Elsevier

Medical Hypotheses

Volume 103, June 2017, Pages 109-117
Medical Hypotheses

Misophonia: A new mental disorder?

https://doi.org/10.1016/j.mehy.2017.05.003Get rights and content

Abstract

Misophonia, a phenomenon first described in the audiology literature, is characterized by intense emotional reactions (e.g., anger, rage, anxiety, disgust) in response to highly specific sounds, particularly sounds of human origin such as oral or nasal noises made by other people (e.g., chewing, sniffing, slurping, lip smacking). Misophonia is not listed in any of the contemporary psychiatric classification systems. Some investigators have argued that misophonia should be regarded as a new mental disorder, falling within the spectrum of obsessive-compulsive related disorders. Other researchers have disputed this claim. The purpose of this article is to critically examine the proposition that misophonia should be classified as a new mental disorder. The clinical and research literature on misophonia was examined and considered in the context of the broader literature on what constitutes a mental disorder. There have been growing concerns that diagnostic systems such as DSM-5 tend to over-pathologize ordinary quirks and eccentricities. Accordingly, solid evidence is required for proposing a new psychiatric disorder. The available evidence suggests that (a) misophonia meets many of the general criteria for a mental disorder and has some evidence of clinical utility as a diagnostic construct, but (b) the nature and boundaries of the syndrome are unclear; for example, in some cases misophonia might be simply one feature of a broader pattern of sensory intolerance, and (c) considerably more research is required, particularly work concerning diagnostic validity, before misophonia, defined as either as a disorder or as a key feature of some broader syndrome of sensory intolerance, should be considered as a diagnostic construct in the psychiatric nomenclature. A research roadmap is proposed for the systematic evaluation as to whether misophonia should be considered for future editions of DSM or ICD.

Introduction

We live in an era in which the major psychiatric classification systems, such as the successive editions of DSM, have been steadily expanding in the number of phenomena that are considered to be mental disorders. This has led to a growing concern that commonplace quirks, eccentricities, or problems of living are becoming over-pathologized and over-diagnosed as mental disorders [1], [2], [3]. Accordingly, there is good reason to be skeptical when some new psychiatric disorder is proposed. The purpose of this article is to critically examine the evidence for a purportedly new mental disorder, misophonia, characterized by marked distress from hearing particular sounds. Misophonia is not listed in any of the major psychiatric classification systems and, until recently, has received little attention from psychiatric researchers, having been described almost exclusively in the audiology literature.

The question of whether misophonia, or some syndrome in which misophonia is a prominent feature, should be classified as a mental disorder is important for several reasons. The recognition of misophonia as a distinct mental disorder, if indeed it is a disorder, could facilitate recognition of the condition to health-care providers, raise public awareness, provide information and validation to sufferers (i.e., the positive effects of labeling), and could facilitate research and treatment. A disadvantage in classifying misophonia as a mental disorder is the possibility of stigmatizing and over-pathologizing possibly benign eccentricities (i.e., negative effects of labeling). Accordingly, it is important to carefully consider whether misophonia meets criteria for a mental disorder, and whether there is sufficient evidence for clearly specifying its essential features and delineating the boundaries of any syndrome of which it might be a part.

This article begins by defining misophonia and related concepts, and by distinguishing it from other phenomena, particularly phenomena arising from dysfunctions of the primary auditory system. This is followed by a review of the common features of misophonia, as described by case studies, case series, and larger investigations. Theories of misophonia are also discussed. Such theories are relevant to the question of whether misophonia is a mental disorder because if it is such a disorder, then it should arise from a psychobiological dysfunction as opposed to some other (e.g., purely audiological) dysfunction. General considerations for diagnosing mental disorders are considered followed by a critical review of the proposals regarding the diagnostic classification of misophonia. Finally, a roadmap for further research is discussed, including research strategies for evaluating the clinical utility of misophonia, or some variant thereof, as a mental disorder.

Section snippets

Definition of concepts

Originally described in the audiology literature, misophonia (literally “hatred of sound”) refers to a strong dislike of sounds—particularly oral and nasal sounds produced by other people—accompanied by unusually intense, distressing emotional reactions [4]. Misophonia has also been called “selective sound sensitivity syndrome” and “soft sound sensitivity syndrome” [5]. The latter term emphasizes the finding that some of the distressing sounds in misophonia are soft rather than loud.

Misophonia

Empirical studies

Descriptive data for the present article were obtained from published case studies, case series, and experimental investigations reporting data on cases classified as having misophonia, as identified in searches of PsychInfo and Medline up to March 1, 2017, using the search terms “misophonia”, “selective sound sensitivity” and “soft sound sensitivity syndrome”. Reference lists of source articles were also searched, along with review articles.

A total of 19 misophonia clinical investigations

Etiological hypotheses

If misophonia is to be classified as a mental disorder, then this carries the assumption that the disorder arises from some type of psychobiological dysfunction. Accordingly, etiological hypotheses are relevant as to how misophonia should be classified.

Diagnostic considerations

There are several important considerations in deciding whether or not a particular diagnostic construct should be included in a diagnostic classification system.

RDoC and misophonia

If the promise of RDoC is fulfilled and it becomes viable as a clinical diagnostic system, the most likely result is that misophonia (and perhaps many other disorders classified in ICD and DSM) would not be diagnostic classifications. Instead the diagnosis would be based on the underlying mechanisms; for example, a diagnostic formulation might be “Mr. A. presents with intense distress when he hears other people chewing. Biometric assessment reveals dysregulation in brain circuits x, y, and z.”

Development and refinement of assessment instruments

In order to establish whether misophonia is a stand-alone disorder or part of a broader syndrome of sensory intolerance, it is important to develop reliable, valid measures of misophonia and other forms of sensory intolerance. Questionnaire measures have been developed for research purposes [29], [43], and a structured clinical interview has been developed, adapted from a measure of OC symptoms [15]. The psychometric properties of these instruments have yet to be firmly established. Most

Conclusion

Misophonia meets many of the general criteria for a mental disorder and there is preliminary evidence as to its clinical utility. Schröder et al. [15] proposed that misophonia be regarded as a new diagnostic category, related to OC disorders. A review of the evidence indicates that this proposal is premature, and that Schröder’s proposed diagnostic criteria overstate the importance of anger, to the relative neglect of other emotional reactions, and fail to adequately capture the clinical

Declaration of interests

The author declares no conflict of interest.

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