The proposed criteria for high perceived misophonia in young healthy adults and the association between Misophonia symptoms and noise sensitivity

Context: The association between noise sensitivity and misophonia has not been explored in any population, according to the available literature. Aims: To assess the proportion of misophonia symptoms among young healthy adults, to propose the criteria for high perceived misophonia, and to explore the association between misophonia with noise sensitivity with adjustment for sex, age, perceived anxiety, and depression. Settings and Design: A cross-sectional study on 1132 medical students, aged 21.4 ± 2.1 years. Methods and Material: Misophonia symptoms were self-reported using the Amsterdam Misophonia Scale. Nine criteria for high perceived misophonia are proposed. Noise sensitivity was measured with Weinstein scale. Perceived anxiety and depression were measured using the Hamilton Anxiety Rating Scale and the Hamilton Depression Rating Scale, respectively. Statistical Analysis Used: Multiple logistic regression. Results: Almost half of the students reported the feeling of irritation against people making provoking sounds. Only one in 10 claimed the feeling of loss of self-control when exposed to provoking sounds. High noise sensitivity and high depression were associated with higher odds of meeting the criteria for high perceived misophonia. Conclusion: Noise-sensitive students are at higher risk of reporting misophonia symptoms and of being classified with high perceived misophonia. The combination of at least four or more symptoms, which classifies every 10th student with high perceived misophonia, is proposed as a self-assessment tool for epidemiological studies among young healthy adults.

Keywords: Criteria, misophonia, noise sensitivity, perceived anxiety, perceived depression, self-assessment

How to cite this article:
Paunovic K&, Milenković SM. The proposed criteria for high perceived misophonia in young healthy adults and the association between Misophonia symptoms and noise sensitivity. Noise Health 2022;24:40-8
How to cite this URL:
Paunovic K&, Milenković SM. The proposed criteria for high perceived misophonia in young healthy adults and the association between Misophonia symptoms and noise sensitivity. Noise Health [serial online] 2022 [cited 2022 Jul 25];24:40-8. Available from: https://www.noiseandhealth.org/text.asp?2022/24/113/40/351966

Key messages:

The proportion of five misophonia symptoms is assessed among medical students.

• Nine criteria for high perceived misophonia are proposed.

• Noise sensitivity increases the odds for the occurrence of misophonia symptoms.

• High noise sensitivity predicts seven of nine criteria for high perceived misophonia.

•The proposed criteria could be used as self-assessment tools in nonclinical studies.

Introduction

Misophonia is defined as an abnormally intense reaction to breathing, coughing, throat clearing, food chewing, crunching, swallowing, lip-smacking, spitting, and similar sounds.[1] These sounds produced by human respiratory and digestive organs are typical triggers for misophonia; other provoking sounds, however, could be made by any other part of the human body, including finger tapping, nail clipping, footsteps,[1] and kissing.[2] In some cases, misophonia is even provoked by pen clicking, keyboard typing, glasses clinking, paper or plastic rustling,[1],[3] by loud human voices, babies crying, noisy neighbors, by traffic, household appliances, and even animals (dogs barking, cat walking, claws clicking).[1],[2],[3] Nevertheless, people with misophonia are generally unbothered when producing these sounds themselves.[4]

Misophonia symptoms range from disgust, distress, and discomfort, to irritation, anger, hatred,[5] fear, and annoyance.[6] Typically, these reactions are not related to the sound per se, they originate from the person’s previous contact with the sound, the evaluation of the sound, the context in which the sound occurs, and the psychological profile of the person.[7],[8] As a result, misophonia symptoms become so excessive and out of proportion to the circumstances that the person reacts aggressively (verbally or physically) against the source of the sounds, and/or avoids social interactions to protect themselves from the stressor.[5] Suicide attempts were also described in this context.[9]

A separate concept in acoustics is sensitivity to noise. Noise sensitivity refers to the person’s internal physiological, psychological, or lifestyle-related states, which describe the degree of reactivity to noise in general.[10] It is considered a stable personality trait, independent from sound characteristics.[11] It plays an important role in the development of adverse health effects of environmental noise exposure.[12],[13],[14] Unlike misophonia, noise sensitivity is not related to any specific sound, but rather to the attitudes toward unwanted sound in various situations.

To the authors’ knowledge, the association between noise sensitivity and misophonia has not been explored in any population. Besides, the proportion of misophonia symptoms has not been reported in our country, neither among healthy adults nor among persons with psychological disorders. Finally, although Schröder et al.[5] proposed several criteria for the diagnosis of misophonia in a clinical setting, we wanted to explore their applicability in epidemiological research. Confronted with these three issues, we decided to undertake an observational study among young healthy adults in order to estimate the prevalence of the problem and to evaluate possible criteria for self-assessment of high perceived misophonia. We also hypothesized that noise sensitivity could be associated with high perceived misophonia independently from other potential confounding factors.

The aim of this study was to assess the proportion of misophonia symptoms among young healthy adults, to propose the criteria for high perceived misophonia, and to explore the association between misophonia symptoms with noise sensitivity, with adjustment for age, gender, perceived anxiety, and perceived depression.

Subjects and methods

This cross-sectional study was performed in 2013 among first and second-year medical students of the Faculty of Medicine. As described previously in detail,[15] about 1200 medical students were approached during classes to join a survey aiming to estimate the prevalence of noise sensitivity, noise annoyance, left-handedness, self-reported anxiety and depression, and misophonia symptoms. Out of 1200 distributed questionnaires, 1132 were completely filled out and returned (response rate 94%). The sample included 409 male and 723 female students, aged 21.4 ± 2.1 years. The study was approved by the Ethics Committee of the Faculty of Medicine.

An anonymous questionnaire comprised students’ age, gender, subjective noise sensitivity, perceived anxiety scale, perceived depression scale, and misophonia symptoms. Misophonia symptoms were self-reported using the Amsterdam Misophonia Scale (A-MISO-S), adapted from Schröder et al.[5] As by definition, misophonia symptoms occur as an adverse reaction to specific or provoking sounds emitted by other persons (breathing, coughing, chewing, spitting, etc.). The occurrence of the following five symptoms was assessed: 1) the presence of an adverse reaction to specific sounds − a person feels an impulsive aversive reaction, irritation, disgust, or anger when hearing these provoking sounds; 2) the loss of resistance against the impulse − a person feels irritated or distressed to the point of screaming or attacking the person making the sounds; 3) the loss of control over the reaction − a person experiences a loss of control when hearing these sounds, and a desire to hurt the person making the sounds; 4) an extreme level of adverse reaction − a person recognizes that the reaction is excessive, unreasonable, or out of proportion to the circumstances; and 5) an impaired social functioning − a person tends to avoid certain social situations, in order to keep away from the person making the provoking sounds. Each item was responded with yes or no. Unlike the original A-MISO-S,[5] the intensity of each symptom was not measured, because the questionnaire was set for screening among healthy adults, instead of applying it for diagnostic purposes.

For the purposes of this study, we propose nine criteria for high perceived misophonia, based on the combination of reported symptoms. Criterion 1 implies the presence of just one symptom reported; criterion 2 implies the presence of just two symptoms reported; criterion 3 implies the presence of just three symptoms reported; criterion 4 implies the presence of just four symptoms reported; criterion 5 implies the presence of all five symptoms reported; criterion 6 refers to reporting at least one or more symptoms; criterion 7 refers to reporting at least two or more symptoms; criterion 8 refers to reporting at least three or more symptoms; and criterion 9 refers to reporting at least four or more symptoms.

The reliability of the proposed misophonia symptom questionnaire translated into our language was assessed on a group of 30 students, who were tested and retested within a 2-week period. The Cronbach’s coefficient alpha equaled 0.753, indicating a strong consistency between the two sets of scores.

Subjective noise sensitivity was measured with Weinstein Noise Sensitivity Scale.[16] It is a 21-item, 6-point scale dealing with attitudes toward noise in general, and emotional reactions to a variety of sounds (minimum score = 26, maximum score = 126).[16] For the purposes of logistic regression, mean noise sensitivity score was stratified according to the tercile distribution of values, and separately by gender. Noise sensitivity levels for men were defined as: low − first tercile (score ≤ 68); medium − second tercile (score between 69 and 82); high − third tercile (score ≥ 83). Noise sensitivity levels for women were defined as: low − first tercile (score ≤ 69); medium − second tercile (score between 70 and 84); high − third tercile (score ≥ 85).

Perceived anxiety level was measured using the Hamilton Anxiety Rating Scale.[17] It is a 29-item, 5-point scale covering somatic and psychic symptoms of anxiety (minimum score = 0, maximum score = 116). For the purposes of logistic regression, mean perceived anxiety score was classified according to the tercile distribution of values and separately by gender. Perceived anxiety level in men was classified as: low − first tercile (score ≤ 20); medium − second tercile (score between 21 and 42); high − third tercile (score ≥ 43). Perceived anxiety level in women was classified as: low − first tercile (score ≤ 26); medium − second tercile (score between 27 and 46); high − third tercile (score ≥ 47).

Perceived depression level was measured using the Hamilton Depression Rating Scale.[17] It is a 20-item, 5-point scale covering somatic and psychic symptoms of depression (minimum score = 0, maximum score = 80). For the purposes of logistic regression, mean perceived depression score was classified according to the tercile distribution of values and separately by gender. Perceived depression level in men was categorized as: low − first tercile (score ≤ 6); medium − second tercile (score between 7 and 16); high − third tercile (score ≥ 17). Perceived depression level in women was categorized as: low − first tercile (score ≤ 7); medium − second tercile (score between 8 and 19); high − third tercile (score ≥ 20).

Statistical analysis

Descriptive statistic was presented as mean values ± standard deviation (SD) for numeric variables, or as percentages (relative numbers) for categorical variables. Differences between groups in parametric data were tested using Student t test for parametric data, and Mann–Whitney U test and chi-square test for nonparametric data. Multiple logistic regression models were fitted to calculate odds ratios and 95% confidence intervals for the occurrence of individual misophonia symptoms, and the criteria for high perceived misophonia, in relation to age, gender, noise sensitivity, perceived anxiety, and perceived depression. The authors used (SPSS, Chicago) software version 15.0 for Windows (SPSS Inc, 1989–2006).

Results

The investigated students were of similar age and had comparable noise sensitivity scores. Female students had significantly higher perceived anxiety scores and perceived depression scores in comparison to male students [Table 1].

The most prevalent misophonia symptom was symptom 1 (42% of the students), followed by symptom 4 (28%), symptom 2 (22%), and symptom 5 (16.5% of the students). The least prevalent symptom was symptom 3, which was reported in every 10th student. This was the only symptom significantly more often reported among male students [Table 2].

Table 2 Number and proportion (%) of students who reported misophonia symptoms 1–5 from the Amsterdam Misophonia Scale by gender

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High noise sensitivity level was an independent predictor of all misophonia symptoms, except for symptom 3–reported feeling of imminent loss of self-control due to specific sounds. High perceived anxiety was an independent predictor for symptoms 3, 4, and 5. High depression level was an independent predictor for the occurrence of all misophonia symptoms. Female gender was a protective factor for the occurrence of symptom 3. Age was not related to any of the five symptoms [Table 3].

Table 3 Odds ratios (OR) and 95% confidence intervals (95% CI) for the occurrence of five misophonia symptoms in relation to gender, age, perceived anxiety, perceived depression, and noise sensitivity

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Almost a half of all students reported no misophonia symptoms (557 participants or 49.2%) [Table 4]. When criteria 1 to 5 for high perceived misophonia are applied, the proportion of students with high perceived misophonia decreases from 16.5% (criterion 1) to 2.7% (criterion 5), because these criteria are mutually exclusive. When criteria 6 to 9 are applied, which are not mutually exclusive, the proportion of students with high perceived misophonia gets higher. Every other student meets criterion 6; one in three students meets criterion 7, one in five students meets criterion 8, and one in 10 students meets criterion 9 [Table 4].

Table 4 Number and proportion (%) of students with high perceived misophonia according to nine different criteria by gender

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Students with high noise sensitivity level had significantly higher odds of being classified as high perceived misophonia according to criteria 1 to 3. Medium and high depression levels were independent predictors of high perceived misophonia defined by criterion 3. With an increase in student’s age by each year, there is an 11% decrease in the odds of meeting the criterion 2 for high perceived misophonia [Table 5].

Table 5 Odds ratios (OR) and 95% confidence intervals (95% CI) for high perceived misophonia according to the proposed criteria 1–5 in relation to gender, age, perceived anxiety, perceived depression, and noise sensitivity

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Students with high noise sensitivity level and high depression level had significantly higher odds of being classified as high perceived misophonia according to criteria 6 to 9. High anxiety level was an independent predictor of criteria 7 to 9 for high perceived misophonia. With an increase in student’s age by each year, there is an 8% decrease in the odds of meeting the criterion 7 for high perceived misophonia. Gender was not related to any of the nine proposed criteria for high perceived misophonia in the presented models [Table 6].

Table 6 Odds ratios (OR) and 95% confidence intervals (95% CI) for high perceived misophonia according to the proposed criteria 6–9 in relation to gender, age, perceived anxiety, perceived depression, and noise sensitivity

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Discussion

To the authors’ knowledge, this is the first study to report the proportion of various misophonia symptoms among young healthy adults in our country. The feeling of irritation or anger against people making misophonia-provoking sounds was reported among 42% of the students. Other symptoms, such as the feeling of irrational anger when hearing the sounds, the wish to react against people making sounds, and the interference with social functioning due to provoking sounds were present in every fifth medical student, independently from gender. A symptom of feeling of imminent loss of self-control was the least prevalent (every 10th student) and was more often reported by male students. We were aware that a single symptom cannot be used to identify the problem, and we proposed nine criteria for self-assessment in population studies. In short, criteria 1 to 5 take into account how many symptoms are reported (exactly 1, 2, 3, 4, or 5 symptoms, respectively), whereas criteria 6 to 9 rely on the least count of the reported symptoms (at least 1, 2, 3, 4, or more symptoms, respectively). Generally, the larger the number of symptoms included in the criterion, the smaller the prevalence of high perceived misophonia in the investigated population. As expected, the proportion of high perceived misophonia was the largest when the reporting of at least one or more symptoms was used as a criterion (criterion 6; 51%); the smallest proportion was observed when all five symptoms were reported (criterion 5; 3%).

Current data on the occurrence of misophonia in the general population or among psychiatric patients are not reliable.[18] Researchers report that the prevalence of misophonia in the general population is about 3%, that it ranges from 10% to 60% among patients with tinnitus, and that it rises up to 92% among patients with decreased sound tolerance.[1],[19] We found two studies dealing with misophonia symptoms among students. In the first study, the prevalence of various misophonia symptoms among 483 undergraduate university students (mean age 21 years) in the USA was about 20%.[3] Similar to our study, authors found no significant gender, age, or ethnicity differences regarding the reporting of the individual symptoms. In the second study, authors found the prevalence of 6% of clinically significant misophonia symptoms among 415 college students (mean age about 19 years) in China.[20] In that case, misophonia symptoms were considered significant if associated with impairments in social, familial, educational, or occupational activities. Such a parameter sets the criteria for clinically significant misophonia very high and explains the lower prevalence of the problem in the mentioned study.

This brings us back to our interest to propose criteria for the self-assessment in epidemiological research. Bearing in mind the proportion of students fulfilling each of the nine proposed criteria, we propose criterion 9–the presence at least four or more symptoms reported − as a decisive measure for high perceived misophonia in the field. This criterion is strict enough to classify 10% of the investigated healthy population as having significant misophonia. We find criterion 5 (all five symptoms reported) the most strict of all, and thus possibly more applicable in the clinical setting. We agree that the proposed cutoff is not validated, and it should be understood as a pioneer attempt to measure the problem in the general population. We suggest the validity and the reliability of the proposed criteria be evaluated in the clinical setting against the psychiatric interview with the original A-MISO-S as the gold standard.[5]

Whether misophonia should be classified as a discrete psychiatric disorder is still a matter of debate.[1],[5],[7],[8],[21] Misophonia is often associated with symptoms of other psychological disorders, predominantly with anxiety and depression.[3],[20],[22] Furthermore, misophonia shares some similarities with obsessive-compulsive disorder,[20],[23] but differs from it in the reaction to the stimuli.[24] Misophonia symptoms were also reportedly associated with post-traumatic stress disorder, attention-deficit disorder, eating disorders, selective mutism, etc.[22]

Noise sensitivity and misophonia could be related through neuroticism as a common feature. As we discussed previously, many studies show significant association between noise sensitivity and neuroticism.[15] Recent studies show that noise sensitivity correlates well with all personality traits from the Big Five personality dimensions, in particular with the introversion–extroversion dimension (without respect to moderators).[25] Neuroticism, however, was the poorest and statistically insignificant predictor of noise sensitivity.[25]

Noise sensitivity should, therefore, be comprehend as a normal cortical phenomenon shaping the processing of environmental sounds, rather than a negative, criticism-oriented personality type.[25] Recent experimental studies focus on the possible biological and electrophysiological foundations of noise sensitivity, for instance, on studying certain cortical areas involved in the processing of auditory stimuli.[26],[27],[28] These studies should not only explain the underlying mechanisms of the phenomenon but help develop objective measures for noise sensitivity instead of currently used self-assessment questionnaires.[26],[28]

The presented study has several limitations. First, we were not able to assess the neurological background for misophonia. Current investigations relate misophonia to dysfunctions within the limbic system, basal ganglia, some cortical regions, and the dysregulation of the dopaminergic and serotonergic neural pathways.[24] The anterior insula in the cortex responses to misophonia-triggering sounds and mediates the consecutive autonomic responses to them.[29] The role of some hormones should also be investigated based on the fact that they may influence the auditory system and play a role in the occurrence of tinnitus and hyperacusis.[30] The characteristics of the triggering sounds (loudness, pitch, duration, and timber) are also worth investigating.[31]

Second, we failed to assess general health and hearing ability, lifestyle habits, eating and drinking habits, and stress level of the investigated population. One study investigated the influence of alcohol, caffeine, nicotine, and other substances on the severity of misophonia symptoms. One in three persons with misophonia reported that alcohol reduced the symptoms. Most participants indicated that caffeine had no effect on the symptoms, and most of them did not use nicotine or other substances. Psychotropic substances marijuana/cannabis reportedly lessened the symptoms as well.[22] In addition, misophonia may be related to the development, exacerbation, or maintenance of eating disorders.[32]Third, the cross-sectional design does not allow us to estimate the onset and the course of misophonia. Literature data point out that misophonia starts in childhood, teenage years, or early adulthood, but dispute over its course over the lifespan, that is, whether it remains stable, increases, or decreases over time.[1],[22]

Fourth, we did not ask about the presence of misophonia among parents, siblings, and other family members. It is possible that people may not be aware of the problem running in the family. This was the case in a study among 300 persons with manifest misophonia; one in five claimed to know a family member with misophonia, one in three claimed that other family members did not have similar problems, and a half of them were ignorant on the matter.[22] A case of familial misophonia was recently described in Brazil.[32] It depicts a family whose 15 members across three generations were diagnosed with misophonia. Most of them were women who developed the symptoms in childhood or early adolescence, and suffered from anxiety, depression, obsessive-compulsive disorder, and tinnitus.[33] On the other hand, noise sensitivity does run in families, as reported in a twin study in Finland. Based on the observation that high noise sensitivity occurs more often in first-degree relatives of noise sensitive people than expected in the general population, the estimated heritability of noise sensitivity was about 36%.[34]

Fifth, the presented study design and the statistical analysis do not allow us to determine the causative relationship between noise sensitivity and misophonia symptoms. The exact process starting from the perception of a provoking sound and resulting in a specific emotional response and the concurrent behavior, and the intermediary role of personality characteristics (including noise sensitivity) remains to be explored.[35]

Finally, we are aware that the results of the study cannot be generalized to other populations, without considering possible social and cultural differences and practices regarding the emission of the specific sounds that provoke misophonia symptoms.

Conclusion

The presented study is the first of its kind in our country that estimated the proportion of misophonia symptoms among healthy young adults. The most prevalent symptom was the feeling of irritation or anger against people making specific misophonia-provoking sounds; other frequently reported symptoms included a strong wish to react against people making specific sounds, and a feeling of irrational anger when hearing these specific sounds. Besides, this is the first study that proposed nine criteria for high perceived misophonia in the investigated population. One of these nine criteria, that is, the reporting of at least four or more other misophonia symptoms could be applied for the self-assessment of high perceived misophonia in epidemiological settings. High perceived misophonia is strongly and independently associated with one’s noise sensitivity level, perceived depression level, and perceived anxiety level. Future studies need to concentrate on the causal association between misophonia, personality traits, and other environmental sound stimuli.

Financial support and sponsorship

The study was financially supported by the Ministry of Education, Science and Technological Development of the Republic of Serbia, projects no. 175078 and no. 41020.

Conflicts of interest

There are no conflicts of interest.

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