Case Studies
The first person I ever did this with was a fifteen-year-old boy who triggered to family members, especially his mother crunching. We did this treatment with a live trigger, so his mom intermittently ate tiny pieces of Fritos while he listened to his favorite music. His reactions melted away. But when he went home and tried eating with his family, he couldn’t because he still triggered to his mother’s jaw movement. So they came back, and we did a couple of more treatments with the jaw movement, where he would look at his mother and then look away. Again, we kept the triggers small, and he would close his eyes or look away as soon as he felt the trigger, all the while he was listening to his music. Pretty soon he stopped triggering to his mother’s jaw movement. He was marginally compliant with the assignments I gave him, but his misophonia reflex response changed very quickly. He went back to eating with his family again without disruption. It wasn’t that it completely eliminated all of his misophonic reactions, but it brought them down to the level that it was reasonable and not emotionally upsetting.
The best-documented case I have was with a forty-eight year-old woman. This case is described in the journal article, “Counterconditioning Treatment for Misophonia,” which is available on MisophoniaTreatment.com. She triggered to the sounds of her husband eating bread or sorbet and scratching his beard, and had a visual trigger to him putting his hand to his face. We used Skype for the treatment sessions. I had the triggers recorded so I could play them, and she would tell me the strength of the reflex response, whether that was a one or two or three. We worked on the trigger of her husband’s eating bread for two weeks, and her response decreased dramatically. Then we took the second trigger, him eating sorbet, and her reflex response to it also dropped. Then we treated the trigger of the sound of him scratching of the beard, and it went down. Each of these triggers took two live treatment sessions with me, plus four homework sessions per week done independently. What we found was that her response to the eating bread trigger continued to die out in the real world, and completely went away while the other two remained low. The last trigger we worked on was one of her husband putting his hand on his face. We found that when I raised my hand toward my face, it triggered her, so we worked with me as the trigger source. It took nine weeks to reduce her response to my hand movement. So her visual trigger was much more resistant to change than her sound triggers. When she finally was not triggered by me, she could generally ignore her husband’s hand movement at home.
The change in her misophonic reflexes was apparent to both of us over the course of treatment. In treatment sessions with me, I observed that the volume of the trigger or the height I raised my hand had to be continually increased to trigger her. She noticed a decline in her response to real triggers from her husband. The graph shows her misophonia assessment questionnaire sum score. This is adding the value of each response of the twenty-one questions on the assessment. The sum score is a measure of the impact of misophonia on a person’s life, or the general severity of their misophonia. The maximum sum score is sixty-three. She started at forty-one. After two treatments and the homework she was down to seventeen. This reduction was likely supported by improved management techniques I taught her in our first meeting. Two more treatments and the homework, and she was down to seven; but her husband had been out of town for a week, so that’s artificially low because she had not heard her worst triggers. She was at a nine after two more weeks, and was still at nine after her eleventh session. We met four months after her treatment ended for a follow up assessment, and her sum score was only five. At the ten-month follow-up her sum score was only three.
Although she still had triggers and occasionally needed to move away from a trigger situation, her response to triggers was small. She may notice a trigger and then look away, but it doesn’t have the emotional upheaval. You can see from her overall misophonia sum score that she is not worried about misophonia. So that’s really a very, very positive benefit to her life.
I worked with an eight-year-old and her parents. We did the Neural Repatterning Technique. Her counterconditioning stimulus was to dance around the room. The parents did multiple sessions with this little girl. They got rid of the trigger to one sound and then another, but they kept having some trouble at the table. Finally, they added some fan noise, and they eat together without a problem now. So while we saw improvement, this treatment didn’t completely eliminate her misophonia.
I had a really interesting case where a college student was home for the summer.[i] She had a couple of really strong triggers with her mom. She did muscle relaxation training the first week before we started the NRT treatment. Her physical reflex was a hand clench, which is a pretty easy muscle to relax. Here’s what she wrote on the Google Play App review: “My life is changed forever. I finally have control over my own suffering. Finding this app has been a complete miracle. Misophonia was ruining my life to the point where I couldn’t stay in classes or couldn’t concentrate because of the noises, and decided to go to Tom Dozier for help. After just two treatment sessions using the app, I could stand being around my mother while we ate (chewing and spoons on porcelain were some of my biggest triggers). Treatment for me worked very fast and I am excited to continue to eliminate other triggers. While I cannot completely eliminate reactions in real life, I barely react to the trigger. At least not with the rage I used to.” (Congrats, Tom!!)
I talked to her after she went back to school, and she applied what she learned during the NRT treatment to real-life triggers. She found that she could ignore some triggers, especially when she relaxed her hands. Sometimes she needed to shake her hands a little when she was being triggered. She no longer experienced the overwhelming rage that she previously felt at school. I checked with her again at the end of the semester, which was six months after her treatment ended. Her misophonia severity was continuing to decline, both as rated by the overall severity and her response to individual triggers. Twelve months after her treatment, she was experiencing a slight increase in her overall misophonia severity, but her responses to the triggers we treated with NRT were completely gone. The increase in her twelve-month misophonia severity rating was likely due to developing generalized anxiety disorder (GAD) between the six and twelve-month ratings. This is shown in the figure below. This case is also described in detail in my journal article, “Treating the Initial Physical Reflex of Misophonia with the Neural Repatterning Technique: A Counterconditioning Procedure,” which is available on MisophoniaTreatment.com.
Another case is with one of the first people who bought the app. He called me and I helped him set up the app and get started with his treatment. Shortly thereafter, he sent me back this email. He wrote, “I have some excellent news. I’ve been doing my work with the app every day for about ten days, for at least an hour each session. If I’m feeling good I can do three hours or so while I’m at work. I was gradually increasing volume, frequency and length of the trigger sound (sniffling). Today I had a conversation with my roommate and partway through I realized he was sniffling and I was having no physical reflex. I then began focusing on the sound as if part of me knew something was supposed to happen but I had no negative feelings each time I heard the sound.
“I have been working on crunching, and I have definitely noticed a sensitivity decrease. I even have noticed an anxiety decrease when I know I might hear the trigger. I’ve realized I still really dislike the sound but I can handle it much better. Just the decrease in anxiety has been great.”
The NRT treatment doesn’t cure misophonia, but it can greatly reduce the reflex response. What do you need to do to make the Neural Repatterning Technique work for you? Your goal is to make your misophonia reflex response like an eye blink – a very small, non-upsetting response. But it needs to include a physical response, not a purely emotional response. In addition to being a small physical reflex action, it needs to go away instantly.
The treatment seems to work better if the reflex is movement of a skeletal muscle, but this is not something you choose. Your misophonic reflex is what it is. It’s already there. But if it’s a skeletal muscle, then you can do muscle relaxation training so that you are better at relaxing that muscle before each trigger. You want to hear triggers often enough that you have a lot of “learning” opportunities, but not so often that it creates any degree of stress. We don’t yet understand the optimum trigger rate, however, patients have had success with the time between triggers set anywhere from fifteen seconds to two minutes. Then you want to increase the length and the volume of the trigger as your reflex response goes down, so that you keep your physical response around a one on a scale of zero to five. I have seen cases where one hundred to three hundred exposures of a trigger produce a meaningful reduction in the reflex response with the Trigger Tamer.
Once the reflex goes away with one recorded trigger, then you switch to another, similar recording. When you stop responding to two to four examples of a single type of trigger with the Trigger Tamer, then you are ready for real-life triggers. You should still expect the reflex response to the trigger, but it will not be nearly as strong as it was before you did the Neural Repatterning Technique.
Generally I recommend you do the NRT treatment thirty minutes a day, four to six days a week. Most importantly, it needs to be a happy time. Smile. Enjoy the music. Relax. Do something fun and hear the tiny triggers. It’s automated with the Trigger Tamer apps, so you can provide the treatment whenever and wherever you want. You have control of it, so you are the boss. You’re in charge.
You need to make sure that you are actually experiencing the physical reflex. If you are just hearing a sound, and it is upsetting or disgusting, but there is no physical reflex, then the NRT treatment will not be effective. You also need to make sure that your lizard brain is changing during the treatment. If you do the treatment four to six times, and you don’t need to increase the volume or duration of the trigger to keep your physical response at a level of “one,” then your brain is not changing. This indicates there is some problem in the way the treatment is set up.
There are some conditions under which the Neural Repatterning Technique does not work. For example, if you can’t be triggered by a sound or audiovisual recording, you can’t use it. If you have no happy place or you can’t relax, then it won’t work for you. If the triggers linger once you are triggered – if the response doesn’t go away instantly, then it won’t work. An example of a lingering reflex response would be things like an intestine constriction, stomach constriction, or sexual arousal. Those tend to linger more, and they don’t respond to the treatment because you can’t get that small, brief response that ends instantly. However, I have seen it work with nausea. A person said their stomach flipped and it worked for her.
The Neural Repatterning Technique does not work on triggers in a broad way. It is not suitable for a generalized trigger, something like gum chewing or sniffling by anyone, anywhere. If you trigger to sniffling everywhere, you can use NRT for the trigger of your child sniffling, but it will probably not have an effect on the sniffling of a stranger. For NRT to be effective, you need to work on a trigger that is by a single person (or thing). It could probably be applied to an emerging trigger – one that’s just coming on, because an emerging trigger will almost always be a single person or single situation.
I had one of my best patients try to overcome a general sniffling trigger with this treatment. She was a teacher, and she did the homework faithfully. She did the muscle relaxation regularly and she used the Trigger Tamer app faithfully until she didn’t trigger with the app. But when she was in her classroom at school and a kid sniffed, she still triggered. The problem was that the setting for the NRT training and the real-life trigger were very different. The research shows that conditioned reflexes can be very context or situation sensitive.
[i] Dozier, in press
