1. Dr. Sukhbinder Kumar” 12:30-1:30pm (EST)
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“An Overview of Misophonia: Latest Research and Q&A with
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2. An Overview of Misophonia Latest Research and Q&A with Dr
An Overview of Misophonia Latest Research and Q&A with Dr. Sukhbinder Kumar
Jennifer Jo Brout, M. Zachary Rosenthal & Sukhbinder Kumar
Duke University and IMRN © Do not copy or use without permission

3. Introduction & Orientation
Individuals with misophonia, parents of children with misophonia, family or friends of an individual with misophonia
Clinicians across disciplines (i.e., audiologists, psychologists, psychiatrists, LPC’s, RN’s, occupational therapists, etc.)
Teachers, and school personnel

4. Misophonia Basics1, 2, 3
Misophonia involves both neurological and auditory processing. It may best be characterized as a neurophysiological condition. Neurophysiological refers to the functioning of the nervous system.
Edelstein, Brang, Rouw, & Ramachandran, 2013
Jastreboff & Jastreboff, 2001
Ledoux, 2015

5. Common Trigger Sounds Chewing Finger tapping Foot shuffling
Keyboard tapping
Rain tapping on roof
Coughing
Clicking noise of turn signal indicator in car

6. Describing the “misophonic response” 1,4
Immediate aversive (very unpleasant) response to specific pattern-based sounds (and sometimes visuals) regardless of decibel (loudness). This means that trigger sounds can be loud or quiet. Elicited by other people, animals and inanimate objects.
(1) Edelstein et al., 2013
(4) Jastreboff & Jastreboff, 2002

7. Typical Responses to Triggers 5, 6
Response to triggers include intense physiological, emotional, and cognitive reactions which all come together within the brain and body within milliseconds and without conscious thought.
Breaking This Down
Emotional: Distress, urge to flee, anger, disgust, rage, panic, anxiety, feelings of inadequacy, etc.
Cognitive: Worrying, difficulty focusing, blaming others and/or self, etc.
Behavioral: Leaving (getting away from sound)asking others to stop making sound/action, verbal (possibly physical) aggression toward self, others, or inanimate objects, “dirty looks” or mimicking, crying
(5) Cavanna & Seri, 2015
(6) Wu, Lewin, Murphy, & Storch, 2014

8. Behavioral Responses
Behavioral responses may vary across different contexts and times
Some days are better than others (lack of sleep or not feeling well)
Children may “hold it together” at school and then fall apart when they get home where they are more comfortable/safe
Acoustic differences may affect reactivity and therefore behavior
Some people (but certainly not all) do better with loud noises in the background in order to mask quieter noises. Some people have difficulty with both loud and quiet noises.
Other features of various spaces may affect acoustics in ways we have not yet studied (e.g. sound travels differently indoors than outdoors).
Take home message: We don’t yet know enough to understand why behavioral responses vary across contexts but it is typical of most people with misophonia

9. Why Are These Sounds Typical Triggers?
Research has not yet identified why people with misophonia share these particular triggers
Some theories include ideas pertaining to the acoustic properties of these particular sounds.
For example they are pattern based and often repetitive.
When we hear a sound, we automatically alert to it. This is part of our defensive motivational system which has enabled us to survive.
This is an automatic, non-conscious process that occurs in milliseconds within the nervous system.
Once alerted, if a sound does not represent danger, or potential harm we put it in the background and react with less and less intensity to it. This is called auditory gating.
Some people don’t automatically gate and this may be part of the picture.

10. Possible Causes of Misophonia5, 7, 8, 9
Misophonia may be related to atypical connectivity between auditory brain areas and the parts of the brain that process emotion (the limbic system).
Two candidate brain areas involved in misophonia include the amygdala and the insula. The amygdala mediates the fight/flight response and the insula integrates information from different senses to produce an emotionally relevant context for outside stimuli. Dr. Kumar will speak much more about this.
(5) Cavanna & Seri, 2015
(7) San Gorgi, 2015
(8) Schroder, 2014
(9) Jastreboff & Jastreboff, 2001

11. The Nervous System

12. The Nervous System
The nervous system is comprised of the brain and the spine (Central Nervous System and a large network of nerves that allow communication to take place throughout the body (parts of which make up the Peripheral Nervous System).
The Autonomic Nervous System (ANS) is the branch of the peripheral nervous system that is responsible for involuntary physical changes and is related to the fight or flight response.
The ANS is divided into two branches (the sympathetic and the parasympathetic systems).
The sympathetic system is involved in what we know to be the fight/flight response, and the parasympathetic system puts the brakes on fight/flight

13. Why Do I Feel So Out Of Control?
The reactivity that you feel when you hear a trigger sound is attributed to the sympathetic branch of the ANS. It acts automatically without any conscious thought in response to stimuli from the outside world.
When you hear a trigger sound this system is set into motion within milliseconds
It is simultaneously accompanied by thoughts, emotions and motivates behavior

14. Why Does My Child Feel Out of Control?
Children may have more difficulty with misophonia than adults because:
They are still developing the more advanced reasoning skills that adults have
They may not have the language development necessary to express what is happening to them and how they feel
Children may also feel intimated or afraid (or too confused) to tell an adult what they are experiencing
Children (and more so in the case of adolescents) may wish to hide their experiences because they feel it is socially stigmatizing

15. Other Common Questions About Misophonia
Is it genetic?
Do triggers spread?
Is there a typical age of onset?
Why is it sometimes called a psychiatric disorder and other times neurological or auditory?
Why is it not in the Diagnostic and Statistical Manual (DSM-5)?
Should someone with misophonia use earplugs, headphones, or in-ear noise generators?

16. What Can I Do if I have Misophonia?
Come to understand the disorder from credible sources
Seek help from qualified professionals
Learn and implement coping skills

17. Misophonia Coping Skills
Seek out a clinician who will help you to:
Understand the disorder from a physiological perspective. This will help you feel less overwhelmed by what is happening to you.
Deconstruct the response so that you can identify and distinguish the physical sensations that occur from those that are cognitive (the thoughts you have associated with the neurophysiological response and about others in the case of people-generated sounds),
Help you to replace negative thoughts with neutral ones. For example, “why is this person doing this to me” vs. “It is the sound that is bothering me, not the person.”
Helps you (and your child/family) learn practical strategies (e.g. when to avoid sounds and when not to, how to handle particular situations in terms of school or the workplace, the car, etc.).

18. How Do I find This Help?
While there are only a small number of doctors and therapists who are aware of misophonia and understand it, be reassured that awareness is increasing.
In the meantime:
Do not be afraid to share information that you have with a practitioner that you are in touch with.
Doctors and therapists should be willing to consult with others who are more familiar with misophonia
We have listed resources at the end that you can utilize for both your own information about misophonia and also to share with your doctor

19. Introduction to Dr. Kumar
Neuroscientist at University College London and Newcastle University.
Received his PhD from Newcastle University in 2004.
Research brain mechanisms of auditory perceptions, cognitions, emotion
Published over 30 peer-reviewed articles in neuroscience journals.

20. A Study: Neurobiological Bases of Misophonia
Sukhbinder Kumar

21. How we got interested in Misophonia?
In our lab, we are interested in understanding how the brain processes emotions, particularly from sounds.
In a 2012 study we looked at how the brain responds to “annoying” sounds
After the study, many asked if we were familiar with misophonia
Misophonia was quite intriguing for us as certain sounds which are considered ‘normal’ evoke a strong emotional response.

22. How we got interested in Misophonia?
We assessed four people in detail at the Cognitive Neurology Clinic in Newcastle and at the National Hospital for Neurology and Neurosurgery
Assessment confirmed a striking similar profile of symptoms and triggers in the individuals.
We designed a questionnaire asking questions about:
Age of onset
Typical triggers
Reaction to triggers
Effect of sound made by stranger/family member etc.

23. How we got interested in Misophonia?
We posted the questionnaire on a misophonia website
Analysis of 157 questionnaires showed (Kumar et al, 2014)
Age of sufferers [12 to 70 years], mean = 34.3 years
Age of onset [5 to 50 years], mean = years
124/157 (79.0 %) are females.
146/157 (93.0 %) describe eating sounds as triggers
135/157 (86.0 %) describe anger as the dominant emotion (other emotions include panic/anxiety)
132/157 (84.0 %) describe leaving the situations which produce trigger sounds
In few cases, the problem exist in most or some close family members

24. fMRI Experiment Design
Three sets of sounds:
Misophonic (Trigger) sounds – trigger misophonic reaction in Misophonia subjects (e.g. apple crunching, drinking water etc.)
Unpleasant sounds- produce annoyance but do not trigger misophonic reaction in misophonia subjects, (e.g. baby crying, person screaming)
Neutral sounds – neither annoying nor produces any annoyance, (e.g. rain sound).
Two visits:
First visit: skin conductance measured while subjects listen and rate sounds on a scale from 1 to 4
Annoyance caused (both groups)
Misophonic reaction triggered (misophonia group) and anti-socialness of sounds
Structural scan acquired (using Multi Parameter Map (MPM) Sequence)

25. Second Visit: Experiment Design
Rating 1
‘How annoying the sound was’, from 1 to 4)
1: not annoying;
4 : very annoying
(Both groups)
Rating 2
‘How effective the sound was in triggering
typical misophonic reaction’ (rate from 1 to 4)
(Miso group)
How antisocial the sound was
(you wouldn’t like to be in the environment
where the sound is being produced)’
(Control group)

26. Summary and Interpretation of Results
GLM analysis showed higher activation in misophonic group compared to controls when listening to trigger sounds.
Activity in anterior insula varied in direct proportion to perceived misophonic distress.
Anterior insula is known to integrate visceral signals from the body (e.g. from heart) and signals from the outer world (e.g. sounds).
There is a large body of evidence (see Craig et al, 2009 for review) which implicates anterior insula in subjective feeling of emotions.
‘Aberrant’ activation of anterior insula to trigger sounds in misophonia is, therefore, consistent with the known role of anterior insula in emotions processing and interoception (perception of bodily signals).

27. fMRI Analysis : General Linear Model (GLM)

28. Summary and Interpretation of Results
Why anterior insula is hyperactive to trigger sounds in misophonia?
A cue to this is provided by the functional connectivity analysis.
Anterior insula is hyper-connected to posterior cingulate cortex (PCC) and ventromedial prefrontal cortex (vmPFC).
The PCC and vmPFC are active when past memories and experiences are recalled.
The vmPFC is also involved in regulation of emotions.
One interpretation, therefore, is that past negative experiences with trigger sounds combined with aberrant emotion regulation is the source of hyperactivity in anterior insula.

29. Summary and Interpretation of Results
Increased heart rate and galvanic skin response is consistent with strong tendency of misophonic subjects to escape from the environment of trigger sounds.
The sources of these hyper-responses are located in the anterior insula.
Overall, hyperactivity of anterior insula combined with its hyper-connectivity underlie misophonia.
See slides for more detailed explanation

30. Work in Progress…
Presently running a study using MEG (Magnetoencephalography).
The objective is to identify (spectral) signatures of trigger sounds.
These signatures can then be measured using EEG which is much cheaper to use compared to fMRI.
These signatures then can be used for self regulation of reaction to trigger sounds by looking at the intensity of brain activity produced by trigger sounds (neurofeedback).

31. Duke University and IMRN © Do not copy or use without permission
Q & A
Please submit questions through WebEx
Duke University and IMRN © Do not copy or use without permission

32. Links for Help and to Support Research
Misophonia Providers
International Misophonia Research Network
Misophoniainternational.com
Misophonia-research.com
Duke Science, Misophonia
Allergic To Sound
Adversity to Advocacy
Different Brains
STAR Institute for Sensory Processing Disorder

33. Dr. Kumar Acknowlegements Sincere thanks to all misophonia participants, who made this study possible

34. THANK YOU! Prof Timothy D Griffiths Dr William Sedley
Olana Tansley-Hancock
THANK YOU!
Dr Phillip Gander
Dr Martina Callaghan
Dr Thomas Cope
Dr Micah Allen
Dr Joel Winston

35. Thank You to:
Shaylynn Hayes Misophonia International
Lisalynn Kelley Duke University Medical Center
Madeline Appelbaum International Misophonia Research Network
Graphics Courtesy of freepik.com, Newcastle University

36. References
Edelstein, M., Brang, D., Rouw, R., Ramachandran, V.S. (June 2013). Misophonia: physiological investigations and
case descriptions. Frontiers in Human Neuroscience. Vol. 7.
Jastreboff, P J. and Jastreboff, M.M. (July 2001). Components of Decreased Sound Tolerance: hyperacusis,
misophonia, phonophobia. Institute of Translational Health Sciences.
Ledoux, J.E. (2015). Anxious.: Using the Brain to Understand and Treat Anxiety. Penguin Press New York.
Jastreboff, P J. and Jastreboff, M.M. (2002). Decreased Sound Tolerance and Tinnitus Retraining Therapy (TRT). The Australian and New Zealand Journal of Audiology. Vol. 24 (2),
Cavanna, A.E. and Seri, S. (2015). Misophonia: Current Perspectives. Neurospsychiatric Disease and Treatments, 11, 2117.
Wu, M. S., Lewin, A.B., Murphy, T.K., Storch, E.A. (2014). Misophonia: Incidence, Phenomenology, and Clinical Correlates in an Undergraduate Student Sample. Journal of Clinical Psychology. Vol. 70 (10),
San Gorgi, R. (2015). Hyperactivity in Amygdala and Auditory Cortex in Misophonia: Preliminary Results of a Functional Magnetic Resnonance Imaging Study.
Schröder, A., Diepen, R., Mazaheri, A., Petropoulos-Petalas, D., Soto de Amesti, V., Vulink, N., Denys, D. (2014). Diminished N1 Auditory Evoked Potentials to Oddball Stimuli in Misophonia Patients. Frontiers in Behavioral Neuroscience. Vol. 8 (123)
Davies, P. and Gavin, W.J. (2007). Validating the diagnosing of sensory processing disorders using eeg technology. Journal of American Occupational Therapy, 61 (2). 176
Spankovitch (2014) in Baguley, D., & Andersson, G. (2007). Hyperacusis: Mechanisms, diagnosis, and therapies. San Diego: Plural Pub.
Baguley, D., & Andersson, G. (2007). Hyperacusis: Mechanisms, diagnosis, and therapies. San Diego: Plural Pub.
Miller, Lucy Jane (2014) Sensational Kids: Hope and Help for kids with sensory processing disorder. Penguin, New York.
For additional website references, please request

37. Jennifer Jo Brout, Psy.D. International Misophonia Research Network (IMRN) SENetwork M. Zachary Rosenthal, Ph.D. Director, Sensory Processing & Emotion Regulation Program Vice Chair, Clinical Associate Professor Department of Psychiatry & Behavioral Sciences Duke University Medical Center & Duke University
Sukhbinder Kumar, Ph.D
Research Fellow
Wellcome Trust Centre for Neuroimaging
University College London
Institute of Neuroscience
Newcastle University

38. Functional connectivity analysis
Change in myelination (within the grey matter)
Functional connectivity analysis

39. Sources of hyper-autonomic responses in misophonia
Autonomic responses (Heart rate and Galvanic skin response)