Treatments to Avoid
As discussed previously, there is something about the misophonia reflex response to triggers that causes them to strengthen with repeated, real world exposure to triggers. Because of this, a person and their therapist should be careful about having a person endure real-world triggers and hoping/expecting that the misophonic response will die out (technically speaking extinguish or habituate).
A commonly occurring view of misophonia is that it seems a lot like obsessive-compulsive disorder (OCD), so it (incorrectly) makes sense to treat misophonia the same way that you would treat OCD, but only to someone who does not understand the different components of the misophonic response. Generally OCD is responding to reduce anxiety caused by the person’s thoughts. For example, a person thinks, “Maybe I didn’t lock the back door.” This causes a bit of anxiety, and when the person checks the back door, the anxiety is reduced. The anxiety and urge to perform the behavior is an involuntary response, but the actual behavior is a purposeful behavior – a choice. The act of performing the compulsive behavior reduces the person’s anxiety, and so the compulsive behavior has an immediate payoff/reward for the individual. When the person resists the compulsion, the anxiety will naturally subside, and so the person learns to allow the anxiety to go away naturally instead of performing the compulsion. This form of treatment is also known as exposure and response prevention. The “exposure” is the normally occurring thoughts and events that trigger anxiety, and “response prevention” is either not doing the compulsive behavior until the anxiety naturally subsides, or doing the act many times (a mild punishment) if the person yields to the impulse. This treatment makes no sense for misophonia, because the misophonic physical reflex response is an involuntary reflex behavior and so is the emotional response. If the punishment is applied for a person getting angry, it will simply increase the frustration because the person is trying to not get angry already, but cannot stay calm. If the punishment is applied for acting out (coping behaviors) after the physical reflex and emotional response, then we are trying to change the acting out behavior using punishment. Using punishment almost always includes bad feelings of some sort, and so it is far less likely to work than using a positive reward for controlling antisocial coping behaviors.
In either case, controlling the coping behaviors does not address the first four components of the misophonic response, and so repeated exposure to the trigger will simply cause these responses to become stronger.
With misophonia, the stimulus is external (sound) and not internal (thoughts). The response to the trigger stimulus is a physical/anger reflex and physiological arousal, which is generally impossible to prevent. It is true that the person can respond in prescribed ways after the anger reflex (such as relaxing all muscles) but they cannot prevent the physical/anger reflex – it is a REFLEX! So exposing a person to typical triggers and instructing them to not respond does not make sense. A misophonic may be able to not act out (stay seated, not yell, etc.) but the person still has the immediate reflex response, and without special training, such as muscle relaxation, the misophonic reflex is likely to become stronger.
As explained previously, relaxing your muscles before a trigger can change the physical reflex. This creates a Pavlovian conditioning event which changes the Pavlovian conditioned misophonic reflex. This is a completely different brain plasticity mechanism than with OCD exposure and response prevention, which is a purposeful behavior.
The Truth and Myth of Exposure Therapy
The truth about exposure therapy is that exposure to full strength misophonic triggers while hoping that the person with habituate (stop responding) does not work, and it is probably the worst possible treatment for misophonia. [The therapist says, “Sit here while I eat this bag of Fritos. I am sure it will help your misophonia if we do it enough times.”] There are very few reports of this working for people, but I expect it will only work when a person is very motivated to engage in this treatment. It is definitely a treatment that should be avoided for children. With flooding exposure therapy, the individual is exposed to full strength, real-life triggers for a period of time. This may initially be a short time, and then be progressively longer and longer. The problem with this treatment is that it can strengthen the initial physical reflex and the emotional response during the treatment. It can also lead to new triggers developing during this process. There are many reports of individuals on misophonia groups who say that such exposure therapy made their misophonia worse.
The myth of exposure therapy is that any and all forms of exposure to triggers during treatment should be avoided – that exposure therapy is always bad. This is absolutely not true. There appears to be correct and incorrect ways to perform exposure therapy. As explained in the section on cognitive behavioral therapy, graduated exposure has been effective in several case studies presented in peer-reviewed journals and as reported by therapists I know. It is important to make sure you are staying calm, and even becoming less distressed as the treatment progresses. But beware of exposing yourself to full strength triggers as a way of reducing your misophonia. You will likely be asked to listen to some triggers with CBT, but you will also be taught ways to calm yourself. It is okay to practice this with a few triggers, and then slowly build up the skill of relaxing, which is a way of reducing the emotional response to the triggers.
Consider the Neural Repatterning Technique (Trigger Tamer). That treatment modifies and reduces the trigger to produce a tiny misophonic response. Yes there is exposure to triggers in a very controlled way that allows your brain to change. With Progressive Muscle Relaxation as a treatment, the person relaxes all of their muscles in a trigger situation, and the miso-response decreases. It is a false myth that any and all treatments which include hearing triggers is harmful
However, if someone suggests you simply expose yourself to real-world triggers until you stop responding, especially someone who is not an expert on misophonia, I suggest you consider another treatment or even another treatment provider.