Misophonia, Autism, PDA, and the Physiology of Sensory Boundaries

Misophonia isn’t just “not liking sounds.” It is disgust. It is rage. It is panic.

That gut-deep reaction when someone chews too close, breathes your air, or invades your sensory space without realizing how violated your body feels. It is not a preference issue. It is a boundary issue, especially for autistic individuals or those with PDA, also known as Pathological Demand Avoidance. The reaction is not fear. It is a survival reflex.

It is also not psychological at first. It becomes psychological when the world refuses to accommodate it. When it is treated like bad behavior, defiance, or oversensitivity. That is when trauma takes root. That is when coping turns into meltdowns, shutdowns, or dissociation.

Autism, PDA, and misophonia often appear together as a kind of sensory and emotional Trinity. Each amplifies the other. Autism heightens sensory sensitivity, PDA intensifies the need for control and autonomy, and misophonia focuses the distress on specific auditory intrusions. Together, they create a perfect storm—one that is often misunderstood and mislabeled as defiance or emotional instability.

A lot of what drives these responses is the unpredictability of the environment. People with this profile are often in a constant state of alert, because they never know when a trigger might come. That unpredictability feels unsafe. They develop a desperate need to control their surroundings, not because they are controlling by nature, but because they are trying to protect themselves from being shocked, invaded, or overwhelmed by sudden sounds that hurt them.

I once worked with a boy who had such severe misophonia that if a classmate sniffed near him, he would lash out. The school did not know what to do. So they placed him alone in the hallway. Every day. For over a year.

No friends. No safety. No relief.

Over time, it got worse. He began to hallucinate the sniffing sounds, even when no one was there. His nervous system was so overwhelmed it could no longer tell the difference between a memory and reality.

I had to refer him to psychiatry. He needed anxiety medication, trauma counseling, and long-term support. Not because he was broken, but because a system had punished him instead of protecting him.

I will always believe that if he had been supported earlier, if he had been given tools, options, and understanding, so much of that suffering could have been prevented.

Here is what people often miss.

The only time individuals with misophonia can truly relax in quiet is when they are completely free of triggers. Not just fewer. None. And when they are not given control over their environment, those triggers do not stay the same. They become more intrusive over time. The nervous system becomes more sensitive, not less, especially when pushed past its limits without support.

These triggers are not always loud or obviously disturbing. They are often subtle, repetitive, and socially acceptable sounds that most people tune out.

Sniffing

Chewing

Throat clearing

Pen clicking

Lip smacking

Foot tapping

Breathing through the nose

Keyboard clacking

Gum popping

Clock ticking

It is not about volume. It is about proximity, predictability, and consent.

Imagine trying to focus or feel safe while someone is quietly chewing next to you, and your body reacts as if you are under attack. Now imagine being told to just sit through it, day after day, with no escape and no tools.

This is what people with misophonia live with.

And while individuals with auditory processing disorder often struggle to hear in noisy environments, people with misophonia are often most distressed in silence. In noise, they can use the background sound to mask the trigger. In silence, every little sound slices through without protection.

For many autistic individuals and those with PDA, this sensory overload is compounded by a lack of trust that the environment will ever adapt to their needs. The more they are forced to endure, the more their nervous system prepares for the next attack. Misophonia, autism, and PDA do not just coexist—they interact in a way that profoundly affects emotional regulation, behavior, and resilience.

That is why I approach things differently in my clinic.

I fit low-gain hearing aids with minimal gain and strong frequency compression, especially in quiet environments. I provide access to Bluetooth and pink noise. I encourage layering earplugs with noise-canceling headphones. I use Roger and FM systems so the person can choose what to hear and what to filter out.

Sometimes the ears are too overstimulated to be usable at all, and that is okay. We switch to visual supports, like captions, transcription apps, or American Sign Language.

In fact, I often suggest transliteration or interpreting as ideal careers for individuals with misophonia. These roles provide structure, focus, and a sense of control over what they hear.

It gives them something else to focus on—something purposeful and engaging, rather than scanning the environment for threats. Instead of bracing for the next trigger, they are actively attending to a voice or a message. They have to stay tuned in, because if they lose focus, they fall behind. That external demand for attention becomes a kind of internal relief. Their brain has a job to do, and it helps quiet the hyper-vigilance.

This redirection of attention can be deeply regulating. It shifts the nervous system from defensiveness into flow.

I am not saying people need to come to me.

This is not a pitch. It is not about building a caseload. It is about letting people know that there is another option.

I have seen what happens when someone with misophonia is finally allowed to feel safe. With the right tools, the right supports, and the freedom to listen or not listen on their own terms, their nervous system begins to settle. Their body stops bracing. There is a kind of softening that looks very much like a vagal reset.

One expert in the Safe and Sound Protocol told me that using the hearing aids seemed to open up the mind, creating enough space and clarity to allow other types of training—like filtered music—to start working. It was not that the hearing aids replaced anything. They unlocked access to the kind of regulation and engagement that makes deeper work possible.

That is what safety does.

When someone knows they will not be thrown into pain, they can begin to take risks. They can try. They can grow. They can stretch a little further. Not because they are forced to, but because they choose to, knowing they can always stop.

Being in control of your own sense of hearing makes all the difference. It determines whether you are willing to risk exposure at all. That is very different from being told to sit through pain. It is very different from intentionally exposing yourself to the point of trauma in the name of desensitization.

We do not heal from being overwhelmed. We heal when we are allowed to pace ourselves, to retreat, and to re-engage on our own terms.

There is another way. There are tools. There is a path forward that honors the person, not just the symptoms.

My approach may also support the work of practitioners like Tom Dozier by creating a more stable auditory foundation. When there is less overwhelm from sound, desensitization can become easier and more effective.

Sometimes, when the body is no longer drowning in input,

the brain is finally free to learn.

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Visual Description

This watercolor-style illustration depicts a young boy sitting at a wooden desk in a quiet school hallway. He has light skin, reddish-brown hair, and wears a long-sleeved blue shirt and jeans. His body is turned slightly, but his head is turned sharply to the left as he looks anxiously toward an open classroom door in the distance.

The boy’s expression is tense and worried, his eyes wide, lips slightly parted, and brow furrowed, as if he is reacting to a sound coming from the room beyond. The hallway around him is softly rendered in muted blues and warm yellows, with light from the open door casting a golden glow onto the floor. Curved lines near the door subtly indicate sound or noise coming from within. The open book in front of him remains untouched, emphasizing his distraction and discomfort.

The painting communicates a strong emotional tone of isolation, vigilance, and sensory tension—capturing the experience of a child overwhelmed by his environment.

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References

Brout, J. J., Edelstein, M., Erfanian, M., Mannino, M., Miller, L. J., Rouw, R., Kumar, S., & Rosenthal, M. Z. (2018). Investigating misophonia: A review of the empirical literature, clinical implications, and a research agenda. Frontiers in Neuroscience, 12, 36.

Kumar, S., Tansley-Hancock, O., Sedley, W., Winston, J. S., Callaghan, M. F., Allen, M., Cope, T. E., Gander, P. E., Bamiou, D. E., & Griffiths, T. D. (2017). The brain basis for misophonia. Current Biology, 27(4), 527–533.

Jastreboff, M. M., & Jastreboff, P. J. (2001). Components of decreased sound tolerance: Hyperacusis, misophonia, phonophobia. Ithaca, NY: Tinnitus Retraining Therapy Clinic.

Williams, Z. J., He, J. L., Cascio, C. J., & Woynaroski, T. G. (2021). A review of decreased sound tolerance in autism: Definitions, phenomenology, and potential mechanisms. Neuroscience & Biobehavioral Reviews, 121, 1–17.

Dozier, T. H. (2015). Treating misophonia with counterconditioning: A review of evidence and theoretical framework. Clinical Case Studies, 14(5), 374–390.

Psychology Today. (2023). Exposure Therapy is Not Treatment for Misophonia. Retrieved from https://www.psychologytoday.com/.../exposure-therapy-is...