Beyond the Noise: Case Study on a Teen’s Story of Resilience with Misophonia

By Brittany Grayless, AuD

Originally published in the Winter 2024 issue of Tinnitus Today Magazine

Misophonia is a condition in which individuals experience an emotional response to specific sounds in their environment. These sounds can include breathing, swallowing, and chewing (1). Individuals with misophonia are typically bothered by these sounds emitted by others, not when they make the sound themselves. Although there is currently no cure for this condition, some treatment strategies have been shown to reduce the intrusiveness of symptoms, including sound therapy (2).

Although misophonia is not specific to the pediatric population, at our clinic it typically presents in pediatric patients, which is consistent with research suggesting the average onset of misophonia symptoms begins around 13 years of age (3). It is important not to ignore misophonic symptoms in children because the condition can lead to social withdrawal and isolation, and negatively affect familial and peer relationships (4). Emerging research shows the prevalence of misophonic symptoms among adult students (18 to 54 years) ranges from 6 percent to almost 20 percent (5,6). Here, I’m sharing a case study of a female adolescent who came to our clinic for help managing misophonia.

 

Case History

At age 14, Amber came to our clinic for an evaluation of misophonia. When she sat down to begin the case history, she immediately began crying. I asked her if she was nervous about the appointment, and she replied yes. I assured her that she was in control of the appointment, and we would not do anything that would make her feel uncomfortable.

During the case history, she revealed that she was bothered by the sounds of others eating and chewing, tapping (repetitive sounds), breathing, and others eating crunchy foods, and it had begun between the fifth and seventh grades. Her mother, who accompanied her to the appointment, shared that Amber had been sensitive to sounds and smells since a young age. Her mom also noted that Amber had a difficult time transitioning to high school at the start of the school year.

Amber already had a 504 plan in place for these symptoms, which allowed her to leave the classroom when she became overwhelmed by trigger sounds. However, Amber said she seldom used the accommodation often pushing through her emotions to avoid attracting attention to herself. When asked about stressful situations that she had experienced, Amber said the COVID-19 pandemic period was especially stressful, with her trigger sounds becoming even less tolerable.

Her emotional reaction to trigger sounds was anger, while her physical reaction included nausea and fist clenching. Because correlations between misophonia and obsessive compulsive disorder have been found in research (7), Amber was also asked about related symptoms. Amber said she liked to keep her things very organized and would get upset when people touched her things. At this time, Amber was still eating dinner at the dinner table with her parents; however, she often felt the need to leave the table to escape the sound of chewing.

Questionnaires

Because misophonia is subjective, it is important to gain as much information as possible from the person to assist in diagnosis. To facilitate this, patients being seen for a misophonia diagnostic appointment at the University of Tennessee Health Science Center (UTHSC) Audiology Clinic are mailed several questionnaires. We use these questionnaires to gain insight into the intrusiveness of misophonic symptoms, as well as other factors that may contribute to overall mental health, including anxiety and depression.

Misophonia Assessment Questionnaire (MAQ): The MAQ assesses severity of misophonic symptoms, and the total sum score is used to indicate severity level. A total score of 1–21 indicates mild, 22–42 indicates moderate, and 43–63 indicates severe (8). Amber scored 46, putting her in the severe category.

Amsterdam Misophonia Scale (A-MISO-S): The A-MISO-S assesses misophonic symptoms in the following areas: time, interference, distress, resistance, control, and avoidance (9). It is a six-item scale, with scores ranging from 0 to 24. Amber’s sum score of 17 suggested severe misophonic symptoms.

Misophonia Impact Survey (MIS): The MIS helps providers gain insight into how misophonia is impacting different areas of the patient’s life (10). It is composed of five questions that explore interpersonal relationships, family life, social life/leisure activities, school and work, and personal activities on a scale of 0 to 10. The questionnaire helps the provider understand what areas to focus on when seeking to improve the patient’s quality of life. Amber reported that her misophonia had impacted her family life (7—severely), social life (8—severely), and schoolwork (9—severely). Amber also reported that her misophonia impacted her individual/alone time (4—moderately).

Misophonia Activation Scale (MAS-1): The MAS-1 is a two-item survey designed to focus on the emotional and physical reactions to a specific trigger sound that a patient may experience (11). Severity levels range from 0 (no discomfort) to 10 (reacts with violence toward a person, animal, or self). Amber’s emotional response to her trigger sounds was an 8: “I experience psychic discomfort and some violence thoughts.” Amber’s physical response to her trigger sounds was a 3: “I feel some physical sensation but have difficulty or cannot ignore it.”

Detailed Trigger Inventory (DTI): The DTI form provides a way for the patient to document their trigger sounds, where the sound comes from (e.g., parent, friend, sibling), and the emotional and physical responses to the trigger sound, referencing the MAS-1 severity levels. At this point in the intake packet, Amber became emotionally distressed from having to think about her trigger sounds. Because of this, she did not complete the rest of the intake packet to avoid further distress. During the case history portion of the appointment, I asked Amber if she felt comfortable simply stating what her trigger sounds were without giving them a severity rating. Her trigger sounds included eating and chewing by family members at home, breathing by individuals at home and in the classroom, and tapping sounds in the classroom.

Revised Child Anxiety and Depression Scale (RCADS): The RCADS is a scale developed to assess anxiety and depression in children in third to twelfth grade (12). It also provides an assessment of subscales, including social phobia, panic disorder, major depressive disorder, separation anxiety disorder, generalized anxiety, and obsessive-compulsive disorder (13). The scale has parent and child forms so that health practitioners can gain insights into both perspectives, and the forms can highlight some of the underlying characteristics of misophonia sufferers, such as obsessive-compulsive disorder and anxiety.14 Amber reported considerable distress that prevented her from completing this form. When completed, I find this questionnaire useful in screening for depression and anxiety in the misophonia pediatric population.

Audiologic Assessment

Although there is no objective test to diagnose misophonia, it is important to rule out hearing loss. Therefore, an audiological assessment including pure-tone thresholds should be completed. Additionally, misophonia may present in patients with normal to reduced loudness discomfort levels (LDLs) (15), so an assessment of LDLs should also be included. Amber presented with normal hearing for both ears at all frequencies tested (250–8,000 Hz). Her LDLs ranged from 60 dB to 85 dB in the right ear and 40 dB to 75 dB in the left ear, indicating the presence of hyperacusis bilaterally.

Recommendations

Based on the severity of the reported misophonic symptoms and their impact on Amber’s quality of life, as well as the presence of bilateral hyperacusis, it was recommended that Amber use ear-level maskers to incorporate sound therapy. Additionally, Amber was recommended to pursue cognitive behavioral therapy to aid coping. Lastly, consideration of where she sat in classrooms was recommended, such as sitting near the air conditioner, so that she could utilize environmental masking in her learning environments.

Ear-Level Masker Fitting and Orientation

Amber was fit with bilateral earlevel maskers (Oticon Zircon 2). She was asked to rate her mood on a scale of 1 to 10 (1 being the worst she has ever felt, 10 being the best she has ever felt). Amber rated her mood at a 3. Because sound therapy is used differently for misophonia and hyperacusis, Amber was asked to choose which she wanted to prioritize; she chose misophonia. Amber selected the following masking sounds as her ear-level maskers: (1) red noise, (2) pink noise, (3) modulated pink noise, and (4) no maskers on. For each masking program, the mics were turned off to ensure that no amplification was provided to her trigger sounds. Amber was instructed to close her eyes to remove visual triggers while her mom chewed gum. The masking level was increased until Amber’s facial reaction was visibly reduced. This process was repeated for each of the masking programs. Because of the severity of her emotional distress and to prevent further trigger sounds from developing, it was recommended that Amber wear her maskers during all waking hours.

One-Week Follow-Up

To understand the effectiveness of the maskers, Amber was asked to rate her mood again on a scale of 1 to 10 at her one-week follow-up. She reported a 7, which was a significant improvement from the week before, when she’d reported her mood at a 3.

She had tried all her masking programs, and the red noise program became her preferred one. She mentioned wanting to raise the masker volume in some environments, specifically when taking exams, where the quiet setting made trigger sounds more noticeable, and in auditoriums, when noise was overwhelming. In both scenarios, she found herself having to leave the room.

She also noted wanting to turn down the masker volume when she got home from school. Amber explained that wearing the maskers at the dinner table seemed to help her tolerate chewing sounds. At this appointment, the masker volume control was activated, and Amber was introduced to the ReSound Tinnitus Relief smartphone app to give her more customized masking options to stream to her hearing aids.

One-Month Follow-Up

At Amber’s one-month follow-up, she said the maskers had been very helpful. She often raised the volume in school settings and lowered it in quieter environments like her home. She said that, although she no longer felt compelled to leave the room to escape trigger sounds, she still was having difficulty with trigger sounds in high-concentration environments such as test-taking and writing. She also reported feeling overwhelmed when she couldn’t identify the source of a trigger sound.

Amber was counseled on concentration strategies and deep breathing to draw on in such situations. She was also encouraged to utilize the preferential seating outlined in her 504 plan, which would allow her to sit in the back corner of the class during tests so she could view where sounds were coming from as a way to reduce her anxiety. It was also advised that she explore use of fidget toys or other methods of distraction like progressive muscle relaxation when she felt triggered by sounds. Amber had yet to explore the smartphone app for additional masking, so she was advised to experiment with the different masking options.

Three-Month Follow-Up

Amber reported wearing her hearing aids all waking hours and was pleased overall with the masking programs. An additional program of white noise was added to the hearing aids to use for when noisy situations felt overwhelming. She reported also seeing a psychologist to help manage anxiety stemming from her misophonia. We revisited the idea of using fidget toys, coloring books, and crossword puzzles as distractions in noisy situations.

Six-Month Follow-Up

Amber had begun a new school year and reported that it was going well. She said her wellness class was the only one in which she struggled because of the volume of noise. She continued to wear her maskers all waking hours and to meet weekly with her psychologist. It was recommended that she increase the volume of the masker before going into noisy situations to preemptively shield her from a triggering environment.

Discussion

Fitting misophonia patients with ear-level maskers has become my most rewarding type of appointment. To see the distress evoked from trigger sounds dissipate from the patient, to be replaced with relief and hope, is a fulfilling experience. Pediatric misophonia affects not only the patient’s quality of life but also the family members’, who are searching for anything that can help their child. Amber’s case is not unique among misophonia patients I’ve worked with.

A thorough case history provides insight into different areas that are affected by the condition. When the assessment is complete, an individualized treatment plan is developed. Sound therapy is utilized to make trigger sounds tolerable. It is important to set realistic expectations in that the goal is not to make the trigger sound a likeable sound but rather a tolerable sound. Stress and anxiety seem to play a role in the reaction to trigger sounds, so discussion of coping strategies and a referral to a behavioral health specialist are important.

Amber began her journey at our clinic experiencing significant distress and anxiety from her misophonic symptoms. She is still being seen annually and now comes in with a smile on her face. She feels more in control of her environment by using the masking sounds in her hearing aids. Her mom has expressed how thankful she is for the services we’ve provided to help her daughter.

Although there currently isn’t a cure for misophonia, in this and other case studies (16), sound therapy provides a way for sufferers of misophonia to improve quality of life and engagement with others in settings that would otherwise be difficult to endure.

Amber recently reached out to me expressing interest in pursuing audiology as a career, reminding me that compassion, dedication, and individualized patient care can lead to life-affirming changes.