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. 2025 Apr 30;20(2):82–92. doi: 10.26599/JOTO.2025.9540013

Psychosocial and Audiological Characteristics in Misophonia: An Interdisciplinary Comparison Study of Adults with Misophonia to Healthy Controls

Mercedes G Woolley 1,*, Hailey E Johnson 1, Emily M Bowers 1, Doris Velasquez 2, Julie M Petersen 1, Karen Muñoz 2, Michael P Twohig 1
PMCID: PMC12510352  PMID: 41069698

Abstract

Despite the increasing investigation into misophonia, its classification remains debated due to symptom overlap with audiological and psychological conditions, as well as methodological limitations in existing studies. In the present study, we compared a clinical sample of adults seeking treatment for misophonia with a non-treatment-seeking sample of age- and gender-matched healthy controls. In these two samples, we examined the psychological and audiological features of misophonia by assessing key psychological processes (anger, disgust, OCD symptoms, anxiety, depression, stress, well-being, and psychological inflexibility) and audiological features (hearing, hyperacusis, and tinnitus). We found that individuals with misophonia exhibit higher levels of psychological inflexibility and stress compared to healthy controls. Audiological comparisons indicated that hyperacusis is more prevalent in the misophonia group, with significantly more impairment in social and occupational functioning. There were no differences between groups on an objective assessment of hearing, although self-report measures indicated that individuals with misophonia may have greater difficulty with auditory processing. These findings suggest that misophonia is a complex disorder marked by transdiagnostic psychological characteristics and sound sensitivities. Our results underscore the need for interdisciplinary assessment and treatment approaches that incorporate psychosocial and audiological perspectives.

Keywords: Misophonia, Audiology, Hyperacusis, Psychological Inflexibility, Transdiagnostic processes

Two decades ago, audiologists Jastreboff and Jastreboff (2001) brought attention to misophonia, a disorder marked by an intense aversion to specific repetitive sounds. Unlike hyperacusis, which involves physical discomfort due to sounds, or phonophobia, characterized by fear of loud sounds, misophonia elicits strong emotions such as irritation, anger, and disgust, significantly impacting individuals’ daily lives. The recognition of misophonia has since fueled research in psychology, psychiatry, neurology, and audiology. Despite growing interest in the topic resulting in over 340 publications and counting (Duke Center for Misophonia and Emotion Regulation, 2024), the classification of misophonia is still debated, with current evidence deemed insufficient for its recognition as a distinct medical or psychiatric disorder (Swedo et al., 2022). Challenges in defining misophonia are exacerbated by its symptom overlap with established audiological and psychological conditions, and by methodological limitations in research, such as reliance on internet sampling without clinical verification or non-clinical control groups.

The overlap between misophonia and psychological conditions has been a considerable focus within the available literature. Initial studies noted similarities between misophonia and obsessive-compulsive disorder (OCD), with individuals experiencing disruptions in daily life from avoidance behaviors triggered by specific sounds (Schröder et al., 2013). Despite evidence that OCD and misophonia are not typically comorbid (Jager et al., 2020), traits akin to OCD, such as harm-avoidance, often correlate with misophonia severity (e.g., Çolak et al., 2021). Furthermore, anxiety and mood disorders are commonly observed alongside misophonia (Jager et al., 2020), with positive correlations found for anxiety and depression with misophonia symptoms (Wu et al., 2014; Zhou et al., 2017). However, because misophonia is associated with significant levels of impairment in daily functioning, some have suggested that the connection between misophonia and anxiety and/or depression may be better explained by heightened levels of psychological distress (Brout et al., 2018). Further support for this hypothesis is seen in the lowered levels of well-being and quality of life reported among those with misophonia (Rinaldi et al., 2022; Rouw & Erfanian, 2018).

The overlap between misophonia and other psychological conditions has spurred discussions about potential transdiagnostic mechanisms contributing to misophonia symptoms. A commonly proposed mechanism is experiential avoidance (Cowan et al., 2022). As a transdiagnostic process, experiential avoidance is the tendency to avoid or escape distressing internal experiences, such as negative bodily sensations, thoughts, and emotions (Hayes et al., 1996). Experiential avoidance is a subprocess involved in the higher-order construct of psychological inflexibility, which is defined by a need to control psychological reactions, like stress or negative emotions, “over chosen values or contingencies, in guiding action” (Bond et al., 2011, p. 678). Psychological inflexibility is thought to be involved in the development and maintenance of a range of psychological conditions, although its manifestation may look different across disorders. In misophonia, psychological inflexibility might manifest in attempts to control intense emotional reactions to specific sounds or the threat of sounds through avoidance, which may interfere with valued activities (e.g., mealtimes with family). These behaviors may mirror the responses seen in individuals with OCD to intrusive thoughts, where attempts to control anxiety disrupt daily functioning. Given parallels across diagnoses, examining the specific transdiagnostic factors like psychological inflexibility in misophonia could provide deeper insights into its underlying mechanisms and inform more effective interventions.

Propensities for disgust and anger are also thought to be transdiagnostic features of misophonia, with these emotions often dominating individuals’ reactions to misophonic sounds. Emerging research links mental contamination, pathogen disgust, and sexual disgust to misophonic reactions, suggesting a unique visceral response to sensory stimuli in misophonia (Barahmand, Mantzikos, et al., 2023). This research also found an association between pathogen disgust and aggressive reactions to misophonic sounds. A predisposition to anger and disgust is speculated to play a role in the development of misophonia due to their distinct roles in misophonic reactions (Barahmand, Peters, 2023; Schröder et al., 2013). Controlled studies are needed to evaluate and compare general levels of disgust and anger in those with misophonia to a general population.

While there is a growing body of literature on the psychological facets of misophonia, research into its audiological correlates remains comparatively limited. Misophonia is often associated with hyperacusis due to shared symptoms of sound sensitivity (Baguley, 2003); however, the distinction between the two conditions is not always clear. For example, a study of 257 patients seeking treatment for tinnitus or hyperacusis found that 42% exhibited misophonic symptoms, which significantly exacerbated their primary complaint (Aazh et al., 2022). Conversely, data from a broader survey indicated that less than two percent of 575 misophonic individuals had a concurrent diagnosis of tinnitus, and even fewer had hyperacusis (Jager et al., 2020), highlighting discrepancies that suggest varying degrees of overlap.

The role of hearing impairment in misophonia is also under-researched, although some have highlighted that hearing difficulties may have implications for misophonia. Specifically, experts in audiology have pointed out that some common misophonic trigger sounds have high-frequency components (Enzler et al., 2021). This finding has led to speculation that individuals with hearing loss at higher frequencies may be less likely to have misophonia. Alternatively, people with hearing loss can experience loudness recruitment, where sounds become loud more quickly than usual once they become audible (Moore & Glasberg, 2004). In this case, even quiet sounds can sound moderately loud and bothersome once detected by the individual. This underscores the need for a deeper examination of the audiological characteristics of misophonia given hearing may impact its manifestation.

Overall, the growing body of research on misophonia highlights its complexity as a disorder spanning psychological and audiological dimensions, overlapping with symptoms and processes seen in other psychiatric and sound tolerance disorders. Few studies to date have compared the characteristics of individuals with misophonia to those with other sound sensitivities (Siepsiak et al., 2022) and anxiety disorders (Guzick et al., 2023). However, due to the documented overlap between misophonia and other audiological and psychological conditions, distinguishing the disorder from similar conditions can be challenging. An alternative approach may be to examine the specificity of transdiagnostic processes related to misophonia compared to healthy individuals without significant mental health concerns. This approach may be especially important because current studies tend to focus either solely on psychological or audiological aspects of misophonia, despite calls from experts for a more interdisciplinary approach that integrates varied fields and expertise to enhance our understanding of misophonia (Swedo et al., 2022; Guzick et al., 2023). Research combining audiological and psychological assessments could refine the classification of misophonia and inform the development of interdisciplinary treatments.

Current Study

The aim of the current study is to examine psychological and audiological features of misophonia by assessing related psychological processes—anger, disgust, OCD symptoms, anxiety, depression, stress, well-being, and psychological inflexibility. Additionally, we explored audiological symptoms via self-report measures and a brief audiometric assessment. To accomplish these aims, we compared a clinical sample of adults seeking treatment for misophonia with a non-treatment seeking sample of healthy, age- and gender-matched controls. This approach attempts to bridge the gaps identified in prior research, employing a more rigorous methodology to provide clearer insights into the phenomenology of misophonia.

Methods

The study was approved by a university review board ensuring ethical standards were met. Informed consent was obtained from all participants. The research was funded by the Misophonia Research Fund, supporting a broader clinical trial focused on evaluating a psychological intervention for misophonia, and the soQuiet Foundation supporting recruitment of a matched non-clinical sample.

Participants

Participants were eligible for the misophonia group if they were 18 years or older, actively seeking treatment for misophonia, and endorsing misophonia symptoms that reached the clinical cut-off on the Duke Misophonia Interview (DMI; Guetta et al., 2022; [total score of 20 or greater]) that we established for the study. Additionally, participants were required to have greater than mild sound sensitivities on the Misophonia Questionnaire (MQ; Wu et al., 2014; [MQ Severity Score > 5]) for inclusion. While prior literature suggests that scores greater than seven indicate clinically significant symptoms, the MQ was used as a screening tool rather than a diagnostic measure, and a lower threshold allowed for broader identification of individuals with meaningful misophonia symptoms. Participants were eligible for the healthy control group if they were age- and gender-matched with participants in the misophonia group (see recruitment section, not currently receiving or seeking professional psychological services for a psychological disorder (determined via self-report), and displayed minimal to no misophonia symptoms as evidenced by scores below three on the MQ. Healthy controls could not meet subclinical or clinical diagnostic criteria for misophonia on the Duke-Vanderbilt Misophonia Screening Questionnaire (DVMSQ; Williams et al., 2022). At the time of healthy control recruitment, approximately 97% of misophonia participants had hearing thresholds within normal limits due to testing conducted with the larger trial (see Muñoz et al., 2024). Therefore, healthy controls needed to self-report normal hearing to be eligible for the study.

Recruitment

Participants were recruited from November 2022 to April 2024 using local advertisements on Facebook and community flyers. Recruitment occurred in two waves; first, participants with misophonia were recruited for a larger clinical trial, then matched controls were recruited. Misophonia participants responded to ads for individuals seeking treatment for misophonia. Healthy controls responded to advertisements seeking healthy adult volunteers for an interdisciplinary study on sound sensitivities. Healthy controls were also recruited from the sample local community via advertisements on Facebook and community flyers to ensure that the sample was demographically similar to the misophonia sample. Stratified sampling was used to recruit a matched healthy sample. There were five age strata (ages 18-25, 26-35, 36-45, 46-55, and 56 and above) and three gender strata (men, women, and agender/non-binary individuals). Healthy control participants who matched the characteristics of the stratified groups at the time of sign up were invited to participate.

Procedures

Misophonia Group: Participants underwent a preliminary screening online, followed by a clinical interview. From 261 screener completions, 232 were deemed initially eligible, and 75 consented to further assessments including the DMI and a battery of demographic, psychological, audiological tests and self-report questionnaires. Participants were compensated $60 for full completion of the baseline procedures in the trial. The final sample included 60 participants. Fifteen participants were excluded due to subclinical symptoms (n = 9), trauma-related sound sensitivities (n = 2), volume-related sensitivities (n = 1), a current manic episode (n = 1), and no longer seeking treatment (n = 2).

Healthy Controls: Controls also completed an online screening questionnaire, with 211 initially responding. Thirty-six individuals were automatically excluded due to reporting mild or greater severity of interference from specific repetitive sounds (MQ Severity Score > 4); among these, five met full criteria for misophonia, and three met criteria for subclinical levels of misophonia on the DVMSQ. An additional 20 individuals were excluded due to reporting a psychological condition for which they were seeking or currently receiving services and/or due to reporting hearing loss. Others were excluded for not matching the age and gender requirements at the time of signup. In total, 67 individuals were invited to participate as healthy controls, and 60 enrolled in the study. Healthy participants were provided with the same battery of demographic, psychological, and audiological self-report questionnaires. Healthy controls were compensated $30 for their involvement in the study procedures.

Audiological Assessment

All participants met with a doctoral student or trained research assistant who conducted a brief intake assessment documenting family history of misophonia and presence of any audiological or health conditions. Participants then underwent the Distortion Product Otoacoustic Emissions (DPOAEs) test using an Otodynamics unit. This involved placing a probe in the ear canal and measuring the emission generated by the cochlea for sounds at specific frequencies and decibel levels (65/55 dB SPL; 1,000-5,657 kHz). The procedure, conducted by trained audiology students under supervision, aimed to detect cochlear function and identify potential hearing deficits. Results were documented for each ear, taking about one minute per ear. All tests conducted for misophonia participants were provided by an audiology doctoral student and supervised by an audiologist. A trained undergraduate research assistant performed all tests for the healthy control group, with 85% of tests being supervised by an audiologist or audiology doctoral student.

Measures

The Misophonia Questionnaire (MQ; Wu et al., 2014) is an 18-item self-report tool measuring misophonia severity through three subscales: symptoms, emotions and behaviors, and overall severity. Symptoms are rated on a 5-point Likert scale, while overall severity is rated from 1 (minimal) to 15 (very severe), with scores above 7 indicating clinically significant symptoms. The MQ demonstrated excellent internal consistency (α = .95).

The Disgust Propensity and Sensitivity Scale-Revised (DPSS-R; van Overveld et al., 2006) is a 12-item self-report tool measuring disgust through two subscales: propensity, evaluating the frequency of disgust reactions (e.g., “I avoid disgusting things”), and sensitivity assessing emotional responses to disgust (e.g., “I think feeling disgust is bad for me”). Each subscale has six items rated on a 5-point Likert scale, with higher total scores indicating greater disgust. The scale demonstrated good internal consistency (α = .88).

The Rage Outbursts and Anger Rating Scale (ROARS; Budman et al., 2008) is a three-item self-report tool measuring rage frequency, intensity, and duration over the past week. Items are rated on a 4-point scale from 0 to 3; scores range up to 9, with higher values indicating more severe rage. The ROARS showed excellent internal consistency (α = .91).

The Mental Health Continuum-Short Form (MHC-SF; Keyes, 2005) is a 14-item self-report tool measuring well-being across emotional (3 items), social (5 items), and psychological (6 items) dimensions. Items are rated on a 6-point Likert scale from 0 (never) to 5 (every day). Higher scores reflect better well-being. The MHC-SF demonstrated excellent internal consistency (α = .92).

The Depression Anxiety Stress Scale-21 (DASS-21; Lovibond & Lovibond, 1995) is a 21-item self-report tool assessing distress with seven items across three subscales: depression, anxiety, and stress. Items are rated on a 4-point Likert scale from 0 (never) to 3 (almost always). Subscale scores are summed and doubled, with higher scores indicating greater distress. The DASS-21 demonstrates good validity, reliability (Henry & Crawford, 2005), and internal consistency (αs = .81 to .93) in this sample.

The Acceptance and Action Questionnaire 3 (AAQ-3; Ong et al., 2020) is a 7-item self-report measure assessing experiential avoidance. The AAQ-3 is a revised version of the AAQ-II (Bond et al., 2011), with adjusted wording to increase clarity and improve item-level functioning. Items (e.g., “I worry about losing control of my thoughts, feelings, or memories) are rated from 1 (never true) to 7 (always true) 7-point Likert Scale. Total AAQ-3 scores range from 7 to 49, where higher scores indicate greater experiential avoidance. The AAQ-3 demonstrated excellent internal consistency (α = .91) in the present sample and in previous studies (Ong et al., 2020).

Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz et al., 2010) is a 20-item self-report questionnaire assessing obsessive-compulsive symptoms across four dimensions: responsibility for harm, unacceptable thoughts, contamination, and symmetry. Each subscale has five items rated on a 5-point Likert scale from 0 to 4, with total scores ranging from 0 to 80. Scores of 18 or more distinguish OCD from no psychiatric diagnosis, and scores greater than 21 distinguish OCD from anxiety disorders (Abramowitz et al., 2010). The DOCS demonstrated excellent internal consistency (α = .93) in this sample.

The Tinnitus and Hearing Survey (THS; Henry et al., 2015) is a 10-item self-report measure with three sections: tinnitus (4 items), hearing (4 items), and sound tolerance (2 items). Participants rate items on a 5-point Likert scale from 0 (no, not a problem) to 4 (yes, a very big problem) based on their experiences over the past week. The tinnitus and hearing subscales score from 0 to 16, with higher scores indicating greater difficulties. The tinnitus subscale assesses issues like difficulty sleeping and concentrating, while the hearing subscale evaluates challenges such as understanding speech in noisy environments. The sound tolerance subscale screens for hyperacusis, with the second question answered only if the first receives a rating of 1 or higher. The THS subscales showed good to excellent internal consistency (αs = .86 to .90).

The Inventory of Hyperacusis Symptoms Survey (IHS; Greenberg et al., 2018) is a 25-item self-report questionnaire assessing hyperacusis symptoms that includes five subscales: general loudness tolerance, emotional arousal, psychosocial impact, functional impairment, and communication. Items (e.g., “Hearing loud sounds can make me feel stressed out”) are rated on a 4-point Likert scale from 1 (not at all) to 4 (very much so), with total scores ranging from 25 to 100. A total score of 69 or higher indicates a high likelihood of hyperacusis, a total score of 80 or higher indicates severe hyperacusis, and a total score of 89 or higher indicates very severe hyperacusis (Greenberg et al., 2018). The IHS demonstrated excellent internal consistency (α = .96) in the present sample.

Analysis

All analyses for this study were conducted using the R software environment (R Core Team, 2024). The full script and output for the main analyses can be found at https://osf.io/wejav/ Descriptive statistics were performed on demographic variables. Pearson’s Chi-squared test and Fisher’s exact test were used to test the independence of groups on sociodemographic variables.

All psychological and audiological self-report variables were continuous, requiring the use of independent groups t-tests for between groups comparisons. Levene’s test of equal variance was conducted prior to between-group comparisons. The following variables exhibited unequal variances and required a Welch’s correction: misophonia severity, symptoms, emotional-behavioral response, psychological inflexibility, anger, anxiety, stress, depression, and the OCD symptom dimensions of unacceptable thoughts, contamination, and symmetry.

The Benjamini–Hochberg false discovery rate (FDR) correction (Benjamini & Hochberg, 1995) was applied, with significant effects indicated by a two-tailed FDR-corrected p-value of less than .05. This method was chosen for its suitability in exploratory research, compared to the more conservative Bonferroni correction. We prioritized group differences with large effect sizes to mitigate the potential risk of Type I errors. We used the following scale to interpret Cohen’s d: ignored = 0.00 < d < 0.20, small effect = 0.20 < d < 0.50, moderate effect = 0.50 < d < 0.80, large effect = d < 0.80.

We examined DPOAE test results by focusing on participant amplitudes at each frequency, measured in decibel sound pressure level (dB SPL). Higher amplitudes indicate a response from the cochlea that is consistent with cochlear health and typical hearing, while reduced amplitudes suggest potential hearing issues (Abdala & Visser-Dumont, 2001). We plotted amplitudes at frequencies from 1,000 to 5,657 Hz for each group, comparing them to the normative range (5th to 95th percentile) for visual inspection. Next, we assessed signal-to-noise ratios (SNRs) at each frequency, comparing the DPOAE signal to background noise in dB. A normal DPOAE outcome requires a DPOAE with greater than 3–6 dB SNR at approximately 70% of data points (Abdala & Visser-Dumont, 2001), which we used to determine normal hearing. Pearson’s Chi-squared tests compared differences between groups on normal hearing status according to DPOAE results. In the misophonia group, two participants were removed due to hearing loss, and tests for two others were not conducted due to equipment issues, while in the healthy control group, two results were not evaluated due to excessive noise during testing.

Data were inspected for missingness prior to measurement scoring and analysis. In the misophonia group, three participants each missed one different item on the IHS. One healthy control participant missed one item on the DASS-21. Following guidelines put forth by Bennet (2001), this small proportion of missing data was treated as ignorable under the completely missing at random assumption. A power analysis using G*power indicated that our sample size would provide 80% power to detect an effect of Cohen’s d = .52 between groups, with a significance level of 5%.

Results

Sociodemographic characteristics

Participants in the misophonia and healthy control groups primarily self-identified as White (88.3 and 98.3%, respectively), non-Hispanic (90 and 96.67%, respectively), heterosexual (76.7 and 86.7%, respectively), women (70 and 75%, respectively), with average ages of 33.8 (SD = 12.18) and 33.62 (SD = 12.20), respectively. Due to a lack of study sign-ups from agender/non-binary individuals in the matched control sample, there was a slight underrepresentation of this group in the healthy control sample. When testing for baseline equivalency, no significant differences (p’s > .05) were found across demographic variables between groups except for household income (p = .013), with participants in the misophonia group reporting higher income than the healthy control group. See Table 1 for all participant demographics.

Table 1. Participant sociodemographic and health characteristics.

Misophonia Group
(N = 60)		 Healthy Control Group
(N = 60)		 p -value 2
1Categories not mutually exclusive.
2 Pearson’s Chi-squared test; Fisher’s exact test.
Age, M (SD) 33.80 (12.18)
Range = 18-67		 33.62 (12.20)
Range = 18-69		 .934
Gender, % 1 .541
Agender 1 (1.67) 0 (0)
Man 14 (23.33) 14 (23.33)
Non-binary 3 (5.0) 1 (1.67)
Woman 43 (71.67) 46 (76.67)
Sexual Orientation, % 1 .076
Asexual 3 (5.0) 3 (5)
Bisexual 4 (6.67) 3 (5)
Heterosexual or straight 46 (76.67) 52 (86.67)
Lesbian 0 (0) 2 (3.33)
Pansexual 6 (10.0) 0 (0)
Queer 2 (3.33) 2 (3.33)
Ethnicity, % .272
Hispanic or Latino 2 (3.33) 6 (10)
Not Hispanic or Latino 58 (96.67) 54 (90)
Race, % 1 .096
American Indian/Alaska Native 0 (0) 1 (1.67)
Asian or Asian American 2 (3.33) 3 (5)
Black or African American 1 (1.67) 1 (1.67)
White or White American 59 (98.33) 53 (88.33)
Not listed 1 (1.67) 3 (5)
Religion and Spirituality, % 1 .077
Buddhist 0 (0) 1 (1.67)
Catholic 0 (0) 3 (5)
Church of Jesus Christ of Latter-Day Saints 27 (45) 30 (50)
Hindu 0 (0) 3 (5)
Jewish 1 (1.67) 0 (0)
Not religious 28 (46.67) 15 (25)
Protestant 0 (0) 2 (3.33)
Not listed 5 (8.33) 8 (13.33)
Household Income, % .013
Less than $20,000 4 (6.67) 15 (25)
$20,000 - $39,999 9 (15) 11 (18.33)
$40,000 - $59,999 4 (6.67) 10 (16.67)
$60,000 – $79,999 8 (13.33) 6 (10)
$80,000 - $99,999 6 (10) 3 (5)
$100,000 or more 24 (40) 10 (16.67)
Unknown 5 (8.33) 5 (8.33)
Marital Status, % .631
Divorced 3 (5) 2 (3.33)
Living with a partner 5 (8.33) 6 (10)
Married 34 (56.67) 28 (46.67)
Single 18 (30) 24 (40)
Employment Status, % .562
Employed full-time 26 (44.07) 22 (36.67)
Employed part-time 17 (28.81) 15 (25)
Other 2 (3.39) 1 (1.67)
Retired 2 (3.39) 1 (1.67)
Student 10 (16.95) 19 (31.67)
Unemployed 2 (3.39) 2 (3.33)
Unknown 1 (1.67) 0 (0)
Health History,%
Has a family member (blood relative) with misophonia 31 (51.67) 4 (6.67) < .001
Recent sudden hearing loss 2 (3.33) 1 (1.67) > .90
Exposed to loud noise (e.g., concerts, machinery) 40 (66.67) 48 (80) .10
Head injury 8 (13.33) 3 (5.0) .110
Heart problems 2 (3.33) 2 (3.33) > .90
Diabetes 0 (0) 3 (5.0) .20
High blood pressure 5 (8.33) 0 (0) .057
Kidney failure 1 (1.67) 1 (1.67) > .90
Headaches/migraines 37 (61.67) 5 (8.33) < .001
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Validation of Group Assignment

Individuals with misophonia reported significantly higher misophonic sound sensitivities (M = 16.90, SD = 5.12) compared to healthy controls (M = 3.68, SD = 3.74), with a large effect size (d = 4.10). Similarly, emotional and behavioral reactions to these sounds were substantially greater in the misophonia group (M = 21.15, SD = 4.94) than in controls (M = 2.90, SD = 2.93), also with a large effect size (d = 4.50). Severity scores further highlighted the impact of misophonia, with the misophonia group averaging a severity score of 6.83 (SD = 1.68) versus 0.82 (SD = 0.83) in controls, and 58% of the misophonia group scoring at or above the clinically significant threshold. In contrast, healthy controls had an average severity score of 0.82 (SD = 0.83), with 82% reporting no or minimal sound sensitivities, and none reporting severity above 3, meaning that the control group all reported below mild levels of impact due to sound sensitivities. The results support the accurate grouping of participants into misophonia and healthy control categories.

Clinical Health History

In the misophonia group, 51.7% reported having a family member with misophonia, compared to 6.7% in the healthy group. Recent sudden hearing loss was rare in both groups (misophonia: 3.33%, healthy: 1.7%). Exposure to loud noise was slightly higher in the healthy control group (80%) than the misophonia group (66.7%) . Self-reported head injuries were more common in the misophonia group (13.33% vs. 5.0%). High blood pressure was reported by 8.33% of the misophonia group but none in the healthy group. Headaches or migraines were significantly more prevalent in the misophonia group (61.67% vs. 8.33%). A detailed summary of health history can be found in Table 1.

Psychological Features

Between-group comparisons revealed significant elevations in disgust and anger within the misophonia group compared to healthy controls, with large to medium effect sizes (DPSSR Total: d = 0.79, ROARS Total: d = 0.57). OCD symptoms were also notably higher in the misophonia group (d = 0.55), particularly in the domain of unacceptable thoughts (d = 0.55). Other DOCS subscales indicated greater OCD symptoms related to contamination and symmetry (both ds = 0.42), although responsibility for harm did not differ significantly between groups (d = 0.23).

The misophonia group exhibited higher levels of stress, anxiety, and depression, with substantial differences in stress (d = 0.98). Well-being was significantly worse in the misophonia group, with the social well-being dimension of MHCSF being notably worse (d = 0.60). Psychological inflexibility was significantly higher in the misophonia group compared to healthy controls (d = 0.85). Full statistical details of all between-group differences on psychological measures can be found in Table 2.

Table 2. Comparison of Psychological Process Variables.

Variable Misophonia Group Healthy Control Group t p 95% CI Lower 95% CI Upper Cohen's d
M SD M SD
Note. p < .01**, p < .05*.
Misophonia (MQ)
Severity 6.83 1.68 0.82 0.83 −24.862 < .001** −6.498 −5.536 4.54
Symptoms 16.90 5.12 3.68 3.74 −16.145 < .001** −14.839 −11.594 2.95
Emotional-Behavioral Response 21.15 4.94 2.90 2.93 −24.621 < .001** −19.721 −16.779 4.50
Disgust (DPSSR)
Total 30.10 7.76 24.65 5.98 −4.311 < .001** −7.953 −2.947 0.79
Propensity 17.07 4.22 14.13 3.50 −4.143 < .001** −4.335 −1.531 0.76
Sensitivity 13.03 4.51 10.52 3.50 −3.415 .002** −3.976 −1.057 0.62
Anger (ROARS)
Total 1.95 1.93 0.98 1.42 −3.129 .004** −1.579 −0.354 0.57
Well-being (MHCSF)
Total 43.63 12.03 50.08 11.46 3.007 .005** 2.202 10.698 0.55
Emotional 11.03 2.25 11.78 1.85 1.995 .052 0.006 1.494 0.36
Social 12.80 5.15 15.93 5.25 3.301 .002** 1.254 5.013 0.60
Psychological 19.80 5.74 22.37 5.57 2.487 .017* 0.523 4.611 0.45
Depression, Anxiety, Stress (DASS-21)
Stress 14.30 8.52 7.33 5.37 5.36 <.001* −9.54 −4.39 0.98
Anxiety 6.33 7.38 3.43 3.55 −2.74 .009* −5.00 −0.80 0.50
Depression 10.03 10.877 5.40 5.04 −2.99 .005** −7.71 −1.56 0.55
Psychological Inflexibility (AAQ-3)
Total 19.28 8.22 13.27 5.80 −4.63 < .001** −8.59 −3.44 0.85
OCD Symptoms (DOCs)
Total 10.77 9.24 6.083 7.86 −2.99 .005** −7.79 −1.58 0.55
Responsibility for harm 2.22 3.04 1.58 2.44 −1.26 .218 −1.63 0.36 0.23
Unacceptable thoughts 3.27 3.40 1.55 2.43 −3.18 .003** −2.79 −0.65 0.58
Contamination 2.617 2.78 1.53 2.32 −2.32 .026* −2.01 −0.16 0.42
Symmetry 2.67 3.49 1.42 2.44 −2.29 .027* −2.33 −0.17 0.42
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Audiological Features

In the misophonia group, seven participants (12%) reached the clinical threshold for hyperacusis, while none of the participants in the healthy control group did. When comparing scores between groups, those with misophonia showed significantly greater hyperacusis severity (d = 1.45), with marked impairments in general loudness tolerance, emotional arousal, social impact, and functional impairment (all ps < .001, ds > .80). The misophonia group also endorsed significantly worse hearing perception scores compared to the healthy controls (d = 0.62), which suggests that those in the misophonia group may experience greater difficulty hearing or understanding speech in noisy environments. Notably, there were no differences in reported tinnitus symptoms between groups. Detailed comparisons for audiological variables are summarized in Table 3.

Table 3. Comparison of Audiological Sound Tolerance Variables.

Variable Misophonia Group Healthy Control Group t p 95% CI Lower 95% CI Upper Cohen's d
M SD M SD
Note. p < .01**, p < .05*.
Tinnitus and Hearing (THS)
Tinnitus 0.75 1.58 0.45 1.40 −1.10 .274 −0.84 0.24 0.20
Hearing 3.78 3.91 1.87 1.94 −3.41 .002** −3.04 −0.80 0.62
Sound Tolerance 1.32 1.71 0.18 0.50 −4.92 < .001** −1.59 −0.67 0.90
Hyperacusis (IHS)
Total 49.80 16.75 31.77 5.15 −7.97 < .001** −22.55 −13.52 1.46
General loudness tolerance 6.44 2.42 3.97 1.13 −7.20 < .001** −3.17 −1.80 1.31
Emotional arousal 12.867 4.51 7.65 2.23 −8.03 < .001** −6.51 −3.92 1.47
Social impact 13.22 5.43 9.28 0.85 −5.54 < .001** −5.35 −2.51 1.01
Functional impairment 13.63 4.99 8.68 2.24 −7.01 < .001** −6.35 −3.55 1.28
Communication 3.63 1.75 2.18 0.57 −6.12 < .001** −1.92 −0.98 1.12
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Distortion Product Otoacoustic Emissions

DPOAE amplitudes showed present responses at most frequencies for each group (see Figure 1). However, amplitudes below the normative range at higher frequencies (2828–5657 Hz) were observed more frequently in the healthy control group, possibly indicating hearing loss at these frequencies. There were no significant differences between ears (left vs. right) in present DPOAEs (70% SNRs > 6 dB) for both the misophonia group (χ2(1) = 0.01, p = 0.918) and the healthy control group (χ2 (1) = 0.02, p = 0.890). Therefore, DPOAEs from both ears were analyzed together. Seventy-eight percent of participants in the misophonia group had DPOAE results that were consistent with normal hearing compared to 71% in the healthy control group. However, the chi-squared test indicated that absent DPOAEs did not significantly differ between groups (χ2(1) = 0.41, p = 0.522).

Figure 1.

Figure 1

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Amplitudes for Distortion Product Otoacoustic Emissions (DPOAEs) for Misophonia Participants relative to Healthy Controls.

Note. DP-Grams Displaying Amplitude for F2 Frequencies. The grey shaded area indicates the normative range (from the 95th to the 5th percentile). The hashed regions represent the range from the 90th to the 10th percentile for amplitude across the frequencies

Discussion

This study compared psychological and audiological phenotypes of individuals with misophonia to those of age- and gender-matched healthy controls. The largest psychosocial differences were seen in levels of psychological inflexibility and stress. Audiologically, the groups were similar, with the exception of higher levels of self-reported hyperacusis and difficulty processing voices in noisy environments in the misophonia group. Our findings add to the growing body of interdisciplinary research on misophonia.

Individuals with misophonia exhibited significantly higher levels of psychological inflexibility and stress. The effect size for psychological inflexibility was much larger than the differences in anxiety and depression. Neither anxiety nor depression reached clinical significance for either group on average. Elevated stress levels in the misophonia group support Brout and colleagues’ (2018) hypothesis that the overlap with anxiety and depression may be due to overall stress levels rather than direct comorbidity. The unpredictability and uncontrollability of trigger sounds reported by individuals with misophonia may contribute to their elevated stress (Swedo et al., 2022). Additionally, because individuals with misophonia often report that their symptoms affect social relationships, it is not surprising that they also reported worse psychological and social well-being (Jager et al., 2020). Overall, these findings suggest that misophonia may be characterized by high levels of psychological inflexibility and stress, as well as decreased psychological well-being.

Consistent with previous studies, the average DOCS scores indicate that both the misophonia group and healthy controls were well below the clinical cutoff for OCD. This result supports the emerging notion that misophonia is a distinct disorder from OCD and is generally not a comorbid condition with OCD (Abramowitz et al., 2010; Schröder et al., 2013). However, specific dimensions of OC symptoms may still be relevant to misophonia (e.g., McKay et al., 2018; Cusack et al., 2018). We found small but significant differences between the misophonia group and healthy controls in concerns about symmetry and contamination. Notably, individuals with misophonia were more prone to react negatively to unacceptable or intrusive thoughts, with a moderate effect size. Similarly, one study found that the OCD dimension of unacceptable thoughts (but not other dimensions) was related to unhelpful cognitive appraisals in misophonia, such as attributing blame to oneself or the sound source (Cusack et al., 2018). This suggests that the similarity between misophonia and OCD may be explained by the overlapping avoidance and distress in response to uncomfortable thoughts and emotions. These findings, along with results indicating heightened levels of psychological inflexibility and stress, suggest that misophonia shares transdiagnostic features seen across various mental health conditions (see Wang et al., 2022). However, the lack of clinical significance across other disorders (e.g., anxiety, depression, and OCD) provides support for the classification of misophonia as a distinct disorder.

Anger and disgust were moderately elevated in the misophonia group compared to healthy controls. Few studies have explored the link between misophonia and these emotions, focusing mainly on their connection to the severity of misophonic reactions (e.g., Barahmand, Mantzikos, 2023; Dibb & Goldings, 2022). One study found a positive association between misophonia symptoms and aggression, which was partially explained by anxiety sensitivity—the tendency to perceive anxiety-related sensations as harmful (Schadegg et al., 2021). Another study indicated that the relationship between disgust and heightened emotional reactions to misophonic triggers was mediated by anxiety sensitivity, particularly the fear of negative evaluation (Barahmand, Mantzikos, et al., 2023). These findings suggest that anger and disgust in misophonia may be linked through transdiagnostic processes like anxiety sensitivity, rather than being uniquely associated with misophonia. While our results show that anger and disgust are higher in individuals with misophonia than in a healthy population, these emotions are also common in other psychological disorders (Culicetto et al., 2023; Owen, 2011). Therefore, further research with clinical control groups (e.g., OCD, posttraumatic stress disorder) may help determine if these affective features are unique to misophonia.

Audiological comparisons showed that hyperacusis was more prevalent in the misophonia group than in healthy controls, supporting previous studies (e.g., Aazh et al., 2022). Specifically, 12% of the misophonia group met the clinical cutoff for hyperacusis, compared to none in the control group. There were no differences in tinnitus levels between the misophonia and control groups. While some studies have found a subset of tinnitus patients with self-reported misophonia, this is less common when examining misophonia samples for tinnitus (Jager et al., 2020). While further studies are needed, tinnitus appears to be a less frequent comorbidity in misophonia.

Despite the vast majority of participants with misophonia having DPOAE results consistent with normal hearing, the misophonia group reported significantly greater difficulty hearing than the healthy controls, particularly in noisy environments. While difficulty with speech in noise is commonly a sign of hearing loss, in cases where hearing is intact, speech-in-noise issues have been linked to other cognitive and psychological concerns (e.g., learning disabilities, attention deficit hyperactivity disorder), suggesting a potential overlap with misophonia (Blomberg et al., 2019, Ferenczy et al. 2022). Speech-in-noise issues have been previously documented in individuals with misophonia (Enzler et al., 2021), though no studies to date have examined this connection. Rather than difficulty with hearing sensitivity, it could be that misophonia involves differences in the auditory processing system. However, before drawing further conclusions, it is important to consider that while DPOAEs provide useful insight into cochlear function, they are a screening tool and do not assess the full auditory pathway. Future research should incorporate comprehensive audiological assessments, including speech-in-noise testing and auditory processing evaluations, to better understand potential auditory differences.

Participants in this study were also asked to report any medical problems as part of the audiological assessment. Surprisingly, 61.7% of the misophonia group reported headaches or migraines, compared to only 8.3% of healthy controls. Previous internet-based studies have reported lower rates of headaches in misophonia (less than 1%), but these were based on self-reported data (Rouw & Erfanian, 2018). Another study found that migraines were associated with the severity of misophonia rather than the presence of the condition alone (Andermane et al., 2023). This suggests that our clinical sample may experience higher rates of headaches than previously reported in internet samples. Furthermore, individuals with severe misophonia often report migraines with aura, possibly due to heightened sensory sensitivity to visual stimuli like light and movement (Andermane et al., 2023). Stress and tension associated with misophonia may also contribute to the high occurrence of headaches. These findings highlight the importance of considering physical symptoms, including headaches, during the assessment and diagnosis of misophonia.

Limitations

The current study has several limitations. First, the sample size, though adequate for initial exploration, may limit the generalizability of the findings. While an a-priori test suggested adequate power to detect effects, we did not control for multiple testing in our power analysis; future studies should include more rigorous methods to control for multiple testing. Additionally, the sample lacked racial diversity. Larger and more diverse samples should be recruited in future research to increase confidence in the understanding of misophonia presentations across diverse groups.

Although age- and gender-matched healthy controls were used, the study did not explore other potentially confounding variables, such as household income, which was significantly different between the two groups. Furthermore, the study focused on misophonia and its overlap with psychological conditions, but other psychological comorbidities were not assessed. Future research should assess for the presence of comorbidities in misophonia samples to better clarify disorder-specific characteristics. However, this should be done cautiously given that comorbidities in misophonia are quite common. Additionally, we did not conduct diagnostic interviews with the healthy controls to confirm the absence of misophonia or other psychological conditions, relying instead on self-report. Future studies should conduct diagnostic interviews with controls to ensure a truly non-clinical comparison.

Conclusions

The current study adds to previous research confirming that misophonia is a multifaceted disorder involving audiological, psychological, and physical symptoms. Our research study adds to the growing literature supporting misophonia as a distinct disorder. However, our findings suggest that misophonia involves transdiagnostic psychological phenotypic features, such as psychological inflexibility, stress, and interpersonal difficulties. Moreover, our findings indicate that misophonia is not solely a psychological condition; it also involves sensitivity to specific sounds possibly connected to its high occurrence with self-reported hyperacusis and may also be linked to auditory processing difficulties, though future audiological studies are needed.

Based on the present findings, we recommend that assessments for misophonia include both psychiatric and audiological perspectives, incorporating evaluations for physical symptoms like headaches. Additionally, treatment should involve a transdiagnostic psychosocial approach to address processes such as psychological inflexibility. Importantly, direct audiological interventions, such as judicious use of noise-canceling devices, should be considered. This interdisciplinary approach is crucial for accurately diagnosing and effectively treating misophonia, ultimately improving the quality of life for those affected by this complex disorder.

Acknowledgments

Data Availability Statement

Data will be made available upon request.

Ethical Approval

The research was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Utah State University Institutional Review Board (Protocol #13771).

Informed Consent

All participants provided informed consent to participate in the research and for their data to be analyzed and presented in a publication.

Declaration of generative AI and AI-assisted technologies in the writing process:

During the preparation of this work the authors used ChatGPT in order to enhance clarity, efficiency, and coherence of the introduction, methods, and discussion sections of this paper. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Financial Disclosures/ Conflicts of Interest

This project was funded by a grant from the Misophonia Research Fund and soQuiet Foundation. Authors have no conflicts of interest to declare.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Citations

  1. Duke CMER Misophonia webinar series. Available at https://www.youtube.com/watch?v=OLM73FiWFkY. Accessed 16 Jun 2024.
  2. R Core Team, 2024. The R project for statistical computing. Available at https://www.R-project.org/.

Data Availability Statement

Data will be made available upon request.

Articles from Journal of Otology are provided here courtesy of Chinese PLA General Hospital

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