Imagine sitting next to a bored stranger fidgeting with a pen. The room is silent, except for that pen. Quiet amplifies—it makes everything sound louder. Yet for people who suffer from misophonia, every tap of that pen is louder than a chisel removing tile. The man on the train breathes with more force than a motorcycle. And that co-worker chews gum as if she were a cow in front of a microphone.
Misophonia—an emotional, decreased tolerance to sound—can make some situations feel uncomfortable, or even unbearable: anger, disgust, anxiety, avoidance. But the first trial for the condition, published recently in the Journal of Affective Disorders, claims to have found an effective treatment: cognitive behavioral therapy (CBT).
“Despite the high burden of this condition, to date there is no evidence-based treatment available,” first author Arjan Schröder wrote in the abstract. Schröder and a team of Dutch researchers treated 90 patients with CBT for eight group sessions, every other week, and found that CBT was effective for half of the patients. What’s more, patients who had more severe symptoms were more likely to respond to treatment.
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“We started this project because hardly anything was known about [misophonia], yet the patients we talked to suffered significantly. So together with the first patients, we decided to investigate it… and tried to figure out if and how it could be treated,” Schröder said. The results of the experimental therapy they decided to implement—combining four techniques individualized to what worked best for each patient—were strong early on, he added. “We know patients who, after successful treatment, noticed at the end of a meeting the core of an apple lying on the table,” Schröder said. “Someone had been eating an apple during the meeting, and they hadn’t noticed it!
“So they had managed to focus on the presentation or questions, not having been distracted or anxious.”
The trial used a set of clinical interview questions called the Amsterdam Misophonia Scale (PDF), according to specific diagnostic criteria and five symptoms. However, misophonia isn’t recognized by the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Various peer-reviewed studies suggest that misophonia could arguably be categorized as a disorder, a syndrome, a symptom, or even a physiological state. It’s associated with many neuropsychiatric disorders and conditions, including autism, OCD, Tourette’s Syndrome, ADHD, and tinnitus.
Tinnitus is where “misophonia” began. Neuroscientists Pawel and Margaret Jastreboff first created the term—“miso” is Greek for hatred, aversion, or disgust—to describe a condition they observed in 60 percent of their patients with tinnitus: “a negative reaction to a sound with a specific pattern and meaning.”
“Showing improvement in a condition that we as yet have very little basic research [about] is significant,” said Fordham psychology professor Dean McKay, who is wrapping up a tele-therapy trial that’s been two years in the making. Using webcams, 40 participants across the world were treated remotely for 12 sessions: six sessions of exposure therapy, and six sessions of stress management therapy. According to the treatment manual, the trial focused on teaching participants to notice what thoughts made them feel worse, and how to manage stress more effectively.
“The primary value of CBT is that it teaches individuals methods of coping,” McKay said. “There are so many situations where circumstances are beyond our control, and if misophonia sufferers can be given specific strategies for tolerating these sounds more effectively… then [they] will make improvements in [their] functioning,” he said.
McKay added that his trial’s approach was largely consistent with the protocol used in Schröder’s trial. CBT is complex, McKay explained. It’s a multi-pronged therapy that borrows from three major theories: classical conditioning, operant conditioning, and cognitive theory.
“Anecdotally, participants in the trial have found it beneficial,” McKay said, “with symptom alleviation at three and six months following treatment.” His team is at work assessing the participants’ misophonia symptom severity (using a scale developed by Eric Storch), in addition to their levels of disgust, anger, anxiety, and depression.
McKay is preparing a similar trial for children. Since the trial will be conducted over the computer, using web cams, parents will be asked to help administer it, he added. “I have several people already on the waiting list… but we are not quite ready to launch,” he said. “We are expecting to start in mid to late March.”
Several strategies used in the open trial—attention shifting, counterconditioning, and relaxation techniques—overlap with other approaches to treat misophonia. Rebecca Schneider, a doctoral candidate at the University of Colorado at Boulder, conducted a case study using related strategies: mindfulness and acceptance-based therapy.
“Traditional CBT focuses on challenging thoughts and changing behaviors in order to affect feelings,” Schneider said. “Both the open trial and our case study aimed to shift the [patient’s] relationship with triggered thoughts and feelings while simultaneously focusing on decreasing physiological arousal,” she said.
Bruce Hubbard is the director of the Cognitive Health Group in New York. He uses CBT—specifically, mindfulness techniques and gradual exposure—to help patients become de-sensitized to triggering sounds (and visual cues, such as smacking lips).
“When done correctly, exposure definitely works for misophonia,” Hubbard said. One of Hubbard’s patients, a 12-year-old boy, is triggered by his mother’s voice. Another has a lot of eating triggers—his most severe reaction is to the sound of his mother snacking.
“It’s painstakingly slow. But we really progress at the level they’re ready for,” he said.
Hubbard often recommends that his patients begin by gradually exposing themselves to triggering sounds with YouTube—at a low volume, to start. Feeling relaxed is important, because it boosts confidence, he said. It can help patients feel like they can handle more.
“It’s staying in the moment with the sounds, and with your emotional experience of them,” Hubbard said. The key is to go slow, and be patient. To be “therapeutic,” exposure can’t be a “white-knuckler.” If you’re desperate for it to be over, you’ve gone too far.
One of Hubbard’s recent patients, a man in his mid-twenties, sought out treatment because he was about to begin graduate school. Though he was triggered by pen-clicking and eating/drinking sounds, his aversion to gum-chewing was the most severe.
“It made it really hard for him to sit in meetings,” Hubbard said. “There were times where he would actually have to make an excuse, and leave. It was actually affecting his productivity at work.”
Hubbard recommended that the patient try “mindful exposure”: First, stay calm, and take an open, accepting, and nonjudgmental stance. Eventually, he began seeking out chances to hear gum-chewing more and more. So, he rode the subway. A lot.
“Instead of noticing someone chewing gum and moving to the other end of the car to avoid them, he would sit right across from them,” Hubbard said. “He would make a point of being able to allow himself to stay there and mindfully experience the trigger, the gum-chewing,” he said. After a lot of hard work, the patient gradually became de-sensitized. Gum-chewing didn’t affect him much anymore.
“He would come in, and I would be chewing gum in session,” Hubbard recalls. “He got to the point where he would just forget about it for periods of time.”
