Research paperCognitive behavioral therapy is effective in misophonia: An open trial
Introduction
Misophonia is a psychiatric disorder, characterized by intense anger and disgust, which are triggered when patients are confronted with particular human sounds such as smacking, chewing, loud breathing, or typing. These sounds provoke agitation and impulsive aggression, which causes patients to avoid situations with possible misophonic triggers (Schröder et al., 2013). For instance, meals with other people, use of public transport or work related meetings are avoided. If situations cannot be evaded they are endured with intense suffering. The suffering and avoidance lead to major social and occupational impairment.
Misophonia is a new disorder and research into this field has only recently been emerging. The etiology of misophonia remains unknown. Patients with misophonia generally have normal hearing and misophonic reactions are not related to hearing thresholds (Schröder et al., 2013; Schröder et al., 2014; Jastreboff and Jastreboff, 2015). Therefore, misophonic reactions are thought to be due to increased connectivity between auditory and limbic brain regions (Cavanna and Seri, 2015, Jastreboff and Jastreboff, 2015). Furthermore, it has been associated with various psychiatric conditions, such as Tourette's syndrome and obsessive-compulsive personality disorder, suggesting a shared etiology (Cavanna and Seri, 2015, Webber et al., 2013, Schröder et al., 2013).
Because of its novelty, misophonia incidence and prevalence rates are still speculative. In an online survey amongst students (N=483) 20% reported significant misophonic symptoms (Wu et al., 2014), with the respondents primarily being comprised of female undergraduates and lacking psychiatric evaluation, therefore limiting generalizability. Based on data from an audiology clinic, it has been estimated that misophonia symptoms in the general population could be as high as 3.2% (Jastreboff and Jastreboff, 2014). However, the authors did not reveal how diagnosis was established, also reducing generalizability. Nevertheless, in just five years nearly 500 patients have been referred to our institute. This further suggests that misophonia is a hidden epidemic. Hence there is tremendous need for effective treatment.
Currently there is no evidence-based treatment available. Even though beneficial effects have been reported in patients treated at an audiology clinic, interpretation is limited due to an absence of a valid assessment method for diagnosis, symptom severity and improvement (Jastreboff and Jastreboff, 2014). Interestingly, positive results have been described in six cases, who were treated with cognitive behavioral therapy (CBT) (Bernstein et al., 2013, Dozier, 2015a, Dozier, 2015b, McGuire et al., 2015, Reid et al., 2016). CBT techniques were also applied in a pilot study at our institute. In this unpublished study seven patients showed promising improvement following bi-weekly group CBT. We therefore decided to determine the efficacy of group CBT in a larger study. Additionally, to add to our current knowledge on misophonia and the effect of CBT, we investigated if clinical and demographic factors predicted treatment response.
Section snippets
Subjects
Ninety patients (65 women, 25 men) referred because of misophonia were included. They visited the outpatient clinic at the department of psychiatry at the AMC between April 2012 and November 2013. Exclusion criteria were the presence of substance dependence, bipolar disorder, autism spectrum disorders or psychotic disorders. The study was carried out in accordance with the Declaration of Helsinki and was approved by the AMC medical ethics committee. All patients provided informed consent. Table
Results
Patients were between 18 and 64 years of age (mean 35.8, SD 12.2) with a mean baseline A-MISO-S score of 13.6 (SD 2.9, range 7–23), corresponding with moderate misophonia (Table 1). Moderate symptoms were characterized by disturbing anger or disgust with definite interference with social and occupational performance. Sufferers were occasionally able to stop or divert their thoughts about misophonic sounds but frequently avoided these triggers. For example, sufferers usually did not have meals
Discussion
This is the first large study to investigate treatment for misophonia and to explore predictive factors of treatment response. Our study shows that group CBT reduced misophonia symptoms in nearly half of the patients. In addition, we found that high baseline A-MISO-S scores and the presence of disgust were positive predictors of treatment response. This indicates that patients with more severe misophonia and those who also experienced disgust when confronted with misophonic triggers were more
Conclusion
Our study demonstrated that misophonia can be treated with CBT. Task concentration exercises, counterconditioning, stimulus manipulation, and relaxation exercises decreased misophonia symptoms in one half of the patients. The results of our study are particularly encouraging because many of the patients at our hospital had suffered from misophonia for many years and had not responded to various treatments they had previously received.
Since our primary aim was to investigate if CBT was
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