Does Miss O’Phonea rage inside your head?

YOU'RE quietly hanging out in a restaurant. Then, a soft, slurping sound worms its way into your brain: somewhere in the background, someone is audibly and disgustingly eating with a smack… smack… smack that resonates every few seconds. Your dining companions seem oblivious; you try to ignore it, talk louder, but nothing works; something in your shoulders waits half-anxiously for the next sound. When will it come? There it is again! Smack!… Smack!!… SMACK!!! There's a gnashing of teeth, a clenching in the jaw, just so your head doesn't unhinge. And before you can say “smack" again, the big Fs are activated: fight or flight.

Welcome to misophonia, friend of Chinese water torture and relative of phonophobia, or fear of loud sounds. The name of the syndrome is derived from the Greek “miso" (hate) and “phon" (sound/voice). It's a condition that affects up to 20% of humanity to a greater or lesser extent. Merriam Webster defines it as follows: mis·​o·​pho·​nia (noun) is “a condition in which one or more common sounds cause an atypical emotional response (such as disgust, distress, panic or anger)".

Quick facts about sound rage

Misophonia — previously known as selective sound sensitivity syndrome (or “sound rage" colloquially) — is a condition characterised by reduced tolerance to specific sounds or their associated stimuli, as explained by Wikipedia. These “triggers" are perceived as unpleasant or distressing and tend to elicit strong negative emotional, physiological and behavioural reactions not commonly observed in most other people. Excessive misophonia can even adversely affect the ability to achieve life goals and enjoy social situations.

It was first recognised, named and described in 2001/2002, although it is not included in, for example, the American Psychiatric Association's DSM-5-TR (2022), the international scripture on mood disorders, or any similar manual. Not yet, in my opinion.

Reactions to triggers range from annoyance to anger, and the responses are not triggered by the loudness of the sound but by the specific pattern or meaning it holds for the listener. Triggers are usually repetitive stimuli and are primarily — but not exclusively — related to the human body, such as chewing, eating, lip-smacking, slurping, coughing, throat-clearing, sniffing and swallowing. However, ticking clocks, barking dogs and even tumultuous TikTokers are also high on the list. Once a trigger is identified, people with misophonia may struggle to distract themselves from the stimulus, experiencing suffering, distress and/or impairment in social, professional or academic functioning.

Some individuals with misophonia know their reactions to triggers are disproportionate. This makes it almost worse: I know I'm overreacting but I can't help it.

The alphabet of phonetics

That's why I lend my ears to Dr Natalie Buttress of NB Hearing in Cape Town. With three decades of experience, impressive international qualifications in sound, and having been a sufferer herself, misophonia is a specialised area for this audiologist.

“What we need to understand is that your hearing is the last sensory modality to fade when we die," she explains. “It forms a primary part of the way we monitor our environment. It's a 360-degree experience, hard to shut off, and linked to the limbic system." This related system of structures located around the midbrain is considered the seat of emotions, motivation and certain aspects of memory.

“So, there is a very strong connection to safety and survival. And this is the interesting key point about misophonia: it's about sound, one of the sensory experiences over which we have no control," says Buttress. “Even if you are unconscious, we can read your brainwaves with scanners as they react to sounds. And while you sleep, your body wants to be aware of any possible dangers through hearing."

As sounds enter our ears, they are already divided into different pitches of frequencies, and their intensity ranges from soft to loud. “But there are several crucial processes all the way from the ear to the auditory cortex," says Buttress, describing how hearing works. It includes a connection with memories, “because if we had nothing to attach meaning to the sound we hear, there would be no understanding; it would just be a sensory experience."

The final straw

As Buttress's career progressed, her interest shifted from the periphery of sound (in the ear itself) to the advanced part — how people process information. “Besides the pathology in the central auditory processing of sounds, through which people cannot process them and derive meaning from them, there are also three areas related to abnormal perception or processing of sound." These are tinnitus (the perception of a sound without an external source; only you hear it), hyperacusis (general hypersensitivity to certain sound frequencies and volumes) and misophonia (irritation/anger/frustration linked to specific sounds).

“My brother and I developed it ourselves when we were young," Buttress says. “It was because our dad had it and overreacted to certain sounds. He got it from his parents. So, we quickly associated it with severe negativity and anxiety. Thus, you develop a type of conditioning cycle of specific sounds; you become more and more aware of them, and the more aware you become, the greater your emotional response. And the reaction only gets worse as time goes on."

The final straw was when her husband was crunching chips behind a cupboard door in the kitchen. From the bedroom, she became so enraged that he finally told her to find a solution. So she did. “At that time, there wasn't even a word for it, and so many in my family suffered from it," she says. “But luckily, it was the turn of the century and misophonia began to receive more attention." Not only did she successfully treat herself, it was also the starting point for treating others.

Genetic vs. environmental factors

Neurologists, psychologists and audiologists are the go-to experts for this growing phenomenon, as the causes are found in the brain, psyche and/or ears — a classic case of genetic and/or environmental factors. “Thanks to our tests, we know it's clearly not a hearing problem but an auditory processing problem," says Buttress. “We are still going to learn a lot about this; what I say now might look different in the future. What we do see indications of is that there is an overdeveloped part in the misophonia sufferer's brain. There is also a genetic link, but again, it's challenging to separate the ‘nature vs. nurture' argument: you might be born with the problem but then likely grow up in a house where certain negative behaviour is associated with certain sounds."

Just as hyperacusis is a challenge, especially for people with autism, misophonia is particularly noticeable among neurodiverse people. “If you are neurodiverse, you are much more likely to have sensory sensitivities; you are much more likely to have learned negative reactions," says Buttress.

“There are two major systems in your brain: on one side, the default mode network that helps us relax; on the other side, the salient network that gives high levels of attention to a specific thing, zooming in on something. With the latter, you are hyper-aware. For neurodiverse people, it becomes very challenging to be vigilant only for certain things. And if it's in the sound arena, there's a greater chance it's misophonia."

According to her, your brain then gives a command to deliver adrenalin to the system, which naturally makes you feel tense. “It's meant for survival, but you are actually in a situation where your life is not threatened. It is also more noticeable if the stimulus sound is made by another person; you feel that person is encroaching on your personal space. For example, if it's a watch, it might bother you less; you can't get angry at a watch. It's also worse if you need to focus at work or just want to relax."

And the prevalence of this in South Africa?

“Neither here nor elsewhere do we have enough data," says Buttress. “But anecdotally, given my own experience, I can tell you that a large number of people here suffer from misophonia, especially if you start working in neurodiverse environments. And the more we live in a world where people have incredible access to negative information about things they can't control, the worse it will get.

“It is closely related to stress and is sometimes only temporary. However, it doesn't help to shut yourself off from the sounds that bother you because it gets even worse when you are exposed to them again. You have to learn to control your interaction with it, and for that you need a guide [like her] in the beginning."

So there is hope?

“Okay, there's no pill or any other quick fix," says Buttress. “It's also an extremely individualised process because the causes vary so much. Moreover, some people have it only temporarily, usually linked to specific stress factors in their lives. And one of the reasons people suffer from misophonia is that they feel out of control. You can learn control; you can change the way you handle things."

How it is diagnosed is too cumbersome to describe here, but an organic evaluation takes place once other hearing issues have been ruled out. “I find it especially useful to help my patients find their core belief about the sounds that irritate them. There is almost always some kind of traumatic event that it can be linked to." Sometimes it's a molehill that has turned into a mountain over time — a specific sound that annoyed someone that finally becomes a series of sounds that make the listener lose their mind. “As misophonia develops, there are also many complex layers of maladaptive reactions and increasing alertness that take place along the way." An unhealthy body and mind, as well as stress, also do not help.

I ask her about Doritos, which introduced the “Doritos Silent" app this month, a groundbreaking “crunch-cancelling" technology that allows gamers to devour their chips — with the microphone on — without distracting other players. For this significant irritation, 5,000 crunch sounds were analysed. “It's a typical maladaptive reaction," Buttress reckons. “E-players experience artificial stress, which means they release adrenalin. No wonder they are so reactive."

Cognitive behavioural therapy

Less stress, a healthier lifestyle, relaxation techniques and especially cognitive-behavioural therapy (CBT) are the best treatments for misophonia. “I can often help my patients delve into the thoughts that come before the emotion, thus forming a narrative about the sound stimuli. If we can do something about it, we can shift the thought patterns. Yes, the dog is barking, but it might be because someone is walking past the fence; so, he is actually protecting you too," says Buttress. “That type of systematic desensitisation, embracing the sounds, helps people normalise them."

CBT is the most used and effective treatment for reducing misophonia symptoms, according to an international study this year based on a randomised trial and case studies/series. However, it is not always the solution. “If I feel that the stress reaction is related to significant psychological issues, I will work with a psychologist or psychiatrist," says Buttress. “Some patients need medication; others intensive clinical psychological counselling.

“It is certainly a manageable problem for most people — you just have to commit to the process, at least a few sessions over a few months. People need to realise there is hope; you don't have to live so heavily with fight-or-flight reactions."

What it means is that you can sit peacefully in the restaurant, oblivious to the smackers and slurpers and nail clippers, while you passionately discuss… well, for example, misophonia.

• A few simple misophonia coping strategies.
• Chinese water torture or a “drip machine" is a psychologically painful process in which cold water is slowly dripped onto the scalp, forehead or face for an extended period. The process induces fear and psychological distress in the subject. The pattern of the drops is often irregular and the cold sensation each time is a shock, causing anxiety as a person tries to anticipate the next drop. This form of torture was first described around the 1500s by Hippolytus de Marsiliis in Italy.

Additional sources:

• NB Hearing in Cape Town
• Misophonia (Wikipedia)
• A systematic review of treatments for misophonia 
• The 4th International Conference on Hyperacusis & the International Misophonia Symposium 2022
• The motor basis for misophonia
• The puzzle of misophonia: exploring the role of control, social triggers, and comorbid conditions

♦ VWB ♦

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