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

Abstract

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 contribute 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. A newly identified feature of phase four is a covert review of the trigger experience. Phase five includes the consequences of those behaviors with internal consequences of beliefs and new emotions (e.g., shame, guilt) based on environmental responses to anger and panic. Conclusions: We assert the Mitchell-Dozier model provides a novel framework to understanding misophonia as a multi-sensory reflex condition. Our model states that misophonia initially develops as a Pavlovian-conditioned physical reflex and subsequent conditioned emotional responses. Treatments that identify patients’ specific conditioned physical reflex of phase two have shown promising early results, further supporting this model