There are no consensus criteria for the diagnosis of the clinical syndromes referred to as hyperacusis and misophonia (Potgieter et al., 2019; Taylor, 2017; Tyler et al., 2014), although a working set of criteria for misophonia has been proposed (Dozier, Lopez, & Pearson, 2017; Schröder, Vulink, & Denys, 2013). The boundaries between these two conditions are not well defined and patients are sometimes diagnosed concurrently with both conditions (Potgieter et al., 2019).
Definitions and Descriptions
Hyperacusis is generally described as a strong aversion to and a marked intolerance of commonplace noises and sounds that most people do not experience as objectionable, threatening, or disruptive to their everyday functioning. This involves the perception of painful and often excruciating loudness independent of decibel level and despite normal hearing thresholds in many cases (Tyler et al., 2014).
Misophonia is characterized by pronounced reactions of anxiety, panic, irritability, anger (that can escalate to outbursts of hate/rage), and/or disgust and repulsion that are relatively specific to sounds and movements of others—so-called “trigger” stimuli. For example, oral sounds like chewing, throat clearing, lip smacking, and coughing, and nasal sounds like sniffing and breathing. Other sounds that can elicit significant overreactivity are finger tapping and foot shuffling. Additionally, triggers can involve visual movements by others, sometimes referred to as “misokinesia,” like leg shaking, arm swinging, and hand gesturing. Intense negative responses to inanimate and/or mechanical noises as well as animal sounds are also frequently observed (e.g., clock ticking, refrigerator humming, keyboard tapping). These severe adverse reactions typically occur in the context of normal auditory acuity (Potgeiter et al., 2019).
Shared phenotypic features include marked annoyance and irritability and high levels of anxiety and general emotional distress. These reactions are coupled with phonophobia, defined as highly adverse reactions of fear, avoidance, and escape behavior involving situations—including social situations like sharing meals—that provoke and/or intensify symptoms. Individuals also frequently report accompanying insomnia and problems concentrating.
Both conditions are strongly associated with at least mild impairment in everyday functioning, although a small percentage of persons are significantly compromised in their ability to perform instrumental activities of daily living and report a generally poor quality of life. This encompasses strained relationships with family and friends, social isolation and withdrawal, and problems with academic and vocational functioning (Brout et al., 2018; Rouw & Erfanian, 2018).
The underlying neurobiological mechanisms of hyperacusis and misophonia remain elusive (Cavanna, 2014). Hyperacusis has established links to neurodevelopmental conditions, notably autism spectrum disorder, and acquired medical factors like tinnitus (Aazh & Allott, 2016; Bruxner, 2016; Danesh et al., 2015). However, many cases are classified as idiopathic (i.e., arising spontaneously or having a cause that is unknown), especially those involving otherwise medically well adolescents and young adults with unremarkable, premorbid everyday functioning. Moreover, misophonia has not been persuasively linked to any neurodevelopmental and/or medical factors (Rouw & Erfanian, 2018; Schröeder et al., 2013; Taylor, 2017).
Symptoms of hyperacusis can occur across the age range, with many adult and older adult onset cases. Symptom onset in misophonia is typically in the childhood, adolescent, and young adult years (Rouw & Erfanian, 2018).
Symptomatic course is variable, although a substantial number of patients with one or both conditions have persistent symptoms over many years (Cavanna, 2014; Taylor, 2017). In misophonia, there is emerging evidence of progression in symptom frequency and severity over time in as many as 75 percent of patients (Rouw & Erfanian, 2018).
There is a paucity of data pertaining to prevalence in community and clinical samples. However, symptoms of these conditions are likely not rare and may not be recognized during the course of mental health intake evaluations (Potgieter et al., 2019; Wu, Lewin, Murphy, & Storch, 2014).
Patients with one or both conditions frequently rely on sound-dampening technology in hearing protective devices (sometimes to the extreme) to cope with their distressing and disruptive symptoms. These include sound generators, headsets, ear plugs, and others. Although there is no clear evidence for efficacy, there is concern about possible iatrogenic effects (Pienkowski et al., 2014).
There is no “gold standard” regarding treatment and a number of audiologic (e.g., tinnitus retraining therapy), occupational, psychopharmacologic, psychotherapeutic, and other interventions have been proposed as potentially helpful, depending on the presumptive etiology and circumstances of the case (Pienkowski et al., 2014). From a mental health perspective, variants of cognitive behavioral therapy (CBT) have been the most widely reported and promising interventions to date (Aazh & Allott, 2016; Muller, Khemlani-Patel, & Neziroglu, 2018; Schröder, Vulink, van Loon, & Denys, 2017). Still, there is limited data on empirically validated treatments (Potgieter et al., 2019).
There is a burgeoning array of literature consisting of case reports and group studies that address the role psychological factors may play in the genesis and persistence of mental health symptoms and psychological difficulties. These may arise specifically as a result of the negative lifestyle consequences of these conditions (Aazh & Moore, 2017; Ferreira, Harrison, & Fontenelle, 2013). Yet, psychiatric factors have not been persuasively shown to be a necessary or sufficient explanation for the onset, pattern, or trajectory of the primary symptoms of either condition.
That said, psychiatric comorbidity is relatively common in hyperacusis and misophonia, especially among physician-diagnosed patients and patients seen in mental health settings as opposed to audiology clinics (Paulin, Andersson, & Nordin, 2016). Relatively high base rate co-occurring conditions include generalized anxiety disorder, social anxiety disorder, obsessive-compulsive disorder, and depressive disorders (Potgieter et al., 2019; Taylor, 2017). There are also links to other conditions like attention deficit disorder, phobic disorders, agoraphobic disorder, posttraumatic stress disorder (PTSD), eating disorders, tic disorders, somatic symptom disorders, excoriation disorder, and bipolar disorder (Potgieter et al., 2019).
In addition, relatively high rates of personality and temperamental patterns or traits related to the construct of “negative affectivity” have been reported (Villaume & Hasson, 2017). Obsessive-compulsive personality disorder may be the most frequent finding among patients who have co-occurring personality difficulties (Schröder et al., 2013). Elevated rates of suicidal thinking have been reported specifically among patients with hyperacusis (Aazh & Moore, 2017).
Despite high rates of psychiatric comorbidity, these syndromes do not reliably co-occur with any specific mental health or personality-related conditions and are observed in a fairly broad range of psychiatric conditions (Brout et al., 2018; Rouw & Erfanian, 2018; Taylor, 2017).
In misophonic patients, the degree of psychiatric comorbidity has been found to be positively correlated with the extent and severity of misophonic symptoms as well as the degree of functional impairment (Rouw & Erfanian, 2018).
Despite an increased number of case reports and studies pertaining to the psychiatric aspects of these conditions, there is little information on the findings of in-depth psychological and neuropsychological testing in severely affected patients, particularly those with no known neurodevelopmental and/or medical basis for their symptoms and compromised everyday functioning.
This article reviews the findings of a detailed psychometric evaluation involving administration of a comprehensive battery of psychological and neuropsychological tests in a case of this kind.
The patient, Ms. T. (not this patient’s actual last initial), was a twenty-one-year-old single young woman and former art college student. She had an insidious onset and progressively worsening and incapacitating course of sensory defensiveness and overreactivity, sound intolerance, and related difficulties over about a five-year period beginning in her mid-adolescent years, which were associated with an array of mental health problems. Ms. T had undergone extensive medical assessments, including an audiologic evaluation as well as two separate neurological assessments before being diagnosed with both hyperacusis and misophonia.
Ms. T. was initially assessed by the first author in a hospital emergency department when she was twenty-years-old due to worsening anxiety, depression, and compelling urges to gouge out her eyes. Several months later, Ms. T. was formally tested by this clinician in a community mental health setting where she was being seen for counseling, psychotherapy, and medication services.
Ms. T. had been more or less housebound since returning from college, secondary to progressively worsening symptoms of hyperacusis and misophonia. Symptoms were triggered by various noises and sounds and repetitive movement. In addition, symptoms were complicated by marked symptoms of anxiety and depression.
Ms. T. had been referred for psychological and neuropsychological testing by her advanced practice registered nurse and medication provider. The aim was to clarify Ms. T.’s clinical status.
Assessment consisted of review of educational, medical, neurologic, and mental health records as well as detailed written narrative accounts completed by Ms. T. and her parents. Interviews were also conducted with Ms. T. and her mother and a feedback interview was completed with both parties to review the findings of this test evaluation. Furthermore, Ms. T.’s case was reviewed with her agency providers, a counselor, and a medication provider.
Ms. T.’s mother completed a series of neurodevelopmental and neuropsychiatric questionnaires and ratings. Ms. T. also completed a number of self-report inventories and rating scales, notably the Millon Clinical Multiaxial Inventory-IV (MCMI-IV), an omnibus measure of personality dynamics and functioning. In addition, a battery of cognitive and neuropsychological tests were administered:
Relevant to neurodevelopmental, neuropsychiatric, and neurologic disorders, Ms. T.’s history included the following:
This history was reported to be unremarkable except for a history of toe walking (i.e., a condition where people walk on their toes without putting much weight on any other part of the foot).
Ms. T. was the younger of two daughters from an intact family residing in a small New England town. Her mother was a “stay-at-home mom,” her father was employed for an airline, and her sister was in her mid-twenties and employed as an administrative assistant.
Ms. T. was living at home with her parents and sister during the time period of this test evaluation. She had resided at home except for about a year and half when she attended an out-of-state art college.
Ms. T. returned to live at home in the early part of 2017 following worsening psychiatric difficulties—including recurrent episodes of nonsuicidal self-injury—in the context of persistent and disruptive symptoms of hyperacusis and misophonia.
Excision of an osteoma (right tibia) and wisdom teeth, anemia apparently related to strict adherence to a “vegan diet;” possible underlying connective tissue disorder, including lupus; fibrocystic breast changes, episodes of low blood pressure, and dysmenorrhea.
Medications taken during the time period of this test assessment were Lexapro, trazodone, an iron supplement, vitamin D, and vitamin B.
Detailed medical work-ups at a highly regarded teaching hospital and medical center beginning in 2015 and continuing through the summer of 2017 were negative for any medical and/or neurologic factors which might explain Ms. T.’s symptoms or her associated mental health difficulties. This included screening for Lyme disease, autoimmune disease, and a number of primary neurologic conditions.
An initial neurological examination in March 2017 yielded a clinical impression of misophonia and hyperacusis “which are likely a manifestation of her underlying anxiety disorder with essentially hypersensitivity throughout most of her senses to touch, hearing, and vision.”
The consulting neurologist added that Ms. T.,
does exhibit some abnormal movements at times, however, and while certainly these may be a manifestation of anxiety, I question whether there could be an underlying metabolic disorder. Wilson’s disease comes to mind. I do not find any significant local abnormalities to suggest a CNS [central nervous system] structural etiology, but certainly an underlying condition such as a demyelinating disease needs to be considered in the differential diagnosis.
An examination by another neurologist at the same medical center was completed in August 2017. This consultation was, in part, to obtain a second opinion regarding a possible medical contribution to Ms. T.’s symptoms of hyperacusis and misophonia, including a rule out of an acoustic neuroma.
The report of this evaluation noted that Ms. T.
presents with progressive symptoms of sensory hypersensitivity to various stimuli that are normally innocuous. She has a dramatic and suggestible reaction to stimuli that accentuates when she is seated on the exam table as opposed to in the waiting room or sitting in a regular chair prior to the exam. Her neurologic exam is normal excepting the intermittent contortions, flinching, and voluntary eye closures. She is able to stop all the behaviors at will.
I do not believe there is a degenerative movement disorder, but we can send testing for Huntington’s disease. She had the lab work that appears to exclude Wilson’s disease as a possibility. She does not have autism, which is frequently comorbid for sensory integration dysfunction. I am concerned that she has a primary psychiatric disorder. Lastly, it would be reasonable to send serum for NMDA antibodies to rule out an inflammatory encephalitis. Pelvic US will also be checked.
Diagnostic impression included the following: sensory integration disorder, panic disorder without agoraphobia, and a psychogenic movement disorder.
A brain MRI (with and without contrast) conducted in May 2017 was read as normal. An audiological examination and a hyperacusis consultation were completed in May 2015. The report of this evaluation referenced previous audiological testing at another clinic, which was unremarkable. The recommendation of this second consultation was for initiation of treatment for hyperacusis, including the wearing of noise generators and methods adopted from tinnitus retraining. A otolaryngologic—that is, the study of ear and throat diseases—examination was unremarkable at that time.
Occupational therapy services were initiated in the fall of 2017, but were discontinued after several weeks due to lack of clear benefit.
Mental Health History
Based on the history provided by the patient’s mother, Ms. T. coped in a satisfactory manner and was leading a productive and successful life with no evidence of mental health difficulties until her mid-teenage years. Around that time her daughter started to appear anxious and depressed, and began to engage in nonsuicidal self-injury in the form of superficial cutting. She was subsequently seen in counseling by two different mental health counselors.
Around the age of seventeen, Ms. T. started to exhibit symptoms of what were subsequently diagnosed as hyperacusis and misophonia. Onset of symptoms included wincing or looking away if someone was chewing with their mouth open and being bothered by the sounds of family members chewing and swallowing food. This was followed by an aversion to eating meat, the adoption of a strict vegan diet, and strong negative reactions to commonplace household noises like the sound of a vacuum, dishes being placed in the dishwasher or put away, and drawers being opened and closed. Ms. T. also responded poorly to the sound of chirping birds.
Ms. T.’s hypersensitivity to commonplace noises worsened to the point that she stopped taking walks in the neighborhood as she could no longer tolerate the sounds of traffic and lawnmowers. She began wearing earplugs and noise-reducing headsets.
Despite these difficulties, Ms. T. entered art school following graduation from high school. She seemed to manage adequately until fall of 2016 when her mental health difficulties and symptoms of hyperacusis and misophonia became more persistent and severe. In the early part of 2017, she tried to cut her wrists. She was evaluated in an emergency department and discharged home.
Ms. T. had sporadically engaged in nonsuicidal self-injury since her mid-teenage years. This has included superficial cutting, hair pulling, poking at her eyes, biting her hand, scratching, and head banging. From time to time Ms. T. had become preoccupied with the idea of gouging out her eyes, but had never attempted to do so and had never actually injured her eyes. This preoccupation led to the previously mentioned urgent mental health assessment at a local hospital-based emergency department in June 2017.
Services at the time of this psychometric assessment involved medication treatment with Zoloft and trazodone, and individual psychotherapy incorporating components of support, insight, and utilization of cognitive behavioral strategies.
There was no history of inpatient mental health evaluation and/or treatment.
Substance Use History
This history was negative for problematic drinking or drug use.
Following graduation from high school, Ms. T. attended an out-of-state art college for approximately three semesters. As previously stated, she left college following an episode of nonsuicidal self-injury in the context of worsening mental health difficulties and symptoms of hyperacusis and misophonia.
Ms. T. had worked as a volunteer at a local ASPCA and a local hospital while attending high school. She was employed at a toy store while attending art school.
Ms. T. presented as alert, oriented, cooperative, and pleasant despite exhibiting frequent and severe anomalous motor movements such as flinching, jerking her head and upper body, assuming a defensive stance that included a “claw-like” posture with her hands, and covering her eyes with her hands.
Triggers for these behaviors were modestly loud speech, gesturing by the examiner during conversation, noise generated by gum chewing and throat clearing, and the sound of occasional conversations transpiring in the hallway. Ms. T.’s symptoms appeared most severe during the feedback interview to review assessment findings and recommendations, perhaps related to heightened anxiety at that time. She wore earphones for her three appointments—ear phones designed to decrease sensitivity to ambient noise.
During formal evaluation and testing, Ms. T. evinced satisfactory attention, concentration, effort, endurance, and task persistence despite the pronounced behaviors previously cited.
Test findings from the cognitive and neuropsychological tests and measures were considered valid. Results from one or more of the self-report measures pertaining to mental health difficulties and symptoms, notably the MCMI-IV, may have reflected a component of overreporting of psychological adjustment difficulties, a fairly common finding in young adults with high levels of psychological distress and who often have “cluster B” personality patterns.
Psychometric Test Findings
Findings from the cognitive and neuropsychological test evaluation were indicative of generally well-maintained intellectual efficiency falling from the average range to sometimes above average limits for age and level of formal education. This included a full scale IQ of 113 (high average range, eighty-first percentile) on the WAIS-IV. These findings were consistent with Ms. T.’s average to high average scores on the Scholastic Aptitude Tests (SATs). Almost certainly, this “normal limits” profile reflected this young woman’s customary long-term neurocognitive baseline.
Ms. T. demonstrated a relative weakness in numeric knowledge and quantitative knowledge, which fell mildly below her general level of performance on the cognitive and neuropsychological test battery in its entirety. This finding was consistent with her SAT scores, which reflected stronger reading and writing skills than quantitative skills. This specific result was thought to constitute a long-term relative academic skill weakness as opposed to a recent negative change in Ms. T.’s neurocognitive baseline.
Ms. T.’s cognitive and neuropsychological profile offered no support for a possible neurologic basis for any of her symptoms, including her symptoms of hyperacusis and misophonia. More specifically, the findings would be quite unusual in a young adult with an inflammatory encephalitis or a progressive neurodegenerative illness, including those that are associated with an involuntary movement disorder.
Based on response to self-report screening inventories, Ms. T. screened negative for a history of attention deficit disorder, dissociative symptoms, bipolar disorder, a psychotic disorder, a binge-eating disorder, and typical symptoms of obsessive compulsive disorder.
In contrast, she screened positive for a number of anxiety disorders—generalized anxiety disorder, panic disorder, agoraphobic disorder, and social anxiety disorder—as well as one or more depressive disorders. In addition, Ms. T. screened positive for behaviors and symptoms associated with borderline personality disorder.
Findings specifically from the MCMI-IV were most compatible with possible diagnoses of several DSM-5 clinical syndromes: generalized anxiety disorder (moderate to severe), a persistent depressive disorder (severe) complicated by a major depressive disorder (severe), unspecified somatic symptom disorder, and posttraumatic stress disorder, the stressors contributory to this latter diagnosis remained undefined, but would include a rule out of Ms. T.’s chronic and impairing sound intolerance and sensitivity symptoms.
Results from this inventory were also consistent with several emergent, maladaptive personality patterns such as avoidant, dependent, melancholic, and borderline (base rate scores of eighty-five and higher) as well as rule outs of negativistic and masochistic patterns.
On other self-report tests and measures Ms. T. reported relatively mild and circumscribed problems with executive functioning pertaining to task initiation and coping with and tolerating situational change. She also reported significant limitations regarding performance of a number of instrumental activities of daily living.
Based on Ms. T.’s history through her early adolescence and her mother’s response to neurodevelopmental and neuropsychiatric questionnaires and rating scales, including the Social Responsiveness Scale 2 (SRS-2), Ms. T. screened negative for a history of autistic behaviors and symptoms preceding the onset of her mental health symptoms and her symptoms of hyperacusis and misophonia. This issue was carefully assessed in view of Ms. T.’s family history (she had a second cousin with autism) and her history of toe walking, which could suggest a vulnerability to autism spectrum behaviors and symptoms.
There appeared to be no neurodevelopmental disorder (including an autism spectrum disorder) other than, perhaps, a minimal to mildly severe learning disorder in mathematics, which was considered a rule-out diagnosis.
Ms. T.’s history and psychometric test findings were consistent with a number of moderate to severe psychological difficulties. These included anxiety disorder and depressive mood disorder (which are fairly common in hyperacusis and misophonia), and a number of problematic personality difficulties compatible with borderline personality disorder and other maladaptive personality patterns that, heretofore, have received little attention in the literature.
Unfortunately, Ms. T.’s panoply of symptoms resulted in a highly restricted lifestyle and significant dependence on family support and community mental health services despite good general intelligence, intact neuropsychological functioning, talent in the visual arts, and no evidence for a neurodevelopmental and/or medical substrate for her symptoms.
This case illustrates the value of in-depth psychological and neuropsychological testing for counselors in clarifying the broad range of difficulties, including the degree of emotional distress and/or suffering that besets some patients with hyperacusis and misophonia. Following the appropriate medical work-up, detailed psychometric testing of this kind also helps to more fully rule out any coexisting cognitive impairment that might support possible neurodevelopmental, medical, and neurologic contributions to patients’ symptoms.
Hyperacusis and misophonia are poorly understood conditions that can result in long-term disability (Rouw & Erfanian, 2018). From the standpoint of nosology, the relationships between these two conditions and their connection to other neuropsychiatric conditions remain unclear. In particular, it is uncertain whether hyperacusis and misophonia should be conceptualized as complex overlapping or distinct neuropsychiatric syndromes falling, perhaps, within a DSM-5 category like “Obsessive Compulsive Disorder and Related Conditions” (APA, 2013).
Alternatively, these conditions might be construed as symptom complexes that sometimes accompany a number of neuropsychiatric conditions, or are perhaps viewed as variants of a sensory processing and integration disorder characterized by varying patterns of intolerance and overresponsivity to various categories of sounds as well as other modality specific stimuli (Taylor, 2017).
Directions for Research
Group studies are needed to include psychological and neuropsychological test batteries, and to expand the knowledge base as to possible, predisposing, premorbid information and/or sensory processing difficulties, mental health conditions, and personality dynamics and patterns. Studies incorporating psychometric testing may also be of value in elucidating affective and behavioral correlates, particularly mental health conditions, which may arise as consequences of the adverse impact on quality of life of these clinical syndromes. Research should also attempt to identify possible clinically relevant variants and subtypes of these conditions (Tyler et al., 2014)—based on specifiers like the presence and/or absence of cognitive and neuropsychological impairment, patterns of psychiatric comorbidity and functional impairment—and clarify the value of such findings for treatment planning, including differential responses to mental health and other types of interventions.
Jerrold Pollak, PhD, ABPP, ABN, received his PhD in counseling psychology at Boston College. Dr. Pollak is a diplomate of the American Board of Professional Neuropsychology and the American Board of Professional Psychology (counseling psychology). He is a clinical and neuropsychologist with Seacoast Mental Health Center in Portsmouth, New Hampshire.
John J. Miller, MD, received his medical degree at the University of Massachusetts Medical School and completed his residency in psychiatry at the University of Massachusetts Medical Center. Dr. Miller is medical director of Brain Health in Exeter, New Hampshire and is a staff psychiatrist with Seacoast Mental Health Center. He also serves as a consultant psychiatrist for the Insight Meditation Society in Barre, Massachusetts and is editor-in-chief of the Psychiatric Times.