In Focus: Clinical Subtypes of Misophonia in Youth

In Focus: Clinical Subtypes of Misophonia in Youth

By Gabrielle M. Armstrong, BA, University of Mississippi
Ogechi C. Onyeka, PhD, Baylor College of Medicine
Eric A. Storch, PhD, Baylor College of Medicine
Andrew G. Guzick, PhD, University of Pennsylvania

Misophonia is a chronic condition characterized by intense intolerance to specific auditory stimuli typically produced by other people, which may include food chewing, breathing, or pen clicking (Lewin et al., 2021; Schröder et al., 2013; Swedo et al., 2022). Although the diagnostic traits of misophonia are heterogeneous, individuals with this condition share key phenotypic features, including significant emotional distress in response to triggers as well as intense physiological and behavioral reactions such as muscle tension, sensory overwhelm, aggression, or escape behavior (Cavanna & Seri, 2015; Edelstein et al., 2013; Schröder et al., 2013). While early research surrounding misophonia was largely delineated by case studies and observational reports (Schneider & Arch, 2017; Schröder et al., 2013), more recent studies have begun to uncover its underlying mechanisms (Rosenthal et al., 2023; Kumar et al., 2021). Despite these advances, a detailed understanding of misophonia and its clinical presentation, particularly in youth, remains unclear.

Is Misophonia a Standalone Condition or Part of a Larger Phenomenon?

The classification of misophonia is a topic of ongoing debate in the literature. While extant research suggests that misophonia may manifest as a distinct, standalone condition (Rosenthal et al., 2022), others indicate that the clinical profiles of misophonia often include a complex interplay of co-occurring psychological or neurophysiological phenomena (Ferrer-Torres & Giménez-Llort, 2022; Guzick et al., 2023; McKay et al., 2018; Wu et al., 2014). These overlapping features complicate efforts to accurately capture the full clinical picture of misophonia and may point to the existence of distinct subtypes of the condition. For example, many individuals with misophonia often share characteristics with various internalizing disorders, such as disgust sensitivity, emotion regulation difficulties, and intense reactions to specific stimuli (Barahmand et al., 2021; Claiborn et al., 2020; Dixon et al., 2024). Additionally, the aggressive reactions observed in misophonia often overlap with behaviors commonly associated with externalizing disorders (Guzick et al., 2023; Ferrer-Torres & Giménez-Llort, 2022), with some evidence suggesting an association between these behaviors and sensory sensitivities (Armstrong et al., 2023). The coexistence of these symptoms suggests that misophonia may manifest differently across individuals, making it challenging to define precise clinical characteristics. This variability in clinical profiles highlights the need for more nuanced diagnostic methods and personalized treatment approaches. Furthermore, while some studies have explored distinct profiles of misophonia in adult community samples (McKay et al., 2018), few have done so with clinical samples, and there is a notable absence with youth samples. Retrospective studies suggest that misophonia typically begins in childhood or adolescence (Clairborn et al., 2020; Jager et al., 2020) and is linked to considerable impairment and distress across various areas of life (Remmert et al., 2022; Rinaldi et al., 2022). This gap is particularly concerning, as early identification and intervention could be crucial for mitigating long-term psychological or social impacts of misophonia. Therefore, further investigation into the clinical diversity of misophonia in youth and various diagnostic contexts is critical for developing more effective and targeted treatment strategies.

Understanding Clinical Subtypes of Misophonia in Youth: Insights from Our Recent Study

We aimed to explore the presence of clinical subtypes of misophonia in youth. Our goal was to better understand how misophonia presents in young people and whether distinct subtypes would be identified based on symptom severity and co-occurring psychopathology.

We collected data from 102 youth (M_age = 13.71) who met the clinical threshold for misophonia. Participants completed a series of validated assessments that measured misophonia severity and impact, internalizing and externalizing symptoms, and sensory sensitivity—in line with previous research demonstrating their respective associations with misophonia symptom severity (Guzick et al., 2023; Rinaldi et al., 2022). Additionally, we gathered demographic characteristics and a validated assessment of quality of life, comparing these factors across different clusters identified in the data. A hierarchical agglomerative cluster analysis was conducted to examine the natural groupings across variables, which was then validated by a k-means cluster analysis.

Results indicated three distinct groups:

1. High Externalizing Symptoms, High Symptom Severity Group: Youth who exhibit strong emotional reactions, often expressed outwardly, with elevated symptom severity
2. Pure Misophonia, Low Symptom Severity Group: Youth primarily affected by misophonia with minimal overall symptom severity
3. High Internalizing Symptoms, High Sensory Sensitivity Group: Youth experiencing high levels of internalizing symptoms (e.g., depression and anxiety) and elevated sensitivity to sensory stimuli

Interestingly, while the groups did not differ by gender, there was a statistically significant difference in age. Youth in the Pure Misophonia, Low Symptom Severity group were the youngest, which may suggest that misophonia symptoms become more pronounced or co-occur with other psychopathology as children age. Additionally, a significant difference was observed in child-reported quality of life. Youth in the Pure Misophonia, Low Symptom Severity group reported the highest levels of quality of life, indicating that less severe symptoms may be less disruptive to their daily functioning and overall well-being.

Implications for Treatment and Support

Our findings suggest that misophonia is not a one-size-fits-all condition. Instead, there may be subtypes representing clinical profiles characterized by severity and comorbidity. The identification of these subtypes is crucial for developing effective, tailored treatment approaches. For example, individuals in the High Internalizing Symptoms, High Sensory Sensitivity group may benefit from therapies targeting anxiety and sensory processing, while those in the High Externalizing Symptoms, High Symptom Severity group may require interventions focused on emotion regulation and behavior management.

This variability also emphasizes the importance of early intervention. While youth in the Pure Misophonia, Low Symptom Severity group may experience fewer disruptions in daily life, they also appeared younger, and thus it may be that early intervention is key to help offset trajectories that corresponds with increasing severity and more comorbidity. Those in the more severe groups may also benefit from earlier, targeted support to manage the emotional and behavioral difficulties associated with misophonia. By recognizing the spectrum of misophonia and its varied clinical presentations, clinicians can tailor treatment strategies to meet the specific needs of each individual, improving the overall effectiveness of care. As research continues to evolve and treatment approaches become more refined, the emotional and social well-being of youth with misophonia is expected to improve, ultimately supporting them in leading more fulfilling lives.

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