Effects of Natural Delivery and Cesarean Section on the Result of First Hearing Screening of Newborns.

BACKGROUND: Early detection and intervention of hearing issues in newborns are crucial for their auditory and speech development, necessitating newborn hearing screenings. This study aimed to investigate the impact of delivery methods, specifically natural delivery and cesarean section, on newborn hearing screening outcomes. METHODS AND MATERIAL: A retrospective analysis was conducted on data from 600 newborns delivered at The First Affiliated Hospital of Shaoyang University between January 2020 and January 2023. The initial hearing screenings used the AccuScreen otoacoustic emission instrument. The study examined the influence of delivery method on the pass rates of newborns' first hearing screenings within and beyond 48 h postbirth. RESULTS: The pass rates for the initial hearing screenings, conducted within and after 48 h of birth, were significantly higher in the natural delivery group compared to the cesarean section group (P < 0.05). Furthermore, multivariate analysis identified the delivery method as a significant factor influencing the pass rates of newborns' first hearing screenings. CONCLUSIONS: The mode of delivery appears to affect the results of the initial hearing screenings of newborns, though further research is needed to validate these findings.

Brigatinib in NF2-Related Schwannomatosis with Progressive Tumors.

BACKGROUND: NF2-related schwannomatosis (NF2-SWN, formerly called neurofibromatosis type 2) is a tumor predisposition syndrome that is manifested by multiple vestibular schwannomas, nonvestibular schwannomas, meningiomas, and ependymomas. The condition is relentlessly progressive with no approved therapies. On the basis of preclinical activity of brigatinib (an inhibitor of multiple tyrosine kinases) in NF2-driven nonvestibular schwannoma and meningioma, data were needed on the use of brigatinib in patients with multiple types of progressive NF2-SWN tumors. METHODS: In this phase 2 platform trial with a basket design, patients who were 12 years of age or older with NF2-SWN and progressive tumors were treated with oral brigatinib at a dose of 180 mg daily. A central review committee evaluated one target tumor and up to five nontarget tumors in each patient. The primary outcome was radiographic response in target tumors. Key secondary outcomes were safety, response rate in all tumors, hearing response, and patient-reported outcomes. RESULTS: A total of 40 patients (median age, 26 years) with progressive target tumors (10 vestibular schwannomas, 8 nonvestibular schwannomas, 20 meningiomas, and 2 ependymomas) received treatment with brigatinib. After a median follow-up of 10.4 months, the percentage of tumors with a radiographic response was 10% (95% confidence interval [CI], 3 to 24) for target tumors and 23% (95% CI, 16 to 30) for all tumors; meningiomas and nonvestibular schwannomas had the greatest benefit. Annualized growth rates decreased for all tumor types during treatment. Hearing improvement occurred in 35% (95% CI, 20 to 53) of eligible ears. Exploratory analyses suggested a decrease in self-reported pain severity during treatment (-0.013 units per month; 95% CI, -0.002 to -0.029) on a scale from 0 (no pain) to 3 (severe pain). No grade 4 or 5 treatment-related adverse events were reported. CONCLUSIONS: Brigatinib treatment resulted in radiographic responses in multiple tumor types and clinical benefit in a heavily pretreated cohort of patients with NF2-SWN. (Funded by the Children's Tumor Foundation and others; INTUITT-NF2 ClinicalTrials.gov number, NCT04374305.).

Relationship between self-reported hearing and vision problems, cognitive decline, depressive symptoms, and life satisfaction in older adults: a retrospective observational study.

BACKGROUND: Sensory impairment in older adults is associated with cognitive decline, elevated depressive symptoms, and low levels of life satisfaction. However, these relationships are usually investigated separately and in pairs. This study examined these relationships comprehensively, for the first time. METHODS: The analysis included 5,658 community-dwelling older adults from the China Health and Retirement Longitudinal Study (aged 50 to 108 years, 52.1% male) who completed the Jorm Informant Questionnaire Cognitive Decline in the Elderly and the Center for Epidemiological Studies-Depression-short form. A questionnaire was used to collect information on hearing, visual status, and life satisfaction. Structural equation modelling was used to examine the direct and indirect relationships between these variables. RESULTS: Self-reported hearing and vision problems are directly associated with cognitive decline and elevated depressive symptoms. In addition, hearing and vision problems are indirectly related to cognitive decline through elevated depressive symptoms. Although hearing and vision problems had no direct effect on life satisfaction, they were indirectly associated with life satisfaction through cognitive decline and depressive symptoms. CONCLUSIONS: This study provides the first epidemiological evidence of the comprehensive relationships between hearing and vision problems, cognitive decline, depressive symptoms, and life satisfaction. When older adults report hearing and/or vision problems, clinicians and caregivers should be aware of the concurrence of declined cognition, elevated depressive symptoms, and compensated life satisfaction. Future studies should examine the causal relationships and potential mechanisms of these relationships.

Clinical characteristics of treatment-seeking youth with misophonia.

OBJECTIVE: Misophonia is a psychiatric condition characterized by strong emotional and/or behavioral responses to auditory stimuli, leading to distress and functional impairment. Despite previous attempts to define and categorize this condition, misophonia is not currently included in the Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases. The lack of formal diagnostic consensus presents challenges for research aimed at assessing and treating this clinical presentation. METHODS: The current study presents clinical characteristics of youth (N = 47) with misophonia in the largest treatment-seeking sample to date. We examined demographic characteristics of the sample, frequency of comorbid disorders, frequency of specific misophonia symptoms (i.e., triggers, emotional and behavioral responses, and impairments), and caregiver-child symptom agreement. Misophonia symptoms were evaluated using a multimodal assessment including clinician, youth, and caregiver reports on empirically established misophonia measures, and concordance among measures was assessed. RESULTS: Youth seeking treatment for misophonia presented with marked misophonia symptoms and an array of comorbid conditions. Youth and caregivers identified various triggers of misophonia symptoms (e.g., chewing sounds, breathing sounds), as well as a wide range of emotional (e.g., anger, annoyance, disgust) and behavioral (e.g., aggression, avoidance) responses to triggers. Youth and caregivers exhibited high agreement on misophonia triggers but lower agreement on symptom severity and associated impairment. Compared to younger children (aged 8-13), older children (aged 14+) appeared to report symptom severity and associated impairment more reliably. CONCLUSION: Misophonia is a heterogenous and impairing clinical condition that warrants future investigation and evidence-based treatment development.

Towards universal access: A review of global efforts in ear and hearing care.

Hearing loss affects 1.6 billion people worldwide and disproportionately affects those in low- and middle-income countries. Despite being largely preventable or treatable, ear and hearing conditions result in significant and lifelong morbidity such as delayed language development, reduced educational attainment, and diminished social well-being. There is a need to augment prevention, early identification, treatment, and rehabilitation for these conditions. Expanded access to hearing screening, growth of the hearing health workforce, and innovations in ear and hearing care delivery systems are among the changes that are needed. To that end, the World Health Organization has prioritized ear and hearing care as a component of Universal Health Coverage, and recent publications have advanced the priority for ear and hearing care. Efforts are underway at the national levels around the world, as evidenced by countries like Zambia and Nigeria that have integrated ear and hearing care within national health strategies. While significant strides have been made in improving access, a critical need remains for additional research, advocacy, and intervention to ensure that no one is left behind in the goal to achieve universal access to ear and hearing care.

Misophonia is related to stress but not directly with traumatic stress.

The relationship between misophonia, stress, and traumatic stress has not been well characterized scientifically. This study aimed to explore the relationships among misophonia, stress, lifetime traumatic events, and traumatic stress. A community sample of adults with self-reported misophonia (N = 143) completed structured diagnostic interviews and psychometrically validated self-report measures. Significant positive correlations were observed among perceived stress, traumatic stress, and misophonia severity. However, multivariate analyses revealed that perceived stress significantly predicted misophonia severity, over and above traumatic stress symptoms. The number of adverse life events was not associated with misophonia severity. Among symptom clusters of post-traumatic stress disorder, only hyperarousal was associated with misophonia severity. These findings suggest that transdiagnostic processes related to stress, such as perceived stress and hyperarousal, may be important phenotypic features and possible treatment targets for adults with misophonia.

An experimental examination of neurostimulation and cognitive restructuring as potential components for Misophonia interventions.

Misophonia is a disorder of decreased tolerance to certain aversive, repetitive common sounds, or to stimuli associated with these sounds. Two matched groups of adults (29 participants with misophonia and 30 clinical controls with high emotion dysregulation) received inhibitory neurostimulation (1 Hz) over a personalized medial prefrontal cortex (mPFC) target functionally connected to the left insula; excitatory neurostimulation (10 Hz) over a personalized dorsolateral PFC (dlPFC) target; and sham stimulation over either target. Stimulations were applied while participants were either listening or cognitively downregulating emotions associated with personalized aversive, misophonic, or neutral sounds. Subjective units of distress (SUDS) and psychophysiological measurements (e.g., skin conductance response [SCR] and level [SCL]) were collected. Compared to controls, participants with misophonia reported higher distress (∆SUDS = 1.91-1.93, ps < 0.001) when listening to and when downregulating misophonic distress. Both types of neurostimulation reduced distress significantly more than sham, with excitatory rTMS providing the most benefit (Cohen's dSUDS = 0.53; dSCL = 0.14). Excitatory rTMS also enhanced the regulation of emotions associated with misophonic sounds in both groups when measured by SUDS (dcontrol = 1.28; dMisophonia = 0.94), and in the misophonia group alone when measured with SCL (d = 0.20). Both types of neurostimulation were well tolerated. Engaging in cognitive restructuring enhanced with high-frequency neurostimulation led to the lowest misophonic distress, highlighting the best path forward for misophonia interventions.

Auditory cortical functioning in individuals with misophonia: an electrophysiological investigation.

PURPOSE: Misophonia is characterized by a reduced tolerance for specific sound triggers. This aspect has been relatively underexplored in audiology, with limited research from the audiological angle. Our primary objective is to compare the auditory late latency response (ALLR) findings between individuals with misophonia and those without it. METHODS: A study compared individuals with significant misophonia to a healthy control group. Thirty misophonia participants were categorized into mild and moderate-to-severe groups based on their Amsterdam Misophonia Scale scores. The latency and amplitude of auditory response peaks were analyzed across the groups using the ALLR. Statistical tests included Shapiro-Wilk for data normality, one-way ANOVA for group differences, and Bonferroni post hoc analysis for detailed variation sources. RESULTS: The result showed a significant difference in latency of P1 and N1 peaks (p < 0.05) of ALLR between the groups in both ears. This suggests a deficit in auditory processing at the cortical level in individuals with misophonia. CONCLUSION: Our study substantiates the potential utility of the ALLR as a valuable instrument for evaluating misophonia, particularly from the audiological standpoint.

Misophonia and Hearing Comorbidities in a Collegiate Population.

OBJECTIVES: Misophonia is a little-understood disorder in which certain sounds cause a strong emotional response in those who experience it. People who are affected by misophonia may find that noises like loud chewing, pen clicking, and/or sniffing trigger intense frustration, anger, or discomfort. The relationship of misophonia with other auditory disorders including loudness hyperacusis, tinnitus, and hearing loss is largely underexplored. This project aimed to investigate the prevalence and hearing-health comorbidities of misophonia in a college-aged population by using an online survey. DESIGN: A total of 12,131 undergraduate and graduate students between the ages of 18 and 25 were given the opportunity to answer an in-depth online survey. These students were sampled in a roughly 50 of 50 sex distribution. The survey was created using Qualtrics and included the following components: electronic consent, demographics questionnaire, Misophonia Questionnaire (MQ), Khalfa's Hyperacusis Questionnaire (HQ), Tinnitus and Hearing Survey, and Tinnitus Functional Index (TFI). To be eligible for compensation, answers for each of the above components were required, with the exception of the TFI, which was only presented to students who indicated that they experienced tinnitus. Respondents were determined to have high or possible likelihood of having misophonia if they gave specific answers to the MQ's Emotion and Behavior Scale or the MQ Severity Scale. RESULTS: After excluding duplicate responses and age-related outliers, 1,084 responses were included in the analysis. Just over 20% (n = 217) of the sample was determined to have a high or probable likelihood of having misophonia. The sample was primarily White, female, and of mid-to-high socioeconomic status. There was a strong positive correlation between MQ total scores and HQ total scores. High likelihood misophonia status showed a significant relationship with self-reported hearing loss and tinnitus. No statistically significant relationship was found between misophonia and age, ethnicity, or socioeconomic status. MQ total scores differed significantly when separating respondents by sex, self-reported tinnitus, and loudness hyperacusis. White respondents had significantly higher MQ total scores than Asian/Asian American respondents. CONCLUSIONS: The estimated prevalence of misophonia was about 8% to 20% of the sample, which agrees with most of the currently published research examining misophonia symptoms in collegiate populations. Results of data analysis suggest that misophonia severity may be related to loudness hyperacusis, sex, and possibly tinnitus. Future studies are needed to further examine the characteristics of these relationships, possibly in populations more optimized to reflect the general population or those with hearing-health disorders.

Targeting beliefs and behaviours in misophonia: a case series from a UK specialist psychology service.

BACKGROUND: Misophonia, a disorder of decreased sound tolerance, can cause significant distress and impairment. Cognitive behavioural therapy (CBT) may be helpful for improving symptoms of misophonia, but the key mechanisms of the disorder are not yet known. AIMS: This case series aimed to evaluate individual, formulation-driven CBT for patients with misophonia in a UK psychology service. METHOD: A service evaluation of one-to-one therapy for patients with misophonia (n=19) was conducted in a specialist psychology service. Patients completed an average of 13 hours of therapy with a focus on the meaning applied to their reactions to sounds and associated behaviours. Primary outcome measures were the Misophonia Questionnaire (MQ) and the Amsterdam Misophonia Scale (A-MISO-S). Repeated measures t-tests were used to compare scores from pre-treatment to follow-up, and reliable and clinically significant change on the MQ was calculated. RESULTS: Scores significantly improved on both misophonia measures, with an average of 38% change on the MQ and 40% change on the A-MISO-S. From pre-treatment to follow-up, 78% of patients showed reliable improvement on the MQ and 61% made clinically significant change. CONCLUSIONS: Limitations included a lack of control group, small sample size, and the use of an outcome measure that had not been thoroughly validated for a treatment-seeking sample. These results suggest that one-to-one, formulation-driven CBT for misophonia is worth exploring further using experimental design. Potential mechanisms to explore further include feared consequences of escalating reactions, the role of safety-seeking behaviours and the impact of early memories associated with reactions to sounds.

Alterations in attentional processing in youth with misophonia: A phenotypical cross-comparison with anxiety patients.

BACKGROUND: Misophonia is a complex condition characterized by extreme emotional distress in response to specific sounds or specific visual stimuli. Despite a growing body of clinical and neuroscientific literature, the etiology of this condition remains unclear. Hyperarousal, that is, a state of heightened alertness and disinhibition, as a core feature of misophonia is supported by behavioral and neuroimaging literature and might represent a viable clinical target for the development of both behavioral and pharmacological interventions. The aim of this study was to investigate how hyperarousal might be linked to neurocognitive processes associated with vigilance and stimulus discrimination in youth with misophonia. METHODS: We compared 72 children and adolescents with misophonia (13.74 ± 2.44 years) (64 % female) and 89 children and adolescents with anxiety (12.35 ± 2.57 years) (58.4 % female) on behavioral and signal detection performance of the immediate memory task (IMT). Anxiety patients were used as a clinical control group to distinguish attentional processes specific for misophonia. RESULTS: Both groups demonstrated similar behavioral performance, including response rate and reaction time. However, misophonia was associated with elevated stimulus discrimination (d prime), which in turn was positively correlated with the severity of misophonia trigger reports. CONCLUSIONS: Our findings are in line with previous cognitive and neuroimaging studies, and support an arousal-based model of misophonia, where individuals with misophonia experience a state of heightened vigilance, being more aware of stimuli in the environment. Our findings provide a neurocognitive basis for future study of neurochemical imaging that might further progress towards clinical targets.

[Retrocochlear diagnostics for acute hearing loss and successful therapy]. / Retrocochleäre Diagnostik im Rahmen der Hörsturzuntersuchung und erfolgreiche Therapie.

A 41-year-old female patient presented due to acute onset of unilateral hearing loss 3 months previously and persistent since then. Systemic therapy with oral glucocorticoids in decreasing doses had been performed beforehand, but did not lead to any improvement. In the course of audiological diagnostics, based on subjective and objective methods, a retrocochlear hearing disorder was suspected. A meningioma was diagnosed by diagnostic imaging. Subsequent surgical removal achieved a significant hearing improvement.

Misophonia matters: A case study of the role of brain imaging in debates over new diagnoses.

Misophonia has gained attention in scientific circles that utilise brain imaging to validate diagnoses. The condition is promoted as not merely a symptom of other psychiatric diagnoses but as a discrete clinical entity. We illustrate the social construction of the diagnostic category of misophonia through examining prominent claims in research studies that use brain imaging to substantiate the diagnosis. We show that brain images are insufficient to establish the 'brain basis for misophonia' due to both technical and logical limitations of imaging data. Often misunderstood as providing direct access to the matter of the body, brain images are mediated and manipulated numerical data (Joyce, 2005, Social Studies of Science 35(3), p. 437). Interpretations of brain scans are further shaped by social expectations and attributes considered salient to the data. Causal inferences drawn from these studies are problematic because 'misophonics' are clinically pre-diagnosed before participating. We argue that imaging cannot replace the social process of diagnosis in the case of misophonia, nor validate diagnostic measures or otherwise substantiate the condition. More broadly, we highlight both the cultural authority and inherent limitations of brain imaging in the social construction of contested diagnoses while also illustrating its role in the disaggregation of symptoms into new diagnoses.

A neuropsychological study of misophonia.

BACKGROUND AND OBJECTIVES: Misophonia is a recently identified condition characterized by negative emotional responsivity to certain types of sounds. Although progress has been made in understanding of neuronal, psychophysiological, and psychopathological mechanisms, important gaps in research remain, particularly insight into cognitive function. Accordingly, we conducted the first neuropsychological examination of misophonia, including clinical, diagnostic, and functional correlates. METHODS: A misophonia group (n = 32) and a control group (n = 64) were screened for comorbidities using a formal semi-structured interview and completed a comprehensive neuropsychological battery and self-report measures of depression, anxiety, stress, impulsivity, and functional impairment. RESULTS: The misophonia group significantly underperformed the control group on only 2 neuropsychological outcomes involving verbal memory retrieval. Subscales of the Misophonia Questionaaire (MQ) were inversely correlated only with measures of attention. The misophonia group reported significantly higher anxiety symptoms, behavioral impulsivity, and functional impairments, and had numerically higher rates of ADHD and OCD. LIMITATIONS: To facilitate comparability, in lieu of a formal diagnostic algorithm for misophonia, we used a commonly used empirical definition for group allocation that has been utilized in numerous previous studies. CONCLUSIONS: Misophonia was associated with a reduction in performance on a minority of cognitive tasks and a modest increase in some psychological symptoms and comorbid conditions. Correlational data suggest that difficulties with attention regulation and impulsivity may play a role in misophonia, albeit attention functions were intact. Results should be interpreted with caution given the variability in diagnostic definitions, and more research is needed to understand cognitive functioning under 'cold' conditions in misophonia.

Mimicry in misophonia: A large-scale survey of prevalence and relationship with trigger sounds.

BACKGROUND: Misophonia is often referred to as a disorder that is characterized by excessive negative emotional responses, including anger and anxiety, to "trigger sounds" which are typically day-to-day sounds, such as those generated from people eating, chewing, and breathing. Misophonia (literally "hatred of sounds") has commonly been understood within an auditory processing framework where sounds cause distress due to aberrant processing in the auditory and emotional systems of the brain. However, a recent proposal suggests that it is the perceived action (e.g., mouth movement in eating/chewing sounds as triggers) of the trigger person, and not the sounds per se, that drives the distress in misophonia. Since observation or listening to sounds of actions of others are known to prompt mimicry in perceivers, we hypothesized that mimicking the action of the trigger person may be prevalent in misophonia. Apart from a few case studies and anecdotal information, a relation between mimicking and misophonia has not been systematically evaluated. METHOD: In this work, we addressed this limitation by collecting data on misophonia symptoms and mimicry behavior using online questionnaires from 676 participants. RESULTS: Analysis of these data shows that (i) more than 45% of individuals with misophonia reported mimicry, indicating its wide prevalence, (ii) the tendency to mimic varies in direct proportion to misophonia severity, (iii) compared to other human and environmental sounds, trigger sounds of eating and chewing are more likely to trigger mimicking, and (iv) the act of mimicking provides some degree of relief from distress to people with misophonia. CONCLUSION: This study shows prevalence of mimicry and its relation to misophonia severity and trigger types. The theoretical framework of misophonia needs to incorporate the phenomenon of mimicry and its effect on management of misophonia distress.

Misophonia Sound Recognition Using Vision Transformer.

Misophonia is a condition characterized by an abnormal emotional response to specific sounds, such as eating, breathing, and clock ticking noises. Sound classification for misophonia is an important area of research since it can benefit in the development of interventions and therapies for individuals affected by the condition. In the area of sound classification, deep learning algorithms such as Convolutional Neural Networks (CNNs) have achieved a high accuracy performance and proved their ability in feature extraction and modeling. Recently, transformer models have surpassed CNNs as the dominant technology in the field of audio classification. In this paper, a transformer-based deep learning algorithm is proposed to automatically identify trigger sounds and the characterization of these sounds using acoustic features. The experimental results demonstrate that the proposed algorithm can classify trigger sounds with high accuracy and specificity. These findings provide a foundation for future research on the development of interventions and therapies for misophonia.

[Language and Hearing Disorders in Adolescents]. / Sprach- und Hörstörungen im Jugendalter.

Communicative impairments during adolescence pose a serious barrier to participation and personality development. The article summarizes relevant disorders of language and hearing in this vulnerable phase of life. A case study exemplifies challenges and potentials in the clinical practice with adolescent patients.

Predictors of Dizziness and Hearing Disorders in People with Long COVID.

Background and Objectives: Individuals report persistent symptoms after becoming infected by SARS-CoV-2 (COVID-19) that last for >4 weeks (long-COVID syndrome). Dizziness and hearing loss have been reported among long-COVID symptoms. However, little is known about the potential predictors of dizziness and hearing loss in individuals with long COVID. This study aimed to explore the presence and correlates of dizziness and hearing loss in a sample of people with long-COVID syndrome. Materials and Methods: Individuals aged 18 years and older who were infected with COVID-19 at least 8 weeks prior to the start of the study were included if they were not diagnosed with dizziness or hearing loss before getting COVID-19. Demographics and COVID-19-related information were collected. Participants completed the Dizziness Handicap Inventory (DHI), Activities-Specific Balance Confidence (ABC) scale, Falls Efficacy Scale International (FES-I), Modified Fatigue Impact Scale (MFIS), and Medical Outcomes Study Short Form 12 (SF-12). Finally, hearing was assessed using pure-tone audiometry (PTA) in a subsample. Results: Two hundred and nine individuals (66% female) with a mean (SD) age of 27 (9) participated in the study. Perceived dizziness and hearing loss were reported in 26 and 15.3% of the sample, respectively. Logistic regression was conducted to identify potential predictors of dizziness and hearing loss separately. After controlling for age and severity of dizziness, female sex and high fatigue severity were associated with an increased likelihood of reporting dizziness (R2 = 31%). The severity of dizziness and neurological symptoms during the acute stage of COVID-19 were associated with an increased likelihood of reporting hearing loss (R2 = 10.4%) after controlling for age. Conclusions: Dizziness and hearing loss present in long COVID and can be disabling. Females with high levels of fatigue should be questioned about persistent dizziness. Hearing loss should be considered in individuals with neurological symptoms and severe dizziness as a consequence of long COVID.

Novel five-phase model for understanding the nature of misophonia, a conditioned aversive reflex disorder.

Background: Misophonia is a recently identified condition in which a person perceives a subtle stimulus (e.g., eating sounds, hair twirling) and has an intense, negative emotional response. Misophonia cannot be classified with established nosological systems. Methods: We present a novel five-phase model of misophonia from a cognitive-behavioral framework. This model identifies a learned reflex of the autonomic nervous system as the primary etiology and maintenance of misophonia. Phase one is anticipatory anxiety and avoidance. Phase two is a conditioned physical reflex (for example, the tensing of calf muscles) that develops through stimulus-response Pavlovian conditioning. Phase three includes intense negative emotional responses and accompanying physiological distress, thoughts, urges, and emotion-driven behavior. Phase four is the individual's coping responses to emotional distress, and phase five is the environmental response and resulting internal and external consequences of the coping behaviors. Each phase helps explain the maintenance of the response and the individual's impairment. Results: Anticipatory anxiety and avoidance of phase one contributes to an increased arousal and awareness of triggers, resulting in increased severity of the trigger experience. Both the Pavlovian-conditioned physical reflex of phase two and the emotion-driven behavior caused by the conditioned emotional response of phase three increase with in vivo exposure to triggers. Phase four includes internal and external coping behaviors to the intense emotions and distress, and phase five includes the consequences of those behaviors. Internal consequences include beliefs fiveand new emotions based on environmental responses to anger and panic. For example, the development of emotions such as shame and guilt, and beliefs regarding how 'intolerable' the trigger is. Conclusions: We assert misophonia is a multi-sensory condition and includes anticipatory anxiety, conditioned physical reflexes, intense emotional and physical distress, subsequent internal and external responses, and environmental consequences.