Item Response Theory Investigation of Misophonia Auditory Triggers

Round 1

Reviewer 1 Report

The authors of this study examined 35 potential misophonic triggers across individuals who self-report experiencing ASMR, those who don’t and those who are not sure. Eating sounds, nose/throat sounds, and general environmental sounds emerged as the three main categories of sound sensitivities. The authors also report that individuals who self-report experiencing misophonia were much more likely to endorse eating sounds as auditory triggers, reported more triggers in general and their impact was more severe compared to individuals who don’t experience misophonia. Overall, this is a well written article which contributes to the existing literature on the topic. I only have a few points to address.

 

1. Could the authors elaborate on how it was ensured that participants were classified correctly as misophonics and controls? What exactly were they asked? Were they provided with a definition or simply asked if they experience misophonia? More information is needed.
2. Could the authors explain how they decided that ‘2.very distracting’ does not constitute misophonia while ‘3.distressing’ was used as a cut-off point indicating the presence of misophonia when calculating TES?
3. Line 147 – the sentence is grammatically incorrect
4. Sentence starting in line 252, can the authors also state what the results were for individuals who don’t experience misophonia? Was the difference between misophonic and unsure group and between the non-misophonic and unsure groups statistically significant? If so could the authors state why they think this is the case and why the unsure group was not used in subsequent analysis?
5. The authors report the triggers to be stable over time but the fact that they tested it isn’t really explained in the methods section and it only becomes apparent in the results and discussion when they mention for the first time that this was tested over a two-week period. Could they elaborate on this in the Methods?

 

Author Response

The authors of this study examined 35 potential misophonic triggers across individuals who self-report experiencing ASMR, those who don’t and those who are not sure. Eating sounds, nose/throat sounds, and general environmental sounds emerged as the three main categories of sound sensitivities. The authors also report that individuals who self-report experiencing misophonia were much more likely to endorse eating sounds as auditory triggers, reported more triggers in general and their impact was more severe compared to individuals who don’t experience misophonia. Overall, this is a well written article which contributes to the existing literature on the topic. I only have a few points to address.

We thank the reviewer for their kind words. 

1. Could the authors elaborate on how it was ensured that participants were classified correctly as misophonics and controls? What exactly were they asked? Were they provided with a definition or simply asked if they experience misophonia? More information is needed.

 

Response to reviewer:

 

We have edited the Methods section (line 104-107) to specify that this was done by asking “Do you identify as having misophonia?”, with the option of yes, no or unsure. At the point of data collection, there was no consensus on the definition of misophonia, on its characteristics and on a formal tool to identify the presence or absence of misophonia. We did not provide a definition of misophonia to participants; our misophonia sample therefore consists of individuals who were already familiar with the term. For comparisons between misophonia and non-misophonia, we used only the “no” group (that is, we omitted anyone who stated that they were not sure if they had misophonia, see line 284).

We have edited the Results to make this clearer (see edits to line 158 in response to your other point 2 about the grammatically incorrect sentence at line 158).

We have added to the limitations of this to the discussion to address properly this comment.

 

2. Could the authors explain how they decided that ‘2. very distracting’ does not constitute misophonia while ‘3.distressing’ was used as a cut-off point indicating the presence of misophonia when calculating TES?

Response to reviewer:

For the purposes of this study, we defined a “trigger” as something that caused a negative emotional reaction. We excluded “distracting” from this definition, as it is not an inherently negative experience to be distracted by a sound. Whilst distraction may be a part of the misophonic experience, it is only when this causes distress or significant impairment that we would consider it to be “triggering”.

Add to discussion/limitations (line 498)

Another limitation was the use of a binary measure of trigger endorsement. For the purposes of this study, we considered a trigger to be endorsed if it was reported as causing distress, but not it if was reported as “very distracting”. It is possible that this choice for the binary measure could have excluded some triggers that cause significant impairment as a result of distraction, but which were not experienced as distressing to the individual. Future research would benefit from gathering more specific information about the reactions to trigger sounds and an exploration of primary, secondary and anticipatory emotions.

 

 

3. Line 147 – the sentence is grammatically incorrect

In response to the reviewer comment we rephrased the paragraph as follows (current line 158).

All participants in the MS stated that they identified as having misophonia. In the MNS, 106 (52.5%) individuals stated that they identified as having misophonia, 54 (26.7%) stated that they do not have misophonia, and 42 (20.8%) said they were unsure if they had misophonia. 

A formal diagnosis of depression was reported by 37% of participants in the MS, and 32.2% in the MNS. Generalized anxiety disorder was reported by the 25.6% and 25.2% of MS and MNS respectively. Tinnitus was reported by 10.3% and 9.4% of MS and MNS, respectively.

4. Sentence starting in line 252, can the authors also state what the results were for individuals who don’t experience misophonia? Was the difference between misophonic and unsure group and between the non-misophonic and unsure groups statistically significant? If so could the authors state why they think this is the case and why the unsure group was not used in subsequent analysis?

 

 

The differences were statistically significant across all three groups (even after adjusting for multiple comparisons). All groups are now reported. We expect that within the unsure group there were individuals who do experience misophonia and individuals who do not, in random proportions. That is why this group scores in between and that is also the reason why we excluded this group. People who belong to this group either did not feel they fully understand misophonia and/or they did not feel confident they could endorse or not misophonia. We have now made these points clearer in the limitations section in response to Comment 1 (line 498 in the document).

 

 

5. The authors report the triggers to be stable over time but the fact that they tested it isn’t really explained in the methods section and it only becomes apparent in the results and discussion when they mention for the first time that this was tested over a two-week period. Could they elaborate on this in the Methods?

 

 

In this work we did not evaluate the stability of triggers in a longitudinal setting. With the term stable in time, we refer to the test-retest reliability (stability), over the course of two weeks, which is a property of the measurement rather than a phenomenon related to misophonia.

We describe the tools used in the reliability assessment in lines 135 to 137, were we now point out that this is a two-week period. Our research team is currently working on a longitudinal study using the S-five tool, which we hope will lead to very interesting findings.

Reviewer 2 Report

The authors present a thorough and clear analysis of potential misophonia trigger sounds in terms of how they are rated by a group identifying as misophonic as well as in the general population. The use of factor analysis and item response theory to provide estimates of how informative the responses to particular sounds broke new ground and can guide future work. I have only minor comments of clarity and English language.

 

CLARIFICATION
121 Is this an example of a precise trigger? If so say so  

210-230 Might help to recap what is meant by ‘discriminative’ - discriminating different levels of sensitivity (not e.g. misophonia diagnosis). Also could help to reiterate difference between discrimination and precision here. 

Tab. 1 Column headings: Agreement in time is a proportion not a %, and for final column it isn’t clear here that this is the item-total correlation (I had to refer back to methods).

Fig. 2 could be visually clearer - not just list of sounds but axes too 

Tab. 2 Abbreviations CTT and FA haven’t been defined - unabbreviated versions might be clearer in this table title   

Tab. 3 Column headers not all visible  

 

ENGLISH LANGUAGE
119 reliable not reliably

147 37% of .... self-reported depression diagnosis.

203 Evidence …. is presented 

440 social media (not the social media)

Author Response

The authors present a thorough and clear analysis of potential misophonia trigger sounds in terms of how they are rated by a group identifying as misophonic as well as in the general population. The use of factor analysis and item response theory to provide estimates of how informative the responses to particular sounds broke new ground and can guide future work. I have only minor comments of clarity and English language.

We thank the reviewer for their kind words which encouraged a lot our research team.

CLARIFICATION

1. 121 Is this an example of a precise trigger? If so say so  

We augmented the example as follows:

The item information refers to how reliably (precise) is a trigger as an indicator of the sound sensitivity (for example, endorsing whistling as a trigger may be an informative indicator of the sensitivity for those with low sensitivity but not informative for those with high sensitivity, that is, whistling can be precise for low scorers but not for high scorers).

2. 210-230 Might help to recap what is meant by ‘discriminative’ - discriminating different levels of sensitivity (not e.g. misophonia diagnosis). Also could help to reiterate difference between discrimination and precision here. 

In response to the reviewers comment we added in text (marked in red):

 Among the eating sounds (Figure 2.a1), the most discriminating trigger was ‘listening to people eating with their mouth open’ (I2). The least discriminating trigger was ‘listening to people chewing gum loudly’ (I23). That is, among all triggers, I2 corresponds to the larger differences in sound sensitivity between those who endorse it and those who do not; on the contrary, I23 endorsement corresponds to the least notable sensitivity differences. Chewing gum was also the least severe symptom in this dimension of triggers (i.e. it was endorsed even by those with low sensitivity to sounds). The trigger indicating the most severe sensitivity was ‘swallowing sounds’ (I5). Interesting results occurred related to the information provided by the eating triggers. The eight items were divided in three groups; one most informative (more reliable, precise) for low scorers, one most informative for average sensitivity, and one most informative for high scorers (Figure 2.a2). For example, ‘eating with the mouth open’ (I2) was very informative for people with low sensitivity but not informative otherwise. ‘Eating’ (I1), ‘mushy’ (I4), and ‘swallowing’ (I5) were very informative for high scorers but less informative otherwise. The rest of the items performed very well for average scorers.

 

3. 1 Column headings: Agreement in time is a proportion not a %, and for final column it isn’t clear here that this is the item-total correlation (I had to refer back to methods).

We thank the reviewer for drawing our attention to this. We have now added the Psi coefficient in the Methods, and we have added the abbreviations under all tables.

4. 2 could be visually clearer - not just list of sounds but axes too 

We have increased the resolution of Figure 2 and we will work with the editing team of the journal to ensure the Figure reads well.

5. 2 Abbreviations CTT and FA haven’t been defined - unabbreviated versions might be clearer in this table title   

All tables have now their abbreviations added at the last row.

6. 3 Column headers not all visible  

Corrected.

 

ENGLISH LANGUAGE

7. 119 reliable not reliably

Corrected

8. 147 37% of .... self-reported depression diagnosis.

(pointed out by another reviewer as well)

Changed to:

All participants in the MS stated that they identified as having misophonia. In the MNS, 106 (52.5%) individuals stated that they identified as having misophonia, 54 (26.7%) stated that they do not have misophonia, and 42 (20.8%) said they were unsure if they had misophonia. A formal diagnosis of depression was reported by 37% of participants in the MS, and 32.2% in the MNS. Generalized anxiety disorder was reported by the 25.6% and 25.2% of MS and MNS respectively. Tinnitus was reported by 10.3% and 9.4% of MS and MNS, respectively.

9. 203 Evidence …. is presented 

Corrected

10. 440 social media (not the social media)

Corrected

Reviewer 3 Report

Item response theory investigation of misophonia auditory triggers

Vitoratou etal 2021

 

1. This is a well written manuscript.
2. Under 2.2 you mention: “see 21, for a complete description of the survey”, please indicate reference 21.
3. The extent and variety of the triggers under question is outstanding
4. I wonder why the researchers did not ask about the differences on the source of the biologic triggers (e.g., chewing and breathing). Are triggers more annoying when the father, mother or sibling of the misophonic individuals generate them in comparison to the people who do not live with the misophonic person?
5. I also did not see any question about the presence of misophonia in the family members of the misophonic individuals. It could add more info into your study.
6. I am not sure about the format of your references and citations. Please cross check with the guidelines of this journal.
7. In general, you have done a great job. Congrats!

Author Response

This is a well written manuscript.

We thank the reviewer for their kind words. 

 

 

1. Under 2.2 you mention: “see 21, for a complete description of the survey”, please indicate reference 21.

Corrected to:

This study was part of a larger study validating a new tool for measuring misophonia, the selective sound sensitivity syndrome scale (S-Five, Vitoratou et al, 2021) and included two more tools to assess misophonia, the Misophonia Questionnaire (MQ; Wu et al., 2014) and the Amsterdam Misophonia Scale (A-MISO-S; Schroder et al., 2013).

 

 

 

 

 

2. The extent and variety of the triggers under question is outstanding. I wonder why the researchers did not ask about the differences on the source of the biologic triggers (e.g., chewing and breathing). Are triggers more annoying when the father, mother or sibling of the misophonic individuals generate them in comparison to the people who do not live with the misophonic person? I also did not see any question about the presence of misophonia in the family members of the misophonic individuals. It could add more info into your study.

 

We agree with the reviewer that this was a limitation of the current study. The reviewer articulates a very interesting research question which should be explored in future research. We added in the limitations a comment about this (lines 505 to 511):

We also did not ask about the source of the trigger sounds. There is some evidence that reactions to trigger sounds may varying depending on who is making the sound [2, 10], and this would be useful to explore further, to establish whether individuals who have stronger reactions to, say, a particular family member, also show broader traits of sensitivity to certain sounds. Additionally, it would be useful to look at these auditory sensitivities in the context of more general sensory sensitivities, and to compare with other groups showing high levels of sensory sensitivity, such as those with autism spectrum conditions [50]

 

 

3. I am not sure about the format of your references and citations. Please cross check with the guidelines of this journal.

Corrected throughout

 In general, you have done a great job. Congrats!

We thank the reviewer for their kind words!

Reviewer 4 Report

This study significantly contributes to the growing base of research into misophonia. I suggest to add some methodological details and a limitation of the study.

pag.3, lines 86-87: [see 21, for a complete description of the survey])? could you add some significant points about the questionnaires administered?

pag. 3, line 97: what do you mean with "formal diagnosis of mental health or auditory conditions"? anxiety? depression?  obsessive compulsive disorder ? hearing loss? tinnitus? hyperacusis?

How did you differentiate hyperacusis or phonophobia from misophonia? Did you consider also a specific question or questionnaire to identify the presence of tinnitus?

The results of the study are based on a survey and the participants were not clinically evaluated by audiologists and/or psychologists. The absence of a clinical evaluation of the participants is a major limitation of the study.

Author Response

This study significantly contributes to the growing base of research into misophonia. I suggest to add some methodological details and a limitation of the study.
We thank the reviewer for their kind words. 

 

1. 3, lines 86-87: [see 21, for a complete description of the survey])? could you add some significant points about the questionnaires administered?

Corrected to:

This study was part of a larger study validating a new tool for measuring misophonia, the selective sound sensitivity syndrome scale (S-Five, Vitoratou et al, 2021) and included two more tools to assess misophonia, the Misophonia Questionnaire (MQ; Wu et al., 2014) and the Amsterdam Misophonia Scale (A-MISO-S; Schroder et al., 2013).

 

2. 3, line 97: what do you mean with "formal diagnosis of mental health or auditory conditions"? anxiety? depression?  obsessive compulsive disorder ? hearing loss? tinnitus? Hyperacusis?

Response to reviewer:

We have edited this line to make it clearer.

Line 104-107. Replace paragraph with:

To establish whether someone self-identified as having misophonia, we asked “Do you identify as having misophonia?”, with the option of yes, no or unsure. Participants were also asked if they had been given a formal diagnosis of tinnitus, hyperacusis, or any of a range of common mental health problems (for example, depression or generalised anxiety disorder). 

3. How did you differentiate hyperacusis or phonophobia from misophonia? Did you consider also a specific question or questionnaire to identify the presence of tinnitus?

Response to reviewer:

Our misophonia specific sample was determined by asking the question “Do you identify with having misophonia?”. Therefore, our sample included people who were already familiar with the term misophonia and identified as having it. We did not differentiate this from hyperacusis or phonophobia, so it’s possible that some of our sample included people who believed they have misophonia but may actually have something else. We have added comments in the discussion to address the limitation of this method of selecting groups.

We asked if participants had a formal diagnosis of tinnitus and have reported the percentages from each sample who reported tinnitus, but we did not use this information in our analysis or as part of the process for selecting the groups for comparisons. With our main psychometric tool (the S-Five) we plan to look at differentiating misophonia from tinnitus and hyperacusis in more detail in a later study.

 

4. The results of the study are based on a survey and the participants were not clinically evaluated by audiologists and/or psychologists. The absence of a clinical evaluation of the participants is a major limitation of the study.

Response to reviewer:

We agree this is a big limitation, we have now elaborated on this in the discussion and recommended future research include diagnostic interviews, suggesting that our results should serve as preliminary results to build on in future research.