Have You Been Wondering About Misophonia Treatment?

Misophonia is best characterized as a disorder that crosses the boundaries of disciplines. For many people with misophonia, it is hard to figure out which kind of clinician to see and what kind of research supports various interventions across audiology, psychology, and occupational therapy. In the mental health realm, cognitive behavioral therapy (CBT) is considered a standard treatment for many disorders.

One such therapy is the unified protocol (for transdiagnostic treatment of emotional disorders, aka UP). While misophonia is not considered a psychological disorder, it certainly causes emotional distress. Kibby McMahon and Clair Cassiello-Robbins were instrumental in developing the UP with the Duke research team at the Duke Center for Misophonia and Emotion Regulation. Here, the researchers answer questions to help those with misophonia understand how the UP is different from other CBTs, how it fits into a multidisciplinary model, and who might benefit from this intervention. They also explain their own clinical findings as they practice with the UP.

Would you explain how the UP is different from other CBT approaches?

Clair: The UP is a transdiagnostic treatment, which means that it addresses presenting problems across diagnostic categories. Instead of focusing on a specific diagnosis or set of symptoms (sometimes called a diagnosis-specific treatment), it focuses on how people experience and manage their emotions, no matter what diagnoses they have or do not have.

How does this differ from other CBT approaches?

Clair: Transdiagnostic treatments came about because diagnosis-specific CBTs don’t necessarily address the various co-occurring issues that bring people to therapy. While we know misophonia causes distress and interference in people’s lives, the ICD and DSM do not provide a diagnostic label for it. Thus, there is not a diagnosis-specific treatment for it. Because the unified protocol focuses on how people experience and respond to their emotions, it can still be helpful for people with misophonia even though there is no diagnosis for the condition.

Why this approach to misophonia?

Clair: Great question! A lot of people with misophonia indicate that they experience strong emotions in response to misophonic cues, notably anger and anxiety (although they can experience any emotions). Many people with misophonia describe the emotions they experience in response to misophonic cues as one of the most aversive parts of the condition and engage in efforts to avoid these emotions that are ultimately unhelpful (e.g., avoidance can feel helpful in the short term, but limiting over time). Therefore, the UP’s focus on learning how to manage strong emotions can help people with misophonia manage this component of the condition.

Would you briefly describe the different modules included in the UP?

Kibby: The UP consists of modules that include motivation enhancement (focusing on and identifying goals), understanding emotions, mindfulness skills, cognitive flexibility, recognizing behavior, tolerating the physical sensations associated with strong emotion, and emotion exposure. Finally, the last module focuses on relapse prevention and how to handle setbacks.

Would you tell me a little bit about what you mean by emotion exposure?

Clair: I know many people with misophonia are understandably hesitant to engage in exposure. Exposure in the UP is about learning to experience and manage emotions, not trying to habituate to a sound (i.e., listening to a trigger sound over and over with the hope that it feels less aversive over time).

Would you tell me more about the difference between the kind of exposure used in the UP versus traditional habituation-based exposure?

Clair: In habituation-based exposure, people with misophonia are instructed to listen to trigger sounds repeatedly until the sound is no longer bothersome (in theory). There is no evidence to indicate that this type of exposure is helpful in treating misophonia. Instead, inhibitory learning exposure takes a different approach as it involves teaching people strategies they can use intentionally to tolerate and manage uncomfortable experiences.

We often talk about multidisciplinary approaches to misophonia care. Of course, the UP is meant for mental health practitioners. Would you suggest utilizing the UP within a multidisciplinary model? How might this work?

Kibby: Absolutely. The UP can help folks with misophonia learn to manage the emotions they experience effectively. A mental health provider using the UP can collaborate with other members of a multidisciplinary team.

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Would you explain how this treatment aligns with the neuroscience studies of misophonia?

Kibby: One example is a recent fMRI study which found that when people with misophonia were exposed to aversive misophonic cues, they had increased emotional responses, physiological arousal, and activation of the auditory cortex and salience network (Schröder et al., 2019). This study highlights the role of emotion in misophonia and the need for treatments that can help people manage these emotional responses.

What should a person expect after treatment with the UP?

Kibby: It is hard for us to know what to expect after treatment with the UP because everybody’s different, and we don’t have enough studies to make general conclusions. In our clinical work and through this study, we have seen several different types of outcomes. Some people found they are less reactive to sounds, others reported feeling like it has “taken the edge off,” and some said that they don’t even notice trigger sounds anymore! Other people found they still have strong reactions to sounds, but they have a few “go-to” skills that they use to respond to their reactions in healthy ways.

Are there any people for whom you would not suggest using the UP? (I am wondering about adults with neurodevelopmental disorders, learning disabilities, language impairment, etc.)

Clair: If a patient is not primarily struggling with managing emotions, the UP is not the right fit. For example, patients with schizophrenia who are primarily struggling with hallucinations and delusions are not a good fit for UP. Additionally, because the UP is primarily a talk therapy, patients who are unable to communicate verbally may also not be a good fit.

Finally, the UP is a cognitive behavioral therapy that has the best outcomes if the patient is willing and able to practice the skills in their daily lives in between sessions (i.e., complete therapy homework). If people are unable to do so, the UP will not be as effective as we would hope. The UP is a very flexible treatment, so it can be adapted for many different learning styles. That being said, it is important for the therapist and patient to collaborate to ensure they both want to use the UP and to determine if any changes are needed to make the treatment more accessible to the patient.

Is the UP effective for children?

Kibby: There are child and adolescent versions of the UP that are well supported by research. There is ongoing research to see if these treatments are helpful to children or adolescents with misophonia. One study suggested that the UP improved evaluator-rated misophonia symptoms in four pilot cases. New research is comparing the UP for children and adolescents to a comparison of relaxation and education conditions. This study will be a significant contribution to this field.

Finally, are there any limitations of the study that you would like to point out?

Kibby: The most notable limitation is that it was a small study using a single case design with eight patients in the first phase and 10 patients in the second phase. While we used a research design that is powerful for small samples, it will still be important to replicate this study in larger samples to ensure that the results are generalizable.