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Reducing hyper mirroring in misophonia: A proposal for cortico-cortical paired associative stimulation (ccPAS) as a potential intervention for treatment

Lookup NU author(s): Dr Pradeep DheerendraORCiD

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This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).

Abstract

© 2025 Elsevier Ltd.Misophonia, a condition characterized by intense emotional and physiological reactions to specific human-generated sounds, was recently proposed as a disorder of hyper mirroring, in which there is an over-representation of the actions of others. A recent study used rTMS to indirectly reduce the hyperactivity in the anterior insula of people with misophonia, leading to a modest reduction in misophonic distress. But further research is needed to optimize TMS for greater efficacy. Recent TMS studies using a paired associative approach have shown that it could be used to reduce automatic mirroring in healthy controls. We propose the use of ccPAS for reducing the aberrant “hyper” connectivity of the motor cortex, suggested to be associated with mirroring, found in misophonia which is directly accessible to TMS. We hope this theoretically driven neuromodulation approach can take advantage of recent advances in brain stimulation and address the need for developing an effective evidence-based treatment for misophonia.

Publication metadata

Author(s): Dheerendra P, Kumar S, Gander PE, Berger JI, Muckli LF

Publication type: Article

Publication status: Published

Journal: Medical Hypotheses

Year: 2026

Volume: 206

Print publication date: 01/01/2026

Online publication date: 24/11/2025

Acceptance date: 23/11/2025

Date deposited: 09/12/2025

ISSN (print): 0306-9877

ISSN (electronic): 1532-2777

Publisher: Churchill Livingstone

URL: https://doi.org/10.1016/j.mehy.2025.111840

DOI: 10.1016/j.mehy.2025.111840

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