Introduction

Misophonia is a neurological condition where specific sounds trigger a strong emotional and physical response in a person that they are unable to control. The most common trigger sounds are produced by other humans, including chewing, sniffing, throat clearing, and whistling.

Phonophobia is a subtype of misophonia characterised by the fear in anticipation of, or in response to sudden, loud, everyday sounds. This may include noises associated with the kitchen, fireworks or slamming doors.¹

These two conditions are distinct, though they are often confused with each other. In this article, we will outline the differences between the two conditions.

Understanding misophonia

Misophonia can begin as early as age five, however, symptoms typically develop at twelve years old.² It is triggered by a specific sound (or sounds) that most people would find easy to ignore or perhaps not even notice. However, people with misophonia find these trigger noises unbearable. Sometimes misophonia can also cause sensitivity to visual movements, such as someone jiggling their leg.

People with misophonia understand that their reaction to these noises is disproportionate. However, they are unable to control their reactions to the noise and often find the situation extremely upsetting.

Common triggers

Misophonia is usually triggered by auditory input, such as sounds made by the nose or mouth of other individuals.³ 

Some examples of auditory triggers include:

• Chewing
• Breathing
• Sniffing
• Coughing
• Throat clearing
• Humming
• Whistling
• Gulping
• Pen clicking
• Rustling food packages

Misophonia triggers are not limited to noise; it can also be triggered by visual stimuli. This includes observing repetitive movements, such as another individual jiggling their foot or leg.³

Emotional reactions 

People with misophonia report strong negative feelings like disgust, anger, panic, distress, and anxiety that are triggered by specific sounds. This can cause them to have a freeze, flee or fight response.⁴

The “freeze” response is when you become overly sensitive to any situation involving your visual or sound triggers. You may remain alert and unable to relax, in case a sound or visual trigger occurs. 

The “flight” response may cause you to try and escape a situation involving the trigger, such as leaving the room or avoiding certain situations altogether. 

The “fight” response involves behaving passive-aggressively towards the person making the noise, or experiencing outbursts of rage you cannot control.⁴

These emotional reactions can be extreme and life-changing. People with misophonia often become socially isolated, as they feel they have to avoid situations involving people to avoid becoming triggered. In severe cases, this can lead some people with misophonia to consider or commit suicide.³

People with misophonia are more likely to have a co-occurring mental health condition, such as:⁴ 

• Depression
• Anxiety
• Obsessive-compulsive disorder (OCD)

Such conditions can have a significant impact on your quality of life.

Physical reactions 

In addition to an emotional response, misophonia causes an abnormal physical response triggered by auditory or visual triggers. 

This includes an increase in the individual’s heart rate and galvanic skin response (the amount they sweat).⁵ They may also experience unwanted sexual arousal. This is due to the overactivation of the autonomic nervous system, which is responsible for:⁶

• Arousal
• Heart rate
• Digestion
• Bladder control
• Temperature regulation
• Blood pressure
• Breathing

The autonomic nervous system cannot be consciously controlled, so the person with misophonia cannot prevent these symptoms from happening and may be distressed by the way their body reacts. 

What causes misophonia?

People with misophonia have an unusually large response in their anterior insular cortex (the part of the brain that monitors your internal awareness, such as digestion, feelings, and emotional response).² They also exhibit changes to the nerves in the ventromedial prefrontal cortex (the part of the brain involved in decision-making, processing negative emotions, and social understanding like recognising facial expressions).⁷

Humans have mirror neurons that are activated when we observe someone else perform an action, such as eating or chewing. Some research suggests that these mirror pathways are overly active in people with misophonia, and this may be what brings on the exaggerated response to certain sounds and vision stimuli.³

However, the exact cause of misophonia is unknown. Some studies suggest that it may be a conditioned, or learned, response after a negative experience, such as feeling disgust in response to a noise (e.g., a family member chewing loudly). More research is needed to understand this.⁸

Risk factors 

While the exact cause of misophonia is unknown, certain factors make it more likely that a person will develop misophonia. These factors include:⁹

• A family history of misophonia
• People assigned female at birth (AFAB) 
• Negative experiences involving the trigger stimuli
• OCD
• Anxiety 
• Panic disorder
• Depression

Diagnosis

Diagnosis may involve a healthcare professional taking a medical history and asking you to complete questionnaires. However, misophonia is often underdiagnosed. This may be due to a lack of understanding or awareness of the condition. This can make it difficult to get a diagnosis and access support. There are also no recognised diagnostic criteria for misophonia, making the condition harder to identify, although studies suggest that it would help with the diagnosis.¹⁰

Many people with misophonia only find out about the condition by researching their symptoms themselves.

Treatment

Currently, there is no clinically proven treatment available. This is in part due to the lack of research.¹⁰ However, cognitive behavioural therapy has been found to benefit some people with misophonia.¹¹ Online support groups such as the UK Misophonia Support Group may be helpful.

Understanding phonophobia

If normal, everyday sounds feel uncomfortably loud or even painful, you may have phonophobia. People with phonophobia experience fear and anxiety as they worry that they may be placed in a situation where a loud noise will cause physical pain, or exacerbate a current medical problem (e.g., tinnitus).¹²

Phonophobia can affect someone’s everyday life as they may isolate themselves due to their fear of unexpected loud noise. This can make aspects of daily living, such as work, social interactions, television, music, supermarkets etc. very difficult to experience.

What causes phonophobia?

Phonophobia often occurs in people who:

• Have had an injury to the brain
• Have had an injury to the inner ear
• Have anxiety
• Have a hearing impairment
• Have difficulties with processing information and attention

Diagnosis

If you think that you have phonophobia, you should speak to your audiologist or general practitioner. You may be referred to a neurologist or psychiatrist for further investigation. 

Your doctor can diagnose phonophobia and provide a treatment plan to manage your symptoms. This will likely include testing your hearing to see if there is any damage or infection.

Treatment

Your health professional team will support you in managing your phonophobia. This may include:

• Recommending you not to wear earplugs or headphones as this can make you more sensitive to noises around you
• Treating any underlying mental health problems (e.g., anxiety) or medical conditions 

You may be recommended exposure therapy which can help gradually expose you to noise in a way that helps desensitise you.

Summary

Misophonia and phonophobia are similar conditions involving a physical and emotional response to noise. Individuals will try to avoid certain situations involving trigger noises, which can lead to isolation. They are both associated with mental health conditions, such as anxiety. However, misophonia begins in adolescence and is characterised by a negative emotional and physical response to specific sounds, regardless of their volume. Treatment options are limited, but some individuals find CBT helpful. Phonophobia is usually caused by an injury to the inner ear or the brain and is characterised by the fear of any loud noise. Treatment may be targeted at the underlying condition and may involve graded exposure therapy.

If you think you may have misophonia or phonophobia, speak to your GP or other medical health professional for help.