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Research Interview

Introducing the Duke Center for Misophonia and Emotion Regulation

Hi there, Dr. Rosenthal! I am thrilled to hear that the Duke Center for Misophonia and Emotion Regulation is officially established. Would you tell me a little bit about how the center is set up?

Hi, Jen! Happy to. The Center is set up to advance research, education, and clinical services for adults with Misophonia. An anonymous and generous family that wants to do help rapidly accelerate knowledge about misophonia recently funded us. It is an incredible honor. And we have a lot of work to do!

The Center includes a post-doctoral researcher, three doctoral students, several faculty researchers, an administrative and regulatory lead, and a growing number of undergraduate research assistants. These staff members are involved in all aspects of our center, and each contributes unique expertise to the work we do.

Would you tell me about the overall goals of the Center in terms of research?

Sure. We want the science we do to have an impact on people who are suffering. Aligned with the Milken Institute report on Misophonia, our first goal is to study the phenotype of Misophonia. This means that we will be doing studies that carefully examine correlates and possible causes of Misophonia in order to better understand what it is, what it isn’t, and where we should then be looking for the most effective treatments.

Our first study is designed to develop and validate a measure that has strong psychometric properties and can be used by researchers to study Misophonia. Our second study will use structured psychiatric diagnostic interviews, a laboratory study, and a prospective study using mobile phones to investigate Misophonia and related difficulties with emotion regulation. And, most recently, our Center researcher Dr. Andrada Neacsiu was funded by the REAM Foundation to use neuroimaging and neuromodulation techniques in an effort to look for candidate neural targets for treatment in Misophonia. We also have begun early collaborative work with colleagues to explore possible genetic underpinnings of Misophonia, and are actively building other collaborations with really smart and motivated scientists.

I understand that the Center is multidisciplinary in nature. Would you describe the various kinds of researchers involved, and how each field may contribute to a better understanding of this disorder?

We think that Misophonia is inherently a multi-disciplinary problem. It involves how we hear things, how our brains process information, what we do with that information, and the emotions we experience. As a result, it needs to be both studied and treated using a multi-disciplinary approach.

We are clinical psychologists, and so we have our own natural biases and blind spots. We tend to focus on emotions and how people manage the experience of strong emotions. Given this emphasis, we are intentional in setting up the Center in a way that enables research, education, and clinical services with disciplines outside clinical psychology. For example, we have collaborators in areas such as auditory and cognitive neuroscience, translational genetic epidemiology, neuropsychology, and audiology. Each field brings unique and important perspectives that collectively should yield better insights than any one field alone.

What kind of treatment will you be offering?

We encourage a multi-disciplinary approach to evaluation that leads to a person-centered treatment plan that is both flexibly tailored and grounded in clinical science. Some people who come into the Center for evaluation will receive treatment recommendations that do not include any psychological services. Others will receive a plan that involves the use of evidence-based approaches for co-occurring psychiatric problems, designed to address Misophonia.

We are psychologists, so we will be offering psychological services. We use a process-based approach using cognitive and behavioral approaches with empirical support for intervening on Transdiagnostic problems—things like attentional hypervigilance, emotional reactivity, cognitive biases, interpersonal difficulties, and unhelpful behaviors.

Will there also be a variety of clinicians available to see individuals with misophonia? Please explain how these different therapists may be of help.

We are currently offering evaluations for misophonia that include treatment recommendations. As I mentioned, these recommendations may involve a range of providers, including psychologists, neurologists, and audiologists. As psychologists, we offer evidence-based treatment designed to help individuals cope with the experience of strong emotions.

These skills can help people in a lot of ways! For example, if someone hears a trigger sound and gets angry, they might be tempted to yell at the person making the sound. Sometimes this behavior will get the other person to stop making the sound, and sometimes it won’t. Yelling at someone also might cause an argument. In this situation, we would help someone learn skills to ask for what they want in an effective way.

All the skills we teach have research indicating they are helpful to people. It’s our job as psychologists to make sure we tailor the skills to each patient, given their context and goals. Additionally, some of our research will focus on treatment and how we can develop existing treatments for Misophonia. Individuals will be able to receive treatment as part of these studies.

Please tell us a little bit about the history of the Center and how it has changed, and what further objectives you have for the Center over the next three years?

Well, as you know, we were launched as a program in the late 2000s with the intention of studying sensory processing and emotion regulation. We published several studies and, over time, tightened the focus to be more specifically on Misophonia. In the next three years, we plan to make progress in all three domains of our Center’s mission: education, clinical services, and research.

We are starting our education initiatives by hosting quarterly webinars on topics of interest to the Misophonia community, including updates from recent research studies. Our clinical services are currently focused on evaluation and treatment recommendations. As we learn more about Misophonia, we plan to expand our clinical services to include treatments designed specifically for Misophonia.

And our research is currently focused on understanding what Misophonia really is. This research is multidisciplinary in nature and involves examining whether any psychological problems, like depression and anxiety, frequently co-occur with misophonia, as well as examining the neurological mechanisms that underlie the condition. Additionally, we are excited to start treatment studies! Using the knowledge we have so far, we are going to start by adapting existing evidence-based treatments to Misophonia in order to help individuals cope with the symptoms.

Is there a particular age group that is appropriate for the Center?

We are able to provide clinical services for adults only. We work with our colleagues at Duke to provide care for children outside the Center, and we hope to raise funds and interest in the future to bring a child psychologist into the Center team.

What about parents?

Parents can be involved in certain research studies and can receive an evaluation and recommendations on ways to manage their emotions, communication, thoughts, and behaviors related to the stress of parenting children with Misophonia.

How can an individual reach the Center?

The best way to contact our center is to email psychcmer@dm.duke.edu. We check this email address daily and respond as quickly as we can! Or, see our website: http://www.misophonia.duke.edu.

What about the Duke Quarterly Research updates?

To sign up for our workshop updates, see MIsophonia Education Duke Quarterly Research Updates

Thank you so much, Zach! This is so exciting for the misophonia community!

November 13, 2019 0 comment

Research Research Interview

Interview with Misophonia Researcher Dr. Kumar

written by Shaylynn H.

A special thank you to Dr. Kumar for agreeing to this interview.

How did you become interested in researching Misophonia?

We did not know that much about misophonia until the year 2012, when we published a paper in which we measured brain responses to some of typical aversive sounds (such as chalk on blackboard). This paper got some attention from the press, and I was invited to speak on the BBC about our findings. After the interview, I got many emails asking if I included sounds such as eating and breathing in my study. Initially we were surprised as we thought these sounds are not ‘annoying’, or typically aversive. However, the emails kept coming, and we became intrigued. Professor Tim Griffiths (neurologist) is the leader of our lab, and he invited four misophonia subjects to his clinic and conducted a detailed interview with each of them. We were surprised by the homogeneity of the profile of symptoms described by the participants, and we decided to investigate misophonia further.

What have you found most surprising about Misophonia research?

I have been involved into misophonia research for more than five years now, and have met and spoken with hundreds of sufferers. I find it most surprising, and disappointing at the same time, that misophonia research hardly receives the attention it deserves from the scientific and clinical community. Considering the devastating effects misophonia has on peoples’ lives, more awareness is needed. The situation has improved in the past couple of years, but not enough.

Many aren’t aware how the research process works. How long did your study take?

From conception of the study to its publication, it took roughly 2 years to complete.

Could you summarize what the important findings of your study were? (as briefly/lengthy as you like)

The most important finding of our fMRI study was the hyper activation of a brain structure called anterior insula (AI) specifically in response to trigger sounds in subjects with misophonia. Now the AI is known to be involved in integrating sensations from within the organs of the body, and from the outside world. One interpretation of our data is that the AI triggers atypical responses in the body (which are interpreted as negative). This may lead to unfavorable emotions in response to trigger sounds.

The other important finding was that the AI was strongly connected to a network of brain areas called the default mode network (DMN) in misophonia subjects. The DMN is known to be involved in recalling memories of past experiences. This may suggest that in misophonia, past experiences with trigger sounds have a strong bearing on the current perception and reaction to trigger sounds.

For those that are less familiar with interoception, could you briefly explain what that is?

Interoception refers to the brain’s perception of the internal states of our bodies. Some people have greater interoceptive awareness, and may feel what is happening inside their body more than others. Other people may have less interoceptive awareness, and therefore will be less sensitive to happenings inside the body.

Could you explain the connection between interoception and Misophonia that you found in your last study?

In consideration of the fundamental question of what emotions are, there are different theories. Some theories hold that emotions are simply the perception of internal state of the body, and nothing further. In the light of this definition, emotions and interoception are tightly linked. One can, therefore, argue that those with higher interoception, who are more sensitive to the internal changes in their bodies, may feel emotions more intensely than those who are less sensitive to changes in the internal states of their bodies. Interestingly, anterior insula (which as mentioned above is seen to be hyperactive in misophonics) is the key structure that is known to be involved in interoception. This raises the question: Do subjects with misophonia feel their internal bodies differently or, more generally? Do they have atypical interoception? Our paper suggested that this may be the case. We asked subjects to fill-in a questionnaire which asked questions related to the sensitivity of their internal sensations (e.g. degree of feeling their heart beating, internal tensions). We found that subjects with misophonia scored higher on these questionnaires (compared to controls) pointing to atypical interoception. Further research is needed to test the interception in misophonia and whether the atypical interoception is the cause or consequence of misophonia.

What’s next for your research on Misophonia?

My next experiment on misophonia involves identification and characterization of brain responses that can be measured on the scalp using electroencephalography (EEG) (or magnetoencephalography, MEG). As mentioned above, our previous fMRI study identified brain areas that are involved in mediating the emotional response to trigger sounds. The fMRI, however, has couple of limitations. It is expensive and it is also ‘slow’ (in the sense that it cannot measure moment-by-moment changes, or dynamics, of brain activity). The aim of the present study is determine the dynamics of the brain activity measured via the scalp using EEG. Also, since it is less expensive, EEG may useful as a measure in clinical practice.

How can those interested best help support your research?

The major problem in carrying forward research in misophonia is lack of funding. Misophonia is not officially recognized as a distinct disorder, and therefore funding agencies show little interest. This is where those interested in misophonia can support research. Any financial contribution is extremely helpful in order for us to continue the research.

For those interested in donating, you can learn more here.

Is there anything else you’d like to add/discuss?

Another finding in our study, not mentioned above, is that subjects with misophonia had differences in the structure of their brains in area that are involved in emotional control and regulation. However, seeing these differences does not tell us if they are a result of misophonia, or if they are causal in misophonia. It is, therefore, very important to direct research on structural brain changes in misophonia with consideration to development. In other words, it is important to study children and adolescents with misophonia, as well as adults.

Those interested in reading about Dr. Kumar’s most-recent misophonia study, can read more here.

Want To Support This Study? Donate Now.

August 1, 2018 0 comment

*SEOWork Research Research Interview

Researcher Miren Edelstein and Misophonia

written by Admin

Would you tell us a little bit about yourself and what you study?

I am an experimental psychology Ph.D. candidate at the University of California, San Diego. I am studying Misophonia under Dr. V.S. Ramachandran and music cognition (specifically absolute pitch) under Dr. Diana Deutsch. In 2011 I received my B.A. in psychology and music from the University of California, Berkeley. Additionally, I’ve been a violinist since I was 5 years old, so when I’m not conducting research I can be found performing all around southern California in orchestras, chamber groups, bands and theatrical productions.

How did you get interested in Misophonia?

Back in 2011 (my first year of graduate school), my advisor Dr. Ramachandran received an email from a member of a Misophonia support group inquiring if we could begin some research on the disorder. At the time, no one had really heard of Misophonia, so we decided to invite a few members of the support group to the lab for preliminary interviews and testing. To an extent, I could relate to some of the negative feelings experienced by these Misophonia sufferers, because nobody loves the sound of another person loudly chewing gum or clicking their pen in class. For the most part these are sounds that people consider to be annoying, and I’ll admit I was a little skeptical at first as to whether this phenomenon was an actual condition or whether these individuals were simply more vocal than others about their sound issues. However, after talking to a few individuals and understanding the toll that Misophonia had taken on the quality of their lives, I realized that the disorder was definitely worth a further look. Ultimately, it was the severity of these people’s reactions paired with a lack of experimental research that inspired us to conduct our first study.

Some of our readers are familiar with your published paper on Misophonia, but some are not. Would you mind describing your study for us and telling us about your findings?

Our paper, “Misophonia: Physiological Investigations and Case Descriptions,” consisted of two main experiments. Experiment one was a series of interviews with self-identified Misophonic individuals. Since there were no official diagnostic criteria at the time, our goal was mainly to elaborate on the symptoms and behaviors associated with the condition, in hopes of gaining a more concrete understanding of the Misophonic experience.

It was in experiment two, however, that we actually collected physiological data. Experiment two was particularly important because, until recently, the only evidence we had was subjective reports from people describing autonomic arousal to certain sounds. Therefore, the goal of experiment two was to see if Misophonics actually show a quantitatively different physiological reaction to certain sounds than non-Misophonic individuals. The experimental design was such that Misophonic and non-Misophonic individuals were asked to view and listen to a series of videos and sounds (some of which we knew they disliked and some of which we considered neutral). While listening to/viewing these, they were simultaneously hooked up to electrodes that measured their skin conductance response (SCR). This equipment is sensitive enough to detect trace amounts of sweat produced from acute emotional reactions.

In addition to collecting this physiological data, we also had participants provide subjective ratings for each clip they saw or heard (on a 0-4 scale, 0 meaning the clip caused no discomfort at all and 4 meaning the clip caused extreme discomfort and anxiety). We found that Misophonic individuals showed heightened ratings and skin conductance responses to auditory but not visual stimuli (relative to non-Misophonic individuals). Additionally, we found evidence that Misophonics find similar stimuli to be aversive and non-aversive on a subjective level. The results of experiment two largely appear to validate the severity of Misophonia beyond anecdotal descriptions, and provide the first physiological evidence in support of this.

A link to the full paper can be found here: http://journal.frontiersin.org/article/10.3389/fnhum.2013.00296/full

What do you think your particular area of research might add to the larger body of Misophonia research?

I believe that our particular area of research is unique in the sense that it provides both qualitative and quantitative evidence for Misophonia. The goal of our first study was to validate the experiences of Misophonia sufferers by showing that there are indeed both psychological and physiological differences in how they process certain sounds. In our future work, we intend to build upon the findings from our first study in order to develop possible strategies or inventions that may be utilized for treatment.

Are there any ways in which you think this research might one day translate into treatment for sufferers, or is it too early to make that connection?

I certainly believe that our research may one day translate into treatment for sufferers – after all, treatment is the ultimate goal. However, as research on Misophonia is still in its infancy, we are currently focusing only on trying understand all of the ‘ins-and-outs’ and quirks of the condition. I believe that once we have a clear understanding of how certain factors can modulate the severity of the Misophonic response, we will be more equipped to devise the most effective means of treatment. Currently, our lab is just beginning a new study that (if successful) may have potential application for treatment. I will definitely keep you posted about that.

I am sure that, since your paper was published, press reporters have asked you about Misophonia. What do they usually ask you? Do you find it difficult to explain the kind of work that you do to press reporters?

Speaking with press reporters can sometimes be tricky, as they have a tendency to sensationalize your research. For the most part though, I would say that I have had positive experiences with the reporters I’ve spoken to, and have been satisfied with the way in which they have portrayed my work to the public. I tend to receive a lot of questions about treatment and cures, a topic I do not feel qualified to speak on at the moment as we simply haven’t found an end-all, standardized treatment yet. Therefore, a strategy that I actively employ when speaking to reporters is to stick strictly to the data and what we already know. If something is still speculation, it is important that it is portrayed as such and not as fact. This can sometimes be difficult when dealing with a topic like Misophonia, on which little research has been conducted, but I’ve found that it is the most effective way to avoid widespread inaccuracies.

You have told us that you are also interested in music. Would elaborate on that and how that applies to your work (and/or inspires you in any way)?

As a lifelong violinist, sounds have always been a huge part of my life. In fact, all of the research I do with both of my advisors revolves around sound, but in two very different ways. With Dr. Deutsch, I study sounds specifically in the context of music, or sounds that people generally enjoy. However, with Dr. Ramachandran I study Misophonia, which is almost the completely opposite scenario. Although I do not suffer from Misophonia, I do feel that my musical background has afforded me a unique perspective when conducting research on it, as I am well aware of the ways in which sounds can evoke profound emotions in people.

If you could set up a lab with a team of cross-disciplinary researchers to study Misophonia, from which disciplines would you choose these individuals (neuroscience, audiology, etc.)?

I think it would be extremely beneficial to have neuroscientists and audiologists, as well as clinical psychologists, psychiatrists, and physicians, all collaborating together to conduct Misophonia research. Right now, a major problem for Misophonia research that needs to be addressed is the lack of communication between various fields of study. Researchers from different disciplines all have unique and valuable perspectives on the topic, but this information is not being communicated in an effective manner across groups. I believe that an interdisciplinary research environment, while simultaneously promoting a more unified dissemination of knowledge, will be the most effective at fostering breakthroughs in the field.

August 24, 2016 0 comment

*SEOWork Research Research Interview

Research Interview with Mercede Erfanian

written by Admin

mercede erfanian research interview misophonia

Jennifer: Can you just tell us a little bit about yourself, and how you got interested in research in general?

Mercede: As long as I can remember, I have been pretty curious and energetic. When I was younger this curiosity manifested in the form of destroying things in order to understand how they worked. This ongoing sense of discovery in me eventually led me to do research. Research can feed my soul and satisfy my sense of discovery.

Eventually I wanted to know why, and people may behave in different situations. This yearning for knowledge led me to the field of psychology. I studied clinical psychology for my bachelor’s and master’s degrees, taking intensive courses in affective neuroscience in Maastricht University. This helped me to specify my area of expertise to mood, anxiety and OC related disorders.

Jennifer: How did you get interested in Misophonia?

Mercede: I was doing a study titled ”Synesthesia in bipolar and schizophrenic patients: a comparative study of their relationship with abstract thinking” in 2013. This opened the door to misophonia, as misophonia and synesthesia could be similar from a neuroscientific standpoint. In short, one way to define synesthesia is provoking one sense by another, like, hearing colors or seeing sounds( Chromesthesia ). Misophonia could be almost the same phenomena, which could be: “ provoking an emotion by a sound or scene or even a touch.

Jennifer: Would you mind describing your study for us? What was your most important finding?

Mercede: While there is still no agreed set of criteria for misophonia and the research is in its infancy, we tried to clarify the very particular criteria for misophonia. Some researchers believe misophonia should be subsumed as “ decreased sound tolerance” while other researchers assume it should be classified under OC related disorders.

In this study, we introduce a wide range of emotional and physical characteristics, and thoughts, as well as an elaborate list of auditory, visual, and tactile triggers, nature of triggers, age of onset, family history, comorbidity with other disorders and phenomena, and severity, to try and get a wider, more exact inventory of the characteristics of Misophonia.

Jennifer: What do you think your particular area of research might add the larger body of misophonia research?

Mercede: My area of research would suggest a number of diagnosis
techniques and treatments for misophonia, although it is highly recommended to study misophonia thoroughly to find out different risk factors, epidemiology and etiology that are still ambiguous. I believe it is essential to do more research in order to fully understand the nature of misophonia before jumping to propose treatment.

Jennifer: If you could set up a lab with a team of cross-disciplinary researchers to study misophonia from which disciplines would these individuals be (e.g. neuroscience, audiology, etc.?)

Mercede: In my opinion, the most efficient multi-disciplinary team of research would consist of general practitioners, psychologists, psychiatrists, neuroscientists, audiologists and audiometrists. A general practitioner would evaluate the physical symptoms of misophonia and differentiate them from other similar physical manifestations. A Psychologist or psychiatrist could study the behavior and mental process of Misophonics as well as their affective and thought related aspects of disorder and copy strategies.

A neuroscientist would identify any brain dysfunction in Misophonics and possible connection of misophonia with other affective and cognitive phenomena. An audiologist could diagnose and monitor the vestibular system of the ear or the presence of other auditory problems and the possible damage to auditory system and cortex. An audiometrist, would administer audiometrist tests to enable the rehabilitation of hearing loss and differentiate Misophonics from other “decreased sound tolerance

August 24, 2016 0 comment

*SEOWork Duke Interviews Research Research Interview

Zachary Rosenthal, Ph.D. Talks Misophonia

written by Admin

duke-university-misophonia Zachary Rosenthal co-runs the Misophonia program at Duke University.

Jennifer: What is the difference of an “emotion” and a “physiological state” such as the fight/flight response?

Zach: Emotions are widely considered to have three basic parts: (1) personal experience, (2) expressive behavior, and (3) physiology. This means that all emotions have underlying physiological components. One cannot experience or express emotion without underlying central and peripheral nervous systems. For example, our brains and bodies are wired with so-called “fight,” “flight,” and “freeze” systems to help us sense and respond to stimuli that may be threatening. These systems can be triggered by all sorts of cues, and when this happens, our physiology dynamically responds in complex ways, we approach, avoid, escape, or become immobile, and we may subjectively label our experience with particular emotional states. Another way to think about the difference between emotions and the physiological states of fight and flight is this: Our brains and bodies respond to threat cues, whether the cues truly are threatening or not, by activating a web of circuitry that functions to help us adapt and respond to these cues. Emotions are commonly a part of this process, but not all emotions are associated with an underlying fight or flight response.

Jennifer: So, Zach the lines between psychiatric disorders and disorders with underlying neurological causes are blurred? Is it fair to say that we are in a time during which we don’t quite have cohesive and accurate terminology and that this could be confusing to people?

Zach: I think it is fair to say that psychiatric problems have neurophysiological and environmental influences, and that many physical health problems, including those that some would call “neurological,” also are influences by both biology and the environment. It would be so much easier to understand if there were simply such things as mental health problems and neurological problems, with completely different causes. But that is not the way it is. Scientists have a hard time understanding how all these things work, so it is no wonder when this is hard for the others to understand.

Jennifer: I’m not holding you to this or making this your responsibility. However, I saw on Wikipedia that Misophonia was described as a neuropsychiatric disorder? Some people call it a neurological disorder, and others call it a psychiatric disorder. If people asked me what it should be called what should I say? Again, I’m not asking you to classify this disorder but it’s very confusing to people.

Zach: I can see why it might be confusing to people. I have people in my own family who struggle with symptoms consistent with misophonia. They wonder what it happening. And they ask me! I would say that it is a syndrome which is not yet understood scientifically. This makes it hard to classify it in a category. The data and clinical anecdotes suggest it is a very real phenomenon, and it is hard to imagine how it could not involve neurological functions associated with sensory processing and the regulation of defensive motivational brain responses to particular sounds. The automatic response to certain sounds appears to resemble behavior consistent with what some have called the “survival circuitry,” which is to say emotional responses that function to move the person away from the sounds as efficiently as possible. The anger response that occurs around others is very interesting, as anger is a functional emotion we have when others are blocking us from our goals to approach desirable things or escape from unpleasant things. So I am not sure that misophonia is all about anger per se, or whether anger is the response to the cue when it is unpleasant, cannot be easily avoided, and the attribution made is that the person causing the sound “should” stop doing so. The other interesting thing is that misophonia symptoms seem to co-occur with various psychiatric problems. We need to do scientific research to determine whether and when misophonia symptoms should be expected in specific psychiatric disorders, non-specifically across mental health problems, or whether it commonly occurs without any co-occurring mental health problems.

Jennifer: Thank you for that great explanation. How would a person know the difference if they were experiencing and emotion or if they were experiencing a physiological reaction?

Zach: Emotions can be thought of as separate categories, such as when we say we feel anger, sadness, joy, and the like. In each of these subjective experiences or emotional expressions, there are complex underlying physiological reactions to environmental cues taking place. Alternatively, some researchers believe emotions are better described dimensionally with components of (1) emotional arousal from low (e.g., calm) to high (excited) and (2) emotional valence from low (very unhappy) to high (e.g., very happy). From this way of thinking, emotions are complex, ongoing, interactive and changeable events with physiological underpinnings that occur in response to environmental cues (both outside and within the body). In both the categorical and dimensional ways of thinking about emotions, there are underlying physiological reactions that happen immediately before, during, and after emotions. So emotions have physiological foundations. Not all physiological reactions, on the other hand, occur during acute emotional states. When I have the physiological reaction of salivation in response to thoughts about key lime pie, I may not use emotion to describe my reaction. Instead, I might say I am hungry, ready for dessert, or the like. If I react with sleepiness when watching a TV show, I might describe feeling tired or sleepy. And so on.

Jennifer: Makes sense! What is the state of the field regarding conditioned versus inborn or genetic response or behavior?

Zach: When trying to make sense of complex health problems, we used to talk about nature versus nurture, conditioning versus genes, and environment versus biology. But what we now know–and in hindsight this is embarrassingly obvious– is that these are overly simplistic false divisions. These things that once were apparent distinctions as “either/or” now are becoming logically combined as “both/and.” The question is no longer whether a phenomenon is caused by conditioning or something physiological. The question is how and in what important ways do nature and nurture interact to predict human behavior? Nature and nurture reciprocally influence each other, likely in many ways and at many levels of analysis, their effects pinging and ponging off of each other. Genes and the environment interactively influence each other. The environment influences genetic expression, and genetic expression influences the environment. As an example, it would be overly simplistic, and flatly incorrect to assert that a disorder such as PTSD or OCD is caused by genes independent of any environmental influence. Genes impact conditioning, learning, and memory, and these processes influence the way in which we express ourselves in our environment, which influences how the world responds to us, which then impacts our underlying biology. It also would be overly simplistic to say that these problems are singularly caused by conditioning in the absence of any underlying biological influences. Conditioning processes are both biologically and environmentally influenced.

Jennifer: So Zach, what you are saying is that the question of nature versus nurture isn’t really the right question anymore, especially in psychiatry. I know this is putting the matter very simply but I want to be very clear. The thinking about this has changed a lot, even since I was in graduate school. Many of us grew up thinking about nature versus nurture (or genetic versus environmental) as very separate ideas.

Zach: Yes. But this is also true outside of psychiatry. For example, environmental stressors can elicit neurobiological changes, and these changes can then influence how someone lives, which of course impacts how the world treats them, which then can influence their neurobiology. It is back and forth kind of thing throughout life.

Jennifer: Okay, in that case… We now know that even if identical twins both have the same “genes”, one twin might manifest symptoms of OCD, or any neurological or health related disorder, while the other may not. This is because genes and the environment interact with one another. Genes can be “turned on” and “turned off” according to factors in the environment, and within the individual human being. So, it’s a lot more complicated than we thought it was, and the take home message is that both nature and nurture contribute to human behavior in a complex and interactive way. Would you say that is a good synthesis of what you said?

Zach: Well said!

Jennifer: Thank you! Having said that, are there any specific disorders or diseases for which there is a clear distinction between a genetic cause versus an environmental cause?

Zach: The search for genetic causes in psychiatry is ongoing. Many researchers with and a whole lot of research funding are dedicated to the search for clear genetic markers of psychiatric disorders. Although there are data suggesting some psychiatric disorders are associated with certain polymorphisms, this is very different than concluding genes cause the disorder. On the other side, there are many examples of environmental correlates or predictors of psychiatric problems, but these environmental causes may also have genetic correlates. In addition, where there are data supportive of genetic correlates to psychiatric disorders, these genetic factors typically account for small amounts of the variance in the disorder and do not appear to be specific to individual disorders per se, but rather to groupings of disorders. The serotonin transporter gene polymorphism, for example, can be found in some people with mood disorders, but is not found in one specific mood disorder.

Jennifer: So, to restate what you said…There are “neuropsychiatric” disorders that have been associated with particular gene polymorphisms. By polymorphism, you are talking about differences in genes that occur over a long time within portions of the population, for example people with Depression? For the sake of simplicity, can we just call them “gene differences” for now?

Zach: Sure.

Jennifer: These “gene differences”, however, that are found in depression, don’t only appear in depression. They might also appear in bipolar disorder, and other mood disorders. In other words, these “gene differences” appear in groups of disorders, such as mood disorders but they don’t really single out any particular disorder. So, the process for finding a cure for a disorder isn’t as simple as just finding “the gene”.

Zach: Absolutely correct. As much as we would all like to find a gene for each problem, or even a set of genes for each problem, the reality is that things are not that simple.

Jennifer: It is interesting; you mentioned serotonin, which is a neurotransmitter (a chemical messenger of neurologic information stated simply). You said, that genetic differences regarding serotonin have been found in people with mood disorders, but not specific to one particular mood disorder? I’m assuming this is true of the many different neurotransmitters we hear about all the time in terms of their associations with mental and other health disorders (e.g. dopamine, etc.) Is that correct?

Zach: Correct. It is important to remember that as advanced as we are in understanding physiology and human behavior compared to 100 years ago, there is a whole lot that we don’t know yet. In 100 years, I suspect people will look back at this time we are in and recognize that we oversimplified the role of neurotransmitters and the relationship between things like dopamine and human behavior. Just as brain regions do many different things rather than only one thing, so too do neurotransmitters like dopamine more than one thing.

Jennifer: So, again while the discovery, for example, of serotonin’s or dopamine’ relationship to numerous psychiatric or health disorders has been very helpful in some ways (e.g. medications) because of the complexity of the genetic/environment interaction, we can neither fully account for how neurotransmitters correspond with different disorders, nor have precision medications been mastered yet?

Zach: I think that is fair to say. There is a lot more precision needed. We are in an era of personalized medicine, where the goal is to understand for whom which interventions will work, and how. In order to understand what will work, for whom, to treat symptoms of misophonia, much much more research is needed.

Jennifer: I think you are also saying that gene polymorphisms or “gene differences” that have been identified in relationship to groups of disorders don’t account for what one can observe in terms of the different behavior of a person with depression or OCD (again just using those as examples). So, while, it is certainly helpful to identify gene/disorders associations, I’m not going to wake up next year and hear on the news that “they found the gene for OCD” or “depression” and thus the cure will be available in a year? Is that fair to say?

Zach: I will be surprised if that happens.

Jennifer: So will I. Ha ha. So, just to clarify my original question then, are there any specific disorders or diseases for which there is a clear distinction between a genetic cause versus an environmental cause? What are those disorders or diseases?

Zach: There are genetic disorders that may co-occur with certain psychiatric disorders (e.g., fragile X). And there are physical diseases with genetic components that are not singularly caused by genes and are influenced by environmental factors (e.g., Type II diabetes). But there are not psychiatric disorders caused only by genes in the absence of any environmental influences.

Jennifer: So, again for purposes of clarification, I’m going to rephrase and please let me know if this is correct. There are genetic conditions (such as Fragile X) for which we know the associated gene involved. Yet even in these genetic disorders environment can play an influence on how an individual is affected. In addition, even in regard to these genetic illnesses, because of this new way of thinking about genetic and environmental interaction we don’t really know how any of this will play out in medicine or psychiatry in the next decade. We do know that in regard to psychiatry, and possibly health in general, we just cannot attribute a disorder only to genes. We are kind of in a new era of the way we think about genes and the environment. Is this fair to say?

Zach: Absolutely!

Jennifer: Then we really can’t say anymore that there are any disorders in psychology for which maladaptive behaviors are definitely attributed to conditioning rather than inborn traits?

Zach: If you open up the DSM-5 and pick a disorder at random, the research investigating the etiology of the disorder will likely point to environmental influences associated with basic process underlying such things as learning, memory, emotion, social cognition, and attention, all of which are critical to conditioning. Even those traits we see early in life can be and are influenced by the environment.

Jennifer: Please continue…

Zach: Conditioning involves attention, learning, memory, and emotion. These processes are critical in the etiology (or multiple causes) and maintenance of all psychiatric disorders.

Jennifer: Are you saying that there are other factors having to do with an individual’s personality and neurological processing that affect conditioning? In other words, conditioning isn’t a simple cut and dry process, as we might believe based on how, for example, it is still represented in popular press?

Zach: Yes.

Jennifer: So again, we are talking about the interaction of nature and nurture (genetics and environment) in terms of any DSM-5 disorder?

Zach: Exactly.

Jennifer: Zach, do you think there are particular bodies of research we can pull from that already exist in order to begin the study of misophonia?

Zach: I do. I think we need to work together with those who study and treat neurological problems, such as neuropsychiatrists, neuropsychologists, audiologists and occupational therapists. I also think that we need to do research with child and adult psychologists, so that behavioral interventions can be developed, tested, and disseminated based on discoveries made by basic scientists.

Jennifer: Other than overlapping with other disorders, what might be a better way of characterizing Misophonia (just from what you know about it)?

Zach: I suspect misophonia symptoms may not be uniquely found in any one psychiatric disorder, but instead may be a transdiagnostic problem observed across those with different disorders. I also believe it is possible that misophonia symptoms may be observed on a spectrum of severity from low and irritating to high and debilitating among individuals with different psychiatric symptoms. Although some with misophonia symptoms likely meet criteria for various psychiatric disorders, I think it is quite possible that misophonia may not overlap with any psychiatric disorder, and may be something that emerges in some who do not meet criteria for any existing psychiatric disorder.

Jennifer: So, misophonia may be a stand-alone disorder, and symptoms of misophonia may manifest in psychiatric and/ or health disorders as well. Likely there will be a range in severity of symptoms, and we have seen some very preliminary data in terms of this (as well as a lot of self-reporting that corresponds with ranges in severity). Classification is not easy, is it? In other interview I think I will address the reasons classification is important, and how difficult it is to do it!

All right, Zach, one final and somewhat more personal question…you are a renowned psychology practitioner as well as a researcher. Would you tell us a little bit about how you feel when you are faced with a patient who has a condition with which you cannot help based on traditional therapies?

Zach: What a great question! When this happens I often feel inspired and motivated to innovate. I try to make sense of where the gap may be between the patient’s problems and the evidence base for behavioral therapies and behavioral principles that may be applied. I make and test hypotheses about possible psychological processes (those that are both biologically and environmentally influenced) that are amenable to change. But if the patient is non-responsive or not interested in contemporary cognitive and/or behavioral approaches, I look to consult, work with a group of others across different disciplines, or refer the patient to treatment options that she or he may find more suitable. Or, in even better circumstances, I use my training as a behavioral scientist to try to scientifically investigate ways to develop new treatments for the problem.

September 10, 2015 0 comment