Introduction
Misophonia is a sound sensitivity disorder characterized by intense emotional or physiological responses to specific sounds called triggers. These responses are often associated with heightened reactions from the autonomic nervous system [1,2]. Despite being under-researched, misophonia significantly affects the quality of life for those who experience it. The condition has both neurological and physiological elements and is associated with various psychiatric symptoms, although growing research indicates that it may be a distinct disorder [3]. Estimates suggest that the prevalence of misophonia is around 3.5%, 18%, and 17.2% in the general population [4-6], 49.1% among UK undergraduate medical students [7], 23.8% among Shiraz undergraduate medical students [8], 34.67% in high school students in India [9], and 12.6% among Turkish high school and college students [6]. Accurately assessing the prevalence of misophonia has proven challenging due to the diverse methodologies, questionnaires, and populations utilized in various studies.
Given the significance of questionnaires in evaluating and managing misophonia, it is essential to translate them into the relevant languages of the target populations. Furthermore, the psychometric properties of these questionnaires should be assessed and documented prior to their use. Some frequently used questionnaires for assessing misophonia include the Amsterdam Misophonia Scale (A-MISO-S) [10], the Misophonia Questionnaire (MQ) [11], the Misophonia Physical Response Scale (MPRS) [12], MisoQuest [13], the Selective Sound Sensitivity Syndrome Scale (S-Five) [14], the Misophonia Activation Scale (MAS-1) [15], and the Duke Misophonia Questionnaire (DMQ) [16]. In 2022, Kula, et al. [17] conducted a systematic study to explore the psychometric properties of instruments for hyperacusis and misophonia, as well as to assess the quality and appropriateness of the methodologies used. They concluded that none of the reviewed studies met all the criteria established by the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) standards.
This study aims to evaluate the psychometric characteristics of misophonia questionnaires across various languages and countries, focusing on findings published in English and Persian databases. The evaluation follows the Joanna Briggs Institute (JBI) methodology for systematic reviews of assessment tools [18]. The JBI handbook outlines several psychometric properties for assessment tools, including reliability (internal consistency and measurement error), validity (covering content validity, face validity, structural validity, hypothesis testing, cross-cultural validity, and criterion validity), and responsiveness. In addition to the JBI methodology, this study also applies the COSMIN framework. The COSMIN framework provides a comprehensive set of standards for evaluating the methodological quality of studies on health measurement instruments [17]. The COSMIN taxonomy distinguishes three fundamental domains: reliability, validity, and responsiveness. Reliability refers to the consistency and stability of questionnaire scores, assessing the degree to which the measurement is free from random error. The validity domain includes content validity (whether items adequately reflect the construct) and structural validity (whether the questionnaire’s factor structure aligns with the construct’s dimensionality). Responsiveness measures an instrument’s ability to detect meaningful changes in the construct over time. By applying both the JBI and COSMIN frameworks, along with a broader psychometric scope and multilingual inclusion, this study aims to provide a robust assessment of the psychometric properties of misophonia questionnaires, highlighting their suitability for use in diverse linguistic and cultural contexts [17,19,20].
The findings of this study will provide clinicians and researchers with updated information on the psychometric properties of misophonia assessment tools, helping clinicians choose suitable tools for specific languages and populations, while also aiding researchers in designing future psychometric studies in this area.
Materials and Methods
This study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [21] statement and the JBI methodology for systematic reviews.
Inclusion criteria
According to the JBI handbook, the inclusion criteria for articles are organized under the headings of Population, Instrument(s), Construct, Outcomes, and Types of Studies, as outlined in Table 1.
Search strategy
A thorough search was performed to gather all available published and unpublished evidence. In March 2023, a bibliographic search was carried out across platforms including Web of Science, Scopus, PubMed, Cochrane Library, and Google Scholar, with no restrictions on article date or language. The following keywords were utilized: “misophonia,” “valid,” “questionnaire,” “scale,” “survey,” and “develop.”
In addition to the strategic database search, a manual search of the reference lists of all included studies was performed to identify additional relevant articles and minimize the risk of missing important publications. Before submitting the final revision of this article on October 26, 2024, a brief search was performed to check for any newly published studies related to the reviewed questionnaires, leading to the identification of several relevant new studies (Fig. 1).
Study selection
This study encompasses cross-sectional and methodological research that employed various misophonia questionnaires. All articles were imported into EndNote X8.1 (Clarivate Analytics). After removing duplicates, titles and abstracts were reviewed by two assessors based on the inclusion criteria. The full texts of the chosen articles were subsequently examined in detail. Any disagreements between the reviewers during selection were resolved. The full texts of the selected articles underwent a thorough review, with any disputes addressed by consulting a third reviewer. Studies that did not meet the inclusion criteria were excluded.
Methodological quality assessment
Initially, two independent reviewers carefully evaluated the eligible studies using standardized critical appraisal tools from the JBI for cross-sectional studies to identify methodological biases [22]. Any differences between the two reviewers were settled through discussion or by involving a third reviewer. Studies receiving a score of half or higher on the assessment questions were classified as having high or moderate quality. Articles deemed to have a high risk of bias were excluded. The methodological quality and critical appraisals of psychometric properties were evaluated using the COSMIN Risk of Bias checklist (Supplementary Table 1 in the online-only Data Supplement), as recommended by the JBI handbook [17,19].
Data extraction
Data extraction was conducted by two independent reviewers using a modified standardized JBI data extraction tool. The extracted information included: authors and publication year, country, language, mode of administration, setting/context, and participants (the review focused on studies related to both general and clinical populations). Psychometric properties—such as content validity, structural validity, internal consistency, reliability, hypothesis testing for construct validity, cross-cultural validity, measurement error, criterion validity, and responsiveness—were also extracted following the recommendations outlined in the COSMIN guidelines [19].
Results
Records/article selection & characteristics of the included studies
We initially identified 229 records, of which 99 were duplicates and subsequently removed. The titles and abstracts of the remaining 130 records were evaluated based on the inclusion criteria. Of the 34 articles that initially met the eligibility criteria, only 25 were deemed suitable after a thorough fulltext review. Nine articles were excluded because they addressed different constructs, did not report psychometric properties according to COSMIN guidelines, were published in languages other than English or Persian, or were excluded based on demographic considerations. Furthermore, two studies were discarded as they employed interviews instead of questionnaires. The screening process and results are represented in a PRISMA flow diagram (Fig. 1).
The criteria employed utilized online platforms for research and data collection. Table 2 provides a summary of the characteristics of all included studies. The eligible studies were published between 2014 and 2024, with the majority (28%) appearing in 2024. A notable number of articles were also published in 2021, 2022, and 2023, accounting for 16%, 24%, and 16%, respectively, when compared to earlier years.
Among the studies, 28% were conducted in the United Kingdom [5,7,11,23-26]. Additionally, studies were evenly split, with 32% published in both the United States [16,23,27,28] and Turkey [6,29-31]. The remaining studies were conducted in Iran, Germany, Poland, Norway, Brazil, Spain, Portugal, and China. The most frequently utilized questionnaire, referenced in five studies, was the Selective Sound Sensitivity Syndrome Scale (S5), created by Vitoratou, et al. [24] in 2022. Other commonly used questionnaires included A-MISO-S, MisoQuest, and MQ.
All of these questionnaires were created to assess or identify misophonia and its effects. Table 2 also outlines the characteristics of the participants in the studies reviewed. The sample sizes across all studies varied from 135 to 2,339 individuals, sourced from both general and clinical populations. Most studies concentrated on general populations, with six specifically aimed at student groups. The majority of the studies that fulfilled the eligibility requirements employed online platforms for their research and data gathering.
The methodological quality of the studies included
Table 3 provides a summary of the methodological quality assessment for the 25 studies included in this review, using JBI appraisal tools. Most studies did not report the confounding factors or the strategies employed to address them. Additionally, all studies evaluated exposure and outcomes using valid and reliable methods. In most cases, objective and standardized criteria were employed to measure the condition (24 out of 25), and the study subjects and settings were clearly defined (22 out of 25).
Psychometric properties of the instruments included
Table 4 displays the evaluations for each psychometric instrument. The psychometric properties identified in the studies were assessed according to the COSMIN criteria for robust psychometric properties [19]. However, none of the instruments could be comprehensively evaluated across all nine psychometric properties due to a lack of essential data in certain instances.
Discussion
This systematic review aimed to provide evidence on the quality of the psychometric properties of tools used to assess misophonia. It serves as an updated systematic review of a prior study conducted by Kula, et al. [17], which identified three measurement tools: MQ, A-MISO-S, and MisoQuest. In contrast, this review found 13 measures and 25 studies investigating the psychometric properties of these instruments. Overall, the methodological quality of the included studies ranged from “moderate” to “high,” based on the JBI handbook for systematic reviews. The COSMIN tool was employed to assess the methodological quality of the identified instruments; however, none of the tools reported data on all nine psychometric properties recommended by COSMIN. The included studies utilized diverse criteria and protocols for developing or translating their questionnaires and applied various statistical methods to assess their reliability and validity (such as concurrent, convergent, and discriminant validity). This variability contributed to a heightened heterogeneity in the findings, making it difficult to perform a meta-analysis in this review. The heterogeneity observed in the studies is largely due to the lack of a gold standard for assessing misophonia. As a result, a wide variety of questionnaires and tests from different domains—such as the Beck Anxiety and Depression Inventory, the Physical Health Questionnaire, and audiometry—have been employed alongside misophonic questionnaires to validate these assessment tools. Additionally, various statistical methods were utilized to evaluate the same psychometric properties. Until 2022 [32], there was no consensus or foundational definition of misophonia among researchers, which led to the use of differing criteria in the development of assessment tools. Even when a consistent definition was applied, researchers pursued different objectives in questionnaire design, such as focusing on the severity or impact of misophonia.
Content validity and face validity were only examined in two studies [27,30], neither of which provided adequate details on how these aspects were implemented.
Structural validity was reported in 96% of the studies included in this review. Three studies received a “sufficient” rating, as they addressed all relevant information required by COSMIN comprehensively. The remaining studies were rated as “indeterminate” or “sufficient,” mainly because they only provided exploratory factor analysis without performing confirmatory factor analysis (CFA). According to the COSMIN checklist, CFA or item response theory (IRT) analysis should be used to test the factor structure. The study by Krong, et al. [33] did not conduct factorial analysis due to a small sample size.
None of the studies assessed all three aspects of reliability, which include reliability itself, internal consistency, and measurement error. Measurement error is clinically important, as increased error diminishes reliability; however, this was not reported in the studies included. Internal consistency, which measures the degree of interrelatedness among items, was rated as “sufficient” in all studies except for those conducted by Remmert, et al. [34,35]. Reliability, defined as the proportion of total variance in the measurements, was not reported in three studies. According to COSMIN guidelines, reliability was rated as “sufficient” in ten studies. Only two studies were evaluated for criterion validity, and their findings were deemed “sufficient.” In these studies, diagnostic interviews and expert opinions served as the gold standard for conducting receiver operating characteristic analysis and calculating the area under the curve.
Regarding cross-cultural validity, two studies received ratings of “sufficient” and “indeterminate.” While some studies adapted the translated questionnaire for cross-cultural use, this was not documented in accordance with COSMIN criteria.
Hypothesis testing for construct validity was reported in the majority of studies (96%), and in most cases, the results were consistent with the hypotheses proposed by the research team. Some questionnaires on misophonia were used in studies evaluating pre- and post-therapeutic interventions; however, these studies were excluded from the current review, which focused on psychometric findings. Consequently, responsiveness was not reported in the included studies, and we could not assess the responsiveness of the questionnaires due to the exclusion of intervention studies. Future research is encouraged to incorporate these intervention studies within the PICOT framework to better evaluate questionnaire responsiveness.
In the studies conducted by Allusoglu and Aksoy [36] and Aazh, et al. [37], the psychometric properties of two questionnaires—the Sound Sensitivity Symptoms Questionnaire (SSSQ) and the Decreased Sound Tolerance Scale-Screening (DST-SS)—were reported to evaluate sound intolerance. Since these questionnaires pertain not only to misophonia but also to phonophobia and hyperacusis, they were excluded from this review. This systematic review included studies with a variety of populations, including both clinical (those with and without misophonia) and nonclinical samples. Therefore, clinicians selecting measures for clinical use should assess how the findings can be generalized to their specific target population, considering the characteristics of the populations involved in the studies.
This systematic review identifies key patterns and methodological considerations in the psychometric evaluation of misophonia questionnaires. The findings reveal that most psychometric research has focused on several widely used instruments, including MQ, A-Miso-R, MisoQuest, and S-Five. Notably, the MQ and A-Miso-R were developed before the comprehensive definition of misophonia was established in 2022. This temporal discrepancy poses challenges when comparing these instruments to those developed after 2022, such as the S-Five, CUDEMM, and SMS-Adult. The assessment of psychometric properties across different versions of these tools—spanning various languages and populations—according to the COSMIN framework, enhances the external validity and cross-cultural applicability of the findings. Based on COSMIN criteria, more rigorous psychometric evaluations have been reported for the S-Five and MisoQuest, making them recommended instruments for future psychometric validation studies and clinical applications.
Given the numerous studies conducted recently in various countries to evaluate the psychometric properties of misophonia questionnaires in different languages, it is advisable for future research to concentrate on individuals with misophonia as the primary clinical population, rather than incorporating those with other conditions, such as depression. Individuals with misophonia can be identified using questionnaires with established psychometric data and defined cut-off points from recent studies. The combined application of multiple questionnaires may facilitate the creation of a gold standard tool or test battery for assessing and diagnosing misophonia.
In conclusion, this systematic review rigorously evaluated the psychometric properties of misophonia assessment tools, guided by the JBI handbook and COSMIN framework. Despite identifying a growing number of instruments, the current evidence remains limited, with no single measure satisfying all nine COSMIN methodological quality criteria. This highlights significant gaps in the reliability, validity, and comprehensiveness of existing tools. The recent establishment of an international consensus on the definition of misophonia in 2022 provides a critical foundation to harmonize future research efforts. Moving forward, it is imperative to conduct more robust psychometric evaluations, develop or refine instruments grounded in this unified definition, and explore the multidimensional nature of misophonia. These advances will be essential for improving diagnostic accuracy and guiding effective interventions for those affected by this complex condition.
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