Wendy Aron

Sounds Awful

Our Future with Cognitive Behavioral Therapy

The new place cognitive behavioral therapy may be heading

Posted Apr 07, 2014

The success of cognitive behavioral therapy in altering the types of maladaptive thoughts that lead to emotions like anxiety, anger and shame that are so common to misophonia has been well-documented in academic research. However, there have been virtually no empirical studies of the use of CBT as an effective treatment for the physiological rage response that occurs in our brains in response to trigger sensations.

That is now changing.

Not long ago, Dr. Crystal Dehle, the director of the University of Oregon’s psychology department clinic, where future cognitive behavioral therapists are trained, decided to take on the case of a 19-year-old female misophonic college student whose trigger sensation was the sound of her housemates chewing. Dr. Dehle wrote me that she was interested in the case because there was a supervising psychologist on staff, Dr. Karyn Angell, who had expertise in treating clients with fibromyalgia and chronic pain, other more well-known conditions with both physiological and psychological components. Dr. Dehle said she saw the case as an opportunity for a psychologist-in-training in the clinic to develop an innovative treatment plan for a client who had no other established options.

Rosemary E. Bernstein, a 28-year-old, fifth-year doctoral candidate in clinical psychology, who hopes to stay primarily in an academic and research setting upon obtaining her degree in 2016, was assigned the case. After working with the misophonia sufferer for ten weeks and having her check in for a progress report four months later, Ms. Bernstein came to the conclusion that cognitive behavioral therapy could address the physiological aspect of misophonia. She wrote up a case study, which was published in a British journal called The Cognitive Behaviour Therapist last year.

Recently, I conducted an email interview with Ms. Bernstein about her thoughts on misophonia and the future of CBT. Here are some excerpts:

Complimenting insights acquired over the years about the cognitive basis for certain emotions, recent advances in brain imaging are giving neuroscientists new glimpses into their physiological origins. As a clinical graduate student, what kind of exposure to neuroscientific research have you had during the course of your schooling?

The clinical psychology department here at the UO is actually much steeped in neuroimaging research, with three of our core clinical faculty pursuing fMRI research, along with several other developmental and social psychology faculty with clinical interests and collaborations. Many others are interested in other indices of physiology, including skin conductance, RSA, cortisol, and sAA. If not exposed to these methodologies in their research, clinical students are exposed to these methodologies in their coursework (for example, in a required class called clinical psychobiology), so I would say that yes, this does influence our thinking to varying degrees. And based on the kinds of grants I see getting published, it doesn't look like this trend will be slowing down anytime soon.

In our clinical training, however, the focus is much more on developing our therapeutic skills. Thus, while we are encouraged and expected to do secondary research on the conditions we treat (especially the less common ones, like misophonia or trichotillomania, with which trainees may be less familiar), it is relatively rare that trainees involve their clients in research. In my case, my client was a psychotherapy client (and not a research participant) for the duration of her treatment, and it was only after treatment had concluded that we decided to write up our experience as a case study (in hopes that it could add something to the as-of-now meager literature base, and possibly help other clinicians or individuals with misophonia).

Do you see a day when the neuroscientists at University of Oregon and the clinicians- in-training will collaborate in order to discover the exact etiology of rare disorders like misophonia?

If we had a faculty member, post doc, or graduate student who was particularly interested, and a grant organization willing to sponsor it, I could definitely imagine an interdisciplinary study (i.e. behavioral and biological) of misophonia being conducted. As I argued in the case study, public awareness of misophonia does seem to be on the rise, so I expect that it will be increasingly on researchers' and granting agencies' radar. However, the graduate student involved would have to be early-on in his or her graduate training, because such a study would likely take several years to get up and running, and at least one or two more years to collect participants--so, it would be a job for someone who is going to be in one place for a awhile. Ideally, a team of researchers from several different universities would collaborate on a shared research study. Pooling resources would expedite the process and greatly improve recruitment, because you’d need at least 200 participants, and you'd be more likely find 200 people with misophonia to study across 8 cities than in just 1.

Your theory about CBT’s physiological effectiveness revolves around the supposition that the “fight or flight” mechanism in the brain can be suppressed by pre-emptive behaviors, such as exercise, and the masking of trigger sounds, but you indicated that you were never actually able to test this hypothesis via physiological monitoring or brain imaging. Was that a financial issue?

Brain imaging is indeed prohibitively expensive, and while we have our own fMRI machine on campus, it is used exclusively for funded research studies. To my knowledge, the clinic has never used measures of CNS or Autonomic functioning for diagnostic, treatment monitoring, or research purposes. It might have been interesting to measure my client's skin conductance in response to triggering sounds over the course of treatment to see if it decreased over time. However, most of our information-gathering came from the tracking/monitoring she did as homework, rather than in-session exposures. We usually rely on "subjective units of distress" (SUDs) to quantify clients' distress in response to stressors.

What’s your take on CBTs in clinical practice implementing physiological monitoring, like the skin conductance testing you mentioned, to evaluate and then individualize treatment for misophonia sufferers?

I think it would be interesting to use skin conductance/heart rate measures as a form of biofeedback for clients during in-session exposures. It is often compelling to show clients data of how, for example, their BDI and/or BAI (Beck Depression Inventory/ Beck Anxiety Inventory, which we collected from clients weekly) score has dropped over the course of treatment. Sometimes when clients are 'in the thick of it' it is hard for them to step back and see the improvements they have made. It could be that these biological measures could serve a similar purpose, but we'd need to test that first to see if these measures would be sensitive enough to measure relatively small changes over time.

Since your study was conducted in the U.S., it’s interesting that you got it published in a British research journal, rather than an American one. Why do you believe this was the case?

I originally submitted the case study to an American journal. They said they found it interesting, but since misophonia was not in the DSM-IV or 5, they ultimately rejected it and told me to approach an audiology journal. I found The Cognitive Behaviour Therapist (a British Journal) to be much more welcoming. I wouldn't be surprised if researchers in the UK beat America to the punch on misophonia.

Blogger’s note: In fact, Newcastle University in the UK just has. An upcoming post will address the first-ever fMRI study conducted to better understand how a misophonia sufferer’s brain processes sensations.