A Brief Course Of Cognitive Behavioural Therapy For The .

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The Cognitive Behaviour Therapist (2013), vol. 6, e10, page 1 of 13doi:10.1017/S1754470X13000172PRACTICE ARTICLEA brief course of cognitive behavioural therapy for thetreatment of misophonia: a case exampleRosemary E. Bernstein , Karyn L. Angell and Crystal M. DehleDepartment of Psychology, University of Oregon, Eugene, Oregon, USAReceived 25 April 2013; Accepted 16 September 2013Abstract. Misophonia is a condition of unknown cause characterized by atypicallyintense negative physiological and emotional reactions to hearing certain sounds –most often those associated with oral functions. Individuals with misophonia oftenreport high levels of psychological distress and avoidance behaviours that seriouslycompromise their occupational and social functioning. As of yet, no effective treatmentof misophonia has been identified, and health care providers often struggle whenthey encounter clients who have it. This case report describes the assessment, caseformulation, and treatment of a client with misophonia using cognitive behaviouraltherapy (CBT), and serves as an initial contribution to the evidence base for the efficacyof CBT in the treatment of misophonia.Key words: Case study, 4S, misophonia, selective sound sensitivity, soft sound sensitivity syndrome.IntroductionMisophonia – a condition characterized by disproportionately strong affective andphysiological reactions to certain sounds – is a relatively recently identified† condition thatis empirically poorly understood (Schwartz et al. 2011). Sometimes called selective soundsensitivity syndrome (SSSS or 4S) or soft sound sensitivity, misophonia is not included inDSM-V (APA, 2013), has no formal diagnostic formulation, and has been referenced in onlya few research articles‡. Many had never heard of the condition before it was featured innews reports from the New York Times (Cohen, 2011) and the Today Show (Carroll, 2011)among others (e.g. Berman, 2011; Huffington Post Healthy Living, 2011; Kivi, 2011; SmithSquire, 2011; Cohen, 2012; Deutsch, 2012; Leaker, 2012). One positive consequence of thisrecent surge of media recognition is that it prompted sufferers to come forward in greater Authorfor correspondence: Ms. R. E. Bernstein, Department of Psychology, University of Oregon, 1227 Universityof Oregon, Eugene, Oregon 97403, USA (email: reb@uoregon.edu).†Historically, the same constellation of symptoms have fallen under the umbrella terms noise aversions or noisephobias, and have often been misdiagnosed as obsessive compulsive disorder or as part of the general sensorysensitivity frequently associated with autism spectrum and other developmental disorders (Robertson & Simmons,2013).‡Electronic database searches (via PsycINFO and Pubmed) for the term ‘misophonia’ on 17 January 2013 yieldeda combined seven journal articles or book chapters published between 2002 and 2012. Searches for related terms‘sound sensitivity syndrome’ and ‘selective sound sensitivity’ yielded zero publications. British Association for Behavioural and Cognitive Psychotherapies 2013

2R. E. Bernstein et al.numbers. Unfortunately, however, with such a dearth of research on misophonia and itstreatment, the practitioners (most of whom are audiologists) receiving this new wave ofpatients often struggle with how to care for them. Presently, the most typical form of treatmentfor misophonia involves a tinnitus retraining therapy device (Jastreboff et al. 1996; Jastreboff& Jastreboff, 2003) or other wearable white-noise generator to minimize awareness of theoffending sounds (Jastreboff, 2001). While this form of intervention can be helpful withmanaging symptoms, it does not treat the underlying syndrome.In this paper we suggest that cognitive behavioural therapy (CBT) may be an effectivetreatment for the underlying mechanisms involved in misophonia. Based on the assumptionthat the condition is not an auditory disorder caused by any anatomical anomaly (Møller,2010), but instead arises from an overly sensitized connection between the limbic andsympathetic nervous systems (SNS; Jastreboff & Hazell, 2004), we hypothesize that thisSNS hypersensitivity may represent a threshold effect amenable to changes in cognition,physiology, and behaviour. Further rationale for the utility of CBT comes from the fact thatmisophonia sufferers often have much stronger negative reactions to the sounds produced byclose others compared to those made by strangers, indicating a potent attributional componentto the syndrome. Indeed, there is already some anecdotal evidence to suggest that CBT mighteffectively treat misophonia. Recent medical journal articles (e.g. Schwartz et al. 2011) positthat CBT may help clients manage their emotions and behaviours when hearing or anticipatingoffending sounds. However, no empirical study has tested the efficacy of CBT for treatingmisophonia, nor has any case study documented a successful CBT treatment protocol. In thispaper, we present a CBT anxiety protocol adapted to treat a case of misophonia in a studentpresenting to a university training clinic.What is misophonia?The marked intolerance of specific sounds that characterizes misophonia was first termedselective sound sensitivity syndome (4S) by audiologist Marsha Johnson in the 1990s.Later, neuroscientist Pawel Jastreboff used the word misophonia (‘miso’ hatred and ‘phonia’sound) to refer to the same ‘abnormally strong negative reactions of the autonomic andlimbic systems to specific sounds resulting from enhanced functional connections betweenthe auditory and limbic systems’ (Tinnitus and Hyperacusis Clinic, 2010). According totheir conceptualization, the auditory system functions normally, without abnormally highactivation. At the behavioural level, however, triggering sounds evoke strong negativereactions (Misophonia UK, 2010).The most common reaction is extreme rage, but can also include feelings of anxiety,frustration, disgust, and harm ideation (Jastreboff & Hazell, 2004). Physiologically, thetriggering sound can induce an overwhelming SNS (i.e. a ‘fight or flight’) response. Sufferersmay experience a panicked desire to escape, or violent urges directed at the individual makingthe noxious sound. The aversive reactions misophonia sufferers experience are often so potentthat they can dominate lifestyle and occupational choices. People with the condition oftenalienate the people they are closest to, resulting in relationship dissolution, unemployment,and social isolation (Schwartz et al. 2011). The most frequently implicated triggering soundsin misophonia are those associated with oral functions (i.e. breathing, yawning, chewing,sniffling, swallowing), but can also include typing, pencil scratching, trickling water, orcrinkling paper (Schwartz et al. 2011).

Cognitive behavioural treatment of misophonia3Aetiology and symptom developmentThe aetiology of misophonia remains unknown. A sudden onset often occurs in late childhoodor early adolescence (Cohen, 2011). Initial symptoms involve noticing a particular feature ofa loved one’s eating or breathing habits. The afflicted individual quickly becomes obsessedby and hypersensitive to the sound(s). This sensitivity typically becomes worse over time, andoften generalizes to other noises, other people, and to visual images and actions associatedwith the noise (Cohen, 2011). Family members often react to sufferers’ first complaints withannoyance or dismissiveness. As afflicted individuals realize that their sensitivity is unique,they often feel ashamed, restrict requests for accommodation, and increase avoidance tominimize exposure. Unfortunately, sufferers tend to be triggered most by those to whom theyare closest (Misophonia UK, 2010).Case studyClient characteristics and presenting problemsLiz , a 19-year-old college student, was referred to our clinic for a profound aversion tothe sounds of people’s slurping, swallowing, and chewing. Although she found the chewingnoises of both close others and strangers unpleasant, she did not react to the same degree withstrangers as with housemates and family members. She typically responded to these soundswith disgust and intense irritation towards the perpetrator, often feeling an intense desire toharshly scold them. In reality, she tended to respond to triggers by glaring at the perpetratoror sighing repeatedly in exasperation. She speculated that she probably came across to othersas angry or annoyed. Because she regarded these sentiments as sharply inconsistent with herself-identity as a compassionate and loving person, she felt helpless, deeply ashamed of hersensitivity and remorseful that she was in any way imposing upon or limiting the personalfreedoms of others.At intake, Liz reported no current or past medical conditions or mental health treatmenthistory. She reported no familial history of mental illness, although one immediate familymember had a history of tinnitus. She reported first noticing her symptoms during familydinners in middle childhood. She used to complain or sometimes exaggeratedly mimicnoxious chewing noises in an attempt to communicate her distress to others, though her familymembers thought she was ‘just being a brat’. They sometimes temporarily (and begrudgingly)stopped making the sound, but they habitually forgot and typically reoffended minutes later.Liz had quickly grown frustrated by this pattern, which she saw as inevitable (‘no one thinksabout these things like I do – of course they’ll forget’). She told very few people about hermisophonia, and reported significant functional impairment, including an inability to enjoysocial meals, and avoidance of social events. At intake Liz was clear in her conceptualizationof her sensitivity as a personal, non-relational problem, and identified ‘fixing it’ as her soletreatment goal. Together with her therapist, realistic and time-limited treatment goals wereoperationalized as (1) significantly increasing her threshold for triggering sounds such that Namesand some identifying details have been changed to preserve the client’s anonymity. Liz originally gave herwritten informed consent to receive an untested treatment that we hoped would be effective for her. After we saw thattreatment had been effective, we obtained Liz’s permission to publish her case in this journal via subsequent consentprocess.

4R. E. Bernstein et al.noises deemed highly aversive or unbearable at pretreatment would become merely unpleasantand tolerable 6–12 weeks into treatment (the typical range for CBT interventions in theuniversity training clinic), (2) increasing the proportion of meals eaten in common areas withher housemates from 25% to 75%, and (3) increasing the proportion of social invitationsaccepted from 33% to 75%.Assessment proceduresLiz’s initial intake assessment included the Structured Clinical Interview for DSM-IV Axis IDisorders (SCID; First et al. 2002), the Stages of Change Questionnaire (SOC; McConnaughyet al. 1983), Beck Anxiety Inventory (BAI; Beck & Steer, 1993), Beck Depression InventoryII (BDI-II; Beck et al. 1996), and Beck Hopelessness Scale (BHS; Beck et al. 1974). She didnot meet diagnostic criteria for any Axis I disorder. She reported slight discomfort with publicspeaking, but no more than the average person. She reported past periods of sadness, but hadnever met criteria for depression. She endorsed no symptoms of disordered eating, no fear ofweight gain, and reported a stable body mass index. Liz’s SOC scores indicated she was in thecontemplation and action phases. Her self-reported scores were: BAI 1, BDI 4, BHS 3, indicating minimal levels of anxiety, depression, and hopelessness. Her Global Assessmentof Functioning (GAF) score was 70, reflecting impairments in her social and occupationalfunctioning .Treatment rationaleBecause Liz’s reactivity to auditory triggers differed by source, we hypothesized that hercognitions influenced her interpretation of and threshold for unpleasant sounds. Giventhe theoretical link CBT proposes between cognition, behaviour, and physiology, wehypothesized that this threshold would be sensitive to changes not only in cognition butin physiology and behaviour as well. We designed a brief, targeted course of CBT to treatmisophonia, informed by the anxiety and hypothalamic-pituitary-adrenal (HPA) axis literature(e.g. Gaab et al. 2003), that aimed to disrupt the pattern of negative reactivity, change coping,and decrease distress. The treatment plan included: (a) a cognitive component to challengedysfunctional automatic thoughts, (b) a behavioural component to interrupt maladaptive andavoidant coping strategies and practice helpful ones, and (c) a physiological component tohelp recalibrate her autonomic reactivity.Informed consentA consent form was designed to inform Liz that there was no established treatment protocolfor misophonia, and that we had never treated misophonia in our clinic. We explained thatwe had created an experimental protocol that we believed would work, but that she wouldbe the first to try it. As alternative options, we also provided a referral list of other treatmentproviders in the community. Impairmentsin Liz’s social functioning included moderate misophonia-related reluctance to socialize and strainedinterpersonal relationships, and those in occupational functioning included moderate distractibility in academicsettings that negatively impacted her school performance.

Cognitive behavioural treatment of misophonia5Table 1. Trigger hierarchySituationSUDSounds of my own chewingCrunching, belching, hiccupping, whistlingTyping, nail clippersSight of open-mouth chewing (no sound)Loud chewing on televisionStranger swallowing loudlyStranger chewing gum behind me in classHousemate swallowing with background noiseClose relative swallowing water with no distractorAnticipating someone about to start chewingHousemate swallowing loudly with no distractor051520306065757590100SUD, Subjective units of distress ratings were made on a 0–100 scale (0 norage, 100 highest rage possible).Session outlineSession 1: Creating a misophonia hierarchy and introducing the CBT modelLiz and her therapist created an exposure hierarchy to systematically review the scope of hertriggers. Subjective units of distress (SUD) ratings were made on a 0–100 scale (Table 1). Lizdescribed substantial variability in her reactivity depending on her relationship to the offender,her mood at the time, and the context of the event. After identifying a range of triggers,the therapist selected several to illustrate the interrelatedness of her cognitions, physiology,affect, and behaviour. In the first diagram (Fig. 1), the therapist emphasized the power ofher cognitive attributions by mapping Liz’s differential responses to the swallowing soundsmade by close others whom she believed were trying to be mindful of their noises (a relative,SUD 75) vs. those made by people who, despite knowing of her sensitivity, ‘seemed tohave forgotten’ (her housemate, SUD 100). A second diagram (Fig. 2) highlighted themoderating influence of behaviour on her affect by illustrating how different coping strategiesto the same moderate trigger (SUD 65) led to divergent functional and affective outcomes.For example, while promptly leaving the vicinity was associated with immediate relief butlonger-term feelings of disappointment; ‘sticking it out’ was associated with feelings ofpride and accomplishment. This understanding increased Liz’s motivation to persevere duringtriggers.Liz and the therapist concluded from this exercise that (1) her thoughts were centraldeterminants of her affective response such that different attributions about the intentionsand understanding of others lead to divergent affective and physiological outcomes, and (2)coping behaviours were key moderators of distress. Given the first of these two conclusions,the therapist used Socratic questioning to challenge Liz’s reluctance to talk to her roommatesabout her sensitivities and open her to the possibility that ongoing dialogue could alter herattributions and hence decrease negative affective response.Homework. (1) Start a monitoring record for all upcoming social eating situations recording:(a) details of the situation, (b) automatic thoughts, (c) her behavioural response, (d)

6R. E. Bernstein et al.Fig. 1. CBT model for situation 1. The interconnectivity between affect, physiology, behaviour, andcognition were illustrated in a five-column diagram. Two variants of a similar situation (one involvinga housemate, the other, one immediate family member) reveal different cognitive appraisals, withdivergent associated behavioural, physiological, and emotional responses. SNS, sympathetic nervoussystem.Fig. 2. CBT model for situation 2. The interconnectivity between affect, physiology, behaviour, andcognition were illustrated in a five-column diagram. While the behaviour of attending to sounds servedto amplify her anxiety and physiology; leaning forward and redirecting focus acted to reduce her noticingand thinking about the noises, dampen her anxiety, and decrease her fight-or-flight response. SNS,sympathetic nervous system.

Cognitive behavioural treatment of misophonia7her physiological response, and (e) her feelings; and (2) discuss her condition with herhousemates.Session 2: Defining the problemLiz’s second session began with a review of her monitoring homework. She recorded oneevening when she had ‘glared’ at her housemate who was eating a meal noisily. She suspectedthat her housemates discussed the incident among each other, for the next night a differenthousemate ate her meal extremely slowly and carefully. Liz initially felt regret and shame atthis possibility, although via Socratic questioning, Liz accepted the possibility that her housemate’s behaviour might signal care and consideration rather than annoyance and resentfulness.Liz and the therapist created a reactivity timeline to identify specific micro-processes inher response to auditory triggers. This revealed that, in anticipation of an impending trigger,she experienced a short period of anxiety and dread, and maintained an increased focus on thesound source. Once the trigger could be heard, her feelings of rage and physiological reactionsbegan. This timeline highlighted the fact that whenever she resisted the urge to leave the room,she found that her rage reliably subsided or habituated over time, rather than increasing untilescape.Liz and the therapist explored the strengths and limitations of her current behaviouralrepertoire by creating an exhaustive list of actual and possible coping strategies. Liz expressedreluctance to ‘overstep [her] bounds’, and a relatively low level of assertiveness. Usinghumour and hyperbole, the therapist modelled both appropriate and inappropriate affectiveresponses, having Liz join her in creating outlandish possibilities. Liz and the therapist thenestimated the utility of each strategy in a variety of contexts. Liz decided that the mosteffective strategies were: (1) distracting herself by creating other noises (e.g. humming,shuffling papers), (2) refocusing on the person instead of the triggering sounds they aremaking, and (3) refocusing on other available auditory stimuli (e.g. background music).Although she had only done so twice (with family members), (4) explaining her sensitivity andpolitely asking people to try not to make the sounds had been both helpful and well received(providing evidence that others may also be receptive).Less effective strategies tended to be less direct and included, in order of descendingutility, (5) leaning away from the source of the sound, (6) leaving the room, which, althougheffective, came with significant negative consequences, (7) ‘gritting her teeth and bearingit’, (8) glaring at the person making offensive sounds but saying nothing, and (9) mockingthem sarcastically. Although Liz had never utilized it as a strategy, she predicted that (10)yelling, lashing out, and/or

formulation, and treatment of a client with misophonia using cognitive behavioural therapy (CBT), and serves as an initial contribution to the evidence base for the efficacy of CBT in the treatment of misophonia. Key words: Case study, 4S, misophonia, selective sound sensitivity, soft

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