Author’s Accepted Manuscript

An Examination of the Relationship between

Misophonia, Anxiety Sensitivity, and Obsessive-
Compulsive Symptoms

Shannon E. Cusack, Therese V. Cash, Scott R.

Vrana
www.elsevier.com/locate/jocrd

PII: S2211-3649(18)30003-4
DOI: https://doi.org/10.1016/j.jocrd.2018.06.004
Reference: JOCRD396
To appear in: Journal of Obsessive-Compulsive and Related Disorders
Received date: 4 January 2018
Revised date: 27 April 2018
Accepted date: 23 June 2018
Cite this article as: Shannon E. Cusack, Therese V. Cash and Scott R. Vrana, An
Examination of the Relationship between Misophonia, Anxiety Sensitivity, and
Obsessive-Compulsive Symptoms, Journal of Obsessive-Compulsive and
Related Disorders, https://doi.org/10.1016/j.jocrd.2018.06.004
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 1

An Examination of the Relationship between Misophonia, Anxiety Sensitivity, and Obsessive-

Compulsive Symptoms

Shannon E. Cusack, B.A.1,2, Therese V. Cash, Ph.D.1, & Scott R. Vrana, Ph.D.1*
1
Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, USA
2
Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University,
Richmond, Virginia, USA

*Corresponding Author: Scott Vrana, Department of Psychology, 806 W. Franklin St. Box
842018, Virginia Commonwealth University, Richmond, VA 23284-2018
Email: srvrana@vcu.edu

Abstract

Misophonia is a decreased sound tolerance condition in which specific sounds elicit an intense

negative emotional response. The aims of the current study were to examine how obsessive-

compulsive disorder (OCD) symptoms and misophonia are related, and to examine the

possibility that the relationship between anxiety sensitivity (AS) and misophonia may be

explained in part by the presence of OCD symptoms. Data were collected from both

undergraduate students (N=451) and community participants (N = 377) using Amazon’s MTurk.

Participants completed an online survey assessing for decreased sound tolerance conditions,

individual differences variables, and clinical variables. Misophonia was more strongly related to

obsessive than to compulsive components of OCD, consistent with case reports of obsessive

thoughts in misophonia. In addition, OCD symptoms partially mediated the relationship between

AS severity and misophonia symptom severity. These results align with the theorized role of

anxiety sensitivity in OCD and in misophonia, and provide suggested directions for future

research into the mechanisms of misophonia.

Keywords: misophonia, obsessive-compulsive disorder, anxiety sensitivity

 2

Misophonia is defined as “a chronic condition in which specific sounds provoke intense

emotional experiences and autonomic arousal within an individual” (p. 1; Edelstein, Brang,

Rouw, & Ramachandran, 2013). These emotional experiences are negative in nature and often

include disgust, anger, and distress. The auditory stimuli are typically sounds made by other

people, usually someone the person knows, and are often mouth sounds such as smacking of the

lips, eating, or chomping of the teeth (Wu, Lewin, Murphy, & Storch, 2014). Roughly 20% of

college students report clinically significant misophonia symptoms (Wu et al., 2014); although

misophonia is not well-recognized among health care professionals, it appears to be occurring at

substantial levels in the population.

Misophonia has been associated with symptoms of many psychological disorders,

including anxiety and depression (Wu et al., 2014; Zhou, Wu, & Storch, 2017), though the

relationship most frequently reported has been with obsessive compulsive disorder (OCD) and

other disorders on the obsessive-compulsive spectrum. Converging evidence for this relationship

has accrued from case reports of misophonia patients presenting with comorbid OC spectrum

disorders such as Tourette syndrome (Neal & Cavanna, 2013) or OCD-like behavior

(Hadjipavlou, Baer, Lau, & Howard, 2008), the prevalence of OC spectrum disorders among

patients who self-referred for clinically-significant symptoms of misophonia (Schroder, Vulink,

& Denys, 2013) and individuals reporting auditory and tactile intolerance (Taylor, Conelea,

McKay, Crowe, & Abramowitz, 2014), and correlations between symptoms of misophonia and

OCD in U.S. (Wu et al., 2014) and Chinese (Zhou et al., 2017) university students. Given the

preponderance of available evidence, Schroder et al. (2013) tentatively conceptualized

misophonia as a potentially new obsessive-compulsive spectrum disorder. From a cognitive-

behavioral perspective, it is characterized by an aversion to specific sounds, an obsessive

impulse to respond aggressively to the sound source, and efforts to reduce distress caused by the
 3

sound by avoiding the stimulus or attempting to neutralize it through compulsive behaviors such

as mimicking the sound, resulting in a paradoxical increase in the frequency of the obsession and

the distress surrounding it (Schroder et al., 2013).

OCD, as defined in the DSM-5, is the presence of obsessions, compulsions, or both

(American Psychiatric Association, 2013). Although both obsessive preoccupation with a trigger

sound and compulsive efforts to reduce distress about the sound have been supported in the

literature (Hadjipavlou et al., 2008; Schroder et al., 2013; Webber & Storch 2015), it is not clear

whether the relationship between misophonia and OCD is best regarded as involving obsessions,

compulsions, or both. This distinction may have important therapeutic implications for clinicians

and researchers developing treatments for misophonia based on effective therapies for similar

syndromes (e.g., Reid, Guzick, Gernand, & Olsen, 2016; Schneider & Arch, 2017; Schröder,

Vulink, van Loon, & Denys, 2017).

Anxiety sensitivity (AS) is a trait-like tendency to react fearfully to anxiety symptoms

(McNally, 1989; Schmidt, Zvolensky, & Maner 2006). It is a multi-dimensional construct that

includes fears of physical, mental, and publicly observable experiences of anxiety (Zinbarg,

Barlow, & Brown, 1997; Schmidt, 2006). According to McNally (1989), the fear of anxiety can

act as a motive for avoiding any stimulus that is a potential trigger for anxiety symptoms.

Numerous studies have found that AS levels are positively related to OCD symptoms (see

Robinson & Freeston, 2014, for a review); further, a one-session AS intervention reduced OCD

symptom severity, suggesting a link between anxiety sensitivity and obsessive compulsive

symptoms (Timpano, Raines, Shaw, Keough, & Schmidt, 2016). Relatively few studies have

examined the relationship between the separate dimensions of AS and OCD symptoms. David

and colleagues (David, Olatunji, Armstrong, Ciesielski, Bondy, & Broman-Fulks, 2009) found

that AS was more highly correlated with obsessions than with other OCD-related symptoms.
 4

More specifically, the cognitive dyscontrol dimension of AS was uniquely predictive of

unacceptable thoughts (Wheaton, Mahaffet, Timpano, Berman, & Abramowitz, 2012), and in

another study cognitive dyscontrol was the only one of the three AS dimensions significantly

associated with the obsessing subscale of the Obsessive-Compulsive Inventory (Raines, Oglesby,

Capron, & Schmidt, 2014). Thus, there appears to be a specific relationship between cognitive

dyscontrol and obsessive symptoms.

The goal of this study is to investigate the link between OCD symptoms, anxiety

sensitivity, and misophonia. The study will examine the co-occurrence of OCD and misophonia

symptoms given the substantial evidence of an association between OCD and misophonia (e.g.,

Schroder et al., 2013; Taylor et al., 2014; Wu et al., 2014). We hypothesize that OCD symptoms

will be associated with misophonia, replicating previous results. Based on the importance of

cognitive appraisals about the source of the sound in misophonia (Bernstein et al., 2013; Johnson

et al., 2013; McGuire, Wu, & Storch, 2015), we further hypothesize that misophonia will be

associated with obsessive moreso than compulsive symptoms of OCD. Second, misophonia is

related to anxiety and has been conceptualized as a conditioned emotional response to the sound

stimulus. The aversion elicited by the sound leads us to hypothesize that individuals with high

levels of anxiety sensitivity will be more sensitive to the sound and their response to the sound,

and will endorse more severe misophonia symptoms; thus anxiety sensitivity will directly

increase misophonia symptoms severity. Further, since anxiety sensitivity increases one’s level

of OCD symptoms (e.g., Wheaton et al., 2012; Reiss, 1986; Calamari, Rector, Woodward,

Cohen, & Chik, 2008), we posit that OCD symptoms will mediate the relationship between AS

and misophonia severity. Finally, because of the noted connection between obsessive thoughts

and cognitive dyscontrol, we will explore the specific role of the cognitive dyscontrol dimension
 5

of AS in misophonia, and if OCD symptoms mediate the relationship between AS cognitive

dyscontrol and misophonia symptom severity.

Methods

Participants

Participants were recruited from two different sources. One sample was recruited from

the Virginia Commonwealth University undergraduate population using an online system for

students to participate in research for extra credit in their psychology courses. The second sample

was recruited from community-based adults in the United States participating in research through

Amazon’s Mechanical Turk (MTurk) program. MTurk is an “online marketplace” where

researchers can post human intelligence tasks and participants can choose tasks to complete for

compensation. Past research has discussed the benefits for conducting research using MTurk.

MTurk has proven to be useful in broadening sample size, sample diversity, and external validity

of survey research (e.g., Mason & Suri, 2012). A total of 828 people were included in the current

study. However, due to missing data, the sample size for each analysis varies. Sample

characteristics are presented in Table 1. Given demographic differences between the two

samples, we first conducted all analyses separately for each sample. Since the results were the

same for each group, we report the analysis of the combined sample for simplicity of

presentation.
 6

Table 1. Sample Characteristics and Means and Standard Deviation

N Student Community Combined

sample sample sample
Demographic items
Age, Mean (SD) 19.58 37.04 27.49 (12.41)
(Range) (3.60) (12.54)* (17-77)
(17-67) (17-77)
Gender*
Female 71.2% 54.6% 63.6%
Male 28.4% 44.6% 35.7%
No response .4% .8% .6%
Ethnic identity*
African American or Black 23.5% 6.9% 15.9%
Asian American 14.9% 13.5% 14.3%
White-Non-Hispanic 42.8% 61.0% 51.1%
White-Hispanic 8.4% 10.3% 9.3%
Middle Eastern 2.9% 0.0% 1.6%
Other 7.5% 8.0% 7.7%
No response 0.0% .3% .1%
DST and related measures
Misophonia Questionnaire Total 826 17.3 (11.0) 16.0 (12.1) 16.7 (11.5)
Symptom scale 7.0 (5.0) 6.4 (5.5) 6.7 (5.3)
Emotions and behaviors scale 11.8 (6.4) 11.7 (6.4) 11.7 (6.4)
Severity scale 3.0 (2.5) 2.9 (2.8) 2.9 (2.6)
Clinical correlate measures
Obsessive Compulsive Inventory-Revised 826 13.0 (10.4) 11.9 (12.0) 12.5 (11.1)
Individual difference and mechanism of
action measures
Anxiety Sensitivity Index-3 826 18.3 (12.9) 18.5 (14.3) 18.4 (13.5)

Note: *Designates a statistically significant difference between the student and community

samples.

Because of the large number of comparisons made, a two-tailed alpha level of p<.001was

employed. DST; decreased sound tolerance condition.

Procedure

The survey was distributed to the undergraduate participant pool and the community

sample with a link to the survey at an external, secure, electronic data management system

(REDCap). Participants were instructed to complete a series of screening questions regarding

sound intolerance. Based on their responses, participants were then asked to answer additional
 7

questions about the reported problems. The questionnaires were administered to each participant

in the same order, which was established to group related constructs together for ease of

comprehension.

Measures

Misophonia.

Screening items were developed based on existing screening questions used in audiology

research and clinical practice (Moller et al., 2011). The Misophonia Questionnaire (MQ) is a

three-part self-report questionnaire that assesses for the presence of misophonia (Misophonia

Symptom Scale), associated emotions and behaviors (Misophonia Emotions and Behaviors

Scale), and the severity (Misophonia Severity Scale) (Wu et al., 2014). For the Misophonia

Severity Scale (range=0-15), individuals that reported a 7 or higher on the MQ Misophonia

Severity Scale were considered to have clinically significant misophonia symptoms (Wu et al.,

2014). The Misophonia Severity Scale and the MQ Total Score (the sum of the Symptom Scale

and Emotions and Behaviors Scale) were used for analyses in the current study.

Obsessive Compulsive Inventory-Revised.

The Obsessive Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) is an 18-item

abridged version of the OCI (Foa, Kozak, Salkovskis, Coles, & Amir, 1998) used to measure

OCD symptoms over the past month in both clinical and non-clinical samples. According to Foa

et al. (2002), 21 is the cutoff score suggesting the presence of OCD. The current study used the

six subscales validated in a clinical sample of patients with OCD (Huppert et al., 2007): washing,

checking, ordering, obsessing, hoarding, and neutralizing. The researchers found high internal

consistency for the subscales, supporting the idea that the six subtypes of OCD are well-

measured by the OCI-R. Additionally, each subscale score was the highest in patients who
 8

identified as having primary concerns with that subscale symptom type and lowest in patients

who denied those symptoms.

Anxiety Sensitivity Inventory.

The Anxiety Sensitivity Inventory-3 (ASI-3; Taylor et al., 2007) is an 18-item self-report

instrument that provides a total score, as well as three domain scores: Cognitive dyscontrol

concerns, Social concerns, and Physical concerns. Factorial validity was supported through

confirmatory factor analyses of six replication samples; internal consistency of the subscales is

also strong (Taylor et al., 2007).

Results

Clinically significant misophonia symptoms were defined as endorsing a seven or greater

on the MQ severity scale. The cutoff score of 21 established by Foa et al., 2002 was used as the

cutoff for clinically significant OCD symptoms. 15.6% of the combined sample endorsed

clinically significant misophonia symptoms. 21.2% of participants were found to have clinically

significant OCD symptoms. To examine the frequency of OCD and misophonia caseness and

rates of co-occurrence, cross-tab analyses were performed to identify the conditional probability

of having clinically significant misophonia symptoms based on the presence of clinically

significant OCD symptoms (and vice versa). The presence of misophonia or OCD significantly

increased the likelihood of clinically relevant symptoms of OCD (45.7%) or misophonia

(34.1%), respectively, χ²(1,817)= 55.37, p<.001.

To further examine the relationship between OCD symptoms and misophonia, Pearson

product moment correlations were conducted. A significant association was found between

misophonia (MQ Total) and OCD symptoms as measured by the OCI-R total score (r = .44, p <

.001), a medium to large effect (Cohen, 1992). Correlations between the MQ Total score and

each of the six OCI-R subscales ranged from r=.27-.42, all p<.001 (see Table 2). Additional
 9

analyses were conducted to test the hypothesis that the OCI-R obsessive subscale was most

strongly related to misophonia. Correlations between MQ Total and each OCI-R subscale were

z-transformed, and then the correlation between the MQ Total and the obsessive subscale was

statistically compared to the correlation of the MQ Total and every other OCI-R subscale using

the Steiger’s z-test (Steiger, 1980). Table 2 includes the Z scores and p values for the statistical

comparisons between these correlations. Using an improved Bonferroni procedure (Simes, 1986)

to correct for multiple comparisons, we found that the correlation between MQ Total and the

OCI-R Obsessive subscale was significantly greater than any other correlation between the MQ

Total and the other OCI-R subscales with the exception of the OCI-R Ordering subscale.

Table 2. Misophonia (MQ Total) and OCD Symptom Subscale Correlations and Z-

scores

Correlations
with MQ Total Z score p value
OCI-R Obsessive .42
OCI-R Neutralizing .27 4.61 <.001
OCI-R Ordering .40 2.06 .04

OCI-R Washing .36 2.73 <.001

OCI-R Hoarding .27 4.56 <.001
OCI-R Checking .32 3.18 <.001

Notes. All correlations between MQ Total and OCI-R subscales are significant at p<
.001 and in the medium to large range (Cohen, 1992). Z-scores and p-values
represent the statistical test of the difference between the correlation of the MQ
Total and that row’s subscale and the correlation of the MQ Total and the Obsessive
subscale.
N = 811, except for the following: OCI Obsessive (n = 817), OCI Neutralizing (n = 815),

OCI Washing (n = 813), and OCI Ordering (n = 813).

Misophonia, OCD, and AS

 10

The relationship between misophonia severity and AS was examined using Pearson

correlations. There was a significant association between ASI-3 total score and misophonia

severity, r = .40, p < .001, as well as misophonia severity and each ASI-3 subscale: ASI

Cognitive, r = .40, ASI Social, r = .35, ASI Physical, r = .33, all p < .001. These are medium to

large effects. These correlations were z-transformed and comparisons revealed no significant

differences in the associations between misophonia and each ASI-3 subscale.

The mediation of the relationship between misophonia severity and AS by OCD

symptoms was assessed using a simple mediation model. The PROCESS macro for SPSS was

used to conduct the mediation analyses (Hayes, 2013), with AS entered as the independent

variable, OCD symptoms as the mediator, and misophonia symptom severity as the dependent

variable. The total effect model was significant, R2 = .09, F(1,815) = 85.41, p < .001, indicating

that OCD symptoms and AS account for 9% of the variance in misophonia severity. Further

examination found that misophonia severity was both directly explained by the presence of AS

and indirectly explained by the presence of AS through a pathway of OCD symptoms (see Figure

1). Greater AS was associated with more OCD symptoms (a = .46), and OCD symptoms were

associated with higher levels of misophonia severity (b = .08). A bias-corrected bootstrap

confidence interval (CI) for the indirect effect (ab = .04) based on 5,000 bootstrap samples was

entirely above zero (.0263-.0472). Because this CI does not include zero, the null hypothesis that

ab1 = 0 can be rejected, meaning that OCD symptoms did mediate between AS and misophonia

severity. However, the direct effect of AS on misophonia symptom severity was also maintained,

independent of its mediation by OCD symptoms (c’ = .06, p <.001), indicating partial mediation.

a = .46* b = .08*
 OCD Symptoms

11

Anxiety
Misophonia
Sensitivity
severity
symptoms c’ = .06*

*p <.001

Figure 1. Simple Mediation of Misophonia Symptoms by Anxiety Sensitivity

The mediation of the relationship between misophonia severity and the cognitive

subscale of the ASI-3 by obsessive OCD symptoms was assessed using a simple mediation

model. The total effect model was significant, R2 = .08, F(1,771) = 70.71, p < .001, indicating

that OCD obsessive symptoms and AS cognitive symptoms account for 8% of the variance in

misophonia severity. Further analyses found that misophonia severity was directly explained by

the presence of cognitive AS symptoms and was indirectly explained through a pathway of

obsessive OCD symptoms (see Figure 2). The presence of cognitive AS was associated with

greater obsessive OCD symptoms (a = .30), and obsessive OCD symptoms were associated with

higher levels of misophonia severity (b = .27). A bias-corrected bootstrap confidence interval

(CI) for the indirect effect (ab = .08) based on 5,000 bootstrap samples was entirely above zero

(.0564-.1119), meaning that the null hypothesis that ab1 = 0 can be rejected and obsessive OCD

symptoms did mediate between cognitive AS symptoms and misophonia severity. The direct

effect of cognitive AS symptoms on misophonia severity was maintained independent of its

relationship with OCD symptoms (c’ = .08, p =.002).

OCD obsessive
a = .30* symptoms b = .27*

AS cognitive Misophonia
symptoms severity
c’ = .08*
 12

*p <.001

Figure 2. Simple Mediation of Misophonia Severity by Anxiety Sensitivity Cognitive Symptoms

 13

Discussion

The aims of the current study were two-fold: to replicate and further clarify the

relationship between OCD symptoms and misophonia, and to examine how OCD symptoms

influence the relationship between misophonia and AS.

Obsessive-Compulsive Disorder and Misophonia

The research on misophonia has established the relationship between misophonia and

symptoms of OCD (e.g., Wu et al., 2014; Zhou et al., 2017). Our results show that having

clinically significant levels of either OCD or misophonia symptoms significantly increases the

risk of having the other. The overlap in clinical caseness between OCD and misophonia was

consistent with prior research (Schroder et al., 2013; Taylor et al., 2014), and this study built

upon previous investigations in assessing these relationships in the general population rather than

in a psychiatric clinic (e.g., Schroder et al., 2013). The current study is consistent with the

finding of McKay, Kim, Mancusi, Storch and Spankovich (2017) that individuals with elevated

misophonia symptoms report significantly greater symptoms on all OCI-R subscales compared

to individuals with lower misophonia symptoms.

The relationship of misophonia to specific types of OCD symptomology is not yet well

established. Both the obsessive and the compulsive aspects of OCD have been reported in cases

of misophonia (e.g., Hadjipavlou et al., 2008; Schroder et al., 2013; Webber & Storch, 2015).

The present results show that misophonia is strongly associated with all OCI-R subscales, with

obsessive and ordering subscales in particular exhibiting correlations at or above r =.40.

However, the misophonia relationship was significantly stronger with obsessive symptoms than

any of the other subscales except for ordering, suggesting that obsessive thoughts are a

particularly important aspect of misophonia. This finding is consistent with the proposed

cognitive behavioral model of misophonia (Bernstein et al., 2013; Johnson et al., 2013; McGuire,
 14

Wu, & Storch, 2015) in which one’s reaction to a sound is influenced by the source of the sound,

and individuals with misophonia report thoughts about the source as disgusting, rude, etc.

Therefore, the thoughts and evaluation of the source may affect one’s reaction to the stimulus,

increasing the severity of misophonia symptoms.

Important questions remain in this area. First, the nature of thoughts in those with

misophonia needs further examination to determine if they are obsessive in nature, or not.

Second, because the OCI-R does not have a compulsions subscale comparable to the obsessions

subscale, the finding that misophonia is more strongly related to the obsessive symptoms is

applicable only to the specific compulsions captured by the OCI-R subscales (i.e., washing,

checking, ordering, hoarding, and neutralizing). Finally, there are some inconsistent findings in

the literature that need to be addressed. A profile analysis of OCI-R subscales, harm avoidance,

incompleteness, and ASI-3 physical symptoms found two profiles, accounting for 70% of the

total variance, that did not distinguish between individuals with and without misophonia

symptoms (McKay et al., 2017). A third profile, accounting for a smaller (11%) amount of

variance, did distinguish individuals reporting misophonia from non-misophonics, and found

those reporting misophonia were characterized by lower symptoms on the obsessive,

neutralizing, and washing subscales, and higher symptoms on the ordering subscale, harm

avoidance, and sensitivity to interoceptive physical concerns on the ASI-3. These findings are

difficult to interpret given that misophonia severity was not distinguished by OCD symptom

types for the two profiles accounting for the majority of the variance, and that this study found

consistently higher levels of OCD symptoms across all subscales for those reporting misophonia.

Anxiety Sensitivity and Misophonia

A relationship between misophonia and AS was expected given that misophonia

involves an exaggerated emotional response to typically innocuous stimuli, and a significant

 15

moderate association between misophonia severity and AS was found. Because those high on the

cognitive dyscontrol subscale may interpret obsessive preoccupation with symptoms of

misophonia as more meaningful, leading them to engage in avoidance behaviors, we further

predicted that misophonia should be more strongly related to cognitive dyscontrol than to other

subscales of the ASI-3. However, this hypothesis was not supported.

The literature has established that AS predicts OCD symptoms (Wheaton et al., 2012;

Calamari et al., 2008; Reiss et al., 1986). To date, there is no specific conceptual rationale for

this relationship aside from the link between anxiety sensitivity and an enhanced vulnerability to

fear conditioning (Robinson & Freeston, 2014). It may be that those with OCD who are high in

AS have negative beliefs about the meaning of their symptoms, and thus are more likely to

engage in avoidance strategies. In misophonia, an individual may experience an obsessive-

aggressive impulse, and engage in compulsive or avoidance behaviors to reduce the distress from

this impulse or thought. Thus, we hypothesized that AS would increase misophonia severity

directly, and would indirectly increase misophonia symptom severity through OCD symptoms.

These direct and indirect mediation hypotheses were confirmed. The total effect model was

significant, indicating that OCD symptoms and AS account for 9% of the variance in misophonia

severity.

Lastly, a mediation model was used to test the mediating effects of obsessive symptoms

on the relationship between the ASI-3 cognitive dyscontrol subscale and misophonia severity.

We hypothesized that the cognitive dyscontrol subscale would increase misophonia severity

directly and indirectly through obsessive symptoms. The overestimation of the importance of

one’s thoughts is a cardinal feature of OCD (Rachman, 1998), and the cognitive dyscontrol

component of AS is higher in individuals with OCD (Calamari et al., 2008). Sensitivity to

failures in cognitive control is higher in those with OCD considering how important obsessions
 16

are to the disorder. Similarly, then, the importance of obsessions in misophonia should be

associated with a higher sensitivity to failures in cognitive control. Consistent with this idea,

results showed that the total effect model was significant and that OCD obsessive symptoms and

anxiety sensitivity cognitive symptoms account for 8% of the variance in misophonia severity.

Misophonia severity was directly explained by the presence of cognitive anxiety symptoms, and

indirectly explained through a pathway of obsessive OCD symptoms.

Future Directions

While other studies have looked at the associations between misophonia and existing

DSM disorders (e.g., Wu et al., 2014), the current study is one of the first to examine how

specific mechanisms may be related to misophonia. A major limitation of the current study is the

cross-sectional nature of the data, limiting the ability to infer causal relationships. The current

study tested theorized relationships between potential mechanisms of action (anxiety sensitivity

and OCD) and outcomes (misophonia symptom severity) through mediation analyses. Future

research using longitudinal and experimentally controlled designs are needed to adequately

assess causal and temporal relationships.

The variance in misophonia severity explained by anxiety sensitivity and OCD symptoms

highlights these symptoms as important to recognize when considering how to treat misophonia.

However, it also highlights the need to examine other target variables that may account for

additional variance. Future investigations should further explore the relationship between

misophonia and the dimensions of the ASI-3. It may be that misophonics are afraid of publicly

observable anxiety symptoms (the social concern), given that they realize their emotions and

thoughts about the sound are excessive (Goodman et al., 2014); in addition, McKay et al.’s

(2017) findings suggests a role for sensitivity to physical manifestations of anxiety. Distress

tolerance may also play a role in the maintenance of misophonia, given its relationship with
 17

anxiety sensitivity (e.g., Laposa, Collimore, Hawley, & Rector, 2015) and the difficulty people

have tolerating misophonic symptoms.

Summary and Conclusions

The current study replicates the finding of a relationship between OCD symptoms and

misophonia, and extends this finding to specify that misophonia is more strongly related to

obsessive than compulsive symptoms. The study also documents a relationship between

misophonia and anxiety sensitivity, and suggests that OCD symptoms may partially mediate the

relationship between AS and misophonia severity. As future research examines how to classify

and treat misophonia, the role of constructs related to OCD and anxiety sensitivity will need to

be further examined.

Funding: This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.

Conflicts of interest: None

 18

References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.

Calamari, J. E., Rector, N. A., Woodard, J. L., Cohen, R. J., & Chik, H. M. (2008). Anxiety
sensitivity and obsessive--compulsive disorder. Assessment, 15, 351–363.
doi:10.1177/1073191107312611

Clark, D. A. (2004). Cognitive-behavioral therapy for OCD. New York: Guilford

Publications.

Cohen, J. (1992). "A power primer". Psychological Bulletin. 112, 155–159. doi:10.1037/0033-
2909.112.1.155. PMID 19565683.

David, B., Olatunji, B. O., Armstrong, T., Ciesielski, B. G., Bondy, C. L., & Broman-Fulks, J.
(2009). Incremental specificity of disgust sensitivity in the prediction of obsessive-
compulsive disorder symptoms: Cross-sectional and prospective approaches. Journal of
Behavior Therapy and Experimental Psychiatry, 40, 533-543.

Edelstein, M., Brang, D., Rouw, R., & Ramachandran, V. S. (2013). Misophonia: Physiological
investigations and case descriptions. Frontiers in Human Neuroscience, 7, 296.
doi:10.3389/fnhum.2013.00296; 10.3389/fnhum.2013.00296

Foa, E.B., Huppert, J.D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P.M.
(2002). The Obsessive Compulsive Inventory: Development and validation of a short
version. Psychological Assessment, 14, 485-496. doi: 10.1037//1040-3590.14.4.485

Foa, E. B., Kozak, M. J., Salkovskis, P. M., Coles, M. E., & Amir, N. (1998). The validation of a
new obsessive-compulsive disorder scale: The obsessive-compulsive
inventory. Psychological Assessment, 10, 206–214. doi:10.1037//1040-3590.10.3.206

Goodman, W. K., Grice, D. E., Lapidus, K. A., & Coffey, B. J. (2014). Obsessive-
compulsive disorder. Psychiatric Clinics, 37, 257-267.

Hadjipavlou, G., Baer, S., Lau, A., & Howard, A. (2008). Selective sound intolerance and
emotional distress: What every clinician should hear. Psychosomatic Medicine, 70, 739-
740. doi:10.1097/PSY.0b013e318180edc2; 10.1097/PSY.0b013e318180edc2

Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A

regression-based approach. New York, NY: Guilford Press.

Huppert, J. D., Walther, M. R., Hajcak, G., Yadin, E., Foa, E. B., Simpson, H. B., & Liebowitz,
M. R. (2007). The OCI-R: Validation of the subscales in a clinical sample. Journal of
Anxiety Disorders, 21, 394–406. doi:10.1016/j.janxdis.2006.05.006

Khalfa, S., Dubal, S., Veuillet, E., Perez-Diaz, F., Jouvent, R., & Collet, L. (2002). Psychometric
normalization of a hyperacusis questionnaire. Orl, 64, 436-442.
 19

McKay, D., Kim, S. K., Mancusi, L., Storch, E. A., & Spankovich, C. (2017). Profile
analysis of psychological symptoms associated with misophonia: A community
sample. Behavior Therapy, 49, 286-294. https://doi.org/10.1016/j.beth.2017.07.002

McNally, R. J. (1989). Is anxiety sensitivity distinguishable from trait anxiety? Reply to

Lilienfeld, Jacob, and Turner (1989). Journal of Abnormal Psychology, 98, 193–194.
doi:10.1037//0021-843x.98.2.193

Mason, W., & Suri, S. (2012). Conducting behavioral research on Amazon’s Mechanical
Turk. Behavior Research Methods, 44, 1-23.

Møller, A. R. (2011). Misophonia, phonophobia, and “exploding head” syndrome.

In A. R. Møller (Ed.), Textbook of tinnitus (pp. 25-27). Springer, New York, NY.

Neal, M., & Cavanna, A. E. (2013). Selective sound sensitivity syndrome (misophonia) in a
patient with Tourette syndrome. The Journal of Neuropsychiatry and Clinical
Neurosciences, 25, E01-E01. doi:10.1176/appi.neuropsych.11100235;
10.1176/appi.neuropsych.11100235

Rachman, S. (1998). A cognitive theory of obsessions: Elaborations. Behaviour Research

and Therapy, 36, 385-401.

Raines, A. M., Oglesby, M. E., Capron, D. W., & Schmidt, N. B. (2014). Obsessive compulsive
disorder and anxiety sensitivity: Identification of specific relations among symptom
dimensions. Journal of Obsessive-Compulsive and Related Disorders, 3, 71-76.

Reid, A. M., Guzick, A. G., Gernand, A., & Olsen, B. (2016). Intensive cognitive-behavioral
therapy for comorbid misophonic and obsessive-compulsive symptoms: A systematic
case study. Journal of Obsessive-Compulsive and Related Disorders, 10, 1-9.

Reiss, S., Peterson, R., Gursky, D., & McNally, R. (1986). Anxiety sensitivity, anxiety frequency
and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1–8.
doi:10.1016/0005-7967(86)90143-9

Robinson, L. J., & Freeston, M. H. (2014). Emotion and internal experience in obsessive-
compulsive disorder: Reviewing the role of alexithymia, anxiety sensitivity and distress
tolerance. Clinical Psychology Review, 34, 256-271.

Rouw, R., & Erfanian, M. (2017). A large-scale study of misophonia. Journal of Clinical
Psychology, 73, 1-27.

Schmidt, N. B., Zvolensky, M. J., & Maner, J. K. (2006). Anxiety sensitivity: Prospective
prediction of panic attacks and Axis I pathology. Journal of psychiatric research, 40,
691-699.
 20

Schneider, R. L., & Arch, J. J. (2017). Case study: A novel application of mindfulness-and
acceptance-based components to treat misophonia. Journal of Contextual Behavioral
Science, 6, 221-225.

Schröder, A. E., Vulink, N. C., van Loon, A. J., & Denys, D. A. (2017). Cognitive behavioral
therapy is effective in misophonia: An open trial. Journal of Affective Disorders, 217,
289-294.

Schröder, A., Vulink, N., & Denys, D. (2013). Misophonia: Diagnostic criteria for a new
psychiatric disorder. PLoS One, 8, e54706.

Simes, R. J. (1986). An improved Bonferroni procedure for multiple tests of significance.

Biometrika, 73, 751-754.

Steiger, J.H. (1980). Tests for comparing elements of a correlation matrix. Psychological
Bulletin, 87, 245.

Taylor, S., Conelea, C. A., McKay, D., Crowe, K. B., & Abramowitz, J. S. (2014). Sensory
Intolerance: Latent Structure and Psychopathologic Correlates. Comprehensive
Psychiatry, 55, 1279–1284. http://doi.org/10.1016/j.comppsych.2014.03.007

Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B., Heimberg, R. G., Ledley, D. R., ... &
Cardenas, S. J. (2007). Robust dimensions of anxiety sensitivity: Development and initial
validation of the Anxiety Sensitivity Index-3. Psychological Assessment, 19, 176-188.

Timpano, K. R., Raines, A. M., Shaw, A. M., Keough, M. E., & Schmidt, N. B. (2016). Effects
of a brief anxiety sensitivity reduction intervention on obsessive compulsive spectrum
symptoms in a young adult sample. Journal of Psychiatric Research, 83, 8-15.

Webber, T.A. & Storch, E.A. (2015). Letter to the editor: Toward a theoretical model of
misophonia. General Hospital Psychiatry, 369-370.
doi:10.1016/j.genhosppsych.2015.03.019

Wheaton, M. G., Mahaffey, B., Timpano, K. R., Berman, N. C., & Abramowitz, J. S. (2012).
The relationship between anxiety sensitivity and obsessive-compulsive symptom
dimensions. Journal of Behavior Therapy and Experimental Psychiatry, 43, 891-896.

Wu, M. S., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014). Misophonia: Incidence,
phenomenology, and clinical correlates in an undergraduate student sample. Journal of
Clinical Psychology, 70, 994-1007.

Zhou, X., Wu, M. S., & Storch, E. A. (2017). Misophonia symptoms among Chinese university
students: Incidence, associated impairment, and clinical correlates. Journal of Obsessive-
Compulsive and Related Disorders, 14, 7-12.
 21

Zinbarg, R. E., Barlow, D. H., & Brown, T. A. (1997). Hierarchical structure and general factor
saturation of the Anxiety Sensitivity Index: Evidence and implications. Psychological
Assessment, 9, 277.

Highlights:

 In misophonia specific sounds elicit an intense negative emotional response

 Misophonia was more strongly related to obsessive symptoms of OCD
 OCD symptoms partially mediated the relationship between AS severity and misophonia
 Results are consistent with cognitive-behavioral conceptualizations of misophonia