CBT/DBT
Cognitive behavioral therapy (CBT) focuses on a person’s thoughts, feelings, and behaviors to identify unhealthy patterns. The patient and therapist then develop appropriate healthy patterns of thoughts, feelings and behaviors to replace the unhealthy patterns. Dialectical behavior therapy is a form of CBT that puts a specific focus on a person’s arousal response to certain emotional situations.
A case study of cognitive behavioral therapy (CBT) to treat misophonia in a young woman reported elimination of impaired social functioning at the end of treatment and at four-months post-treatment, although the woman still found the trigger stimuli unpleasant.[i] The treatment plan included “(a) a cognitive component to challenge dysfunctional automatic thoughts, (b) a behavioral component to interrupt maladaptive and avoidant coping strategies and practice helpful ones, and (c) a physiological component to help recalibrate her autonomic reactivity.” This last component was thirty minutes of exercise a day, and it was unclear whether the patient did this or not. It seems as if the individual still did not like the sounds because she was still triggering to them, as this treatment did not address the physical reflex. But if the individual could remain calm, then perhaps with time the physical reflex would decline. This needs more research.
A second case study was reported on CBT treatment for two youths with misophonia ages eleven and seventeen.[ii] I preface the description of treatment by saying that I do not advise this method because it used enticing rewards to motivate a child to control or suppress her outward, aggressive coping behavior after a trigger, without reducing the physical reflex. This has created situations where a child controlled their “acting out” to triggers, but inwardly developed new triggers and stronger misophonic reflexes until the misophonia re-emerged much worse than when the treatment began. The treatment in this study included psychoeducation about misophonia and focused on helping the patients develop the ability to tolerate triggers without aggressive or avoidant behaviors. The treatment included a progressive exposure of trigger severity and response prevention. This allowed the patients to develop the ability to tolerate the triggers and remain calm. A reward hierarchy was provided for the younger patient for completion of the exposure steps. Cognitive restructuring was included to address dysfunctional beliefs about the sounds, such as “my family makes these sounds to annoy/aggravate me.” Both youth progressed though treatment and were able to eat with their families without accommodations. Both youth showed a reduction of their misophonia severity at the end of treatment based on a self-report questionnaire, though the decline for the younger child was fairly small. The study did not include any follow-up measures for the youth.
My concern about this treatment is that it did not address the initial physical reflex. It was successful at helping the youth develop the emotional and behavioral control to stay calm when triggered, but it did not eliminate the physical reflex. There is a risk that the physical reflex will strengthen and other triggers will develop. It is very beneficial for a person with misophonia to learn to remain calm when triggered, but this does not eliminate the risk of an escalation of misophonia severity through repeated exposure to triggers. The risks here are discussed more fully in the chapter How Triggers Spread.
CBT can help reduce the emotional upheaval that comes with misophonia, and there are many anecdotal reports of individuals benefiting from this form of treatment. CBT or similar therapy is also recommended by the Misophonia Management Protocol to help a person change the way they think about triggers and live with misophonia as a chronic condition.
[i] Bernstein, Angell, & Dehle, 2013
[ii] McGuare, Wu, & Storch, 2015
