Neural Repatterning Technique (NRT)
I developed the Neural Repatterning Technique in the spring of 2013. The treatment involves hearing an intermittent, very weak trigger while experiencing a positive situation, such as listening to your favorite music or talking about positive life experiences. The trigger is so weak that you don’t have the negative emotions, so the treatment is a very positive experience. It proved to be so successful that I decided to automate the treatment by creating a smartphone app available for iPhone and Android systems. The app is called the Misophonia Trigger Tamer, so this treatment is often referred to as the Trigger Tamer treatment.
Martha’s Story
Martha was a professional in her mid-forties with a lifelong history of misophonia ranging from mild to extremely debilitating. Efforts to decrease her symptoms included extensive work to reduce autonomic reactivity, which included breath work, relaxation techniques, noise reduction headsets, and musician earplugs. She reduced her misophonia to the point that she rarely experienced extreme misophonic emotions, but she was still occasionally agitated by one trigger. After listening to a recording of the trigger in preparation for the NRT treatment, she reported that she became aware of the muscles behind the ear contracting when she heard the sound. She used the NRT treatment for the trigger stimulus and eliminated the reflex. With the reflex gone, the real-life trigger stimulus no longer elicited negative emotions.
Misophonia Response and NRT
When we think about misophonia, we generally think of it as having a trigger and that causes us to have an involuntary, extreme emotion or fight-or-flight response.
But misophonia is actually a two-step process. You hear the trigger, there is a physical reaction, a physical reflex, and the physical reflex jerks the extreme emotion or the fight-or-flight response out of you. If we can stop the physical reflex then there’s no emotional response.
Therefore, the Neural Repatterning Technique is about stopping or reducing the emotional response to misophonia by first eliminating or reducing the physical misophonic reflex response. As shown below, the trigger stimulus causes a physical reflex in almost everyone with misophonia, and the physical reflex jerks the emotional response out of the person.
If we can eliminate the physical reflex, then it breaks the primary connection between the trigger and the emotions, as shown below.
Usually the physical reflex is not completely eliminated with the NRT treatment. The reflex is greatly reduced, and it can die out with time, or may remain weak, providing a greatly reduced emotional response to the trigger.
Virginia’s Story
This case is about eliminating a trigger to a family member singing around the house.
“I think probably it was about three weeks into it I started realizing that this is really working, because I have to say that I did not think anything would work. I think a lot of people feel that way who have this. And of course when I was young I felt that I was the only person in the world that had ever experienced this. But after about three weeks I started seeing the improvement, and it was gradual but it was definite. And I could tell that the trigger was going away, and it was getting lighter. And then when I started experiencing the trigger in real life and realized I wasn’t having those emotions or that anger. It was like a miracle.”
The Neural Repatterning Technique is not an unpleasant treatment. It is happy time. Virginia describes the Neural Repatterning Technique treatment sessions, using the Trigger Tamer app:
“I’m almost seventy-five years old, so for all of these years I have just tried to avoid these sounds. After I got through the apprehension of the whole thing, I began to look forward to this treatment and hearing those sounds was amazing to me. It was life changing.”
The following is from Understanding and Overcoming Misophonia by Thomas Dozier
Neural Repatterning Technique (NRT)
I developed the Neural Repatterning Technique in the spring of 2013. The treatment involves hearing an intermittent, very weak trigger while experiencing a positive situation, such as listening to your favorite music or talking about positive life experiences. The trigger is so weak that you don’t have the negative emotions, so the treatment is a very positive experience. It proved to be so successful that I decided to automate the treatment by creating a smartphone app available for iPhone and Android systems. The app is called the Misophonia Trigger Tamer, so this treatment is often referred to as the Trigger Tamer treatment.
Martha’s Story
Martha was a professional in her mid-forties with a lifelong history of misophonia ranging from mild to extremely debilitating. Efforts to decrease her symptoms included extensive work to reduce autonomic reactivity, which included breath work, relaxation techniques, noise reduction headsets, and musician earplugs. She reduced her misophonia to the point that she rarely experienced extreme misophonic emotions, but she was still occasionally agitated by one trigger. After listening to a recording of the trigger in preparation for the NRT treatment, she reported that she became aware of the muscles behind the ear contracting when she heard the sound. She used the NRT treatment for the trigger stimulus and eliminated the reflex. With the reflex gone, the real-life trigger stimulus no longer elicited negative emotions.
Misophonic Response and NRT
When we think about misophonia, we generally think of it as having a trigger and that causes us to have an involuntary, extreme emotion or fight-or-flight response.
But misophonia is actually a two-step process. You hear the trigger, there is a physical reaction (a physical reflex) and the physical reflex jerks the extreme emotion or the fight-or-flight response out of you. If we can stop the physical reflex then there’s no emotional response.
Therefore, the Neural Repatterning Technique is about stopping or reducing the emotional response to misophonia by first eliminating or reducing the physical misophonic reflex response. As shown below, the trigger stimulus causes a physical reflex in almost everyone with misophonia, and the physical reflex jerks the emotional response out of the person.
If we can eliminate the physical reflex, then it breaks the primary connection between the trigger and the emotions, as shown below.
Usually the physical reflex is not completely eliminated with the NRT treatment. The reflex is greatly reduced, and it can die out with time, or may remain weak, providing a greatly reduced emotional response to the trigger.
Virginia’s Story
This case is about eliminating a trigger to a family member singing around the house. Virginia said,
“I think probably it was about three weeks into it I started realizing that this is really working, because I have to say that I did not think anything would work. I think a lot of people feel that way who have this. And of course when I was young I felt that I was the only person in the world that had ever experienced this. But after about three weeks I started seeing the improvement, and it was gradual but it was definite. And I could tell that the trigger was going away, and it was getting lighter. And then when I started experiencing the trigger in real life and realized I wasn’t having those emotions or that anger. It was like a miracle.”
The Neural Repatterning Technique is not an unpleasant treatment. It is happy time. Virginia describes the Neural Repatterning Technique treatment sessions, using the Trigger Tamer app:
“I’m almost seventy-five years old, so for all of these years I have just tried to avoid these sounds. After I got through the apprehension of the whole thing, I began to look forward to this treatment and hearing those sounds was amazing to me. It was life changing.”
Counterconditioning the Misophonia Reflex
As we discussed earlier in the book, there is something about experiencing a trigger that is causing the misophonic-conditioned reflex to be strengthened. It seems that the miso-emotions and tightened muscles after a trigger cause the reflex to become stronger.
To reduce the misophonia reflex, we need to hear a trigger and then have a smaller than typical reaction. We need to do something that will reduce or eliminate the miso-emotions, or have a situation where the reflex action (tight muscle) will be reduced or relax immediately after the trigger.
To get this effect, you could have positive emotions – relaxed or happy instead of the upset misophonia emotions. Another way would be to reduce the reflex using muscle relaxation, but you will need to relax before the trigger for this to work. If the lizard brain is hearing the trigger and sees a weaker reflex response a half second after the trigger, then over time the lizard brain is going to reduce and even stop responding.
This is called counterconditioning. But the problem is that during the zero- to two-second pairing window after the trigger, the counterconditioning actions are not powerful enough to overcome the emotion that comes with misophonia. So it’s very unusual that a person can just countercondition away one of these reflexes, although there are stories and cases where this has been done.
To overcome this limitation of counterconditioning, I started by reducing the trigger for the Neural Repatterning Technique. When we reduce the trigger enough, we diminish the intensity of the physical reflex. So instead of getting a full-sized reflex, you get a tiny reflex. It is like an allergy treatment for peanuts. If you are highly allergic to peanuts, you can die if you eat one. However, the allergy treatment consists of injecting you with a serum of the very thing that could be fatal. Only an infinitesimally small level is administered at any given time, which produces only a small response. By doing this multiple times, your body adjusts to the peanut and stops reacting. That’s what the Neural Repatterning Technique is. You get just a little bit of the trigger sound to let your lizard brain stop responding.
It is usually best to use a recorded trigger, although I have worked with live triggers. When I was setting this up, I decided to use a rating scale of zero to five for the strength of the misophonia reflex, with five being a huge trigger and zero being something that doesn’t cause a reaction or reflex.
What I look for with this Neural Repatterning Technique is to get a response of one. Maybe a two, but generally around a one, where the person can stay positive, calm, and happy. Then we pair the trigger with something that’s pleasant. I have had it work with calming, relaxing music – something like pan-flute music, which you might hear if you get a massage. I have people who use happy, up-beat music. The first person I worked with liked a really harsh type of rock music. It was not my kind of music at all, but he really got into it. I also worked with an individual where we talked during the treatment about uplifting, successful events in her life. That worked great for the positive stimulus. I have seen cases where the positive stimulus was massage. One person used pictures of her nephews, and another used pictures of her dog that she said just lifted her heart. But you need to have something that puts you in a positive state, either calm or happy, so that it can be paired against the disruptive response from the trigger, even though the response to the trigger is small. Once you determine what will put you in that positive state, then close your eyes, relax, and utilize the Trigger Tamer app so you have tiny reaction and allow your lizard brain to change.
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, eating sorbet, and scratching his beard, and had a visual trigger of 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, but there have also been cases where there was no benefit to a person after having 1,000 exposures to a trigger.
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 response. 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.
The Trigger Tamer Apps
There are two versions of the Trigger Tamer apps. The app with the blue brain icon is called the Misophonia Trigger Tamer, and it uses an audio recording for the trigger. The app with the green head is the Visual Trigger Tamer, and it uses a video recording for the trigger.
MisophoniaTrigger Tamer, Home Screen
Misophonia Trigger Tamer, Treatment Screen
Visual Trigger Tamer, Home Screen
Visual Trigger Tamer, Treatment Control Screen
The Misophonia Trigger Tamer has better control of the trigger for sounds and is available on both iTunes and Google Play. The Visual Trigger Tamer is available on Google Play and the iTunes version is in development. It allows you to use a visual and audio trigger, so if you have trouble triggering to an audio recording, you may trigger to the video/audio combination. But the Visual Trigger Tamer has less control of the timing and options for the trigger. The Misophonia Trigger Tamer has a recorder and good sound editor built into it, but for the Visual Trigger Tamer, you will need to use other programs to record and edit your triggers.
Another difference in the two apps is that the Misophonia Trigger Tamer only allows audio recordings for the positive stimulus playlist, but the Visual Trigger Tamer lets you use a combination of audio recordings, pictures, and videos for the positive stimulus playlist.
The Neural Repatterning Technique complements other treatments such as the Misophonia Management Protocol, where you use either background sound or the audiologist-provided sound generators that go behind the ear. The MMP provides a way to reduce your real-world response to triggers, and the NRT treatment helps you bring those reflexes down to make it even better. Cognitive or dialectal behavioral therapy (CBT or DBT) are very good for dealing with the emotional upheaval from the trigger, but they don’t get rid of the actual trigger response. Adding the NRT treatment helps you reduce the misophonia trigger reflex that is the cause of the strong misophonic emotions.
[i] Dozier, in press
