Misophonia is described as a condition marked by negative reactions toward primarily oral and nasal auditory stimuli, such as smacking or slurping. These are usually conceptualized as “triggers” as they are responsible for the sequelae of subsequent intense emotional (e.g., irritation, anxiety, disgust, and tension), physiological (e.g., increased heart rate), cognitive (e.g., internalizing or externalizing appraisal of own reaction), and behavioral (e.g., avoid the stimuli) reactions (1). Misophonia is currently not included in the International Classification of Diseases (ICD-11) (2) or Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (3) although most research demonstrates significant symptom presentation which seems unrelated to hearing levels or perceptual abilities (1, 4, 5).

The existing consensus definition on misophonia includes a general description (1) but where and how to define a clinical threshold for the specific features and their combination is a challenge still to be mastered. Accordingly, estimates on how often misophonia occurs [e.g., reported here, (6–17)] are characterized by a considerable heterogeneity regarding measures and suggested cutoffs. For example, in the cited studies, ten different measures in six different languages were used to assess misophonia, mostly using self-reports such as the Amsterdam Misophonia Scale (A-MISO-S) (18), the Misophonia Questionnaire (MQ) (16), or one item only (7). Some studies included a diagnostic interview on mental disorders and/or misophonia as a disorder (14, 18, 19), which includes functional impairment. The heterogeneity led to frequency estimates between 5 and 49% across studies, with sample sizes ranging from 94 (14) and 2,519 (9), including two samples representative of the general population (9, 10). For estimates based on self-report, 5% (9) and 7.3% (15) may be the best evidence currently available, for the first study because of the large representative sample, but the estimate is based on one item only (item 18 = the MQ severity scale); for the latter because of the sample size and the use of the Duke-Vanderbilt Misophonia Screening Questionnaire (DVMSQ), which includes impairment in its screening algorithm. Still, Swedo et al. (1) concluded in their Delphi study that a prevalence estimate would be premature.

The higher estimates [e.g., about 35–50% in a help-seeking or student sample (8, 11)] usually include a mild symptoms group as suggested by the developers of the A-MISO-S (18). However, it is unclear if mild symptoms correspond to a clinical level of a mental disorder including sufficient functional impairment or suffering. This is somewhat implied as five groups can be identified with the A-MISO-S and only one group is described as “no symptoms/subclinical.” Questions on the extent of distress and functional impairment are included; however, it is not required to indicate impairment or suffering to score in the clinical groups. The MQ in contrast derives the clinical group assignment from one item only, leading to estimates for clinical symptoms of 16.6–19.9% in college students (16, 20).

Misophonia symptoms have been reported to be associated with symptoms of other mental disorders and lower quality of life in clinical as well as student samples. In their large clinical sample, Jager et al. (19) reported mild symptoms of anxiety and depression and lower quality of life. The comorbidity rate was 28%, with major depressive, attention deficit (hyperactivity), and obsessive–compulsive disorder as the most common comorbid disorders. The prevalence of these disorders was elevated in the misophonia sample compared to the general population. Obsessive–compulsive personality traits were also very common in the clinical sample (23.8%). Accordingly, Wu et al. (16) reported medium significant correlations of misophonia symptoms and anxiety, obsessive–compulsive, and depressive symptoms in their student sample. Emotion regulation difficulties were reported to be associated with misophonia symptoms, even beyond the associations with depressive and anxiety symptoms (21, 22). As both, the experienced emotions toward certain sounds and the appraisals of the emotional reaction (externalizing: blaming others; internalizing: blaming oneself), differ in individuals with versus without misophonia (23), a closer investigation of emotion regulation processes appears warranted. Many individuals report misophonic symptoms to occur with family members and/or significant others but not, or at least not to the same extent, to unfamiliar others. We were therefore interested to evaluate if there is any relation to interpersonal aspects that may function as a discriminating factor between individuals with or without misophonic disorder.

In the present study, we examined responses from an online survey advertised through different media [(online) newspaper, social media, and mailing lists] to recruit individuals who are affected as well as unaffected by misophonia. The study had three aims: First, to assess the frequency of self-reported misophonia symptoms and compare the scoring across various common symptom measures in a large sample (n = 1,881). Second, to perform a clinical group assignment based on functional impairment due to misophonia symptoms and examine differences between these groups regarding symptoms, associated characteristics (e.g., triggers), general psychopathology, interpersonal emotion regulation, and quality of life. Third, to provide cutoffs for existing symptom measures to differentiate functional impairing from non-impairing misophonia based on the same measure of functional impairment for each symptom measure.

The present study aimed at assessing the frequency of misophonia symptom (severity) in a large non-representative sample according to common misophonia measures, describing differences in the clinical picture of misophonia for those with versus without significant functional impairment, and to provide cutoffs on misophonia questionnaires for the purpose of identifying those best who reported significant functional impairment in their daily lives due to misophonia, and as such, are most likely individuals who would need access to and benefit from treatment for this condition.

First of all, this is to our knowledge the first study to compare scoring across various misophonia symptom measures in a large sample of n = 1,881. We found 85% of the individuals in the mild-to-severe misophonia symptoms range based on the A-MISO-S or AMISOS-R. The MQ and MAQ only identified 50% of this sample to be in the clinical range. The measure comparisons revealed that 12 to 28% of individuals scored in the “mild group” of one but the “moderate–severe” group of another misophonia measure, indicating that the measures at least partly assess different aspects of misophonia. The pattern was even more pronounced for the functional impairment measure WSAS compared to symptom severity measures, with a proportion of up to 37%. This underlines the subordinate role of misophonia-caused functional impairment in the classification into mild and moderate–severe of these measures. It demonstrates that the majority of classifications within misophonia measures so far are based primarily on severity (e.g., simply reflecting the extent to which a person is triggered by sounds) and put less emphasis on the difference between impairment due to and severity of the misophonic reaction. The consequences may be less significant the more severe the misophonic reaction, as with increasing severity is it likely to also find more impairment. However, especially in the moderate range of misophonic reactions, this discrimination may be significant. The developers of the A-MISO-S and AMISOS-R, respectively, name the lowest symptom class “subclinical,” implying that all other symptom classes exceed the clinical threshold: the mild symptom class and the moderate and severe class (18, 29). Based on our results, we suggest to conceptualize the mild symptom class still as subclinical, rather reflecting variations in this specific form of decreased sound tolerance than meeting threshold for a clinical disorder. This would also be in line with our attempt to identify a disorder (clinical threshold) by using misophonic-related functional impairment in daily lives as a quantification of one of the suggested revised diagnostic criteria for misophonia (19). When differentiating the sample in those reporting clinically significant impairment, we identified 44% of the present sample to be affected by a clinical expression of misophonia. This is much lower than the number of participants who self-assigned to the condition before they started the survey (87.5%). Similarly, Williams et al. identified 7.3% as clinical and 10% as subclinical misophonia cases using the DVMSQ that differentiated between the groups by a functional impairment item (15). On the one hand, these findings demonstrate that experiencing symptoms, such as not liking specific sound stimuli, is overestimating the presence of a functional impairing condition. On the other hand, it underlines that self-identification with misophonia is rather based on a dimensional construct than a categorical disorder approach. We follow up on a suggestion made by a reviewer of this article (Zack Williams) and propose to use the term “misophonic disorder” for a clinically relevant manifestation of this condition only and use “misophonic reactions” when subclinical manifestations are the focus of research on misophonia. Thus, we suggest misophonia might be used as an umbrella term for all manifestations, analog to for example, depression for depressive symptoms and depressive disorders or in the context of tinnitus symptoms (and tinnitus as a disorder) (47). The dimensional approach still leaves open what defines the respective underlying construct (s). We propose to follow up on this aspect in future research investigating whether the tendency of experiencing misophonic (emotional) reactions varies between individuals; and if this individual tendency is rather representing a risk factor for the development of a misophonic disorder (alike behavioral inhibition in anxiety disorders) or if it is in itself a main criterion of the disorder and only needs to reach a certain threshold. For example, it might be important to compare the patterns of symptoms in non-misophonic, subclinical, and clinical misophonia groups across multidimensional measures.

We determined large group differences between the subclinical and the clinical manifestation with literally more severe/more frequent symptom scores across all measures, independently of whether they focus on misophonic symptoms or general psychopathology including depressive, anxiety, or obsessive–compulsive symptoms. These differences also extend to other concepts, such as quality of life with medium and interpersonal emotion regulation skills with small effect sizes. This study is adding a comparison group study to the existing evidence and it suggests mostly more severe reactions in the clinical compared to the non−/subclinical group (16, 19) and extends findings on emotion regulation (22) to interpersonal emotion regulation skills. However, as in (48), there is also evidence for qualitative differences, e.g., in emotional reactions to misophonic stimuli.

Regarding potential comorbid or differential diagnoses and phenomena, the pattern is similar for diagnosed hyperacusis and phonophobia with odds around 7 times higher for these diagnoses in the clinical versus non−/subclinical group. However, the rates of diagnosed tinnitus and experiences of ASMR and synesthesia were not significantly different and reported less often in the group with clinical versus non−/subclinical manifestations of misophonia. Finally, the types of stimuli that are experienced as annoying are vastly the same across both groups, primarily sounds related to eating and breathing. This may indicate a normative power of these stimuli to elicit annoyance in many individuals, although this should be interpreted with caution in light of the high proportion of individuals self-identifying with misophonia in the current study.

However, it remains unclear why these sounds are annoying for so many people. The similarity in trigger sounds in both groups may imply cognitive and emotional processes involved in evaluating the stimuli to be key when trying to make a difference for those affected by misophonia (23). In the current study, the difference between functionally impaired and non-impaired groups rather lay in the intensity to which these stimuli were experienced and evaluated as annoying. In line with the idea mentioned earlier, we hypothesize that the difference between clinical and subclinical manifestations may be more a matter of quantity than quality (“quantity hypothesis”); that is a clinical group may not be characterized by a specific symptom profile or different (types of) stimuli that function as a trigger but may be more reflected by similar symptoms and a similar ranking of functional stimuli (i.e., with the power to trigger the specific emotional, behavioral and physiological reactions associated with misophonia). Similarly, Savard et al. (49) found support for the idea of a continuum for misophonia symptom severity from their online-survey results. Additionally, derived from results of an experimental masking paradigm with different (trigger) sounds, they found that individuals with high versus low misophonia symptoms had similar detection rates of sounds—triggers were identified best in both groups, followed by unpleasant and neutral sounds—but differed regarding the subsequent emotional reaction with higher ratings of negative emotions in the high versus low symptom group.

Interestingly, the “quantity hypothesis” appears to also apply within the clinical group: when examining differences between moderate and severe clinical presentations, all scores descriptively increase when moving to the severe group. The size of these effects varies around one standard deviation (d = 0.69–1.53), roughly, across all measures—except for the interpersonal emotion regulation questionnaire. Effect sizes for the differences drop clearly with the largest one reaching roughly d = 0.25 on “Enhancing positive affect,” and going further down to d < 0.01 on the other three scales. Thus, the differences on the interpersonal emotion regulation subscales are statistically significant (exception: social modeling). However, the effects are small and were only detectable due to the large sample size, which may suggest that the group differences for the subscales “soothing” and “perspective taking” are not clinically meaningful. At the same time, this may point at the relative significance of positive emotion regulation and the lack of adaptive regulation skills within the clinical group while both interpersonal maladaptive and adaptive emotion regulation skills distinguish clinical from subclinical presentations. The interpersonal emotion regulation questionnaire is a measure that reflects how individuals may utilize others to regulate their own emotions (41) and this specific subscale “Enhancing positive affect” is significantly correlated with reappraisal, tolerating and accepting emotion regulation skills. It may be beneficial to include a treatment module on how to deliberately improve one’s own positive affect when working with more severe cases (in addition to working on reducing maladaptive interpersonal emotion regulation for everybody in treatment). Another interpretation of these findings would be that the lack of interpersonal emotion regulation is adaptive in the clinical group as long as misophonia symptoms are still present, as individuals with misophonia may have experienced invalidation of their emotions and others might rather trigger (negative) emotions than regulate them. These suggestions need to be considered with caution because the comparisons rely on very different sample sizes per group. The percentage of those with severe presentations is proportionally small in the entire sample. Nevertheless, it is still a considerable number of individuals (n = 34) and in light of the few empirical findings helping to derive treatment recommendations, it may add some further ideas on what to include in psychological treatment (packages). Further, we mainly looked at interpersonal enhancing positive affect. This does not necessarily relate to one’s own skills. When thinking about clinical implications, one way to go may include a module of specific emotion regulation skills. However, it is unclear from our results, if individuals are generally lacking in their ability to experience positive affect or if this is more specific to interpersonal emotion regulation. In the latter case, it may also imply to include interventions related to drawing on others to support their own emotion regulation. Following the interpretation of the lack of interpersonal emotion regulation as adaptive and a result of misophonia, interpersonal emotion regulation would not be targeted in treatment but would possibly improve eventually with a decrease in misophonia symptoms. These different implications may be tested in future studies.

Another interesting result relates to the emotions experienced in response to triggers. It may be noted that misophonia measures partly differ regarding the emotional reactions they assess. While the A-MISO-S and AMISOS-R do not assess anxious/distressed reactions—in contrast to the MQ—the latter does not assess disgust. According to the MQ, annoying, anxious/distressed, and angry emotional responses to misophonic stimuli were the responses most frequently endorsed in our study. Although sad/depressed feelings also occur (similarly disgust, AMISOS-R), they ranked clearly behind anxiety and anger, mentioned only about half as often. Comparing irritation and anger, group differences in endorsement rates were larger for anger, indicating that anger might be better able to discriminate clinical from subclinical reactions. In the consensus definition of misophonia, Swedo et al. (1) name all the aforementioned emotions as “most common” reactions to triggers (pp. 10) and dispense with weighting further. In contrast, Jager et al. (19) define (only) irritation, anger and/or disgust as required emotional reaction toward triggers in their revised criteria of misophonia, and leave out anxiety. They discuss anxiety as potentially mistaken emotional response as their study participants with clinical misophonia did not mention anxiety as first (i.e., as fear reaction) but either anticipatory or secondary emotional response. Similarly, lower endorsement rates of the fear/panic item were found in the validation of the Duke-Vanderbilt Misophonia Screening Questionnaire (DVMSQ) (15). As distress and anxiety are combined in the MQ item, they cannot be disentangled in the responses. Because of the somewhat mixed findings across studies, we suggest continuing to capture all these different emotions, including disgust and anxiety, as a potential response in research studies until the evidence basis points more clearly to an emotional reaction which is the most typical and/or differentiates misophonic disorder best from subclinical misophonic reactions or other conditions.

Regarding group differences in the current study, with severity increasing, the steepest increase is observed in anxious or depressed emotional responses relative to angry and annoyed responses when exposed to annoying stimuli. Externalizing attributions may increase the externalizing emotional reactions (i.e., angry, annoyed). We speculate that this externalizing pattern might be common along the continuum of symptom severity, whereas the internalizing emotional reactions might appear more often and more strongly in those individuals with higher, clinical symptom severity and duration. Thus, providing skills to regulate specifically anger and/or attributional retraining may be another promising candidate for a treatment module—on the one hand, to prevent the significantly increased occurrence of verbally as well as physically aggressive reactions in individuals with clinical misophonia (medium effect sizes) and, on the other hand, to prevent or decrease secondary depressive reactions.

Finally, when screening for misophonia with the purpose of identifying clinical manifestations that deserve treatment-related attention, it is recommended to use a higher cutoff on the common instruments for misophonia symptoms (e.g., A-MISO-S or AMISO-R) or to add a functional impairment requirement in the interpretation of the scales. A (mental) disorder usually requires clear impairment in areas of daily life (e.g., ICD-11) (2) and health insurances usually only cover treatment expenses when a clinical threshold is met. While this diagnostic issue is best addressed with a clinician-administered interview, pre-selection, for example for inclusion in randomized controlled treatment trials, could be successfully conducted based on recommended cutoff scores. We provide several possibilities of sum score cutoffs across misophonia instruments with associated costs and benefits on sensitivity and specificity to help tailoring the cutoff score to the associated research purpose². Of those published previously (e.g., AMISO-S, AMISO-R), our recommended cutoffs are higher, and of those without cutoff recommendations so far (MQ, MAQ), we provided our suggestions. The former indicates that clinical cases may have been underrepresented in previous studies, specifically in the mild symptom class.

Assignment to a class also requires reflecting upon the best conceptual match with other examples of the overall disorder group. Focusing on the emotional reactions, one might come to different conclusions depending on which emotion (s) one focuses on. Whereas anger, irritation, or fear/anxiety indicate an emotional disorder (anxiety and mood disorders, e.g., disruptive mood dysregulation disorder), distress and/or disgust reactions point more toward an obsessive–compulsive spectrum. Even if there is rather little evidence from our study that OCD-related assumptions maybe transferred to this condition, valid conclusions still appear premature. Progress in classification also requires to reflect upon potentially effective psychological treatments. The present study supports CBT strategies already used in the treatment of misophonia such as attention training and arousal reduction (51). Further, it suggests that it may be worthwhile to assess changes in interpersonal emotion regulation in other interpersonal contexts beyond the misophonic reaction itself during treatment. If individuals experience persisting difficulties, the therapeutic strategies may be extended to interpersonal emotion regulation, for example, teaching (specific) emotion regulation skills to enhance positive affect as well as skills to reduce negative affect and anger in these non-misophonic contexts in general.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by ethics committee, Bielefeld University, Bielefeld, Germany. The patients/participants provided their written informed consent to participate in this study.

AM: formal analysis, data curation, writing—original, and writing—review and editing. NH: conceptualization, resources, writing—original, writing—review and editing, and supervision. LI: investigation, project administration, writing—review and editing. NP: investigation, project administration, and writing—review and editing. HK: conceptualization, investigation, resources, writing—review and editing, and supervision. All authors contributed to the article and approved the submitted version.

We acknowledge the financial support of the German Research Foundation (DFG) and the Open Access Publication Fund of Bielefeld University for the article processing charge.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.