Exploring the Impact of Misophonia Through the Lens of the World Health Organization’s International Classification of Functioning, Disability and Health Framework

Abstract

Background:

Misophonia is characterized by reduced tolerance to specific sound stimuli known as triggers. The reactions can be emotional, behavioral or physiological. In response to triggers, a person with misophonia might express irritation, anger, or disgust by being verbally or physically aggressive. This ultimately affects their quality of life.

Purpose:

The present study aimed to determine the impact of misophonia on everyday life using the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) framework.

Research Design:

The study used a cross-sectional survey design and collected data through a qualitative resurvey search method.

Study Sample:

The study sample included 51 individuals with misophonia aged 18 to 30 years. The sample was recruited through the administration of the Revised Amsterdam Misophonia Scale.

Data Collection and Analysis:

The data were collected using two open-ended questions, the Problem Question (PQ) and the Life Effects Question (LEQ). The responses were linked to categories within ICF using a simple content analysis approach. The Wilcoxon signed-rank test was conducted to check for the significant difference between the number of responses.

Results:

Among 294 responses, 222 were related to PQ, and 72 were associated with LEQ. Participation in activities was most affected by misophonia, followed by impairments in body function. The most frequently affected functions were focusing attention from activity limitations and participation restrictions, followed by appropriateness of emotion from impairments of body function.

Conclusions:

The findings indicate that misophonia most significantly affects the domain of Activities and Participation, with subsequent impacts on Body Functions and Environmental Factors. This underscores the heterogeneous and multifaceted nature of misophonia’s effects, demonstrating the effectiveness of open-ended questions in capturing the varied impacts on affected individuals.

INTRODUCTION

Misophonia is a disorder characterized by strong adverse reaction to specific sound stimuli, known as triggers. The reaction to these triggers can be emotional or physiological. The word misophonia was coined in 2002 and derives from the Greek words miso, meaning hatred, and phonia, meaning sound (Jastreboff and Jastreboff, 2014).

Recent consensus has defined misophonia as a disorder characterized by decreased tolerance to specific sounds or stimuli that provoke an intense emotional response (Swedo et al., 2022). These stimuli, often referred to as “triggers,” are perceived as unpleasant or distressing and typically elicit strong negative emotional, physiological, and behavioral responses, distinguishing affected individuals from the general population. Current evidence shows high prevalence of misophonia, with notable variations observed globally (Kılıç et al., 2021; Aryal and Prabhu, 2022; Patel et al., 2023; Vitoratou et al., 2023; Dixon et al., 2024). Such variations, ranging from 5–25 percent (Kılıç et al., 2021; Patel et al., 2023; Vitoratou et al., 2023; Dixon et al., 2024), may stem from diverse factors including ethnicity, race, and differing research methodologies. Studies within the Indian population suggest a prevalence rate of 15–23 percent (Aryal and Prabhu, 2022; Patel et al., 2023). This underscores the influence of regional demographic and methodological differences on the reported rates of misophonia.

Misophonia can occur in isolation or along with other psychiatric disorders, such as mood disorders, obsessive-compulsive personality disorder, and attention-deficit/hyperactivity disorder (Schröder et al., 2013). It can also occur alongside other decreased sound tolerance disorders, such as tinnitus, hyperacusis, and phonophobia (Jastreboff and Jastreboff, 2014). According to Jastreboff and Jastreboff (2014), the sound can also be related to a previous negative experience. Individuals with misophonia express their irritation, anger, and disgust aggressively in response to the triggering sound. This can be verbal or behavioral. Misophonic individuals understand that their response is excessive and tend to avoid social situations (Schröder et al., 2013). Their response inadvertently affects their relationships with family, friends, and colleagues. The impact of misophonia extends to all situations of life and, thus, lessens the quality of life.

The World Health Organization (WHO) initially developed the International Classification of Impairments and Handicaps in 1980, a framework designed to assess disability based on impairment, disability, and societal limitation (Thuriaux, 1995). Criticized for its overly medicalized focus and the neglect of environmental factors, this approach led to significant revisions and the adoption of the International Classification of Functioning, Disability and Health (ICF) in 2001 (Imrie, 2004). The ICF adopts a more holistic view of disability, incorporating a biopsychosocial model that emphasizes the interplay of various factors affecting an individual’s health (World Health Organization, 2001).

The ICF framework categorizes key domains to provide a comprehensive assessment of individual health and disability. Body Functions cover physiological and psychological functions of body systems, including cognitive and emotional processing. Body Structures are defined as anatomical parts such as organs and limbs. Activity Limitation addresses challenges in executing activities, and Participation Restrictions detail difficulties experienced in life situations. Environmental Factors describe the physical, social, and attitudinal environments that either facilitate or hinder an individual’s functioning. Finally, Personal Factors consider the unique background of an individual, including aspects such as gender, race, and age, contributing to a nuanced understanding of the impact of health conditions on functioning. This multidimensional approach facilitates a detailed analysis of how personal and environmental factors interact with health conditions, crucial for developing targeted clinical, research, policy, and public health interventions (World Health Organization, 2001).

There have been several studies conducted in the literature to classify different auditory disorders using the ICF framework (Ramkumar and Rangasayee, 2010; Granberg et al., 2014; Durisala et al., 2017; Manchaiah et al., 2018). Classifying hearing loss through ICF found most ICF categories under the activity and participation division, followed by the division of the environmental factors (Granberg et al., 2014). For single-sided deafness, functional impairment had the most ICF categories, followed by activity, participation, and environmental factors (Durisala et al., 2017). Likewise, activity participation has the most affected ICF categories for tinnitus (Manchaiah et al., 2022). Specifically, in the Indian context, the most affected ICF domain for individuals with tinnitus was recreation and leisure (Manchaiah et al., 2022). However, no multidimensional and comprehensive view of the functional and disabling aspects of misophonia currently exists. While several questionnaires such as Amsterdam Misophonia Scale (Jager et al., 2020), Misophonia Assessment questionnaire (Johnson and Dozier, 2013), and Duke Misophonia Questionnaire (Rosenthal et al., 2021) exist, they do not cover all mental, emotional, health, personal, and social issues faced by the individuals with misophonia. Although close-ended questionnaires can highlight a few psychosocial and attitude-based issues faced by those with misophonia, most of them are not validated across diverse cultural and ethnic groups. In contrast, widespread ramifications of misophonic symptoms can be disentangled and coded under different categories of the ICF framework. Current evidence suggests that using open-ended questionnaires to elicit the responses will provide broader responses (Connor Desai and Reimers, 2019), which can then be coded using the ICF framework. Thus, the current study aims to use the ICF framework to highlight the daily barriers and life effects experienced by individuals with misophonia. Specifically, the study will focus on the full effects of misophonia on body function, activity limitation, participation restriction, environmental factors, and personal factors.

The current study aims to profile the impact of misophonia experienced by individuals in their everyday lives. The study objectives are (1) to record the consequences and life effects of misophonia using the ICF framework, particularly for the domains of body function, body structures, activities participation, contextual factors, environmental factors, and personal factors; (2) to understand which domain among body structure(s), body function, activity limitation and participation restriction, environmental factors, and personal factors of the ICF framework is most impactful in everyday life for individuals with misophonia; and (3) to evaluate whether there are any gender differences in the various domains of ICF categories.

MATERIALS AND METHODS

Research Design and Participants

The study used a cross-sectional survey design and collected data through a qualitative resurvey search method. It included individuals with misophonia who reported experiencing a strong adverse reaction to specific sound stimuli. Individuals were identified using the diagnostic criteria given by Schröder et al. (2013). Additionally, AMISO-R (Revised Amsterdam Misophonia Scale) was used to determine the presence and severity of misophonia. Fifty-one individuals diagnosed with misophonia aged 18–30 years (mean = 23.25 years, standard deviation = 4.5 years, 38 females) participated in the study.

Inclusion Criteria and Exclusion Criteria

Inclusion Criteria

• Age range: Participants were aged 18 years or older to ensure adult consent and understanding of the study framework.

• Education level: All participants had completed high school to facilitate comprehension of the questionnaires and study materials.

• Language proficiency: Participants demonstrated the ability to read, understand, and communicate in English fluently to ensure effective participation and accuracy in data collection.

• Consent: Participants provided informed consent indicating their willingness to participate in the study.

Exclusion Criteria

• Tinnitus: Individuals with a clinical diagnosis or self-reported persistent ringing or buzzing in the ears were excluded to avoid confounding auditory hypersensitivity with misophonia. The Tinnitus Handicap Inventory was used to confirm the absence of tinnitus.

• Hyperacusis: Participants experiencing extreme sensitivity to everyday sounds unrelated to specific triggers were excluded to maintain focus on misophonia-specific reactions. The Khalfa Hyperacusis Questionnaire was used to confirm the absence of hyperacusis.

• Migraine: Individuals with recurrent migraines were excluded because migraine may influence auditory sensitivities or sound perception.

• Hearing impairment: Individuals with self-reported or diagnosed reduced hearing sensitivity or hearing loss were excluded to ensure that sound perception was not a limiting factor in the study.

• Neurological or psychiatric conditions: Individuals with neurological or psychiatric conditions (e.g., schizophrenia, autism spectrum disorder) that could independently influence sensory or emotional responses to sound were excluded. The Generalized Anxiety Disorder Scale was used to rule out any anxiety disorder.

The study included individuals who reported adverse reactions to sound. All participants had completed high school and demonstrated comprehension of English. Exclusion criteria encompassed individuals with tinnitus, hyperacusis, migraine, or reduced hearing sensitivity.

Procedure

The study procedure was explained to the participants. Informed consent was obtained from all the study participants. The participants’ demographic details, including age and gender, were collected. The informed consent and demographic information were obtained through the online Google form created for the study. The study was conducted in two stages.

Phase 1: Obtaining Responses to the Online Survey Form

The initial phase of the study involved collecting participants’ responses using an online survey distributed via Google Forms. This digital format was chosen for its accessibility, ease of use, and ability to streamline data collection.

1. Introduction and Context:

   1. The first section of the Google form provided participants with an overview of the study, emphasizing its aim to explore the impact of misophonia.
   2. A clear explanation of misophonia, including its defining characteristics and relevance to the WHO ICF was included.
   3. Participants were also presented with an outline of the survey structure, ensuring they understood the progression and purpose of the questions.
2. Provision of Supporting Information:

   1. All introductory content was provided in written form within the Google form, allowing participants to review the details at their own pace.
   2. Contact information, including an e-mail address and phone number, was included in the form to enable participants to reach out to the research team for any clarifications, additional information, or support as needed. This method ensured a user-friendly and transparent process, making it easy for participants to engage with the survey while providing them with avenues for assistance if required.

3. The following section obtained the demographic details, including age and gender and informed consent. The contact details of the participants were also obtained. This section also included questions about whether the person has tinnitus, hyperacusis, migraine, and reduced hearing sensitivity. The Tinnitus Handicap Inventory (Newman et al., 1996), Khalfa Hyperacusis Questionnaire (Khalfa et al., 2002), and Generalized Anxiety Disorder Scale (GAD-7) (Spitzer et al., 2006) were used to identify individuals with tinnitus, hyperacusis, and anxiety, respectively. Low questionnaire scores indicated that the person did not suffer from any conditions. In the Khalfa Hyperacusis Questionnaire, a score lower than 28 indicates no hyperacusis; a score of less than 16 in the Tinnitus Handicap Inventory indicates no handicap; and a score of less than 4 in the Generalized Anxiety Disorder Scale indicates no anxiety. If a person had any of the above-mentioned conditions, they were excluded from the study.

4. The next section consisted of the AMISO-R (Jager et al., 2020), the revised version of the Amsterdam Misophonia Scale (Schröder et al., 2013). It includes checklists for specific misophonic sounds and the emotions related to the sounds. The information from the checklist is not included in the rating. For the rating, 10 questions focusing on the severity are used. The rating scale is from 0–4, which can result in a total score between 0 and 40. The scores can be rated as follows: 0–10: typical to subclinical misophonia; 11–20: mild misophonia; 21–30: moderate-severe misophonia; 31–40: severe to extreme misophonia (Jager et al., 2020).

5. The final section consisted of two open-ended questions: the Problem Question (PQ) and the Life Effects Question (LEQ). These questions were obtained from previous studies on hearing loss (Durisala et al., 2017) and tinnitus (Rangasayee, 2010; Manchaiah et al., 2018; Ramkumar and Manchaiah et al., 2022).

   • i.
     Problem Question: Make a list of difficulties you have due to your sound issues. Write down as many as you can think of.
   • ii.
     Life Effects Question: Make a list of the effects of your sound issue on your life. Write down as many as you can think of.

The participants were instructed to elaborate as much as possible on their difficulties and their effects on their daily lives. The answers obtained from the online form were compiled for analysis. Any further inquiries regarding the answers given by the participants were conducted through telephonic conversations.

Stage 2: ICF Coding

An analysis method known as the seven-step linking procedure (Hsieh and Shannon, 2005) was used to code the answers obtained to the ICF framework. The seven-step linking procedure was developed on qualitative content analysis. This analysis method was described by Granberg et al. (2014) and classifies hearing loss using the ICF framework. The seven-step linking procedure includes the following steps:

1. Meaningful Unit Identification:

   • ∘
     The first step involved thoroughly reviewing the responses to extract words, phrases, or segments of text that conveyed significant information or insight.
   • ∘
     These meaningful units represented discrete expressions of participants’ experiences and perceptions regarding misophonia.
2. Defining Significant Concept(s):

   • ∘
     The identified meaningful units were analyzed to determine the significant concepts they represented.
   • ∘
     This step focused on abstracting the core idea or message conveyed by each unit while maintaining its original context and meaning.
3. Underlying Meaning Interpretation:

   • ∘
     Each significant concept was then interpreted to uncover its underlying meaning.
   • ∘
     This involved contextual analysis to ensure that the interpretation reflected the participant’s intended message, as well as its relevance to the study’s objectives.
4. Determining the Linking Unit(s):

   • ∘
     Based on the underlying meaning, linking units were established.
   • ∘
     A linking unit is a synthesized representation of a concept that can be applied consistently across similar responses, serving as a bridge between raw data and the structured coding system.
5. Appropriate ICF Category Derivation:

   • ∘
     The linking units were then assigned to appropriate categories within the ICF framework.
   • ∘
     This process involved matching the linking units to the most relevant ICF domains (e.g., Body Functions, Activities and Participation, Environmental Factors) using standardized guidelines to ensure accuracy and consistency.
6. Documenting the Linking Rule Applied:

   • ∘
     The linking rules used to assign codes were carefully documented.
   • ∘
     These rules provide clear justification for the coding decisions, ensuring transparency and allowing for reproducibility of the analysis.
7. Verifying Representativeness of the ICF Categories Chosen:

   • ∘
     Finally, the assigned ICF categories were reviewed to verify their representativeness and appropriateness.
   • ∘
     This step ensured that the selected categories accurately reflected the participants' experiences and adhered to the ICF framework’s structure.

The analysis began with identifying words that can be considered meaningful units. These words were counted and analyzed to determine meaningful patterns and concepts. These concepts are interpreted to obtain the underlying meaning. From the underlying meaning, the linking unit is determined. This unit is used across multiple responses with similar ideas and patterns. The unit is then coded according to the domains under the ICF framework. The linking rules were used to determine the appropriate codes (Cieza et al., 2005; Granberg et al., 2014; Durisala et al., 2017; Manchaiah et al., 2018). The linking rules, as described in the seven-step procedure, were meticulously applied to ensure consistency and validity in coding decisions. Additionally, the representativeness of each selected ICF category was verified to confirm that it aligned with the study’s focus on the impact of misophonia.

The responses to the open-ended questions were analyzed and coded by two experienced coders who were extensively trained in the use of the ICF framework. Their training included formal instruction in ICF coding procedures, as well as hands-on practice applying the framework to qualitative data. Both coders had prior experience in using the ICF framework in research and had published peer-reviewed articles demonstrating their expertise in ICF-based analysis.

1. Independent Coding:

   • ∘
     Each coder independently reviewed and analyzed the participant responses, assigning codes based on the ICF framework.
   • ∘
     The framework’s domains—Body Structures, Body Functions, Activity Limitations, Participation Restrictions, Environmental Factors, and Personal Factors—provided a structured approach for categorizing responses.
2. Handling Discrepancies:

   • ∘
     When discrepancies arose between the two coders’ assignments, these were noted and subjected to further discussion.
   • ∘
     If the two coders could not reach an agreement, a third, equally qualified coder was consulted. The third coder provided an independent review of the data and proposed a resolution based on the ICF linking rules and established guidelines.
3. Consensus Building and Decision-Making:

   • ∘
     The involvement of a third coder ensured a systematic and unbiased approach to resolving differences.
   • ∘
     A final decision was made collaboratively, prioritizing consistency and adherence to the ICF coding framework.
4. Enhancing Reliability:

   • ∘
     This multi-coder process enhanced the reliability and validity of the coding.
   • ∘
     Independent coding by trained individuals, followed by resolution of discrepancies through a third-party review, minimized subjective bias and ensured that the assigned codes accurately reflected the data.

Statistical Analysis

The statistical analysis was done using IBM Statistical Package for Social Sciences (SPSS) Version 26.0 (IBM Corp., Armonk, NY) and GraphPad Prism version 9.3.1 software (GraphPad Software, San Diego, CA). Descriptive statistics for means and standard deviation were obtained. The total number of responses to the PQ and LEQ questions was obtained. A normality check was performed using Shapiro-Wilk’s test. Based on the normality test results, the Wilcoxon signed-rank test was conducted to check for the significant difference between the number of responses. The Mann–Whitney U test was used to determine whether there was a significant difference between genders. The effect size was calculated for significant results using Rosenthal and Rubin’s measure of effect size (Rosenthal and Rubin, 2003). Spearman’s rho correlation coefficient was tested to determine the relationship between the problems mentioned in the PQ and LEQ questions with AMISO-R.

RESULTS

The current study aimed to profile the problems and life effects endured by individuals with misophonia using the ICF framework. Fifty-one individuals with misophonia were asked two open-ended questions through an online form. Their responses were drafted and linked to ICF codes by the coders. Shapiro-Wilk’s test of normality showed that the data of this study are not distributed normally (p < 0.05). Therefore, nonparametric tests were administered for inferential statistics. The results of the study are detailed below.

Estimation of Problems and Life Effects of Misophonia

The two open-ended questions resulted in 294 responses (PQ: 222, LEQ: 72). The meaningful responses ranged from 1–12 for PQ and from 0–7 for LEQ. Participants provided one to four responses for PQ and zero to three responses for LEQ, as illustrated in Figure 1. The average response per participant was 4.35 and 1.41 for PQ and LEQ, respectively.

Figure 1.

(Panel A) The number of meaningful responses reported by the participants in problem questions (the x axis represents the number of response codes and the y axis represents frequency for each count of response code). (Panel B) The number of meaningful responses reported by the participants in Life Effect Questions (the x axis represents the number of response codes and the y axis represents frequency for each count of a response code).

Significant differences were noted in the total number of responses between the two questions (/z/ = 5.63, p < 0.001, r = 0.78). There was also a significant difference between the two questions in terms of the domains body function (/z/ = 5.52, p < 0.001, r = 0.77), activity limitation and participation restriction function (/z/ = 3.59, p < 0.001, r = 0.50), and personal factors (/z/ = 2.44, p < 0.014, r = 0.34). However, no significant difference was observed between the two questions for the domain of environmental factors (p = 0.54), as seen in Table 1.

Table 1.

Number of Responses in Each of the ICF Domains Listed in PQ and LEQ

Category	PQ mean (SD)	LEQ mean (SD)	Wilcoxon (Z)	Significance (p)	Effect size (r = Z/$\surd \mathrm{N}$)
All responses	4.35 (2.925)	1.41 (1.699)	–5.635	0.000	−0.78
Impairment of Body Function	1.47 (0.880)	0.35 (0.522)	–5.528	0.000	−0.77
Activity Limitations and Participation Restrictions	1.75 (1.798)	0.75 (0.997)	–3.593	0.000	−0.50
Environmental Factors	0.45 (0.901)	0.39 (1.185)	−0.600	0.549
Personal Factors	0.33 (0.653)	0.08 (0.337)	–2.446	0.014	−0.34

LEQ = Life Effects Question; PQ = Problem Question; SD = standard deviation.

The individuals with misophonia had the highest mean scores in the activity limitations and participation restrictions for both questions (PQ mean = 1.75, LEQ mean = 0.75). The results of the Wilcoxon signed-rank test showed significant difficulty in focusing attention under activity limitations and participation restrictions (/z/ = 2.39, p < 0.017, r = 0.33). No significant differences between the genders were seen for impairment of body function (p = 0.44), as tabulated in Table 2.

Table 2.

Effect of Gender on Each of the ICF Domains

Category	Mean (SD)	Z	Significance (p)	Effect size (r = Z/$\surd \mathrm{N})$
Impairment of Body Function	1.82 (1.178)	−0.764	0.445
Activity Limitations and Participation Restrictions	2.49 (2.327)	−2.391	0.017	−0.33
Environmental Factors	0.84 (1.515)	−2.349	0.019	−0.32
Personal Factors	0.41 (0.753)	−0.555	0.579

SD = standard deviation.

Spearman’s rank correlation between AMISO-R scores and the LEQ responses revealed a weak relationship with Environmental Factors (r = 0.29). There was a meaningful moderate positive relationship between the responses from both open-ended questions and the AMISO-R scores for all categories and Environmental Factors alone. No significant correlation was observed for Impairment of Body Functions, Activity Limitation, Participation Restrictions, or Personal Factors (p > 0.05). These results are given in Table 3.

Table 3.

Correlation Between AMISO-R Scores and PQ and LEQ for Each of the Domains

Category	Correlation coefficient (r)	Significance (p)
All Categories
PQ	0.413	0.003
LEQ	0.020	0.890
Total	0.032	0.017
Impairment of Body Function
PQ	0.230	0.871
LEQ	−0.217	0.126
Total	−0.087	0.544
Activity Limitations and Participation Restrictions
PQ	0.499	0.000
LEQ	0.185	0.194
Total	0.483	0.000
Environmental Factors
PQ	0.217	0.126
LEQ	0.292	0.038
Total	0.335	0.016
Personal Factors
PQ	0.062	0.666
LEQ	−0.032	0.826
Total	0.064	0.653

LEQ = Life Effects Question; PQ = Problem Question.

Activity Limitations and Participation Restrictions

Activity Limitations and Participation Restrictions were most frequently occurring, with 131 responses, as shown in Table 4. There were 93 responses to PQ and 38 responses to LEQ. The most affected category was “Focusing attention” (d160), with 25 responses. This was succeeded by “Higher education” (d830), “Conversation” (d350), and “Socializing” (d9205). Significant gender differences were observed in the measures of Activation Limitation and Participation Restrictions (p = 0.017), as shown in Table 2.

Table 4.

Frequency Counts of the Responses Under Activity Limitations and Participation Restrictions

Function	ICF codes	PQ (n = 93)	LEQ (n = 38)	Total (n = 131)
Focusing attention	d160	22	3	25
Higher education	d830	11	10	21
Conversation	d350	16	1	17
Socializing	d9205	5	6	11
Focusing attention on the environment	d1601	8	1	9
Thinking	d163	8	0	8
Carrying out daily routine	d230	3	5	8
Listening	d115	5	1	6
Regulating behaviors within interactions	d7202	4	2	6
Reading	d166	3	1	4
Focusing attention on the person	d1600	3	0	3
Basic interpersonal interactions	d710	1	1	2
Shopping	d6200	2	0	2
Handling stress	d2401	1	1	2
Conversing with many people	d3504	0	1	1
Using communication devices and techniques	d360	0	1	1
Using transportation	d470	1	0	1
Looking after one’s health	d570	0	1	1
Informal relationships with friends	d7500	0	1	1
Informal relationships with peers	d7504	0	1	1
Child–parent relationships	d7601	0	1	1

ICF = International Classification of Functioning, Disability, and Health; LEQ = Life Effects Question; PQ = Problem Question.

Impairment of Body Function

The second-most-affected domain was Body Functions, with 94 responses in total. Seventy-six responses were from PQ, and 18 responses were from LEQ. The most affected category was “Appropriateness of emotion” (b1520), followed by “Range of emotion” (b1522) and “Sleep functions” (b134). The frequency count of the categories affected by Impairment of Body Function are tabulated in Table 5. No significant gender differences were found for impairment of body function (p = 0.45), as shown in Table 2.

Table 5.

Frequency Counts of the Responses Under Impairment of Body Function

Function	ICF codes	PQ (n = 76)	LEQ (n = 18)	Total (n = 94)
Appropriateness of emotion	b1520	38	6	44
Range of emotion	b1522	17	3	20
Sleep functions	b134	8	7	15
Maintenance of sleep	b1342	3	0	3
Pain in head and neck	b28010	1	1	2
Emotional functions	b152	1	0	1
Amount of sleep	b1340	1	0	1
Onset of sleep	b1341	1	0	1
Quality of sleep	b1343	1	0	1
Temperament and personality functions	b126	1	0	1
Extraversion	b1260	1	0	1
Agreeableness	b1261	1	0	1
Psychic stability	b1263	1	0	1
Energy level	b1300	1	0	1
Memory functions	b144	0	1	1

ICF = International Classification of Functioning, Disability, and Health; LEQ = Life Effects Question; PQ = Problem Question.

Environmental Factors and Personal Factors

The least affected domain, with 43 responses, was Environmental Factors, as shown in Table 6. It consisted of 23 responses from PQ and 20 responses from LEQ. The most frequently occurring category was “Friends” (e320), with 11 responses. This category was followed by “Immediate family” (e310), “Acquaintances, peers, colleagues, neighbors, and community members” (e325), “Individual attitudes of friends” (e420), and “Individual attitudes of acquaintances, peers, colleagues, neighbors, and community members” (e425). Significant gender differences were observed in the measures of environmental factors (p = 0.019); however, no significant differences were found for personal factors (p = 0.58), as shown in Table 2.

Table 6.

Frequency Count of Responses under Environmental Factors

Function	ICF codes	PQ (n = 23)	LEQ (n = 20)	Total (n = 43)
Friends	e320	7	4	11
Immediate family	e310	5	1	6
Acquaintances, peers, colleagues, neighbors and community members	e325	2	3	5
Individual attitudes of friends	e420	3	2	5
Individual attitudes of acquaintances, peers, colleagues, neighbors, and community members	e425	1	4	5
Strangers	e345	1	2	3
Individual attitudes of immediate family members	e410	2	1	3
Individual attitudes of strangers	e445	0	3	3
Health professionals	e355	1	0	1
Architecture and construction services, systems and policies	e515	1	0	1

ICF = International Classification of Functioning, Disability, and Health; LEQ = Life Effects Question; PQ = Problem Question.

The most common personal factor was avoidance, with 13 responses (10 in PQ and 3 in LEQ). The other personal factors reported included Coping Strategies and Habits. The personal factors are tabulated in Table 7.

Table 7.

Frequency Count of Responses Under Personal Factors

Functions	PQ (n = 16)	LEQ (n = 4)	Total (n = 20)
Avoidance	10	3	13
Coping strategies	5	1	6
Habits	1	0	1

LEQ = Life Effects Question; PQ = Problem Question.

DISCUSSION

This study used open-ended questions to investigate the problems and life effects affecting 51 individuals with misophonia. The responses to the open-ended questions were linked and coded utilizing the ICF framework. The questions obtained a total of 294 responses from the participants. Most individuals provided one to four meaningful answers to both questions, revealing the multidimensional nature of misophonia through detailed descriptions of its emotional, physiological, and social effects. This qualitative approach enabled a deeper understanding of the disorder, because it allowed individuals to express the complexity of their experiences. Furthermore, the varied responses facilitated the identification of common and unique individual experiences that can be systematically categorized using the ICF framework to further analyze the functional and psychosocial implications of misophonia. Consequently, employing open-ended questions proved invaluable in capturing the extensive and varied effects of misophonia.

Participation in activities (e.g., focusing attention, socializing, conversation) was most affected by misophonia, followed by impairments in body function, environmental factors, and personal factors. No studies have used the ICF framework to explore misophonia. However, some studies have used the ICF framework to determine the problems and life effects caused by tinnitus in the existing literature. Tinnitus and hyperacusis occur as conditions associated with misophonia. Sztuka et al. (2010) reported that 10 percent of their study sample of 44 patients with tinnitus and hearing within the reference range had misophonia. In a study examining 149 patients consulting a tinnitus and hyperacusis clinic, patients with misophonia made up 57 percent of the sample, and of these individuals, 28.9 percent had only misophonia and no hyperacusis. Having established the association between misophonia, tinnitus, and hyperacusis, it becomes crucial to understand the outcomes of tinnitus studies conducted within the ICF framework. Manchaiah et al. (2022) reported that for tinnitus, activity limitations and participation restrictions were the most prevalent consequences, followed by impairments in body functions and limited effect due to contextual factors. A similar study conducted by Manchaiah et al. (2018) among the population of the United Kingdom revealed contradictory results. In this study, impairment in body functions was the most dominant effect, followed by activity limitations and participation restrictions, and a limited effect was caused by contextual factors.

Functioning and Disability

The category with the most responses under activity limitation and participation restriction, at 25 responses, was “focusing attention” (d160). In the present study, participants reported that in the presence of the trigger stimuli they focused their attention on the trigger, and it was difficult to divert their attention away from it. Edelstein et al. (2013) investigated the attentional abilities of individuals with misophonia, reporting similar experiences among those with misophonia. In our study, 9 out of 11 participants reported the trigger impeded their attentional abilities. They reported being hyperfocused and unable to ignore the trigger sounds. They also reported difficulty paying attention at a movie or in class when a person is producing the trigger. A study evaluating selective attention reported that those with misophonia may have impaired selective attention when exposed to sounds that trigger misophonic reactions (Silva and Sanchez, 2019). Likewise, Frank et al. (2020) also reported similar findings for individuals with misophonia who were asked to attend to visual stimuli during and after hearing aversive stimuli.

The second most affected category was “higher education” (d830). Most participants in the present study were undergraduate or graduate students who expressed that misophonia affected their academic functioning. Multiple studies have used university students as their study sample when investigating misophonia. Wu et al. (2014) investigated impairment associated with misophonic symptoms in 484 undergraduate students. The study revealed moderate or higher levels of functional impairment among 14.9 percent for work and school-related functioning. A similar study by Zhou et al. (2017) showed that 25.7 percent of 415 Chinese undergraduate students revealed moderate or higher work or school functioning impairment.

The third and fourth most affected categories were “conversion” (d350) and “socialization” (d9205). The present study participants said engaging in conversions with aversive sounds present was challenging. They also admitted that it was difficult to participate and enjoy different social situations fully. Studies on impaired social functioning among those with misophonia are available. Moderate or higher levels of impairment in social functioning were observed in 6.4 percent of the study sample when investigating undergraduate students (Wu et al., 2014). Likewise, Zhou et al. (2017) stated that 11.0 percent of 415 participants reported impaired social functioning. In a case report, the participants expressed significant social impairment, including an inability to enjoy social meals and avoidance of social events (Bernstein et al., 2013).

Additionally, in our study, the category affected the most under impairment of body function was “appropriateness of emotion” (b1520), followed by “range of emotion” (b1522) and “sleep functions” (b134), as illustrated in Figure 2. Nearly all the participants in the present study reported experiencing negative emotions when hearing the triggering sounds. They expressed anger, disgust, annoyance, and irritation. Some individuals reported an impulse to respond verbally or physically toward the source producing the aversive sound. They understood that their reaction was disproportionate and exaggerated but expressed feeling helpless and agitated due to the presence of the aversive sound. Similar reports of impaired emotional functioning are available in the existing literature. Edelstein et al. (2013) reported that those with misophonia stated a range of negative feelings, including anger or rage, intense anxiety, panic, and extreme irritation. Likewise, Schröder et al. (2013) stated that exposure to aversive stimuli led to an immediate physical reaction among their study sample of 42 patients. It started as irritation or disgust for 59.5 percent and 40.5 percent of the sample, respectively, that instantaneously became anger. Twelve of 42 patients reported becoming verbally aggressive. Seven patients admitted to physical aggression directed toward objects. Five patients admitted to being physically aggressive with their partner at the time.

Figure 2.

Bar graph depicting the most affected categories for all domains.

Many participants in our study have reported difficulties falling asleep or maintaining sleep when exposed to aversive sounds. This finding aligns with the study by Bishop (2023), which documented a significant relationship between misophonia symptoms and impaired sleep functions. Similarly, Neal and Cavanna (2013) described a case involving a patient with Tourette syndrome and misophonia who had experienced sleep problems since childhood. The link between misophonia and other psychological conditions, such as depression, also warrants attention. For instance, Siepsiak et al. (2020) noted that 8.5–12.76 percent of inpatients with depression were diagnosed with misophonia, whereas Bishop (2023) reported a high prevalence of depression among those with misophonia, suggesting a complex interplay between these disorders.

Contextual Factors

The most affected category under activity limitation and participation restrictions were “friends” (e320), with 11 responses. It was followed by “immediate family” (e310), “acquaintances, peers, colleagues, neighbors and community members” (e325), “individual attitudes of friends” (e420), and “individual attitudes of acquaintances, peers, colleagues, neighbors and community members” (e425), as tabulated in Table 4. In the present study, participants gave accounts of friends teasing them about their trigger by producing it despite being told that it is aversive to them. Participants also mentioned losing their temper toward their immediate family members and friends, leading to their relationships being affected by their misophonic symptoms. Some participants reported avoiding certain acquaintances and peers as they produced the aversive sound, and they internalized their negative emotions toward the person producing it. Case reports with similar experiences are available in the existing literature. A case report on two young patients with misophonia reported negative feelings toward family members, friends, peers, teachers, and strangers. One patient stated significant irritation and distress caused by family members and friends compared to strangers. The second patient reported outbursts toward family members, leading to having meals in separate rooms and avoiding conversations with their parents. They also reported suppressing their irritation and distress toward teachers and peers (McGuire et al., 2015).

Avoidance was the most frequently reported personal factor, with 13 responses, as illustrated in Figure 2. Participants reported actively avoiding places, persons, and situations that caused their triggers to occur. This avoidance strategy affected their ability to participate fully in everyday life events. It also affected their interpersonal relationships, especially with friends and immediate family members. The available literature reports on the use of avoidance to cope with misophonia. Schröder et al. (2013) reported avoidance of situations with the aversive sounds by all 42 patients in their study. Similarly, Wu et al. (2014) stated that individuals with misophonia adopted avoidance as maladaptive behavior after the triggers elicited negative emotions. Edelstein et al. (2013) stated that misophonic individuals avoided situations with aversive sounds as a coping strategy.

The present study determined a weak positive relationship between AMISO-R scores and LEQ responses for environmental factors. A moderate positive relationship existed between the AMISO-R scores and the total number of responses for all categories and Environmental Factors alone. No studies exist that support or contradict the relationship between AMISO-R scoring and the domains of ICF. However, the current study did indicate that as the AMISO-R score increased, the responses to the PQ and LEQ questions increased. The responses were greater for PQ than for LEQ. Thus, future studies can examine the extent to which the severity of misophonic symptoms affects everyday functioning.

Relation to Gender and AMISOS-R Scores

In our study, we analyzed gender differences across the various domains of the ICF. Significant differences were observed in the domains of activity limitations, participation restrictions, and environmental factors. However, no significant differences were observed in personal factors and impairments of body function. In contrast, prior research using the ICF framework to explore tinnitus did not interpret gender differences across individual domains (Manchaiah et al., 2018). These studies primarily focused on the relationship between gender and overall responses to the PQ and LEQ, reporting only a weak association. The literature on the impact of gender on misophonia is mixed. Whereas some studies report no gender effect on the severity of misophonic symptoms or on its prevalence (Wu et al., 2014; Quek et al., 2018), others have identified a higher prevalence among women (Erfanian et al., 2018; Siepsiak and Dragan, 2019). This variability suggests that the influence of gender on different ICF domains in misophonia warrants further investigation.

CONCLUSIONS

Although research on misophonia has rapidly increased over the last decade from neurological (Edelstein et al., 2013; Kumar et al., 2021; Grossini et al., 2022), audiological (Aazh et al., 2022; Aryal and Prabhu, 2023a,b; Aryal and Prabhu, 2024a,b,c; Suraj et al., 2024), and psychological perspectives (Cassiello-Robbins et al., 2021; Guetta et al., 2022; Rosenthal et al., 2022; Barahmand et al., 2023), its impact has not been investigated using the WHO ICF classification. The present study investigated the impact of misophonia on daily life through two open-ended questions (PQ and LEQ). Findings revealed that the domain of Activities and Participation was most affected, followed by Body Functions and Environmental Factors. These results underscore the heterogeneous nature of misophonia’s impact and highlight the utility of open-ended questions in capturing its varied effects. Incorporating open-ended questions alongside standardized measures may enhance assessment efficacy by allowing individuals with misophonia to convey detailed personal experiences. Furthermore, this study suggests that future assessment and treatment protocols for misophonia could benefit from a multidimensional framework to better address the disorder’s complexity. Future studies should aim to explore the impact of misophonia across different age groups.

Abbreviations

AMISO-R

revised version of the Amsterdam Misophonia Scale

ICF

International Classification of Functioning, Disability and Health

LEQ

Life Effects Question

PQ

Problem Question

WHO

World Health Organization