a sound depend only on its physical characteristics. In the majority of these patients, the physical characteristics of bothersome sounds were secondary, and patients were able to tolerate other sounds with levels higher than sounds bothersome for them. The dominant feature determining the presence and strength of negative reactions are specific to a given patient's patterns and meaning of bothersome sounds. Moreover, negative reactions frequently depend on the situation in which the offensive sound is presented or by whom it is produced. Importantly, physiological and emotional reactions to bothersome sounds are very similar (even identical) for both hyperacusis and misophonia, so reactions cannot be used to diagnose and differentiate them. To label this non-reported phenomenon, we coined the term misophonia in 2001. Incorporating clinical observations into the framework of knowledge of brain functions allowed us to propose a neurophysiological model for misophonia. The observation that the physical characterization of misophonic trigger was secondary and frequently irrelevant suggested that the auditory pathways are working in identical manner in people with as in without misophonia. Descriptions of negative reactions indicated that the limbic and sympathetic parts of the autonomic nervous systems are involved but without manifestations of general malfunction of these systems. Patients with misophonia could not control internal emotional reactions (even when fully realizing that these reactions are disproportionate to benign sounds evoking them) suggesting that subconscious, conditioned reflexes linking the auditory system with other systems in the brain are the core mechanisms of misophonia. Consequently, the strength of functional connections between various systems in the brain plays a dominant role in misophonia, and the functional properties of the individual systems may be perfectly within the norms. Based on the postulated model, we proposed a treatment for misophonia, focused on the extinction of conditioned reflexes linking the auditory system with other systems in the brain. Treatment consists of specific counseling and sound therapy. It has been used for over 20 years with a published success rate of 83%.

Did Kant suffer from misophonia?

“…As we shall see below, the hypothesis developed in this article aims to complete this explanation and also to provide a slightly alternative view. While accepting that the learning and conditioning mechanisms proposed by Jastreboff and others ( Jager et al, 2020 ; Jastreboff and Jastreboff, 2023 ) play a major role in misophonia, we believe that misophonic sounds are not neutral and that they themselves act as a negative reinforcer. Indeed, we suggest that misophonic sounds have acquired a negative valence as a consequence of social learning and the resulting perceived world.…”

“…” Briefly, classical conditioning was developed establishing an association between the misophonic stimulus (that is initially neutral) and the affective reaction (anger and disgust). The repetition of the association between the conditioned stimulus and the conditioned response increases the functional connections between the different regions of the brain involved in the processing of information, that is the auditory system and the autonomic and limbic nervous system ( Jastreboff and Jastreboff, 2023 ). According to this model, the negative reinforcement exacerbates any negative emotional or physiological state, and any sound can become misophonic trigger.…”

“…Beside the order–disorder (sensibility to order and/or ability to integrate a disorder into another order), any (neutral) sound can become a trigger sound, as a result of classical conditioning ( Jastreboff and Jastreboff, 2023 ). In this case, a fortuitous association between a stimulus and an emotion can durably, perhaps definitively, link the stimulus to the emotion (see the Little Albert experiment with white mice), whereas the two are strictly independent.…”

“…The term misophonia ( miso : hatred, phonia : sound) was coined by Jastreboff in the early 2000s ( Jastreboff and Jastreboff, 2001 ; Jastreboff and Jastreboff, 2002 ; Jastreboff and Jastreboff, 2023 ). Misophonia is sometimes classified as a sub-category of hyperacousis ( Tyler et al, 2014 ).…”

Letter to the Editor: Misophonia: A Need for Audiological Diagnostic Guidelines

“…Should these sound tolerance disorders be unique, or should misophonia be a subtype of hyperacusis when loudness intolerance is present? Are the underlying mechanisms similar or distinct (Jastreboff and Jastreboff 40 )? What audiologic measures can be used or developed to provide differential diagnosis?…”