Dr. Zach Rosenthal - Hopeful Advancements in Misophonia Research

Adeel [0:00]: Welcome to the Misophonia Podcast. This is Season 4, Episode 6. My name's Adeel Ahmad, and I have Misophonia. I'm so excited to bring you today's guest. As listeners know, this podcast is mainly about my fellow Misophones, people who have the condition and their story. But occasionally, I try to bring in other voices in the community, and today's guest is a major one. Dr. Rosenthal is the director of the Duke Center for Misophonia and Emotion Regulation. This is really one of the leading groups around the world studying misophonia, doing numerous research projects, providing education, and also dealing with patients in a clinical setting. I'll have the link to the center in the show notes, but misophonia.duke.edu is where you can go for more information. Dr. Rosenthal was one of the authors of the paper released last week discussing a consensus definition for misophonia, and actually we recorded this conversation just an hour before it went public, so I wanted to squeeze this episode in this week. We'll be back to our regular schedule of amazing upcoming episodes next week. I want to put in a word from my first sponsor. The Animal Q&A Podcast is a podcast to answer all your burning questions about animals. Produced every week by my nine-year-old daughter. Perfect for kids of all ages. Find it anywhere you get podcasts and submit questions at animalqna.com. And now my conversation with Dr. Zach Rosenthal. Zach, welcome to the podcast. Good to have you here. Great to be here. Thanks for having me. Yeah, we're very excited to have you, and I'm sure a lot of folks are here. So why don't we first, I want to let you introduce yourself a little bit first. Tell us a little bit about who you are, what you do, and where you are.

Zach [2:00]: Sure, sure. So I am Zach Rosenthal. I'm a clinical psychologist at Duke University, and I am currently directing the Duke Center for Misophonia and Emotion Regulation. I have been at Duke since 2001, so we're pushing 20 years. And I am one of those academic people who kind of does a lot of different things. So I do the things you think of when you think of a professor. I teach undergraduates and teach graduate students. But I also do really mostly research and provide treatment and training of people who are learning how to provide treatment. So I do a lot of different things. I also get myself out into the community and do a lot of work disseminating best practices for evidence-based therapies for adults throughout the state of North Carolina and elsewhere. So I feel really privileged and fortunate to have a career where I'm able to do a lot of different things and get to experience the reward of trying to help people in a lot of different ways.

Adeel [3:23]: Yeah, that sounds great. And so you're the director of the Center of Misophonia and Emotion Regulation. Was this something that you found yourself or did you join? And kind of when did this start?

Zach [3:39]: So, you know, having been at Duke for a long time, I've been... I've been leading a different group called the Cognitive Behavioral Research and Treatment Program, which is actually a larger group of clinical psychologists who do research and teach and train and provide therapy. And the clinic that we run at Duke has long been kind of a very busy outpatient clinic for the community, providing psychotherapies for adults and training various trainees and how to do that. So in that context, I was doing research really in the early 2000s, doing more research on emotion and borderline personality disorder. And at the time, my research was really driving towards the question of how can we characterize problems with emotion and emotional regulation? in people with borderline personality disorder. And at that time, misophonia was really a brand new thing and just a few years before had formally been kind of named. Very little was being discussed about it. I certainly hadn't even heard of it at that time. But I started doing research on sensory processing and the relationship between sounds and sensation with emotion and emotion regulation. And so that work was something I was really interested in, again, as part of understanding how to characterize problems with emotion. And it just so turns out that the people that we were studying at that time were people who tend to be characterized by sensitivity, reactivity, and difficulty recovering once they become emotionally aroused. Now you might think, well, that sounds a lot like misophonia. And it does in some ways. And so that kind of earlier research that I was doing on emotion and emotion regulation and borderline personality disorder, that's really what on the professional side of my life got me involved ultimately with misophonia. And so the center for misophonia and emotion regulation kind of organically grew. It wasn't something that existed until 2000. actually very recently the the duke center for misophonia and emotion regulation is only a couple of years old it is something that i did begin formally a couple of years ago but again for a number of years over 10 years before formally launching it we were doing research on the relationship between emotion and auditory responsivity. So sort of like sensory over responsivity to sounds and other senses and how that relates to emotion and how that relates to problems with mental health. What happened to start the Duke Center for Misophonia and Emotion Regulation is really, there's sort of a long version of the story. The shortest version for this moment, though, is that we were extraordinarily fortunate to have two things happen. One is advocates and supporters in the greater Misophonia advocacy community who really helped launch this work and frankly, and I'll be happy to tell a story about this deal in a few minutes if you like, but really getting me going in this research space. The second piece that's really just an extraordinary sort of catching lightning in a bottle is that we have a generous and anonymous family. that reached out to me by way of our advocacy supporters and wanted to know if we wanted to start a center. And they wish to remain anonymous, and so we honor that. But they've been extraordinary and essentially have provided the funding to launch this center at Duke. And that funding began a couple of years ago. So that's really formally where the center launches is when we have this family that comes to me and says, hey, you know, we'd like to help rapidly accelerate research.

Adeel [8:19]: That's very interesting. Okay. And I'm assuming this family, this anonymous family, there was a misophonic person in that family. It wasn't just a random interest, I would imagine.

Zach [8:29]: Right, right, right. Exactly. As is the case often with philanthropy. There was a personal interest in the family in moving the needle forward in misophonia research, misophonia knowledge and advocacy. And yeah, just incredibly lucky and feel very, very grateful to this group.

Adeel [8:53]: That's fantastic. So, yeah, maybe how was that connection made? Tell us that story of advocacy, because that is another piece I think we all want to be inspired by, what has been working for advocacy.

Zach [9:05]: Yeah, it's so important. It is so fundamentally important in the world of Misophonia to have advocacy and to build advocacy and to partner with allies and advocates and to partner with people who have the ability to not only raise awareness, but also to provide, if they can, to provide funding. Research on misophonia is very difficult to do without having funding. And the most important questions, the questions that most people listening to this podcast probably want answers to, really require a lot of funding and time So having advocacy and having philanthropic advocates to support the work that's done, I actually think it's essential. I mean, it really is essential. So in my case, Adeel, in my case, there's a woman who you, I don't know if you've interviewed yet in your series, named Dr. Jennifer Braut.

Adeel [10:10]: No, yeah, but her name's well known. I'd love to have her at some point, yeah.

Zach [10:14]: And Jennifer is someone who approached me in the mid-2000s. And she knew of my work in emotion and borderline personality disorder. And she knew that borderline personality disorder was being characterized, again, as a problem that... in some ways, looks like misophonia. In key ways, it does not look like misophonia and is not misophonia. But in some ways, there was a little bit of overlap, in particular with this feature of highly sensitive, highly reactive to certain types of cues. So she approached me and asked me if I was interested in doing any kind of research on this. And the kind of the funny story here is that when she approached me, she didn't tell me that she had any funding to offer. She didn't tell me she had a family foundation. just reached out and said, hey, I'm a psychologist. I'm a mother. I have misophonia. I have children that do. Would you like to meet to talk about doing research on the relationship between emotion and sounds? And for a young academic researcher that I was at the time, this wasn't exactly an email that I was immediately responsive to. It's not uncommon to get emails from people from all over the world asking to talk or meet about all sorts of things. So I didn't really put it at the front of the queue of things to do. And eventually I started getting sort of feeling guilty about that and feeling anxious about that and kind of just being my neurotic self about those kinds of things. And I reached back out to her. And so we got on the phone and we talked. And it turned out that she not only was a mother of someone with misophonia and not only was someone who had misophonia, but she was actually just quite brilliant. Just a brilliant woman who was able to make connections that I hadn't quite made yet at that point between emotion, emotion regulation and sounds and sound processing. And so I was really intrigued. And we drew up a number of different studies together. And at the end, I said, well, this has been great. It's been fun talking. We've thought of a number of different research studies to do. This is great. But unfortunately, it's going to take grant writing. And we may get rejected. And it may take years to get the funding and so on. So we may or may not ever be able to do this work. At which point, she said, oh, I should have mentioned to you. I have a family foundation and would like to fund you. I can make it rain with some money. Right. Exactly. So that was a humbling moment and a really critical moment in my career. And really that was a moment where that's really the fundamental thing that started progression towards what would become the Duke Center for Misophonia and Emotion Regulation without Jennifer Brout. there would not be a center because she really got me started with this work many years ago. And over time, even when she wasn't able to provide funding from her family foundation, she became a colleague and an advocate and a friend and someone who, over time, would continue to be supportive in ways she could be, including helping to direct philanthropic interests in Misophonia over to me for discussions about what kind of work we could do at Duke. So that's kind of a long explanation of how this got started. It didn't start overnight. It actually took many years to get started. And I give Jennifer Brout a lot of the credit for getting it started.

Adeel [14:25]: Yeah, that's really interesting. Thanks for giving that context because, you know, I think both your names come up a lot in in the in the history. So it's it's really interesting. I didn't realize that there was that that that kind of story. I wasn't sure how you know how closely you guys work together, whether she was part of the your center or not, or how that worked. And it's also inspiring to know that that people are willing to anonymously fund this research that's going to help a lot of people. in the future. Another question I was going to ask you is, you know, earlier you were saying that you were noticing, you know, sound processing behaviors that kind of look like misophonia. I'm curious, was there like a light bulb for you that made you realize that this is something different? Like, I'm curious what in your mind made misophonia unique compared to what you were observing in other conditions?

Zach [15:23]: Yeah, good question. Well, you know, Adeel, the kind of problems we were studying mostly were different than misophonia. So the only place I really saw direct overlap was with respect to emotions and kind of emotional reactivity and difficulties regulating emotions. Misophonia is, it became pretty clear as we started

Adeel [15:51]: understanding more scientifically and and working more with patients clinically that this is completely a different entity than borderline personality disorder and then again there's a little bit of overlap but they're not they're not okay so people with borderline personality disorder they had there was like a giant umbrella of symptoms and this this just happened to be something that was part of it the the sound processing thing but um

Zach [16:16]: Yeah, yeah, exactly, exactly. And I think, you know, my thinking has been that as sensory processing problems emerge in childhood and through teen years and into adult years, a lot of times what can happen is that difficulties regulating emotions follow, right? Because it's natural to have emotional arousal and to have difficulties with kind of figuring out how to cope and what do I do with those emotions, whether you're a kid or a teen or an adult. And so then what you can kind of easily see can happen next is that what starts maybe as a sensory processing problem becomes a sensory processing and emotion regulation problem. And then the nature of that emotion regulation problem can be very different in different people. And so some people might end up, for various reasons, developing problems with coping with emotions when triggered. That can take them down a path of dysfunctional kinds of behaviors that could look like borderline personality disorder or could look like other psychiatric disorders. So if you kind of think about developmentally what's the trajectory, what could happen, it could be that some people are being diagnosed with psychiatric disorders, but really the psychiatric disorder has emerged secondary to difficulties responding to sensory cues and the kind of emotional stuff that happens with that over time evolves into a pattern of symptoms that just so happens to look like a psychiatric disorder.

Adeel [18:09]: Yeah, that's interesting because during a number of interviews I've had, there's almost always been some comorbidity with something else. Anxiety, OCD, bipolar. I haven't seen borderline personality as much, but there's always something that gets the misophonia symptoms kind of get thrown into that. Like there isn't like a independent diagnosis these days yet. Hopefully that'll change. for misophonia.

Zach [18:40]: Yeah, no, that's right. Our group just published a paper showing a relationship between a borderline personality disorder and other disorders with misophonia, very small kind of preliminary study. And there are a few other papers that have kind of pointed towards personality disorders being one of the co-occurring conditions. Not all personality disorders, probably just more likely to be a few of them. But I think you're raising a really important point, which I think is useful for us to talk about for a second. A lot of times people ask me in my role, parents, people with misophonia, they'll ask me, you know, is misophonia really just a particular disorder? You know, is it really, is this just OCD? Is this just a panic disorder? Is this just like PTSD? Is this borderline personality disorder? I get asked that question a fair amount. And I just, I think I'd like to say that What we think right now scientifically is that misophonia does not look like it specifically and uniquely is associated with any specific one psychiatric disorder. So there's no reason coming from kind of a scientific basis at this moment in time to say that misophonia is really the same as any disorder. In other words, it's not OCD. It is not OCD. There is not scientific evidence. data to support that. There just isn't. In fact, there's scientific data to suggest the opposite of that, that it's not related to anyone, to OCD or to any one particular disorder. What it seems to be is correlated with a number of different psychiatric disorders, a number of different mental health problems, most typically mood disorders and anxiety disorders. And mood disorders and anxiety disorders are some of the most common presentations we see in the mental health world. So then that raises the question of, is misophonia its own thing, its own disorder? Is it separate from other disorders and really warrants its own? disorder name in the world of naming disorders? Is it something that is associated with a lot of other mental health problems because there's just a lot of other mental health problems? And maybe it's just associated with those things because those things have base rates. And so it's associated with those things because those things are there. So it raises a lot of interesting questions. But I think, again, just to be crystal clear, there isn't any reason to think misophonia is one, is related to only one specific mental health problem.

Adeel [21:49]: Right. And so would you, so another thing people ask, literally ask me is like, you know, after having talked to this many people, like how would you explain misophonia? Like if I have to explain it to my family member or my boss or whatever, What language should we use? Should we call it a disorder? Should we call it a syndrome? Should we call it something else? Processing issue? Is there something that you can recommend that people say? If it's in a moment that matters, like they're looking for accommodations or are desperate to get some kind of help, when there isn't something in the DSM-5 code, which I'd like to talk about later as well, what words would you recommend people use?

Zach [22:31]: Yeah, it's a good question. I think it partly depends on what the context is, what the need is for how they define it. People variously describe misophonia, even in the clinical world and the scientific world, amongst those of us who treat people and who do research on this. We have various terms for it, right? I mean, you could talk to, you know, 20 different so-called misophonia experts. And, you know, all 20 of us might have slightly different ways we define misophonia. And some might call it a disorder. Some might call it a condition. Some might call it a syndrome. And frankly, the logic behind differentiating those terms might just be like personal preference. You know, it's not as though there is a sort of scientific-based truth that differentiates those things that we've all discovered with Misophonia. We're just not there yet. We're just not there yet. I'm more likely to prefer calling it a condition or a syndrome than a disorder only because disorder is a term that is, you know, is used in kind of a nomenclature, you know, kind of a, there are psychiatric disorders, right? Mental health disorders.

Adeel [23:55]: It's a loaded term a little bit. Yeah.

Zach [23:57]: It's kind of a loaded term, and it refers to something that's been designated as a disorder. Now, that's my own kind of take. That's not the only way to do it. Adeel, one thing that might be helpful to share with your audience is that this challenge of naming misophonia and defining it is a significant impediment to the field. I mean, it really is a significant problem for patients, for people, for loved ones, for clinicians, for scientists. We don't have a consensus yet. We don't have scientific data to tell us exactly what it is and what it isn't perfectly. We're just not there. It's too new of a scientific field. And we don't yet have professional consensus. So this is really one of the primary problems that we all face, whoever we are as a stakeholder in this world. The problem is one that is partially being addressed. So let me share with you what's happening in this world. So you may have already heard this. Your listeners may have already heard this. But if not, this may be news to some, which is that the Misophonia Research Fund partnered with the Milken Institute for Strategic Inquiry has over the last year been working with a group of us, a multidisciplinary group of clinicians and scientists from around the world who have some expertise in misophonia. And they've been working with us to derive a consensus definition of misophonia. And we've used a very kind of formal process for reviewing the literature, reviewing definitions, voting on language to use or not use, sentence by sentence, word by word. And very excited to say that that work is near completion and will soon be submitted for publication. And likely when we submit it for publication, we'll probably do what's called a pre-print, which means we'll look to kind of put it forward facing to the public to see before it's even published yet, just to kind of put it out there for the world to see and to respond to. So this will be really exciting because this really will be the first time there will be a kind of, quote, consensus definition on what misophonia is. And I will give you just a little preview. We do call it a disorder. Wow. You heard it here first, guys.

Adeel [26:54]: It is going to be called a disorder.

Zach [26:57]: Yeah, we decided to label it a disorder. And, you know, there can be different opinions about that. And it's important to have different opinions. there is some benefit to labeling it as a disorder, even in a kind of consensus definition way. One of the benefits is that the term disorder for the lay community, it can be used in certain situations where it might be helpful for them in terms of getting accommodations or having, in a situation where they need to be taken seriously for misophonia, If the consensus definition calls it a disorder, there may be some real benefit to real people around the world that comes from this.

Adeel [27:49]: Yeah, that's a good thing. That's fascinating. And then, yeah, my next question was, I'm glad I asked about the naming of it. Please let me know when this goes to pre-print. That would be really interesting to get in front of people. My next question was also going to be just about what's next after that? Because I know the DSM-5 codes are a major, I think, something that comes up a lot. People want to have that. one of his funny included in these codes so that I think it's easier than to get treated and also have research funding for for a condition if it's actually recognized in this you know magical Bible of psychiatric codes is that is that maybe a potentially next step is that important or what do you think about that question

Zach [28:38]: Yeah, I have a lot of thoughts about that, Adeel. I mean, one of the thoughts is that it's very, very difficult and takes a long time and a lot of science, which means a lot of funding, a lot of money and time and science has to go in to justify in the eyes of those who are responsible for the next version of the DSM, which by the way, I think is 2026.

Adeel [29:09]: Yeah, I heard it's kind of like the census. It's not like every year, it's like every 10, 15, 20 years, something like that. So I'm like, oh.

Zach [29:18]: Yeah, it's not a common occurrence and it's extraordinarily difficult. The bar is very high. to to add a new a new term it really does require a body of research that's very compelling in differentiating misophonia from other disorders not because you know someone did a survey online and people said this or said that a facebook or tick tock quiz doesn't work i guess to get into the dsm right Right, right. I mean, those things are useful to get things started and self-report types of research where you survey people is important and it is a way to get things going and it's not as expensive as other things. But you really have to have... multiple studies from multiple different groups using really gold standard methods to determine that people who have misophonia are really different than those who have psychiatric disorders, other psychiatric disorders. Now, the challenge with that is huge because as we just talked about a minute ago, we don't even as of now have a consensus definition on what misophonia is. So if we don't know what it is, how are we going to have it be different than other conditions? Those of us who study and treat people with misophonia, we know what it is. We see it. We feel like we know what it is. But from a scientific perspective, to be in the DSM-5, there has to be a lot of research to show what it is and what it isn't and what happens with it over time. No one's done studies yet over time looking at misophonia. By the way, there's not even really good psychometrically validated measures of misophonia. So not only do we not know what it is at a consensus level, we don't have measures of it that have been rigorously, carefully tested Now, I'll add a caveat. There are a couple of measures that have more kind of scientific basis behind them than others, but it's still early. It's still new. And so if we don't know what it is and we don't have great measures yet of it, and we haven't really defined what it isn't yet, we don't really know what causes it. We don't know what happens over time with it. We don't have treatments yet that have been shown to change it. It makes it tough to build a scientific case to add this it to the next DSM. It will be very difficult to do. Now, not impossible. The only way to get that done is going to be through a significant amount of funding that comes from, I would argue, will need to come from a wide range of stakeholders and philanthropic stakeholders probably will be the ones to get that going because it's very difficult if not impossible, to write grants to the federal government about misophonia right now for all of the reasons I just said.

Adeel [32:49]: Great, yeah. So we need to find rich people who have misophonia and get them to write some checks and to further get the ball rolling, I guess.

Zach [32:59]: The Misophonia Research Foundation has been extraordinarily generous in giving out grant funding in the last couple of years. I am a scientific advisor on their board, and I just think the world of this organization and indebted to them, they've done just extraordinary work to push the needle forward in this world. And they are essentially coming from a family that launched this foundation as a way to push the field forward.

Adeel [33:34]: Why did they choose to do a fund specifically focused on misophonia? This wasn't the one from the, this is separate from the family, right? Yeah, okay.

Zach [33:46]: Yes, this is a different family, right? The family that has been generous to Duke is a different family than the family that launched the Misophonia Research Fund. They're two different families. But again, the... what's similar is that you have a personal interest in families that have the ability to give and the ability to really help move knowledge forward and discoveries forward and to plant seeds with researchers throughout the world to get them studying misophonia so that we can start having answers to all of the questions that people listening to this podcast want answers to. It takes families with means to really be generous to get these things started. And I know all of us in the Misophonia scientific community are extremely grateful to the Misophonia Research Fund for their generosity.

Adeel [34:39]: Okay, so yeah. So it sounds like we'll probably miss our 2026 deadline for DSM, but maybe we could talk about the actual science that you're doing. Do you wanna talk a little bit about what are some of these studies? What are you looking at? How are you conducting these studies? Just to give the layperson a little bit of insight into how you're studying misophonia.

Zach [35:04]: Yeah, yeah, happy to. So when we started with our funding a couple of years ago, we thought quite a bit about, you know, what would be the right place to start with doing research? And I should say, at Duke in our center, we're doing research, we're also doing clinical work, and we're also doing education. So we kind of do all three things. We do webinars quarterly, partnered with the International Misophonia Research Network through Dr. Brout and her team. And, you know, I provide trainings and my team provides trainings to clinicians when they ask it. I have clinicians from literally, you know, around the country and sometimes around the world who want to learn about what misophonia is. And I'm happy to spend time with them, talking to them and teaching them or educating them, problem solving with them, how they can adapt the treatments that they're doing. to be helpful for misophonia if they're new to misophonia. So we do a lot of work on education. And again, thanks to this family for providing the funding for me to have the time to do that. We also will educate the lay public. So time spent doing all sorts of different things that can kind of put us out there to communicate to the lay public about misophonia. That's part of our mission as well. And we're going to be starting to do some support and advocacy work as well this year. So we do a lot of work on that front. We also do work clinically with patients. We do evaluations and make treatment recommendations mostly because we don't yet have the kind of the funding to hire all of the clinicians and kind of person power that we would need to provide all of the treatment. But we hope to be able to do that in time. Most of what we do is research. Most of what we do is research. So on the research front, we started with the question of how can we best create resources for the world to use to advance work on misophonia? So that was kind of our organizing question. What can we do to sort of help everyone? And what we landed on was a study to develop a new measure of misophonia, which we call the Duke Misophonia Questionnaire, and is something that we've posted on our website in kind of pre-publication form for those who are interested in just seeing what it looks like, and is going to be submitted for publication as a manuscript soon. So first step was develop a measure. Very carefully, very rigorously, took us two years to do. And we started from the ground up by getting input from family members of those with misophonia and people with misophonia to tell us what they thought the question should be in the questionnaire. Rather than so-called experts like me and others deciding what the question should be, we went to the grassroots. We went to the community and said, you tell us. And then we went to the existing measures in the world, all of the different measures that have been made so far, and we went to experts. And we came up with a list of several hundred questions that would address what it is, how severe it is, how impaired someone is with misophonia, what kinds of thoughts they have about themselves, others, and their future because of misophonia, what kind of difficulties they have coping before, during, and after being triggered. And we created this questionnaire. And it went from several hundred items, statistically, after we administered it to many people. It went from that down to its final form, which is right around 70 items. So first step was make a measure and make it well. And we're really happy with what we did. The second step was make an interview measure because there's no existing kind of... validated interview measure of what misophonia is and clinic we think clinicians need a tool to interview people and we think scientists need a tool to reliably interview people to to be able to to assess severity of misophonia so we're doing a study right now where we're developing the duke misophonia interview which would be again for clinicians and for for researchers around the world to use when it's when it's validated So first two steps, build a measure, build an interview, validate those two things, and let's get them out to the world for people to use. The next step was we decided to try to validate a library of sounds that could be used by researchers around the world to study misophonia. And, you know, this is one of these things that sort of, you know.

Adeel [40:12]: It sounds a little bit scary. It sounds like a library of trigger sounds. I don't want to go near, but please continue.

Zach [40:22]: Yeah, well, it kind of, you know, it is that. If you want to discover insights about misophonia, you have to study what happens when people with misophonia are triggered. And you have to figure out, you know, if you want to know what's happening inside the brain and inside the body when someone's triggered, you have to kind of study that. And so you have to have sounds. And so if you look in the research literature, you see some really interesting, great work that's been done these last couple of years in the neuroscience area of studying misophonia. Dr. Sukhbinder Kumar, for example, a colleague who's done just really extraordinary work to begin identifying and characterizing the kind of underlying neural areas of functioning that are correlated with misophonia. Well, how do you do that work? You have to have sound cues that you can use with people and if if we fast forward to a future where there's a lot of research going on about misophonia there's a lot of researchers studying misophonia then there's going to be a lot of sounds being used to study misophonia so our thinking was wouldn't it be great if if there was a standardized validated library of sounds so that there's some consistency in the research so that we can make some conclusions a little bit faster. You know, I don't want to wait 20 years to have conclusions. I don't want to wait 30 years. I want to figure things out now and as soon as possible. So building this library of sounds and validating them is something we're doing currently. And, you know, it's not the, in some ways, it's not the most fascinating research to talk about, but it's, again, one of these sort of building blocks, we think, could be helpful for others. I think it's actually very interesting.

Adeel [42:18]: How large do you plan this library to be? The only thing that came to mind is coming from being a software engineer, I know that there were huge strides in deep learning when there were actual, a standard set of images to be able to train neural networks to do image recognition. So the idea of having a library of sounds, if it's large enough and encompassing enough, I think that's very interesting. It could be used for research, but also maybe training noise-canceling earbuds to like in real time filter stuff out. So yeah, I think that's very interesting what you guys are doing.

Zach [42:55]: That's exactly right. There's all sorts of things that could be done if we had a nice, robust, scientifically validated library of sounds that people could use and then consistently use to kind of see what the features are and how they're associated with misophonia and maybe, you know, over time, how people and treatment change in their responses to these sounds can be, you know, sort of a validated endpoint that's an objective measure. That would be a great thing because self-report symptoms is, it only takes you so far kind of scientifically. It's in some ways really helpful to have more objective ways of measuring things. So the other thing we're doing that's really been the... Kind of the principal thing we've been studying for the last two years has been what we call our phenotyping study. And phenotyping is just a fancy word for trying to understand what misophonia is. So looking at its features, its correlates, trying to gain insights into things like which psychiatric disorders and which medical presentations are associated with misophonia and which ones aren't. trying to gain insights into what particular problems with emotions seem to be most relevant for misophonia. We've collected data on over 200 people, and we've got a lot of data at this point. And we're going to begin soon looking at these data to start writing up some manuscripts to kind of inform the field about what does... What really are the correlates? What really are the features when you look at these things in a pretty darn rigorous, scientifically speaking, a rigorous way? So that phenotyping study is really key. The other research we're doing, Adeel, is we're doing something where we look over time for several weeks in another study at the experience of people with misophonia throughout the day, every day. So this type of study is what we call a prospective study where you look not at one time point and ask people questions, but you look at many time points over time. And what's nice about that is that statistically that allows us to draw some conclusions about what the patterns of people with misophonia really are. So when triggered, which emotions really do occur and maybe in which sequence and what happens next and next and next within people and across people.

Adeel [45:29]: within one day within multiple days with over weeks and this type of study has never been never been done before so this will be a really interesting we're excited to see what we get with that actually yeah i was going to say i mean the having a library of sounds i mean you can do all kinds of frequency analysis or whatever to to get an objective look but i was thinking of you know, thinking to people who say that, you know, this person triggers me, but this person doesn't with the same sounds or obviously different times of day and different stress levels. But there's also, there are other factors which sounds like have not been studied at all. Like my, you know, my kids don't trigger me, but other people will trigger me with the same sounds. That is a whole other dimension that I have no idea how to explain, but I'm sure that you guys are thinking about.

Zach [46:14]: That's right. Yeah, that's exactly right. There's just a lot of unknown things about misophonia. And so we're doing all these studies. The other studies we're doing, we're doing a couple of other studies where we have a... scientist in our group, Dr. Andrada Nekshu, who has funding from the Misophonia Research Fund to do neuroimaging and to do what's called neurostimulation with misophonia. So she's doing a study to try to find the circuits in the brain that are really responsible for what happens when people are triggered by cues. And what's really amazing about this study is that she's comparing this to people who don't have misophonia, but who are highly emotionally dysregulated people. And one of the big gaps in knowledge about misophonia is that we don't have studies that have compared misophonia to other people who also are emotionally aroused easily, triggered easily, but not to sounds and not to misophonic triggers.

Adeel [47:29]: Yeah, that would be really interesting to learn that.

Zach [47:31]: If you only compare misophonia to healthy controls. it doesn't really tell you what misophonia is compared to other kinds of things. It just tells you how people with misophonia are different than healthy people, which is important. But it doesn't really get at characterizing exactly what misophonia is relative to other kinds of things people struggle with. So you have to have those clinical controls. And my colleague, Dr. Nexhew, is doing that work. And so that will be really fascinating when that is done. The other studies we're doing are treatment studies. We have a couple of different psychotherapy treatment studies where we're using evidence-based cognitive behavioral therapies that have already been kind of developed and tested for other kinds of people, but never really tested with misophonia per se. And we're kind of taking what we think are probably pretty good pretty good treatment approaches that are likely to be helpful in the kind of psychotherapy part of what's helpful for mystophonia and testing that out.

Adeel [48:35]: So as you're doing education to clinicians, what are some of the, I guess, the leading, the methods that you kind of, knowing what you know, tell people works the best in dealing with it?

Zach [48:47]: Yeah. Well, we don't know what works the best. It's a good honest answer. We just don't know. And it's really important, I think, to be humble and honest and to not provide false hope to people. Whenever you have a significant problem that's really distressing, that a lot of people have and there's no kind of, you know, gold standard treatment. It's a recipe for problems from kind of a public health perspective. So I, you know, I do worry about... people who are feeling really desperate and may be led in different directions, probably by well-meaning, well-intentioned people, but might be led astray into kind of false hope and solutions that may not actually have any real rationale for being likely to work or just kind of...

Adeel [49:55]: Yeah, I mean, this is definitely something that I noticed. People are so desperate that they are... And this is not just misophonia, but they can do some research online and then it can end up in the hands of... Or in places where it's not necessarily super helpful, but they don't have the... There isn't as much... There just isn't any definite research to help guide them in one way or the other. And so... they can get some dubious, maybe dubious advice.

Zach [50:27]: I deal. I get emails from people not infrequently. who ask me direct opinions about various treatment types or treatment providers in kind of the misophonia world and have all sorts of negative stories to tell. I think it's a real challenge. It's a real challenge. My approach is to try to be humble, is to try to be honest, it's to be hopeful, but in a way that's realistic. There's no cure for misophonia. We don't have any scientific knowledge about exactly which treatments work. There's only a little bit of scientific research that's been done looking at any treatments. So what I tell people in a nutshell is this. I suggest a multidisciplinary approach where the first step is to get an evaluation and really to get multiple evaluations done by multiple different providers from different areas of expertise. I think of misophonia as a multidisciplinary problem that warrants a multidisciplinary solution. So I think of it as a problem we don't quite understand scientifically that isn't really owned by psychiatry or psychology or mental health. It isn't. It isn't completely owned by audiology or occupational therapy, and it certainly isn't owned by pediatrics or primary care, but it's somewhere in the intersection of all of those things, all of those disciplines, and arguably other disciplines, depending on the case presentation, right? Neurology, neuropsychology, music therapy, You know, there's different disciplines that have insights that the other disciplines just don't have. And I really look at it that way. I look at it from what I think is a sort of a professional humility stance that we don't have the answers. And I'm a clinical psychologist. So I think the way clinical psychologists do. And the audiologists think the way the audiologists do. And I think it's helpful to get evaluations from an audiologist, from a clinical psychologist, maybe from a psychiatrist if the person's wanting medications, from an occupational therapist. Because after all, the occupational therapists, they're the ones that are experts in sensory processing. Psychologists are not. Mental health people are not. That's not our area, right? Mental health people like psychologists, we can give input as it relates to attention, cognition, behavior, emotion, communication, right? We have a lot to offer, but we don't have everything to offer. The OTs, the occupational therapists, they can really provide expertise around sensory processing and how to quantify the problems with sensory processing, as well as what to do about it. And they can look across all sensory processes, not just sound, not just hearing. And of course, the audiologists are the experts in hearing and sound. And so they can be invaluable from a multidisciplinary perspective in assessment and measurement, in helping the patient understand what's going on with hearing processes, and also in providing interventions that might be helpful from an audiological perspective. So I look at it a deal as the approach to give is multidisciplinary wherever possible. and that each different discipline potentially has something to offer the individual. Now, it's easier said than done, but that's the aspirational approach that I try to educate people to strive for.

Adeel [54:57]: Yeah, no, that makes sense. Yeah, at this point, it's good to be humble and healthily skeptical and try to be as evidence-based as possible.

Zach [55:05]: There's too much nonsense out there. There's too much baloney, right? And there's too many... things in the world, and you've probably had them on your show before, where people say things in a very cavalier way, as though it's true about misophilia, when it in fact hasn't yet been shown scientifically to be true. It's just their opinion, or it's something they heard, or something they wish was true. And I, you know, I'm sure I've been guilty of that at times as well. I'm not, you know, I'm I'm human and I'm imperfect too, but I think it's something to strive for is to try to be honest and try to be hopeful.

Adeel [55:45]: Yeah, I try to, in this show at least, I try to keep that fine line between trying to be as open as possible because I'm mainly hearing about the experience of sufferers and then the therapies that they're seeing and just trying to be as... open and uh empathetic as possible but also you know obviously have uh always have the disclaimer as uh we really don't know much about this and i try to remind people of that and uh you know be as skeptical as be skeptical but uh be informed and uh get get as many opinions as possible um Maybe a few, a couple of just rapid fire questions before I want to hear just kind of your thoughts on what you'd like to see on the horizon. But like autism, a lot of people ask about that. Do you see any jury out or any link between misophony and autism? Just to get that question out of the way.

Zach [56:38]: Yeah, I would. I see a correlation, but I see it. to be not the same thing. So portions of what we see in autism, some of the components of autism probably do correlate with some of what we see in misophonia. One of our studies, we're asking that question. And we are seeing some kind of significant correlations, but significant statistical correlations at a level that suggests that they're similar, but they're also quite different.

Adeel [57:07]: And then the debate of, you know, nurture versus nature, like, is this, you know, we'll have people come on and then they're like, you know, I know my dad had it or my mom had it. And then unless people think, is this genetic? Is this inherited? I try to say, well, and again, I always put this disclaimer. I feel like there might be some component that is brought in, but then it gets maybe activated by certain things that happen around that pubic pubescent age. But I'll shut up and just ask you, what do you think about the genetic versus kind of environmental nature of this?

Zach [57:48]: Yeah, it's a common question, isn't it? Most things are genetic in part, right? So the way I think about it is twofold. One, there's no data to answer the question yet. So again, like a lot of things with misophonia, we don't know scientifically. So now let's just think what seems reasonable? What can we guess? What would be a hypothesis? Most likely, there's a genetic underpinning as there is in most things. But the amount of genetic underpinning for most things in the kind of behavioral world, in my world, in the world of psychology or behavior or mental health, the amount of genetic underpinning, in other words, the amount of the problem that you can say is caused specifically by genes is usually pretty underwhelming. I mean, it's generally the case that most behavioral health-related problems have some genetic underpinning, but much less than the environmental underpinning, much less than the environmental kind of explanation. Now, the other thing to think about, though, is that the question of nature versus nurture itself, just the way to frame that question, drives a lot of the answer to the question. So if you think about the question as an either or, that's going to lead you to sort of do what I just said. Well, maybe it's more this, maybe it's more that. But if you frame the question as to what extent is it both and how do both impact each other? Now you're likely to get somewhere. And I think that's the real question to ask. In other words, the real question to ask isn't, is it nature or is it nurture? Or what percent genes is it? Or what percent family environment is it? I don't think that's the most important question. I think the more important question is how, how, does nature impact nurture, and how does nurture impact nature? In other words, how does our environment that we're in impact our biology? And how does our biology impact our environment? And you can picture this almost like a tennis match, back and forth, where on the one end of the court you have biology, and the other end of the court you have the environment. And the two just kind of go back and forth, impacting each other. where the world around us presses the buttons on our underlying genetic vulnerabilities. The genetic vulnerabilities may be there, but the world around us presses the buttons to activate what's there. And then that impacts how we behave and how we live and what we do, which of course then impacts the world around us, which then of course transacts and it's just a tennis match going back and forth. It then impacts our biology, which of course then impacts our environment, which impacts our biology and our environment. And we're just doing a tennis match back and forth here. So this idea of a transactional environment back and forth where nature and nurture are constantly at interplay with each other, impacting each other, I actually think that's the smarter way to think about it.

Adeel [61:12]: Yeah, that makes a lot of sense to me. And that's kind of what I kind of tell people is it feels like there's maybe some... um i don't know if maybe this takes it a step further maybe there's some like ancient lizard uh kind of genetic kind of skill back that was useful back in the olden olden days millions of years ago where uh to detect uh danger uh where you know sensitivity to sound was uh was important and that's some relic of that has has um made us made some of us more vulnerable to an environmental um uh factor that makes it super sensitive to sound i'm totally um speculating there but i but ultimately i do i do like that analogy of this ping pong between environmental and nature i think that that makes sense to me in in the absence of like heart truth on it yeah and and there's you know there's some early research that's been done suggesting that there are parts of the brain that seem to be responding differently in people with misophonia

Zach [62:13]: compared to people without misophonia to misophonic trigger cues and that's important right that's that's really important validation that there is there is something happening here that's real it's not you know it's not just something that people are talking about that's some new phenomenon it's it's it's something that people are talking about that's reflecting what's happening inside their bodies. That's real. It's very, very real. And there's even some work that is beginning to be done that you may see in the near future that is kind of challenging the question of, is it sound processing that's the problem? that people with misophonia are being alerted because of the sound, per se, in terms of thinking about what parts of the brain are responsible. And that's really interesting. Because at first blush, you might think, well, gosh, it must be that people with misophonia have things happening in their brains in the auditory processing centers that are responsible for how they're reacting. But the data that are coming in in these different studies are really intriguing, and they're pointing to really a more broad network of circuits that might be responsible. It's not probably just as simple as circuits responsible for hearing are messed up. It doesn't look like it's that simple. In fact, one of the really interesting things to think about is it might be that there's something visual that's important here. Because people with misophonia also, it isn't just hearing a sound, but it's also seeing the production of the trigger that can

Adeel [63:59]: Oh, we're very well aware of that.

Zach [64:01]: Yeah, I mean, this is really common and even in the absence of the sound itself. So that tells you there's something other than just sound that's happening here.

Adeel [64:10]: Yeah, fascinating. So there is research being done on, so mesokinesia is the term that we've been using for visual triggers. Is that correct? Is that kind of what term do you use for those kinds of visual triggers?

Zach [64:24]: Yeah, the misokinesia is a term that's used to describe the over-responsivity to visual cues in the absence of sound or other sensory cues. And some people will report that that is really different from their misophonia-related triggers and kind of experience. But some people with misophonia will, many people with misophonia will say that they respond to the same trigger cue whether the sound is being made or not. And that's a different, it's similar, but it's a different kind of thing than, you know, misokinesia per se. So, you know, you think of misokinesia, you think of the leg movement. tapping or the knee moving. And there's not really ever a sound associated with that, but it can be aversive and trigger a response. That is in some ways similar, but in some ways different from someone who, let's say, has a trigger sound to people eating. And they can see someone eating, but they can't hear them. They see the mouth moving and they see the, you remember most of the time for most people, not always, but most of the time, misophonic trigger cues are oral or nasal. So most people with misophonia have my author. So why is that? I mean, it's interesting to think about, is there something about the way we attend to people's faces? Is there something about how we're hardwired to look at people's faces? and how our brains respond when we see faces that might be a part of the story underlying what's going on in the brain of people with misophonia.

Adeel [66:22]: That's interesting. Yeah. Cause I mean, you know, we're always told that body language is so important, is an important form of communication. Is there something, and obviously the face is important, is the most important part of that body language. Maybe there is something, yeah, that's not primarily audio. That's right. That's, uh, that's happening. I never thought about that. That's really interesting. Anyone studying that?

Zach [66:43]: Yes. Yeah. There, there's a couple of groups that are studying that. And, um, again, Dr. Kumar, Dr. Sukhbinder Kumar, uh, and his group, uh, really leading the way in kind of thinking about these kinds of things. So stay tuned for more from his group.

Adeel [66:59]: All right, Dr. K, I'm going to call him Dr. K, whether he likes it or not, but that's, yeah, he's definitely a rock star in this community. Yeah, I would love to, maybe as we close it out, I'd love to hear on that note, like you guys are doing some really exciting stuff. Dr. Kumar's group is doing exciting stuff. Do you want to give a shout out to other groups out there who you think are doing interesting work or, and then maybe just kind of like stuff that is not, maybe not being worked on that you'd like to see happen?

Zach [67:29]: Yeah, I mean, there's a number of people now that are starting to do work in misophonia, and then there's people who have been doing work on misophonia for a long time and maybe just aren't doing as visible scientific work as some of the other groups. So, you know, you think about, and I know you've had some of these people on your show before, but you think about some of the clinicians, Dr. Jastrowoff, Dr. Johnson, you know, these folks have been doing work for decades in what we are now studying as Misophonia. And they really deserve all the credit in the world for getting this work going in the first place, even if they're not actively doing as much research right now on this. So we all owe them. Everyone owes them just a huge debt of gratitude for their work to get all of this work moving in all of the directions it's going. More recently, there are a couple of, I think a really couple of interesting things happening scientifically and clinically. And in two different places, two different groups of researchers are doing something that I think is very similar. And I don't even know if they know each other yet. I may need to introduce them because I know them both, but I don't know if they know each other yet. And that is the Amsterdam group, which you probably know has led the world in research on misophonia since 2013. And then there's a group led by Nick Davidenko at UC Santa Cruz. And Dr. Davidenko's work is really more kind of coming from a neuroscience perspective. The Amsterdam group's work is coming from, broadly speaking, a clinical team that treats misophonia. They have treated arguably more people with misophonia in the world than anywhere else. Maybe save Dr. Jastuboff or Dr. Johnson, maybe, with the exception of them. And here's the thread that connects them. One of the things that the Amsterdam group does in their treatment for misophonia, which is a treatment that they are studying and they have published on, though it's still early, it is a group therapy. And it's a relatively brief group therapy that takes three hours per week over the course of a couple months. It has a number of components, but I'll just cut to the chase. One of the things they're doing in it is they are using counter conditioning methods. They have patients self-produce videos, short videos, where they have their trigger sound that is played with a visually incongruent stimulus. And they kind of make these short videos where they, for example, show the easiest way to visualize this The easiest way to visualize this is imagine on your computer monitor, you have a black screen with schematic footsteps stepping one at a time. Like you see just visual of a shoe stepping down. And each time there's a step, you hear the sound of leaves crunching. And so that sound might sound something like... That. Right. And it's a sound of leaves crunching because you see the feet stepping. And each time the foot steps, or maybe it's gravel. Maybe it's someone walking on gravel. But actually, it's not. It's the person's trigger. In that example, it would be the person's sniffling trigger. So the sniffle is the stimulus, but because the visual is feet stepping, the brain registers it not as sniffling. It sees the context of feet stepping and hears the sound and registers it as a sound associated with feet stepping. So this is something that they do with their treatment. The other thing they do is they have people record their triggers and create visually incongruent stimuli that are pleasant, that are positive. So when I went over there to Amsterdam a couple of years ago, I met with them and they showed me this. And it's fascinating what they're doing. What they showed me was a video of a mother with a baby and the baby is being held and the mother tears a sheet of paper. in front of the baby and the baby busts into laughing, just busts a gut laughing. And of course, we're hardwired to kind of laugh and smile when babies laugh and smile. If you think of a baby smiling, it's kind of hard not to smile. If you imagine hearing a baby laughing and giggling, it's hard not to feel good. It's just how we're built, right? But of course, the paper tearing isn't a paper tearing. That's the sound of... In this example, it was also the sound of sniffling. So you see a paper tearing, you hear a paper tearing, but it's actually not paper tearing, it's sniffling. So the idea behind the Amsterdam Group's intervention here, which again is part of a group therapy, it's a cognitive behavioral therapy, and they have multiple parts to it. This is just one part. But the idea there is to try to train the brain to respond differently to trigger sounds by pairing it with different kinds of visual cues so that the sound itself, those acoustic properties don't always trigger the same response because they are trained to be associated with a range of different brain responses. It's really fascinating. It's a really fascinating way of thinking about how to help people with misophonia. Now, over to UC Santa Cruz, Dr. Davidenko's group is studying this in a more experimental way, in a lab setting. And Dr. Davidenko's group is creating a library of videos like this. They are in the midst of creating this. And they are creating a library and validating a library of cues that essentially are misophonic trigger sounds that are common, but presented in a visual way where the visual makes you think it's not a trigger sound.

Adeel [74:12]: Gotcha. Interesting. Okay. Huh. Yeah, they should definitely, it sounds like they should put their heads together and see where this goes. It's very interesting. Because this kind of like brings together the ideas we talked about in terms of, well, visual and sound, but also the idea of body language and maybe this is not a purely auditory processing issue. Yeah, that's really interesting.

Zach [74:35]: cool um yeah any other yeah any other groups that are doing interesting things that that uh or that you're curious or or that are not yet and that you'd like to see uh well there's a number of groups now again the misophonia research fund has provided funding to a number of groups now across a couple of years of funding so now you know there's there's a number of people there's there's probably too many right now to mention which is a really really good thing i mean I've talked a lot in this podcast about the challenges and the problems to solve and the things to be careful about. But I want to really emphasize that this is a hopeful time for the science of misophonia. This is a really hopeful time because we do have stakeholders in the form of the Misophonia Research Fund, in the form of other funding entities, in the form of the first of the kind of major philanthropic families to begin giving. This is an exciting time. If you look back to 10 years ago, none of that was there, but Misophonia was there. So really an exciting time. And I think there's a lot of research that's being done. And one thing that's nice is that you know, to develop a treatment and kind of validate a treatment as working can take decades. I mean, it's sad, but true. It can take decades to do that for any particular treatment. So rather than start with a brand new treatment and wait, you know, 10, 20 years, Those of us who are doing treatment research are beginning to kind of appropriate existing treatments that we think are reasonable as starting points. And you're starting to see some of that research, not just in our group, but in other groups as well. So I think there's a lot to be hopeful for on the treatment front, on the neuroscience front, on the building of new measures. There's a lot to be hopeful for, but boy, there really needs to be a lot more funding and a lot more, really just a lot more funding and a lot more scientific effort that's done around the world to really tackle the problems of misophonia. We have to figure out what it is and what it isn't. We have to figure out what causes it. We have to figure out what happens over time with people with misophonia. We have to figure out how prevalent it is. We don't know how prevalent it is. We don't know.

Adeel [77:04]: Right, there's a bunch of guesses, but yeah, we don't know.

Zach [77:05]: Yeah, I mean, we did a study in our group where we surveyed people kind of nationally, just a random sampling nationally, and we found that 12% of people indicated they had moderate or higher severity of misophonia using the misophonia questionnaire as a kind of a tool. We don't know if that's true. You know, we don't know if that's sort of the, you know, the final percentage. That seems like a lot of people, 12%. If you look at the 23andMe data, which I'm sure you're familiar with, you can see in their data set with 100,000 or so people that they get close to 20% of people indicate having rage or irritation in response to chewing sounds. But is that the prevalence? It's hard to imagine that that's the prevalence. That seems pretty high. But it's easy to imagine that there's a lot of people that have various levels of symptoms of misophonia. So anyway, we've got to figure out how prevalent it is. We've got to figure out what happens over time. We have to figure out what causes it. We have to understand why in the world this is so, it presents so commonly with family members being primary triggers. Why is that? We have to figure that out. We have to figure out ways for families that are vulnerable for this occurring to do things that will prevent misophonia from developing. We, of course, have to figure out treatments. There's many, many, many things that need to be done. All of them take time. All of them cost a lot of money. But there's a lot of hope now, again, if you just take a step back and you think compared to five years ago or 10 years ago. there is a lot more activity and there's a lot more knowledge. And I think there's a lot of reason to be hopeful.

Adeel [78:58]: Yeah, well, let's end on that note, on an optimistic note. And I want to make sure, yeah, to say, Dr. Zillow, thank you for everything you've done, starting the group at Duke, all the advocacy you've done, connecting people. You're a big reason why this is an exciting time. So I just want to thank you on behalf of the community.

Zach [79:19]: It's my pleasure. It's something that matters quite a bit to me. It's in my household as well. So I know about it and live with it.

Adeel [79:28]: Oh, do you have family members that have misophonia? I didn't know that. I guess I should have asked that up front.

Zach [79:32]: I do. I do. Yeah. It's interesting because when my wife and I got married in 1999... she had always had a kind of sensitivity to sounds, but there wasn't a name for it, right? There wasn't, misophonia wasn't a thing in 1999. And... So we just kind of, you know, she's sensitive. She's sensitive. And, you know, not significantly impaired. She has a PhD and is a cell and molecular biologist and very successful in her career and a super mom to our boys. You know, she's kind of a does everything, does it all, and does it all well. She's one of those moms that other moms probably don't like because she kind of does absolutely everything and does it well. But she does have misophonia and she's very open to me talking about it. I've talked about it before publicly. It's one of the main reasons I got involved in this work is because I understand it from a loved one, from a partner perspective. And it's severe enough that I know what it looks like in the home to have to have kind of accommodations to manage it, to deal with all of the things that come with it, to raise kids in that context. It's something I've lived with now for decades. a long time. We've been together since the mid 90s. So a long time. So yeah, I understand it from that perspective, personally. And so that's a big part of what drives me is to really try to help with that motivation in mind.

Adeel [81:14]: Yeah, no, thank you for that context. That's really interesting. I didn't know that. Yeah, well, yeah, thanks again. Thanks again, Zach. It's been great to have you here. My pleasure, Adeel.

Zach [81:24]: Anytime, anytime. Happy to share anytime.

Adeel [81:29]: Incredible conversation. Thank you, Zach. Remember, you can find more information about the Duke Center at misophonia.duke.edu. If you liked this episode, please leave a quick review or just hit the five stars wherever you listen to this podcast. Find us on social media at Misophonia Podcast on Instagram and Facebook and now on TikTok or Misophonia Show on Twitter. You can find all the links on the website misophoniapodcast.com and even send me a message from there. Music as always is by Moby and until next week, wishing you peace and quiet.