Prevalence of misophonia in the general population and those with complaints of tinnitus: An epidemiological study

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Although both conditions share underlying auditory-limbic mechanisms, their coexistence has not been widely studied in large-scale populations. This study aimed to estimate the prevalence and severity of misophonia among adults with normal hearing and those with tinnitus in India and to examine demographic and clinical correlates. Design/Study sample A descriptive cross-sectional survey was conducted among 10,500 participants recruited across India, including 10,000 adults with normal hearing (6,073 males, 3,927 females; mean age 39.3 ± 4.7 years) and 500 individuals with tinnitus (365 males, 135 females; mean age 42.6 ± 6.9 years). Participants completed the Amsterdam Misophonia Questionnaire (A-MISO-S), Selective Sound Sensitivity Syndrome Scale (S-Five), Tinnitus Handicap Inventory (THI), and Tinnitus Case History Questionnaire (TCHSQ). Results Misophonia was identified in 26% of the normal-hearing group and 17% of the tinnitus group. Among normal-hearing individuals, 66% exhibited mild, 24% moderate, and 10% severe symptoms, whereas tinnitus participants showed higher severity, with 23% mild, 44% moderate, and 33% severe. Misophonia prevalence was higher in females, urban residents, and those with higher education levels. A strong positive correlation (r = 0.83, p < 0.01) was found between THI and A-MISO-S scores, indicating that greater tinnitus-related distress was associated with more severe misophonic symptoms. Conclusions These findings provide large-scale evidence that misophonia and tinnitus frequently co-occur and may share overlapping neural mechanisms, underscoring the importance of integrated audiological and psychological assessment in clinical practice. Misophonia prevalence tinnitus education prevalence sound intolerance Figures Figure 1 Figure 2 Introduction Misophonia is a decreased sound tolerance disorder characterized by intense emotional and physiological responses, such as irritation, anger, and anxiety, to specific auditory triggers. These triggers are commonly human-generated sounds like chewing, sniffing, and breathing, or repetitive environmental noises such as pen clicking and typing (Jastreboff Margaret M., 2014 ; Schröder et al., 2013 ). Although misophonia is not yet formally recognized in major diagnostic systems, its impact on daily functioning and psychological well-being has been increasingly documented (Norena, 2023 ). Individuals with misophonia often experience social withdrawal, occupational impairment, and chronic stress due to the unpredictability of sound triggers (Wu et al., 2014 ). Misophonia frequently coexists with other auditory and psychological conditions, including tinnitus, hyperacusis, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD) (Rodrigues, 2023 ; Smit et al., 2023 ). The neurophysiological model suggests that tinnitus and misophonia share overlapping auditory-limbic-autonomic pathways, contributing to heightened emotional salience and sound intolerance (Jastreboff & Jastreboff, 2003 ). Dysregulation in these circuits amplifies emotional salience to certain sounds, explaining why co-occurrence of tinnitus and misophonia can heighten distress and reduce coping capacity (Aazh et al., 2022 ). This overlap emphasizes the need for integrated assessment and management approaches, as treating one condition in isolation may leave residual emotional or perceptual difficulties unaddressed. Epidemiological studies have revealed considerable variation in misophonia prevalence globally, ranging from approximately 5% in German adults (Jakubovski et al., 2022 ), to 4.6% in a nationally representative U.S adult sample (Dixon et al., 2024 ), and up to 49% among university students in the U.K (Naylor et al., 2021 ). In India, prevalence estimates range between 15.8% and 48%, with studies indicating that misophonia is widespread but under-recognized (Aryal & Prabhu P, 2022 ; Patel et al., 2023 ). However, these studies were limited by small or regional samples and did not investigate their relationship with tinnitus, a significant gap in the Indian literature. Demographic and contextual factors may further modulate misophonia expression. Urban populations, for instance, may experience more frequent exposure to environmental noise, potentially sensitizing individuals to specific auditory triggers (Patel et al., 2023 ). Gender differences have also been consistently observed, with women showing higher prevalence and greater symptom severity. These differences may reflect broader patterns in sensory processing and emotional expressivity reported in the literature, though the underlying mechanisms remain unclear (Almadani et al., 2024 ). Educational attainment may influence awareness and reporting, as individuals with higher education may possess better recognition and articulation of symptoms (Aryal & Prabhu P, 2022 ). Given the lack of comprehensive data, there remains a pressing need for large-scale, methodologically robust studies exploring misophonia prevalence and its relationship with tinnitus within the Indian population. The present study addresses this gap by examining the prevalence, severity, and demographic correlates of misophonia among individuals with normal hearing and those with tinnitus. This work represents one of the largest Indian investigations to date, offering insights into the shared mechanisms and clinical implications of misophonia and tinnitus for audiologists, psychologists, and public health researchers. Methods Study Design A large-scale, descriptive cross-sectional survey was conducted to determine the prevalence and severity of misophonia in adults with normal hearing and in individuals with tinnitus. The study also examined the influence of gender, residential background, and educational level on misophonia expression. Data collection and reporting adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ensuring methodological transparency and replicability. Participant and Recruitment A total of 10,980 individuals were identified through nationwide recruitment channels, including community outreach programs, social media advertisements, and tertiary care audiology centers. Following screening, 480 respondents were excluded due to incomplete responses, ineligibility, or missing demographic data. The final sample included 10,500 participants, 10,000 with normal hearing (6,073 males, 3,927 females; mean age = 39.3 ± 4.7 years) and 500 with self-reported tinnitus (365 males, 135 females; mean age = 42.6 ± 6.9 years). Eligibility Criteria Participants were eligible if they were between 18 and 50 years of age, provided informed consent, and demonstrated normal hearing sensitivity, or, in the tinnitus group, mild sensorineural hearing loss confirmed through audiological evaluation. Exclusion criteria were established to minimize potential confounders and included: (a) a history of chronic otitis media, ear surgery, or external auditory canal abnormalities; (b) active ear infection or reversible causes of tinnitus; (c) a clinically documented psychiatric illness such as psychosis; (d) use of ototoxic medications including aspirin, aminoglycosides, or ibuprofen; and (e) ongoing participation in sound therapy or masking programs. These criteria ensured that all participants had stable auditory function and were free from other otological or neurological conditions that could interfere with the study. Development and Validation of the Questionnaire A structured general questionnaire was developed by the research team to collect information on demographic characteristics, audiological history, and symptoms related to misophonia and tinnitus. The instrument also included screening items for potential comorbidities such as post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), which are known to be associated with decreased sound tolerance. The questionnaire underwent content validation by a panel of five senior audiologists, each with more than ten years of professional experience. Based on their expert recommendations, three redundant items were removed, four new items were introduced to explore trigger specificity, and several items were reworded for clarity and cultural appropriateness. The final version comprised nine primary items, designed to capture both auditory and psychological dimensions of sound sensitivity. To ensure accessibility and secure data management, the questionnaire was digitized using Google Forms, incorporating an embedded informed consent section and automatic data logging. Participants were able to complete the survey either online or in person, ensuring broad coverage across urban and rural populations. Assessment Tools Participants completed a series of validated instruments administered either in paper or digital format, depending on accessibility. The General Questionnaire was used to obtain demographic, educational, and residential information as well as self-reported auditory health details. Misophonia severity was assessed using the Amsterdam Misophonia Questionnaire (A-MISO-S), which evaluates emotional, behavioral, and cognitive aspects of misophonic reactions, and the Selective Sound Sensitivity Syndrome Scale (S-Five), which measures the functional and emotional impact of specific trigger sounds. Participants with tinnitus completed the Tinnitus Handicap Inventory (THI) to quantify functional and emotional burden, and the Tinnitus Case History Questionnaire (TCHSQ) to document tinnitus characteristics, including onset, laterality, and duration. All instruments demonstrated high internal consistency and construct validity in prior studies, and minor linguistic modifications were made to ensure clarity and contextual relevance for the Indian population without altering the conceptual framework. The detailed information about the questionnaire used in the study is available as Appendix. Procedure All participants received detailed information about the study objectives and procedures prior to participation. Following written or digital informed consent, eligible individuals completed the questionnaire either online or during in-person sessions. Participants who screened positive for misophonia completed the A-MISO-S and S-Five, while those with tinnitus completed the THI and TCHSQ. Data collection was carried out under the researcher's supervision when in person, and automated validation ensured completeness for digital responses. All responses were anonymized and stored in a password-protected database for analysis. Statistical Analysis Data were analyzed using IBM SPSS Statistics (Version 21). Descriptive statistics, including means, standard deviations, and frequency distributions, were computed to estimate prevalence and severity patterns. The association between categorical variables (gender, residence, and education) and misophonia prevalence was analyzed using Chi-square tests, while independent t-tests compared mean severity scores between groups. The relationship between tinnitus distress (THI scores) and misophonia severity (A-MISO-S scores) was assessed using Pearson’s correlation coefficient. Statistical significance was set at p < 0.05. Ethical Considerations The Institutional Ethics Committee of the All India Institute of Speech and Hearing (AIISH), Mysuru, approved the study (AIISH/IRB/2024/35). Written informed consent was obtained from all participants. Results A total of 10,500 adults participated in the study, comprising 10,000 individuals with normal hearing (6,073 males and 3,927 females; mean age = 39.3 ± 4.7 years) and 500 individuals with tinnitus (365 males and 135 females; mean age = 42.6 ± 6.9 years). All participants in the normal-hearing group had no self-reported otological or audiological complaints, while those in the tinnitus group reported chronic subjective tinnitus with predominantly mild sensorineural hearing loss. Demographic and psychometric characteristics of all participants are summarized in Table 1 . Table 1 Demographic and psychometric characteristics of participants across study groups. Group n Female (%) Urban (%) Mean Age (years) Key Measure Mean ± SD Dominant Severity Normal hearing with symptoms 437 54.5 71.9 24.8 N/A N/A N/A Normal hearing with misophonia 2,615 68.1 71.7 24.8 A-MISO-S 1.61 ± 0.66 Mild-Moderate Tinnitus without misophonia 74 50.0 50.0 37.6 THI 28.9 ± 18.6 Mild Tinnitus with misophonia 85 71.8 88.2 39.1 THI; A-MISO-S 27.4 ± 13.6, 6.4 ± 2.3 Mild-Moderate A-MISO-S = Amsterdam Misophonia Scale; THI = Tinnitus Handicap Inventory; SD = Standard deviation. “Dominant severity” reflects the most common severity category within each subgroup. Prevalence of Misophonia The study revealed a substantial presence of misophonia in both groups, although prevalence and severity differed. Among individuals with normal hearing, 26% (2,615 of 10,000) met the criteria for misophonia. Within the tinnitus group, 17% (85 of 500) showed comorbid misophonia. Symptom severity followed distinct patterns: in the normal-hearing group, 66% of affected individuals reported mild symptoms, 24% moderate, and 10% severe. In contrast, among tinnitus patients with misophonia, 33% had severe, 44% moderate, and 23% mild symptoms. Although misophonia was more common among those with normal hearing, it presented with greater intensity among individuals with tinnitus, suggesting an additive effect of tinnitus-related distress on emotional reactivity to sound. Normal-Hearing Individuals with Sound Sensitivity A subset of 437 individuals from the normal-hearing sample reported sound sensitivity or intolerance without fulfilling the diagnostic criteria for misophonia. Of these, 238 (54.5%) were female and 199 (45.5%) were male. Most participants were urban residents (71.9%), and rural participants accounted for 28.1%. Age distribution showed that 246 (56.3%) were between 18–25 years, 104 (23.8%) were 26–35 years, and 87 (19.9%) were 36–50 years. Educationally, 43% were undergraduates, 41.6% diploma holders, 14.8% postgraduates, and 0.5% illiterate. These findings suggest that younger, urban, and better-educated participants were more likely to report subclinical sound sensitivity, possibly reflecting greater environmental noise exposure and awareness of auditory discomfort. Normal-Hearing Individuals with Misophonia Among the 2,615 normal-hearing participants diagnosed with misophonia, 1,780 (68.1%) were female and 835 (31.9%) were male. Most were urban residents (71.7%), compared with rural (28.3%). Regarding education, 1,224 (46.8%) were undergraduates, 706 (27%) diploma-level, and 685 (26.2%) postgraduates. None were illiterate. A subsample of 200 participants completed detailed psychometric evaluation using the A-MISO-S scale. Scores ranged from 1–4 (Mean = 1.61 ± 0.66), indicating mild-to-moderate misophonia. The mean age of this subgroup was 24.8 ± 7.1 years (range = 17–50). Overall, misophonia among those with normal hearing was more prevalent among young, educated, and urban females, suggesting possible sociocultural or lifestyle factors influencing symptom recognition and reporting. Tinnitus Without Misophonia Among 74 tinnitus participants who did not meet criteria for misophonia, gender and residential distribution were equal (50% male/female, 50% urban/rural). Educationally, 35 (47.3%) had diploma-level or lower education, 21 (28.4%) were undergraduates, 10 (13.5%) postgraduates, and 8 (10.8%) were illiterate. The mean Tinnitus Handicap Inventory (THI) score was 28.9 ± 18.6 (range = 2–88), corresponding to mild tinnitus handicap . The mean age of this group was 37.6 ± 9.4 years (range = 18–50). This indicates that tinnitus without comorbid misophonia was generally mild in its functional impact and relatively evenly distributed across demographic categories. Tinnitus Participants with Comorbid Misophonia Eighty-five participants exhibited both tinnitus and misophonia. Of these, 61 (71.8%) were female and 24 (28.2%) male. Most were urban residents (88.2%), and none were illiterate. Educational levels were high, with 43 (50.6%) undergraduates, 27 (31.8%) postgraduates, and 15 (17.6%) diploma-level. Among a subset of participants with complete psychometric data (n = 7), the mean Tinnitus Handicap Inventory (THI) score was 27.4 ± 13.6 (range = 10–50), indicating mild tinnitus handicap , while the mean Amsterdam Misophonia Scale (A-MISO-S) score was 6.4 ± 2.3 (range = 3–10), representing moderate misophonia severity . The mean age of this subset was 39.1 ± 8.8 years (range = 26–47). A strong positive correlation was observed between tinnitus severity (THI) and misophonia severity (A-MISO-S) (r = 0.83, p < 0.01), suggesting that individuals with higher tinnitus distress tended to experience more pronounced misophonic reactions. This relationship supports emerging evidence of overlapping auditory-limbic pathways contributing to both conditions [1]. Figure 1 depicts the linear association between THI and A-MISO-S scores. Discussion Prevalence and Severity of Misophonia Among individuals with normal hearing, 26% exhibited misophonia symptoms, consistent with prior Indian and international research. Previous studies reported prevalence rates of approximately 23% among Indian university students and 31.4% among Indian adults aged 30–50 years, most of whom demonstrated subclinical symptoms (Aryal & Prabhu P, 2022 ; Valsa et al., 2025 ). In contrast, university samples in the U.K. showed considerably higher rates, with nearly 49.1% exhibiting clinically significant symptoms (Naylor et al., 2021 ), whereas population-level data from Germany indicated a much lower prevalence of around 6% (Jakubovski et al., 2022 ). These large disparities may reflect differences in demographic characteristics, cultural expectations, and assessment tools used across studies. It has also been suggested that population-level variability may arise from differences in awareness, sound environments, and overall psychological profiles (Rouw & Erfanian, 2018 ). In the current study, symptom severity among normal-hearing participants was primarily mild (66%), followed by moderate (24%) and severe (10%). This distribution aligns with the general understanding of misophonia as a spectrum disorder, in which most individuals experience mild distress, while a smaller subset reports profound impairment. Misophonia has been shown to interfere with social, occupational, and emotional functioning, contributing to avoidance patterns and heightened anxiety (Schröder et al., 2013 ). The present findings reinforce the importance of recognizing misophonia as a clinically relevant and often impairing conditionn. Misophonia Among Individuals with Tinnitus Among individuals with tinnitus, 17% demonstrated comorbid misophonia, slightly lower than earlier clinical reports (Aazh et al., 2022 ). Notably, misophonia severity in the current tinnitus group was substantially higher, with one-third exhibiting severe symptoms. This pattern suggests that tinnitus-related distress may intensify emotional sensitivity to sound, potentially through shared neurophysiological pathways. A strong positive correlation was found between tinnitus handicap (THI) and misophonia severity (A-MISO-S), indicating that individuals experiencing greater tinnitus distress also reported stronger emotional reactivity to sound. Evidence from previous neurobiological studies indicates that both conditions involve heightened activation of auditory and limbic structures, including the amygdala and anterior cingulate cortex (Kumar et al., 2017 ). Additional work has described how auditory-limbic coupling contributes to emotional salience of sound and decreased sound tolerance (Jastreboff Margaret M., ). Recent neuroimaging data further support altered cortical morphology associated with increased limbic engagement in tinnitus (Pandey et al., 2024 ). Together, these findings suggest that maladaptive plasticity within interconnected auditory and emotional networks may underlie both tinnitus distress and misophonia. The coexistence of tinnitus and misophonia presents a unique clinical challenge, as both conditions can reinforce one another’s emotional impact. Higher tinnitus distress has been linked to increased misophonia-related anxiety and avoidance tendencies (Norris et al., 2022 ), highlighting the need for integrated management strategies that address both auditory and emotional dimensions simultaneously. Gender, Background, and Educational Influences Female participants demonstrated higher misophonia prevalence across both study groups, consistent with earlier findings showing greater emotional sensitivity and sound intolerance among women (Sujeeth et al., 2024 ; Zhou et al., 2017 ). These differences may relate to broader patterns in sensory processing and emotional expressivity, although definitive mechanisms remain unclear. Urban participants reported higher misophonia prevalence than rural participants, consistent with prior evidence linking environmental noise exposure and urban stressors to increased sound sensitivity and emotional reactivity (Stansfeld et al., 2000 ; Sujeeth et al., 2024 ). Furthermore, participants with higher educational attainment (undergraduate or postgraduate) reported misophonia more frequently, possibly reflecting increased awareness and self-recognition of symptoms. Previous findings have suggested that greater educational exposure may enhance sensitivity to one’s auditory environment (Aryal & Prabhu P, 2022 ). These demographic trends underscore the multifactorial nature of misophonia and highlight the importance of considering environmental and psychosocial context in clinical assessment. Clinical and Psychological Implications The co-occurrence of tinnitus and misophonia imposes a significant emotional burden. Both conditions have been associated with elevated anxiety, stress, and depressive symptoms, which may intensify perceived severity (Langguth et al., 2013 ; Zöger et al., 2006 ). These observations highlight the need for multidisciplinary approaches incorporating audiological, psychological, and behavioral interventions. Previous research indicates that combined therapeutic approaches, such as tinnitus retraining therapy (TRT), cognitive-behavioral therapy (CBT), and sound desensitization, can effectively alleviate the emotional distress associated with both tinnitus and misophonia (Aazh et al., 2016 ; Hesser et al., 2014 ; Jastreboff Margaret M., 2014 ). CBT in particular has been shown to decrease misophonia severity and tinnitus-related anxiety (Aazh, 2025 ). Cognitive-behavioral models of tinnitus further demonstrate how maladaptive interpretations and attentional biases sustain distress, supporting the utility of CBT-based interventions (McKenna et al., 2014 ). Routine screening for misophonia in tinnitus clinics may therefore enhance treatment precision and improve patient quality of life. Limitations and Future Directions While the present study benefits from a large, diverse sample and validated assessment tools, several limitations warrant consideration. The cross-sectional design limits causal inference between tinnitus and misophonia. Psychometric data in the tinnitus-misophonia correlation subset were based on a smaller sample, necessitating larger confirmatory studies. Furthermore, self-report measures may be influenced by recall bias or underreporting. Future research should include neurophysiological and longitudinal studies to elucidate causal mechanisms and to examine the effectiveness of integrated intervention models. Conclusions This large-scale investigation demonstrates that misophonia is common among both normal-hearing adults and individuals with tinnitus, although symptom severity is markedly higher in the tinnitus group. The strong association between tinnitus-related distress and misophonia severity aligns with models implicating shared auditory-limbic pathways, heightened autonomic reactivity, and reduced emotional regulation capacity. These findings highlight the importance of routinely screening for misophonia within tinnitus clinics, as unrecognized sound intolerance may contribute to treatment resistance and reduced quality of life. Integrating audiological, psychological, and behavioral interventions may therefore offer more comprehensive and effective management strategies for individuals presenting with coexisting tinnitus and misophonia. Declarations Acknowledgements The authors extend their sincere gratitude to all participants for their voluntary contribution to this study. The research team acknowledges the All India Institute of Speech and Hearing (AIISH), Mysuru, for providing institutional support, ethical clearance, and research facilities. We also thank the faculty and postgraduate students of the Department of Audiology for their valuable assistance in data collection and participant coordination. Funding This study did not receive any specific grant from public, commercial, or not-for-profit funding agencies. Disclosure Statement The authors declare that there are no conflicts of interest related to this study. The views expressed in this article are solely those of the authors and do not necessarily represent those of the All India Institute of Speech and Hearing, the Ministry of Health and Family Welfare, or any affiliated institutions. Author Contribution Prashanth Prabhu (PP): Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Writing – Original Draft, Project Administration, Supervision.V. G. (VG): Data Collection, Investigation, Data Curation, Project Coordination, Writing – Review & Editing.S. S. 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Psychosomatics 47(4):282–288. https://doi.org/https://doi.org/10.1176/appi.psy.47.4.282 Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8333185","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":558816689,"identity":"1e7506af-cc79-4ee1-9231-aff5bcbd26c4","order_by":0,"name":"Prashanth Prabhu","email":"data:image/png;base64,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","orcid":"","institution":"University of Mysore","correspondingAuthor":true,"prefix":"","firstName":"Prashanth","middleName":"","lastName":"Prabhu","suffix":""},{"id":558816690,"identity":"b584d41b-69b7-449f-b129-1bdbff4aa03f","order_by":1,"name":"Vidya Gowda","email":"","orcid":"","institution":"University of Mysore","correspondingAuthor":false,"prefix":"","firstName":"Vidya","middleName":"","lastName":"Gowda","suffix":""},{"id":558816691,"identity":"83af2a1c-7256-4c34-ba60-7ed2b4c565db","order_by":2,"name":"Selva Samaeii","email":"","orcid":"","institution":"University of Social Welfare and Rehabilitation Sciences","correspondingAuthor":false,"prefix":"","firstName":"Selva","middleName":"","lastName":"Samaeii","suffix":""}],"badges":[],"createdAt":"2025-12-11 06:23:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8333185/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8333185/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98388107,"identity":"104e14d6-b1a8-4b67-ba30-30a85012b1f4","added_by":"auto","created_at":"2025-12-17 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09:05:21","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78762,"visible":true,"origin":"","legend":"","description":"","filename":"cea51b32b1f8456d94363418903db8621structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8333185/v1/367b8afb65b674495027d94f.xml"},{"id":98388114,"identity":"89c0f62e-bed7-43f8-88cf-996771c7336b","added_by":"auto","created_at":"2025-12-17 09:05:21","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":88442,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8333185/v1/99aec079937abecde3bf430f.html"},{"id":98388103,"identity":"c6e672cb-4083-46bf-9427-3913f4022563","added_by":"auto","created_at":"2025-12-17 09:05:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35684,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart showing participant identification, exclusions, and final allocation to study subgroups.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8333185/v1/cf4f82cfe852e731991ad877.png"},{"id":98388104,"identity":"2d2022e4-b98f-4929-8cb9-d81d3dd8c2ff","added_by":"auto","created_at":"2025-12-17 09:05:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56671,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e. Correlation between tinnitus handicap (THI) and misophonia severity (A-MISO-S) among participants with tinnitus and misophonia (n = 7).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8333185/v1/13e84b47253fb5001408b3c5.png"},{"id":104403045,"identity":"479c0112-4188-4314-b97b-3237e8fcc30d","added_by":"auto","created_at":"2026-03-11 12:17:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":774041,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8333185/v1/d567db41-e18b-4011-96b2-14cc85d57576.pdf"},{"id":98388105,"identity":"69745472-cd5e-488a-82a4-4cc8f84a5e1c","added_by":"auto","created_at":"2025-12-17 09:05:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21213,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8333185/v1/5af45ed18132498cbd1648ec.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Prevalence of misophonia in the general population and those with complaints of tinnitus: An epidemiological study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMisophonia is a decreased sound tolerance disorder characterized by intense emotional and physiological responses, such as irritation, anger, and anxiety, to specific auditory triggers. These triggers are commonly human-generated sounds like chewing, sniffing, and breathing, or repetitive environmental noises such as pen clicking and typing (Jastreboff Margaret M., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Schr\u0026ouml;der et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Although misophonia is not yet formally recognized in major diagnostic systems, its impact on daily functioning and psychological well-being has been increasingly documented (Norena, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Individuals with misophonia often experience social withdrawal, occupational impairment, and chronic stress due to the unpredictability of sound triggers (Wu et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Misophonia frequently coexists with other auditory and psychological conditions, including tinnitus, hyperacusis, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD) (Rodrigues, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Smit et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe neurophysiological model suggests that tinnitus and misophonia share overlapping auditory-limbic-autonomic pathways, contributing to heightened emotional salience and sound intolerance (Jastreboff \u0026amp; Jastreboff, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2003\u003c/span\u003e). Dysregulation in these circuits amplifies emotional salience to certain sounds, explaining why co-occurrence of tinnitus and misophonia can heighten distress and reduce coping capacity (Aazh et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This overlap emphasizes the need for integrated assessment and management approaches, as treating one condition in isolation may leave residual emotional or perceptual difficulties unaddressed.\u003c/p\u003e \u003cp\u003eEpidemiological studies have revealed considerable variation in misophonia prevalence globally, ranging from approximately 5% in German adults (Jakubovski et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), to 4.6% in a nationally representative U.S adult sample (Dixon et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), and up to 49% among university students in the U.K (Naylor et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In India, prevalence estimates range between 15.8% and 48%, with studies indicating that misophonia is widespread but under-recognized (Aryal \u0026amp; Prabhu P, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Patel et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). However, these studies were limited by small or regional samples and did not investigate their relationship with tinnitus, a significant gap in the Indian literature.\u003c/p\u003e \u003cp\u003eDemographic and contextual factors may further modulate misophonia expression. Urban populations, for instance, may experience more frequent exposure to environmental noise, potentially sensitizing individuals to specific auditory triggers (Patel et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Gender differences have also been consistently observed, with women showing higher prevalence and greater symptom severity. These differences may reflect broader patterns in sensory processing and emotional expressivity reported in the literature, though the underlying mechanisms remain unclear (Almadani et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Educational attainment may influence awareness and reporting, as individuals with higher education may possess better recognition and articulation of symptoms (Aryal \u0026amp; Prabhu P, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGiven the lack of comprehensive data, there remains a pressing need for large-scale, methodologically robust studies exploring misophonia prevalence and its relationship with tinnitus within the Indian population. The present study addresses this gap by examining the prevalence, severity, and demographic correlates of misophonia among individuals with normal hearing and those with tinnitus. This work represents one of the largest Indian investigations to date, offering insights into the shared mechanisms and clinical implications of misophonia and tinnitus for audiologists, psychologists, and public health researchers.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA large-scale, descriptive cross-sectional survey was conducted to determine the prevalence and severity of misophonia in adults with normal hearing and in individuals with tinnitus. The study also examined the influence of gender, residential background, and educational level on misophonia expression. Data collection and reporting adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ensuring methodological transparency and replicability.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipant and Recruitment\u003c/h3\u003e\n\u003cp\u003eA total of 10,980 individuals were identified through nationwide recruitment channels, including community outreach programs, social media advertisements, and tertiary care audiology centers. Following screening, 480 respondents were excluded due to incomplete responses, ineligibility, or missing demographic data. The final sample included 10,500 participants, 10,000 with normal hearing (6,073 males, 3,927 females; mean age\u0026thinsp;=\u0026thinsp;39.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years) and 500 with self-reported tinnitus (365 males, 135 females; mean age\u0026thinsp;=\u0026thinsp;42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9 years).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eParticipants were eligible if they were between 18 and 50 years of age, provided informed consent, and demonstrated normal hearing sensitivity, or, in the tinnitus group, mild sensorineural hearing loss confirmed through audiological evaluation. Exclusion criteria were established to minimize potential confounders and included: (a) a history of chronic otitis media, ear surgery, or external auditory canal abnormalities; (b) active ear infection or reversible causes of tinnitus; (c) a clinically documented psychiatric illness such as psychosis; (d) use of ototoxic medications including aspirin, aminoglycosides, or ibuprofen; and (e) ongoing participation in sound therapy or masking programs. These criteria ensured that all participants had stable auditory function and were free from other otological or neurological conditions that could interfere with the study.\u003c/p\u003e\n\u003ch3\u003eDevelopment and Validation of the Questionnaire\u003c/h3\u003e\n\u003cp\u003eA structured general questionnaire was developed by the research team to collect information on demographic characteristics, audiological history, and symptoms related to misophonia and tinnitus. The instrument also included screening items for potential comorbidities such as post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD), which are known to be associated with decreased sound tolerance.\u003c/p\u003e \u003cp\u003eThe questionnaire underwent content validation by a panel of five senior audiologists, each with more than ten years of professional experience. Based on their expert recommendations, three redundant items were removed, four new items were introduced to explore trigger specificity, and several items were reworded for clarity and cultural appropriateness. The final version comprised nine primary items, designed to capture both auditory and psychological dimensions of sound sensitivity.\u003c/p\u003e \u003cp\u003eTo ensure accessibility and secure data management, the questionnaire was digitized using Google Forms, incorporating an embedded informed consent section and automatic data logging. Participants were able to complete the survey either online or in person, ensuring broad coverage across urban and rural populations.\u003c/p\u003e\n\u003ch3\u003eAssessment Tools\u003c/h3\u003e\n\u003cp\u003eParticipants completed a series of validated instruments administered either in paper or digital format, depending on accessibility. The General Questionnaire was used to obtain demographic, educational, and residential information as well as self-reported auditory health details. Misophonia severity was assessed using the Amsterdam Misophonia Questionnaire (A-MISO-S), which evaluates emotional, behavioral, and cognitive aspects of misophonic reactions, and the Selective Sound Sensitivity Syndrome Scale (S-Five), which measures the functional and emotional impact of specific trigger sounds. Participants with tinnitus completed the Tinnitus Handicap Inventory (THI) to quantify functional and emotional burden, and the Tinnitus Case History Questionnaire (TCHSQ) to document tinnitus characteristics, including onset, laterality, and duration. All instruments demonstrated high internal consistency and construct validity in prior studies, and minor linguistic modifications were made to ensure clarity and contextual relevance for the Indian population without altering the conceptual framework. The detailed information about the questionnaire used in the study is available as Appendix.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eAll participants received detailed information about the study objectives and procedures prior to participation. Following written or digital informed consent, eligible individuals completed the questionnaire either online or during in-person sessions. Participants who screened positive for misophonia completed the A-MISO-S and S-Five, while those with tinnitus completed the THI and TCHSQ. Data collection was carried out under the researcher's supervision when in person, and automated validation ensured completeness for digital responses. All responses were anonymized and stored in a password-protected database for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using IBM SPSS Statistics (Version 21). Descriptive statistics, including means, standard deviations, and frequency distributions, were computed to estimate prevalence and severity patterns. The association between categorical variables (gender, residence, and education) and misophonia prevalence was analyzed using Chi-square tests, while independent t-tests compared mean severity scores between groups. The relationship between tinnitus distress (THI scores) and misophonia severity (A-MISO-S scores) was assessed using Pearson\u0026rsquo;s correlation coefficient. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The Institutional Ethics Committee of the All India Institute of Speech and Hearing (AIISH), Mysuru, approved the study (AIISH/IRB/2024/35). Written informed consent was obtained from all participants.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 10,500 adults participated in the study, comprising 10,000 individuals with normal hearing (6,073 males and 3,927 females; mean age\u0026thinsp;=\u0026thinsp;39.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years) and 500 individuals with tinnitus (365 males and 135 females; mean age\u0026thinsp;=\u0026thinsp;42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9 years).\u003c/p\u003e \u003cp\u003e All participants in the normal-hearing group had no self-reported otological or audiological complaints, while those in the tinnitus group reported chronic subjective tinnitus with predominantly mild sensorineural hearing loss. Demographic and psychometric characteristics of all participants are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and psychometric characteristics of participants across study groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUrban (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean Age (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKey Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDominant Severity\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal hearing with symptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e437\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal hearing with misophonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2,615\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eA-MISO-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMild-Moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTinnitus without misophonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e37.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTHI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTinnitus with misophonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e88.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e39.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTHI;\u003c/p\u003e \u003cp\u003eA-MISO-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6, 6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMild-Moderate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA-MISO-S\u0026thinsp;=\u0026thinsp;Amsterdam Misophonia Scale; THI\u0026thinsp;=\u0026thinsp;Tinnitus Handicap Inventory; SD\u0026thinsp;=\u0026thinsp;Standard deviation. \u0026ldquo;Dominant severity\u0026rdquo; reflects the most common severity category within each subgroup.\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence of Misophonia\u003c/h2\u003e \u003cp\u003eThe study revealed a substantial presence of misophonia in both groups, although prevalence and severity differed.\u003c/p\u003e \u003cp\u003eAmong individuals with normal hearing, 26% (2,615 of 10,000) met the criteria for misophonia.\u003c/p\u003e \u003cp\u003eWithin the tinnitus group, 17% (85 of 500) showed comorbid misophonia.\u003c/p\u003e \u003cp\u003eSymptom severity followed distinct patterns: in the normal-hearing group, 66% of affected individuals reported mild symptoms, 24% moderate, and 10% severe.\u003c/p\u003e \u003cp\u003eIn contrast, among tinnitus patients with misophonia, 33% had severe, 44% moderate, and 23% mild symptoms.\u003c/p\u003e \u003cp\u003eAlthough misophonia was more common among those with normal hearing, it presented with greater intensity among individuals with tinnitus, suggesting an additive effect of tinnitus-related distress on emotional reactivity to sound.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNormal-Hearing Individuals with Sound Sensitivity\u003c/h2\u003e \u003cp\u003eA subset of 437 individuals from the normal-hearing sample reported sound sensitivity or intolerance without fulfilling the diagnostic criteria for misophonia.\u003c/p\u003e \u003cp\u003eOf these, 238 (54.5%) were female and 199 (45.5%) were male.\u003c/p\u003e \u003cp\u003eMost participants were urban residents (71.9%), and rural participants accounted for 28.1%.\u003c/p\u003e \u003cp\u003eAge distribution showed that 246 (56.3%) were between 18\u0026ndash;25 years, 104 (23.8%) were 26\u0026ndash;35 years, and 87 (19.9%) were 36\u0026ndash;50 years.\u003c/p\u003e \u003cp\u003eEducationally, 43% were undergraduates, 41.6% diploma holders, 14.8% postgraduates, and 0.5% illiterate.\u003c/p\u003e \u003cp\u003e These findings suggest that younger, urban, and better-educated participants were more likely to report subclinical sound sensitivity, possibly reflecting greater environmental noise exposure and awareness of auditory discomfort.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eNormal-Hearing Individuals with Misophonia\u003c/h2\u003e \u003cp\u003eAmong the 2,615 normal-hearing participants diagnosed with misophonia, 1,780 (68.1%) were female and 835 (31.9%) were male.\u003c/p\u003e \u003cp\u003eMost were urban residents (71.7%), compared with rural (28.3%).\u003c/p\u003e \u003cp\u003eRegarding education, 1,224 (46.8%) were undergraduates, 706 (27%) diploma-level, and 685 (26.2%) postgraduates. None were illiterate.\u003c/p\u003e \u003cp\u003eA subsample of 200 participants completed detailed psychometric evaluation using the A-MISO-S scale. Scores ranged from 1\u0026ndash;4 (Mean\u0026thinsp;=\u0026thinsp;1.61\u0026thinsp;\u0026plusmn;\u0026thinsp;0.66), indicating mild-to-moderate misophonia.\u003c/p\u003e \u003cp\u003eThe mean age of this subgroup was 24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 years (range\u0026thinsp;=\u0026thinsp;17\u0026ndash;50).\u003c/p\u003e \u003cp\u003eOverall, misophonia among those with normal hearing was more prevalent among young, educated, and urban females, suggesting possible sociocultural or lifestyle factors influencing symptom recognition and reporting.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eTinnitus Without Misophonia\u003c/h2\u003e \u003cp\u003e Among 74 tinnitus participants who did not meet criteria for misophonia, gender and residential distribution were equal (50% male/female, 50% urban/rural).\u003c/p\u003e \u003cp\u003eEducationally, 35 (47.3%) had diploma-level or lower education, 21 (28.4%) were undergraduates, 10 (13.5%) postgraduates, and 8 (10.8%) were illiterate.\u003c/p\u003e \u003cp\u003eThe mean Tinnitus Handicap Inventory (THI) score was 28.9\u0026thinsp;\u0026plusmn;\u0026thinsp;18.6 (range\u0026thinsp;=\u0026thinsp;2\u0026ndash;88), corresponding to \u003cem\u003emild tinnitus handicap\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThe mean age of this group was 37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 years (range\u0026thinsp;=\u0026thinsp;18\u0026ndash;50).\u003c/p\u003e \u003cp\u003e This indicates that tinnitus without comorbid misophonia was generally mild in its functional impact and relatively evenly distributed across demographic categories.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTinnitus Participants with Comorbid Misophonia\u003c/h2\u003e \u003cp\u003eEighty-five participants exhibited both tinnitus and misophonia. Of these, 61 (71.8%) were female and 24 (28.2%) male. Most were urban residents (88.2%), and none were illiterate. Educational levels were high, with 43 (50.6%) undergraduates, 27 (31.8%) postgraduates, and 15 (17.6%) diploma-level.\u003c/p\u003e \u003cp\u003eAmong a subset of participants with complete psychometric data (n\u0026thinsp;=\u0026thinsp;7), the mean Tinnitus Handicap Inventory (THI) score was 27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;13.6 (range\u0026thinsp;=\u0026thinsp;10\u0026ndash;50), indicating \u003cem\u003emild tinnitus handicap\u003c/em\u003e, while the mean Amsterdam Misophonia Scale (A-MISO-S) score was 6.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3 (range\u0026thinsp;=\u0026thinsp;3\u0026ndash;10), representing \u003cem\u003emoderate misophonia severity\u003c/em\u003e. The mean age of this subset was 39.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.8 years (range\u0026thinsp;=\u0026thinsp;26\u0026ndash;47).\u003c/p\u003e \u003cp\u003eA strong positive correlation was observed between tinnitus severity (THI) and misophonia severity (A-MISO-S) (r\u0026thinsp;=\u0026thinsp;0.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), suggesting that individuals with higher tinnitus distress tended to experience more pronounced misophonic reactions. This relationship supports emerging evidence of overlapping auditory-limbic pathways contributing to both conditions [1]. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts the linear association between THI and A-MISO-S scores.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003ePrevalence and Severity of Misophonia\u003c/h2\u003e \u003cp\u003eAmong individuals with normal hearing, 26% exhibited misophonia symptoms, consistent with prior Indian and international research. Previous studies reported prevalence rates of approximately 23% among Indian university students and 31.4% among Indian adults aged 30\u0026ndash;50 years, most of whom demonstrated subclinical symptoms (Aryal \u0026amp; Prabhu P, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Valsa et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). In contrast, university samples in the U.K. showed considerably higher rates, with nearly 49.1% exhibiting clinically significant symptoms (Naylor et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), whereas population-level data from Germany indicated a much lower prevalence of around 6% (Jakubovski et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These large disparities may reflect differences in demographic characteristics, cultural expectations, and assessment tools used across studies. It has also been suggested that population-level variability may arise from differences in awareness, sound environments, and overall psychological profiles (Rouw \u0026amp; Erfanian, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the current study, symptom severity among normal-hearing participants was primarily mild (66%), followed by moderate (24%) and severe (10%). This distribution aligns with the general understanding of misophonia as a spectrum disorder, in which most individuals experience mild distress, while a smaller subset reports profound impairment. Misophonia has been shown to interfere with social, occupational, and emotional functioning, contributing to avoidance patterns and heightened anxiety (Schr\u0026ouml;der et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The present findings reinforce the importance of recognizing misophonia as a clinically relevant and often impairing conditionn.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eMisophonia Among Individuals with Tinnitus\u003c/h2\u003e \u003cp\u003eAmong individuals with tinnitus, 17% demonstrated comorbid misophonia, slightly lower than earlier clinical reports (Aazh et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Notably, misophonia severity in the current tinnitus group was substantially higher, with one-third exhibiting severe symptoms. This pattern suggests that tinnitus-related distress may intensify emotional sensitivity to sound, potentially through shared neurophysiological pathways.\u003c/p\u003e \u003cp\u003eA strong positive correlation was found between tinnitus handicap (THI) and misophonia severity (A-MISO-S), indicating that individuals experiencing greater tinnitus distress also reported stronger emotional reactivity to sound. Evidence from previous neurobiological studies indicates that both conditions involve heightened activation of auditory and limbic structures, including the amygdala and anterior cingulate cortex (Kumar et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Additional work has described how auditory-limbic coupling contributes to emotional salience of sound and decreased sound tolerance (Jastreboff Margaret M., ). Recent neuroimaging data further support altered cortical morphology associated with increased limbic engagement in tinnitus (Pandey et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Together, these findings suggest that maladaptive plasticity within interconnected auditory and emotional networks may underlie both tinnitus distress and misophonia.\u003c/p\u003e \u003cp\u003eThe coexistence of tinnitus and misophonia presents a unique clinical challenge, as both conditions can reinforce one another\u0026rsquo;s emotional impact. Higher tinnitus distress has been linked to increased misophonia-related anxiety and avoidance tendencies (Norris et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), highlighting the need for integrated management strategies that address both auditory and emotional dimensions simultaneously.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eGender, Background, and Educational Influences\u003c/h2\u003e \u003cp\u003eFemale participants demonstrated higher misophonia prevalence across both study groups, consistent with earlier findings showing greater emotional sensitivity and sound intolerance among women (Sujeeth et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Zhou et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). These differences may relate to broader patterns in sensory processing and emotional expressivity, although definitive mechanisms remain unclear.\u003c/p\u003e \u003cp\u003eUrban participants reported higher misophonia prevalence than rural participants, consistent with prior evidence linking environmental noise exposure and urban stressors to increased sound sensitivity and emotional reactivity (Stansfeld et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Sujeeth et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Furthermore, participants with higher educational attainment (undergraduate or postgraduate) reported misophonia more frequently, possibly reflecting increased awareness and self-recognition of symptoms. Previous findings have suggested that greater educational exposure may enhance sensitivity to one\u0026rsquo;s auditory environment (Aryal \u0026amp; Prabhu P, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). These demographic trends underscore the multifactorial nature of misophonia and highlight the importance of considering environmental and psychosocial context in clinical assessment.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eClinical and Psychological Implications\u003c/h2\u003e \u003cp\u003eThe co-occurrence of tinnitus and misophonia imposes a significant emotional burden. Both conditions have been associated with elevated anxiety, stress, and depressive symptoms, which may intensify perceived severity (Langguth et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Z\u0026ouml;ger et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). These observations highlight the need for multidisciplinary approaches incorporating audiological, psychological, and behavioral interventions.\u003c/p\u003e \u003cp\u003ePrevious research indicates that combined therapeutic approaches, such as tinnitus retraining therapy (TRT), cognitive-behavioral therapy (CBT), and sound desensitization, can effectively alleviate the emotional distress associated with both tinnitus and misophonia (Aazh et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Hesser et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Jastreboff Margaret M., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). CBT in particular has been shown to decrease misophonia severity and tinnitus-related anxiety (Aazh, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Cognitive-behavioral models of tinnitus further demonstrate how maladaptive interpretations and attentional biases sustain distress, supporting the utility of CBT-based interventions (McKenna et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). Routine screening for misophonia in tinnitus clinics may therefore enhance treatment precision and improve patient quality of life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Future Directions\u003c/h2\u003e \u003cp\u003eWhile the present study benefits from a large, diverse sample and validated assessment tools, several limitations warrant consideration. The cross-sectional design limits causal inference between tinnitus and misophonia. Psychometric data in the tinnitus-misophonia correlation subset were based on a smaller sample, necessitating larger confirmatory studies. Furthermore, self-report measures may be influenced by recall bias or underreporting. Future research should include neurophysiological and longitudinal studies to elucidate causal mechanisms and to examine the effectiveness of integrated intervention models.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis large-scale investigation demonstrates that misophonia is common among both normal-hearing adults and individuals with tinnitus, although symptom severity is markedly higher in the tinnitus group. The strong association between tinnitus-related distress and misophonia severity aligns with models implicating shared auditory-limbic pathways, heightened autonomic reactivity, and reduced emotional regulation capacity. These findings highlight the importance of routinely screening for misophonia within tinnitus clinics, as unrecognized sound intolerance may contribute to treatment resistance and reduced quality of life. Integrating audiological, psychological, and behavioral interventions may therefore offer more comprehensive and effective management strategies for individuals presenting with coexisting tinnitus and misophonia.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors extend their sincere gratitude to all participants for their voluntary contribution to this study. The research team acknowledges the All India Institute of Speech and Hearing (AIISH), Mysuru, for providing institutional support, ethical clearance, and research facilities. We also thank the faculty and postgraduate students of the Department of Audiology for their valuable assistance in data collection and participant coordination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grant from public, commercial, or not-for-profit funding agencies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest related to this study. The views expressed in this article are solely those of the authors and do not necessarily represent those of the All India Institute of Speech and Hearing, the Ministry of Health and Family Welfare, or any affiliated institutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrashanth Prabhu (PP): Conceptualization, Methodology, Investigation, Data Curation, Formal Analysis, Writing \u0026ndash; Original Draft, Project Administration, Supervision.V. G. (VG): Data Collection, Investigation, Data Curation, Project Coordination, Writing \u0026ndash; Review \u0026amp; Editing.S. S. (SS): Literature Review, Writing \u0026ndash; Review \u0026amp; Editing, Formal Analysis, Writing \u0026ndash; Original Draft, Manuscript Preparation Assistance,\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAazh H (2025) Cognitive Behavioural Therapy (CBT) for Managing Tinnitus, Hyperacusis, and Misophonia: The 2025 Tonndorf Lecture. Brain Sci 15(5). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/brainsci15050526\u003c/span\u003e\u003cspan address=\"10.3390/brainsci15050526\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAazh H, Erfanian M, Danesh AA, Moore BCJ (2022) Audiological and Other Factors Predicting the Presence of Misophonia Symptoms Among a Clinical Population Seeking Help for Tinnitus and/or Hyperacusis. 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J Obsessive-Compulsive Relat Disorders 14:7\u0026ndash;12. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1016/j.jocrd.2017.05.001\u003c/span\u003e\u003cspan address=\"10.1016/j.jocrd.2017.05.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZ\u0026ouml;ger S, Svedlund J, Holgers K-M (2006) Relationship Between Tinnitus Severity and Psychiatric Disorders. Psychosomatics 47(4):282\u0026ndash;288. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/https://doi.org/10.1176/appi.psy.47.4.282\u003c/span\u003e\u003cspan address=\"10.1176/appi.psy.47.4.282\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Misophonia, prevalence, tinnitus, education, prevalence, sound intolerance","lastPublishedDoi":"10.21203/rs.3.rs-8333185/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8333185/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eObjective\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMisophonia is characterized by strong emotional and physiological reactions to specific trigger sounds, while tinnitus involves the perception of sound in the absence of an external source. Although both conditions share underlying auditory-limbic mechanisms, their coexistence has not been widely studied in large-scale populations. This study aimed to estimate the prevalence and severity of misophonia among adults with normal hearing and those with tinnitus in India and to examine demographic and clinical correlates.\u003c/p\u003e\u003cp\u003e\u003cb\u003eDesign/Study sample\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA descriptive cross-sectional survey was conducted among 10,500 participants recruited across India, including 10,000 adults with normal hearing (6,073 males, 3,927 females; mean age 39.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 years) and 500 individuals with tinnitus (365 males, 135 females; mean age 42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9 years). Participants completed the Amsterdam Misophonia Questionnaire (A-MISO-S), Selective Sound Sensitivity Syndrome Scale (S-Five), Tinnitus Handicap Inventory (THI), and Tinnitus Case History Questionnaire (TCHSQ).\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMisophonia was identified in 26% of the normal-hearing group and 17% of the tinnitus group. Among normal-hearing individuals, 66% exhibited mild, 24% moderate, and 10% severe symptoms, whereas tinnitus participants showed higher severity, with 23% mild, 44% moderate, and 33% severe. Misophonia prevalence was higher in females, urban residents, and those with higher education levels. A strong positive correlation (r\u0026thinsp;=\u0026thinsp;0.83, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) was found between THI and A-MISO-S scores, indicating that greater tinnitus-related distress was associated with more severe misophonic symptoms.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThese findings provide large-scale evidence that misophonia and tinnitus frequently co-occur and may share overlapping neural mechanisms, underscoring the importance of integrated audiological and psychological assessment in clinical practice.\u003c/p\u003e","manuscriptTitle":"Prevalence of misophonia in the general population and those with complaints of tinnitus: An epidemiological study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-17 09:05:12","doi":"10.21203/rs.3.rs-8333185/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a5bbd499-8fd7-4bd6-83a3-c77c60933596","owner":[],"postedDate":"December 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-06T12:26:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-17 09:05:12","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8333185","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8333185","identity":"rs-8333185","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}