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

• Using non-invasive TMS to alleviate symptoms and reduce distress in misophonia sufferers. • Using cortico-cortical paired associative stimulation (ccPAS) for reducing the aberrant “hyper” mirroring in misophonia. • Mirror motor system is directly accessible to TMS unlike anterior insula which was investigated previously using rTMS. 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.