Cognitive Behavioral Therapy
CBT May Be an Effective Treatment for Misophonia
Research explores the effectiveness of CBT for misophonia.
Posted July 24, 2021 | Reviewed by Gary Drevitch
- Misophonia means hatred of or aversion to sound, particularly certain sounds related to breathing and eating.
- Misophonia is associated with negative emotional, physical, and behavioral responses (e.g., stress, muscle tension, aggressive outbursts).
- Cognitive behavioral therapy is a promising evidence-based treatment for misophonia, according to a new study.
In a study published in the July 2021 issue of Depression and Anxiety, Jager and colleagues present findings from the first randomized, controlled trial of cognitive behavioral therapy for the treatment of misophonia. Before summarizing the investigation's findings, let me describe what misophonia is and what causes it.
What is misophonia?
Misophonia means hatred of certain sounds. Typical misophonia triggers are breathing sounds and eating sounds — heavy breathing, sniffing, chewing, lip-smacking, swallowing, throat clearing, sucking, slurping, sighing, and yawning. However, misophonia triggers are not the same for everyone (or at different times). Indeed, any patterned and repetitive sound (e.g., clicking, tapping), especially sounds that are difficult to avoid, could be triggering.
Emotional reactions to misophonia triggers can include stress, anxiety, discomfort, irritation, disgust, and particularly anger and rage. Misophonia is associated not only with strong emotional reactions but also physical reactions (e.g., muscle tension, increased heart rate), and behavioral responses (e.g., aggressive outbursts). A variety of mental illnesses may co-occur with misophonia, the most common one being obsessive-compulsive disorder (OCD).
What causes misophonia?
Little is known about the causes of misophonia. Misophonia is not recognized as a psychiatric illness or a neurological disease, meaning there are no standard diagnostic criteria. Nevertheless, misophonia appears to be more of a psychiatric condition than a neurological one. For instance, hearing sensitivity seems to be normal in people with misophonia, though the processing of sound may be abnormal, perhaps due to autonomic nervous system and limbic excitation.
Some research suggests that what underlies misophonia is a combination of “abnormal salience attributed to otherwise innocuous sounds” and altered interoception, meaning abnormal perception of internal states.
Misophonia often develops in childhood or the early teenage years. In one investigation, one-third of people with misophonia had family members with misophonia, suggesting the existence of genetic risk factors or genetic causes. And nearly half the sample had co-occurring mental health conditions (e.g., tinnitus, PTSD, ADHD, eating disorders).
Nearly 4% also had hyperacusis—a condition often confused with misophonia. Hyperacusis is characterized by high sensitivity to sounds experienced as unbearably and painfully loud (e.g., car engines, vacuum cleaners, barking dogs, refrigerator fans). Misophonia differs from hyperacusis in that it is characterized more by emotional reactions to specific sounds than by intolerance of sounds experienced as too loud.
In the above study, half of the sample also experienced autonomous sensory meridian response (ASMR)—tingling sensations on the scalp, neck, and back, and accompanied by feelings of relaxation and euphoria. The significance of this link between ASMR and misophonia is not clear.
Cognitive behavioral therapy for misophonia
Let me now turn to treatments for misophonia; specifically, the study of cognitive behavioral therapy (CBT) for misophonia by Jager et al.
People with misophonia were recruited from an outpatient clinic. The diagnostic criteria used were proposed by Schroder et al. Exclusion criteria included taking certain drugs, a recent diagnosis of psychiatric disorders (e.g., anxiety, depression, schizophrenia, autism, bipolar disorder), and stroke or structural nervous system disorders.
Participants (54; 38 women; average age of 33 years) were randomly assigned to a misophonia treatment and a waiting list condition.
The intervention was a version of group CBT. It consisted of the following components: task concentration exercises, stimulus manipulation (manipulating the trigger sounds on a computer), arousal and stress reduction, positive affect labeling, reevaluation of eating norms, psychoeducation for family and friends, and practicing the learned techniques with the family.
The intervention comprised seven weekly meetings of psychotherapy and psychomotor therapy, plus a follow-up session three weeks later.
The primary outcomes were misophonia symptoms, which were assessed using the Amsterdam Misophonia Scale‐Revised (AMISOS‐R).
Secondary outcomes, mostly related to mental and physical health and functioning, consisted of the CGI Severity scale (CGI‐S), Symptom Checklist‐90‐Revised, the five‐dimensional EuroQol (EQ5‐D), the WHO Quality of Life‐BREF (WHOQoL‐BREF), and the Sheehan Disability Scale (SDS).
Analysis of data showed that "CBT resulted in statistically significantly less misophonia symptoms in the short‐term (−9.7 AMISOS‐R; 95% CI, −12.0 to −7.4; p < .001, d = 1.97).”
Clinical improvement in symptoms, operationalized as CGI‐I < 3, was noted in 37% of individuals with misophonia in the CBT treatment, compared to 0% in those in the waiting list control condition (p < .001).
Aside from the improvement in misophonia symptoms, there was a reduction in mental dysfunction and physical dysfunction—particularly in terms of impairment and disability in social and family functioning. The beneficial effects of cognitive behavioral therapy were maintained a year later.
How to deal with misophonia
As noted, misophonia is commonly defined as hatred of sound, especially certain eating sounds (e.g., slurping) and breathing sounds (e.g., yawning). A variety of self-help and therapeutic methods are used to manage misophonia: earplugs, headphones, white noise, distraction, anti-anxiety medications (e.g., benzodiazepines), antidepressants (e.g., the SSRIs), certain therapies (e.g., tinnitus retraining therapy), etc. However, these approaches have had limited success.
The findings reviewed today—of the first randomized, controlled trial of CBT for treating misophonia—indicate CBT may be an effective intervention for misophonia worthy of serious consideration.
If you already have a diagnosis of misophonia and are seeing a therapist, ask if CBT might be helpful for managing your symptoms.
In terms of self-help strategies, it is important to follow a healthy lifestyle—regular physical activity, sufficient sleep, eating healthily, and using effective stress management techniques (e.g., relaxation exercises, meditation practices).
Finally, regardless of the nature of the triggers and causes of misophonia, sometimes the quickest and simplest solution is to leave a triggering situation. While away from the situation, you can work on reducing your stress and tension (e.g., by engaging in breathing techniques, mindfulness meditation, or progressive muscle relaxation). Return only when feeling more centered, calm, and relaxed.