These cases support the assertion that misophonia is an aversive Pavlovian conditioned reflex that develops when a person is in a state of distress and hears a repeating sound. In most of these cases, the sound could be a source or contributing factor for distress. In the case of Carla, it is not clear that the sound contributed to her distress, but the sound was being made by the person who was the source of her distress.
To develop the reflex, you have to have a state of distress and hear some repeating sounds. One way this happens is to experience distress where there is also an irritating sound that increases the distress.
Think of an open hand as a distress indicator: I got a little distressed (fist 25% closed); I heard a crunch (fist 50% closed); I heard the crunch again (fist 75% closed); I heard the crunch yet another time (fist very tight). I now have this extremely tight- muscle distress that is paired with the crunch sound. The next time I hear that crunch my lizard brain may not pull the muscle 100% tight, but it may pull it 25% or 50% tight. That jerk of the muscle to the trigger sound is misophonia.
The other possible situation is when you have tight muscles or a reflex for any reason and hear a repeating sound. You need to notice the repeating sound and have a slight increase in muscle tension. This can create the acquired reflex in your lizard brain. So simply being put in distress and noticing a repeating sound (or sight) may also create misophonia.
Both of these scenarios are explained by the fundamental neurological process called classical conditioning that we discussed earlier in this chapter. Viewing misophonia as a conditioned reflex helps us understand how misophonia develops and how new triggers develop, including visual triggers. This also implies that misophonia is not a sign of a defective brain. Rather, it is the sign of a properly functioning lizard brain, whose job is to protect you and help you adapt to your environment by developing acquired reflexes.
Note the emotional response of misophonia is also a conditioned response (a conditioned emotional response or CER). As mentioned previously, the fMRI study by Sukhbinder Kumar31 provides strong evidence that the emotional response of misophonia is a learned (or acquired) response and not a hard- wired response in the brain. The emotional response of misophonia is still an involuntary emotional reflex, so we should not expect the individual with misophonia to simply control their emotions. As a conditioned emotional reflex, it can be changed, but such change requires effort and takes time (and often professional help).