I’ve been told that a trigger is more like being slapped or being poked in the ribs with a stick or being zapped with a cattle prod or mini–Taser. I sometimes demonstrate to a non–misophonic person what a trigger is like by taking a rubber band, putting it against my chest, pulling back the center, and popping myself. Ouch! That hurts. That’s the way I think of misophonia. It is an initial “POW” response. And it has very extreme emotions that come with the “POW.”
There’s quite a bit of diversity in this physical reflex. In my practice, I estimated that about 95% of those I had worked with recognized a physical reflex. However, I had four clear cases where no matter how hard we tried to identify a physical reflex; the only experience of the person to a trigger was an emotional response of irritation. I worked with one person a second time, and using a different test method, he felt a muscle jerk in his legs. After working with another person for over six months, one session she declared that she had identified her physical reflex. She said a coworker had asked her why she was mad, but she replied she was not. The coworker said, “Then why are you frowning? You frown almost all the time.” My client recognized that she did frown a lot, and that the frown was caused by her triggers. Every time she was triggered, her forehead muscles jerked and forced her to frown.
That was her reflex. The third person reported not having a physical reflex, but the physical reflex in his face was visible. So with the people that I have worked with, about 99% had a physical reflex.
A lot people with misophonia say, “I simply have rage. I don’t have a physical reflex,” but when we get into a treatment setting or the individual can relax and observe their response to a weak trigger, they can identify the reflex. I worked with one girl who said she only had rage (no physical reflex at all). Yet whenever we used a very, very small trigger during treatment, her mother and I could see her shoulders jerk. She identified the muscle jerk herself when we finished the treatment and talked about it. Incidentally, she did not feel the negative emotion during the treatment. She felt the muscle jerk reflex. This is shown in the figure below – that the misophonic trigger elicits the physical reflex, as shown in the next figure. (Note: Elicit is a technical term that means to “cause a reflex to happen.”)
In Chapter 7 I presented the wide variety of physical reflexes reported in our recent study. One weakness of this study is that it used self–report of the individuals in the study. Even though we explained what we did in our manuscript, and that the individuals were reporting an immediate physical response to a very weak trigger (rather than a secondary stress response), one of the peer– reviewers of the manuscript thought we had a novel way of presenting what had been reported in other studies. But the well–noted Edelstein study18 that measured the increase in skin conductance (sweating when triggered) showed that the reading was stable for two seconds and then steadily increased for the remaining 15 seconds of the trigger. Her study showed a delayed, secondary response, not an immediate physical flinch elicited by the trigger. There is no recognition of this immediate physical reflex response in any misophonia research, except in my articles.
To show that the immediate physical reflex is real, we decided to measure the physical response with electromyography (EMG). This system measures the voltage of the muscle, and is very similar to an electrocardiogram which measures the electrical voltage when your heart beats. The drawing below shows the EMG
output for a misophonic person when triggered. The top line shows a timing pulse that the person does not hear. The actual trigger does not show of this EMG chart, but occurred immediately after the timing pulse as shown by the oval. Note that the calf muscle contraction started only 200ms (two tenths of a second) after the trigger started. This provides hard data of the initial physical reflex response, which is a key part of the misophonic response.
Now it’s time to add the emotional response to your misophonic reflex response into our drawing. It appears that the
emotional response is jerked out of you (elicited) by the sensation of the physical reflex as shown in the next figure. The emotions happen immediately, and come so quickly that they seem to be caused by the trigger
As noted above, misophonic individuals all reported that it was impossible for them to not become upset when exposed to trigger stimuli, although they had repeatedly tried to remain calm. It is commonly said that “anger is a choice,” or that “another person cannot make you mad unless you let them.” This may be true for things people say because the meaning of the words is determined by a person’s learning experience with language and other social factors. A person’s response to a statement such as “I hate you” is affected by their evaluation of the context and social dynamics at that moment.
With misophonia, however, anger is not a choice. The physical misophonic reflex (or combination of the sound/sight and the physical reflex) elicits a conditioned emotional response. The physical reflex is intrusive and difficult to ignore; even when a person tries to use a technique to avoid attending to the auditory stimulus, the physical reflex is perceived. The sensation of the physical reflex has been paired many times with frustrating, irritating situations. This pairing of emotions, physical sensation, and the trigger can cause associative learning or conditioning, such that the stimulus elicits the emotional response.
The role of associative learning in misophonia is supported by a 2017 fMRI (functional magnetic resonance imaging) study of individuals with misophonia which was conducted by Sukhbinder Kumar and presented at the 2015 Misophonia Association Conference19. Dr. Kumar presented data that supported associative learning for the extreme emotions of misophonia. However, fMRI has a slow response time, taking about two seconds to measure the
change of blood flow in the brain which shows the areas of higher activity. Therefore, this method cannot show the timing between the trigger stimulus, physical reflex, and extreme emotions that accompany misophonia.
Dr. Kumar’s study showed a relationship between emotional activity and a small structure that is behind your eyes called the ventromedial prefrontal cortex (vmPFC). The vmPFC has been shown to be related to experiential learning, or conditioned learning. This conditioned emotional response to triggers is supported by the extreme, immediate, and involuntary response to triggers of most individuals with misophonia. The extreme emotions are literally jerked out of the person, often against their will and best efforts to avoid them.
In some individuals, the physical reflex is very strong. The sound elicits an intrusive, uncomfortable reflex response. I propose that this physical reflex response is a form of physical assault on the person, although the actual physical assault is performed by their autonomic nervous system. The response to the repetitive physical reflex is the array of the extreme emotions.
You can’t feel electricity, but if you’ve been shocked you felt something. What you actually felt was muscle contraction. The electricity made you tighten your muscles, and that was uncomfortable. We know that the reason our muscles move is that our brain sends out electrical impulses, which cause our muscles to contract. So when the lizard brain perceives the trigger, it sends out an electrical shock! The emotional response to aversive events is consistent with research. The electric shock is an assault on your body, and it’s that physical assault that produces the strong emotions.
Research studies have shown that aversive stimuli cause fight–or–flight emotions in humans.20 The strength of these
emotions is affected by a number of factors, and the urge to fight may not be outwardly visible but it’s there. This is consistent with the emotions for individuals with misophonia, and their reported effort to resist aggressive impulses. Furthermore, activity in the limbic system of humans in response to aversive odors and tastes has been demonstrated.21 Evidence suggests that the aversive physical misophonic reflex may cause the commonly reported
emotions of hate, anger, rage and disgust.
As I mentioned earlier, one woman reported feeling like a shovel was run through her sternum and out her back when she was being triggered, but said this was metaphorical, incorporating both the physical and emotional feelings. She couldn’t describe which muscle was contracting, but she sure felt it. Her reflex was a gasp for breath. Do a quick exercise to gain an understanding of what that felt like for her. Close off your windpipe and try to take a quick breath. You may want to close your mouth and pinch your nose to do this. That hurts around the sternum. The girl I mentioned earlier as having a visible shoulder jerk to a tiny trigger during a treatment probably had a very strong, physical jolt from a trigger. In treatment, under controlled circumstances when her trigger was presented minimally, we could see her shoulders jump almost an inch. I can only imagine how strong her reflex was in real life.
In summary, your miso–emotions are an intrusive emotional reflex response. Generally they are triggered either by the physical response or a combination of the trigger stimulus and the physical response. So we need to add one more connection to our drawing of misophonia. The figure below shows the development of a direct connection between the misophonic trigger and the emotional response. I consider this a secondary process. In some cases, the individual has both an emotional response and a physical response to the very weak trigger used in the Neural Repatterning Technique (NRT) treatment (to be discussed later). The directly elicited emotional response is a secondary process because in many cases there is first a clear physical reflex which occurs without an emotional response during the NRT treatment.
As discussed in the section on Progressive Muscle Relaxation (PMR), relaxing the initial physical response muscle can significantly reduce the emotional response and in time, eliminate the trigger. Additionally, in the physical reflex identification study we conducted in 2016, participants exposed to a very weak trigger were twice as likely to identify a physical response but no emotional response than the opposite (identifying an emotional response but no physical response).
The NRT, PMR, and above study results all support that the direct connection from the trigger stimulus to eliciting emotions is a secondary path. I would like to conduct a study to test the theory of the secondary path shown below, but we will need research funding to do this. It is possible in some cases to immobilize the immediate physical reflex. Comparing the severity rating of triggers with and without the immediate physical reflex would indicate the strength the secondary path for that individual.