The Cognitive Behaviour Therapist (2013), vol. 6, e10, page 1 of 13
A brief course of cognitive behavioural therapy for the
treatment of misophonia: a case example
Rosemary E. Bernstein∗, Karyn L. Angell and Crystal M. Dehle
Department of Psychology, University of Oregon, Eugene, Oregon, USA
Received 25 April 2013; Accepted 16 September 2013
Abstract. Misophonia is a condition of unknown cause characterized by atypically
intense negative physiological and emotional reactions to hearing certain sounds –
most often those associated with oral functions. Individuals with misophonia often
report high levels of psychological distress and avoidance behaviours that seriously
compromise their occupational and social functioning. As of yet, no effective treatment
of misophonia has been identiﬁed, and health care providers often struggle when
they encounter clients who have it. This case report describes the assessment, case
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 sound sensitivity syndrome.
Misophonia – a condition characterized by disproportionately strong affective and
physiological reactions to certain sounds – is a relatively recently identiﬁed†condition that
is empirically poorly understood (Schwartz et al. 2011). Sometimes called selective sound
sensitivity syndrome (SSSS or 4S) or soft sound sensitivity, misophonia is not included in
DSM-V (APA, 2013), has no formal diagnostic formulation, and has been referenced in only
a few research articles‡. Many had never heard of the condition before it was featured in
news 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; Smith-
Squire, 2011; Cohen, 2012; Deutsch, 2012; Leaker, 2012). One positive consequence of this
recent surge of media recognition is that it prompted sufferers to come forward in greater
∗Author for correspondence: Ms. R. E. Bernstein, Department of Psychology, University of Oregon, 1227 University
of Oregon, Eugene, Oregon 97403, USA (email: email@example.com).
†Historically, the same constellation of symptoms have fallen under the umbrella terms noise aversions or noise
phobias, and have often been misdiagnosed as obsessive compulsive disorder or as part of the general sensory
sensitivity frequently associated with autism spectrum and other developmental disorders (Robertson & Simmons,
‡Electronic database searches (via PsycINFO and Pubmed) for the term ‘misophonia’ on 17 January 2013 yielded
a 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 its
treatment, the practitioners (most of whom are audiologists) receiving this new wave of
patients often struggle with how to care for them. Presently, the most typical form of treatment
for misophonia involves a tinnitus retraining therapy device (Jastreboff et al. 1996; Jastreboff
& Jastreboff, 2003) or other wearable white-noise generator to minimize awareness of the
offending sounds (Jastreboff, 2001). While this form of intervention can be helpful with
managing symptoms, it does not treat the underlying syndrome.
In this paper we suggest that cognitive behavioural therapy (CBT) may be an effective
treatment for the underlying mechanisms involved in misophonia. Based on the assumption
that 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 and
sympathetic nervous systems (SNS; Jastreboff & Hazell, 2004), we hypothesize that this
SNS 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 that
misophonia sufferers often have much stronger negative reactions to the sounds produced by
close others compared to those made by strangers, indicating a potent attributional component
to the syndrome. Indeed, there is already some anecdotal evidence to suggest that CBT might
effectively treat misophonia. Recent medical journal articles (e.g. Schwartz et al. 2011) posit
that CBT may help clients manage their emotions and behaviours when hearing or anticipating
offending sounds. However, no empirical study has tested the efﬁcacy of CBT for treating
misophonia, nor has any case study documented a successful CBT treatment protocol. In this
paper, we present a CBT anxiety protocol adapted to treat a case of misophonia in a student
presenting to a university training clinic.
What is misophonia?
The marked intolerance of speciﬁc sounds that characterizes misophonia was ﬁrst termed
selective 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 and
limbic systems to speciﬁc sounds resulting from enhanced functional connections between
the auditory and limbic systems’ (Tinnitus and Hyperacusis Clinic, 2010). According to
their conceptualization, the auditory system functions normally, without abnormally high
activation. At the behavioural level, however, triggering sounds evoke strong negative
reactions (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, the
triggering sound can induce an overwhelming SNS (i.e. a ‘ﬁght or ﬂight’) response. Sufferers
may experience a panicked desire to escape, or violent urges directed at the individual making
the noxious sound. The aversive reactions misophonia sufferers experience are often so potent
that they can dominate lifestyle and occupational choices. People with the condition often
alienate the people they are closest to, resulting in relationship dissolution, unemployment,
and social isolation (Schwartz et al. 2011). The most frequently implicated triggering sounds
in misophonia are those associated with oral functions (i.e. breathing, yawning, chewing,
snifﬂing, swallowing), but can also include typing, pencil scratching, trickling water, or
crinkling paper (Schwartz et al. 2011).
Cognitive behavioural treatment of misophonia 3
Aetiology and symptom development
The aetiology of misophonia remains unknown. A sudden onset often occurs in late childhood
or early adolescence (Cohen, 2011). Initial symptoms involve noticing a particular feature of
a loved one’s eating or breathing habits. The afﬂicted individual quickly becomes obsessed
by and hypersensitive to the sound(s). This sensitivity typically becomes worse over time, and
often generalizes to other noises, other people, and to visual images and actions associated
with the noise (Cohen, 2011). Family members often react to sufferers’ ﬁrst complaints with
annoyance or dismissiveness. As afﬂicted individuals realize that their sensitivity is unique,
they often feel ashamed, restrict requests for accommodation, and increase avoidance to
minimize exposure. Unfortunately, sufferers tend to be triggered most by those to whom they
are closest (Misophonia UK, 2010).
Client characteristics and presenting problems
Liz∗, a 19-year-old college student, was referred to our clinic for a profound aversion to
the sounds of people’s slurping, swallowing, and chewing. Although she found the chewing
noises of both close others and strangers unpleasant, she did not react to the same degree with
strangers as with housemates and family members. She typically responded to these sounds
with disgust and intense irritation towards the perpetrator, often feeling an intense desire to
harshly scold them. In reality, she tended to respond to triggers by glaring at the perpetrator
or sighing repeatedly in exasperation. She speculated that she probably came across to others
as angry or annoyed. Because she regarded these sentiments as sharply inconsistent with her
self-identity as a compassionate and loving person, she felt helpless, deeply ashamed of her
sensitivity and remorseful that she was in any way imposing upon or limiting the personal
freedoms of others.
At intake, Liz reported no current or past medical conditions or mental health treatment
history. She reported no familial history of mental illness, although one immediate family
member had a history of tinnitus. She reported ﬁrst noticing her symptoms during family
dinners in middle childhood. She used to complain or sometimes exaggeratedly mimic
noxious chewing noises in an attempt to communicate her distress to others, though her family
members 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 thinks
about these things like I do – of course they’ll forget’). She told very few people about her
misophonia, and reported signiﬁcant functional impairment, including an inability to enjoy
social meals, and avoidance of social events. At intake Liz was clear in her conceptualization
of her sensitivity as a personal, non-relational problem, and identiﬁed ‘ﬁxing it’ as her sole
treatment goal. Together with her therapist, realistic and time-limited treatment goals were
operationalized as (1) signiﬁcantly increasing her threshold for triggering sounds such that
∗Names and some identifying details have been changed to preserve the client’s anonymity. Liz originally gave her
written informed consent to receive an untested treatment that we hoped would be effective for her. After we saw that
treatment had been effective, we obtained Liz’s permission to publish her case in this journal via subsequent consent
4R. E. Bernstein et al.
noises deemed highly aversive or unbearable at pretreatment would become merely unpleasant
and tolerable 6–12 weeks into treatment (the typical range for CBT interventions in the
university training clinic), (2) increasing the proportion of meals eaten in common areas with
her housemates from 25% to 75%, and (3) increasing the proportion of social invitations
accepted from 33% to 75%.
Liz’s initial intake assessment included the Structured Clinical Interview for DSM-IV Axis I
Disorders (SCID; First et al. 2002), the Stages of Change Questionnaire (SOC; McConnaughy
et al. 1983), Beck Anxiety Inventory (BAI; Beck & Steer, 1993), Beck Depression Inventory
II (BDI-II; Beck et al. 1996), and Beck Hopelessness Scale (BHS; Beck et al. 1974). She did
not meet diagnostic criteria for any Axis I disorder. She reported slight discomfort with public
speaking, but no more than the average person. She reported past periods of sadness, but had
never met criteria for depression. She endorsed no symptoms of disordered eating, no fear of
weight gain, and reported a stable body mass index. Liz’s SOC scores indicated she was in the
contemplation and action phases. Her self-reported scores were: BAI =1, BDI =4, BHS =
3, indicating minimal levels of anxiety, depression, and hopelessness. Her Global Assessment
of Functioning (GAF) score was 70, reﬂecting impairments in her social and occupational
Because Liz’s reactivity to auditory triggers differed by source, we hypothesized that her
cognitions inﬂuenced her interpretation of and threshold for unpleasant sounds. Given
the theoretical link CBT proposes between cognition, behaviour, and physiology, we
hypothesized that this threshold would be sensitive to changes not only in cognition but
in physiology and behaviour as well. We designed a brief, targeted course of CBT to treat
misophonia, 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 challenge
dysfunctional automatic thoughts, (b) a behavioural component to interrupt maladaptive and
avoidant coping strategies and practice helpful ones, and (c) a physiological component to
help recalibrate her autonomic reactivity.
A consent form was designed to inform Liz that there was no established treatment protocol
for misophonia, and that we had never treated misophonia in our clinic. We explained that
we had created an experimental protocol that we believed would work, but that she would
be the ﬁrst to try it. As alternative options, we also provided a referral list of other treatment
providers in the community.
∗Impairments in Liz’s social functioning included moderate misophonia-related reluctance to socialize and strained
interpersonal relationships, and those in occupational functioning included moderate distractibility in academic
settings that negatively impacted her school performance.
Cognitive behavioural treatment of misophonia 5
Table 1. Trigger hierarchy
Sounds of my own chewing 0
Crunching, belching, hiccupping, whistling 5
Typing, nail clippers 15
Sight of open-mouth chewing (no sound) 20
Loud chewing on television 30
Stranger swallowing loudly 60
Stranger chewing gum behind me in class 65
Housemate swallowing with background noise 75
Close relative swallowing water with no distractor 75
Anticipating someone about to start chewing 90
Housemate swallowing loudly with no distractor 100
SUD, Subjective units of distress ratings were made on a 0–100 scale (0 =no
rage, 100 =highest rage possible).
Session 1: Creating a misophonia hierarchy and introducing the CBT model
Liz and her therapist created an exposure hierarchy to systematically review the scope of her
triggers. Subjective units of distress (SUD) ratings were made on a 0–100 scale (Table 1). Liz
described 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 of
her cognitive attributions by mapping Liz’s differential responses to the swallowing sounds
made 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 to
have forgotten’ (her housemate, SUD =100). A second diagram (Fig. 2) highlighted the
moderating inﬂuence of behaviour on her affect by illustrating how different coping strategies
to 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 but
longer-term feelings of disappointment; ‘sticking it out’ was associated with feelings of
pride and accomplishment. This understanding increased Liz’s motivation to persevere during
Liz and the therapist concluded from this exercise that (1) her thoughts were central
determinants of her affective response such that different attributions about the intentions
and 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 roommates
about her sensitivities and open her to the possibility that ongoing dialogue could alter her
attributions 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, and
cognition were illustrated in a ﬁve-column diagram. Two variants of a similar situation (one involving
a housemate, the other, one immediate family member) reveal different cognitive appraisals, with
divergent associated behavioural, physiological, and emotional responses. SNS, sympathetic nervous
Fig. 2. CBT model for situation 2. The interconnectivity between affect, physiology, behaviour, and
cognition were illustrated in a ﬁve-column diagram. While the behaviour of attending to sounds served
to amplify her anxiety and physiology; leaning forward and redirecting focus acted to reduce her noticing
and thinking about the noises, dampen her anxiety, and decrease her ﬁght-or-ﬂight response. SNS,
sympathetic nervous system.
Cognitive behavioural treatment of misophonia 7
her physiological response, and (e) her feelings; and (2) discuss her condition with her
Session 2: Deﬁning the problem
Liz’s second session began with a review of her monitoring homework. She recorded one
evening when she had ‘glared’ at her housemate who was eating a meal noisily. She suspected
that her housemates discussed the incident among each other, for the next night a different
housemate ate her meal extremely slowly and carefully. Liz initially felt regret and shame at
this possibility, although via Socratic questioning, Liz accepted the possibility that her house-
mate’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 in
her 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 the
sound source. Once the trigger could be heard, her feelings of rage and physiological reactions
began. 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 until
Liz and the therapist explored the strengths and limitations of her current behavioural
repertoire by creating an exhaustive list of actual and possible coping strategies. Liz expressed
reluctance to ‘overstep [her]bounds’, and a relatively low level of assertiveness. Using
humour and hyperbole, the therapist modelled both appropriate and inappropriate affective
responses, having Liz join her in creating outlandish possibilities. Liz and the therapist then
estimated the utility of each strategy in a variety of contexts. Liz decided that the most
effective 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 are
making, 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 and
politely 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 descending
utility, (5) leaning away from the source of the sound, (6) leaving the room, which, although
effective, came with signiﬁcant negative consequences, (7) ‘gritting her teeth and bearing
it’, (8) glaring at the person making offensive sounds but saying nothing, and (9) mocking
them sarcastically. Although Liz had never utilized it as a strategy, she predicted that (10)
yelling, lashing out, and/or throwing food at them (hyperbolic suggestion) would be the most
ineffective strategy. Liz and the therapist reﬂected on the fact that although she used a number
of effective strategies, all were regulatory and post hoc – occurring after her physiological
and emotional reactions had begun. They brainstormed ways to modify these strategies for
earlier use to prevent the response cascade before it began. For example, she might distract
herself with humming, shufﬂing papers, or focusing on background noise prior to becoming
physiologically aroused, or engaging in conversation with someone before they start eating to
promote a focus on the person rather than the offensive sound.
Liz had not completed her homework because she did not have a conversation with her
housemates about her misophonia. She reported that she had not found the ‘right opportunity’
as she did not want to ‘disrupt or shame’ them while they were eating. In the spirit of using
8R. E. Bernstein et al.
pre-emptive strategies, she offered to initiate such a conversation while they were not making
offensive noises. Liz was nervous about initiating this conversation ‘out of the blue’, but the
therapist reminded her that evidence from previous interactions with relatives and housemates
suggested that she was more likely be met with sensitivity and care than anger and resistance.
Homework. (1) Continue practising effective regulatory coping strategies, (2) start using new
preventative strategies, and (3) use a four-column format to record behaviours, thoughts,
emotions, and physiology. Such monitoring would help test whether disrupting her automatic
thoughts might prevent distress escalation, and to determine the ﬂexibility of her cognitions.
Session 3: Testing physiology
On the third session, Liz’s monitoring noted one instance of her looking away before a
housemate drank water, which had kept her from becoming agitated. She also reported that
she had talked with two of her housemates while out on a walk about her continued reaction
to their eating sounds. Her housemates seemed surprised by her admission. They told her
they had been respecting her previous assurance to them that the problem was hers; and that
they should not change their behaviour on her account. Her housemates had listened and
remained non-defensive during this conversation. However, she noted little if any difference
in their behaviour since, which left her feeling irritated, exasperated, and doubtful that
they could change. Using Socratic questioning and reviewing the evidence, Liz re-evaluated
her scepticism, and reasoned that given many requests she had made of her family, one
conversation with her housemates would not likely resolve everything. Reframed, this was
seen as a ﬁrst step towards a constructive, open dialogue, which engendered more optimism.
Liz reported that she looked forward to continuing the conversation with more speciﬁcs about
the triggers that are especially bothersome.
Next, the therapist introduced the role of physiology in misophonia. She described the role
of the HPA axis in sound reactivity via the ﬁght-or-ﬂight mechanism, and the ﬂexibility of this
system to change. A brief psychoeducational segment outlined how physical exercise serves
two important therapeutic functions: (1) it modiﬁes HPA axis reactivity, and (2) increases
endorphins (notable here as Liz had previously reported lowered reactivity to offensive sounds
when in a good mood). Liz reported having no current meditation or exercise routine other
than bike-commuting to campus. She enthusiastically agreed to complete 20 minutes of
exercise immediately before dinner for three or four nights during the week. Refraining
from exercising the remaining nights would serve as an experimental manipulation to test
the hypothetical association between physical activity and symptomology.
Homework. (1) Eat all her evening meals in the company of others, (2) track her reactions
to eating sounds after exercise, and (3) document her thoughts using a thought record during
Session 4: Developing alternative strategies
Liz reported improvement in her symptoms. Twice she had exercised before dinner, so she
and the therapist reviewed her detailed thought record. Although she enjoyed feeling more
active, her uniformly low levels of self-reported distress throughout the week made it difﬁcult
Cognitive behavioural treatment of misophonia 9
to conclude whether exercise was a factor in this. Liz partially attributed her good week to
her realization that ‘if someone makes an effort for me or asks questions, I’m more lenient
... [and more]. . . willing to make the effort for them [to be forgiving or patient]because
they did the same for me’. This realization came after a conversation with a housemate, who
asked if it was okay to ask questions about her symptoms. To this, Liz felt immense warmth
and gratitude. Liz’s report of this interaction in session led to a conversation about her current
communicative tendencies, and an examination of their effectiveness. The four people with
whom she had discussed her symptoms responded positively and non-defensively, and three
of those had made accommodative efforts. This again provided evidence that close others are
receptive to these requests even though she feels reluctance and shame bringing them up.
Next, Liz and the therapist examined the difference between direct speciﬁc requests and
vague or non-speciﬁc methods. They concluded that Liz’s non-speciﬁc sighs and glares do
a good job at communicating displeasure, but do not help the offender understand how
they might behave differently. Direct speciﬁc requests, on the other hand, may seem more
confrontational (and thus aversive) but are more likely to solve the problem. Liz further
reﬂected that over time, her own indirect pleas for accommodation may have perpetuated
her aggravation with others (i.e. ‘why don’t they get that I’m mad, and why won’t they ask me
about it?’). The self-effacing verbal qualiﬁers she had given her housemates (e.g. ‘I’m going
to therapy to work on this myself’, and ‘please don’t feel you have to change for me, I know
it’s my issue’) were counterproductive. Once Liz understood why her current methods might
be ineffective, she and the therapist role-played ways of talking openly to her housemates that
felt sensitive, not demanding, and sufﬁciently speciﬁc. In this way, Liz would also be able to
model to them that the topic was not taboo.
Once again, the therapist used humour and hyperbole to challenge Liz’s conception of
what was ‘too’ demanding, and to facilitate a more realistic, balanced example of appropriate
assertiveness. Using a continuum, the therapist plotted extreme demanding and rude behaviour
(e.g. ‘Shut up, idiot!’) at one end of the continuum and the most passive and non-speciﬁc
methods (e.g. glaring, sighing) on the other. The therapist then prompted Liz to imagine what
might belong in the middle. Via an iterative process, Liz generated language that was speciﬁc,
friendly, optimistic, and collaborative (e.g. inviting continued dialogue, joint problem solving,
and labeling offensive noises.) Using this new language, she anticipated that her housemates
might feel a better sense of control, she would feel more comfortable making speciﬁc requests
in ways that her housemates preferred, and all parties might feel more effective in their
communication. Liz wrote down what she had composed in session, and expressed excitement
about her next talk with her housemates.
Homework. (1) New communication with housemates, (2) continue exercising before meals,
and (3) practice the behavioural pre-emptive and coping strategies previously covered.
Session 5: Consolidating gains
Liz continued to report improvement. She had a productive, open conversation with her
housemates who reacted positively and appeared more relieved than defensive. Together, they
agreed on a method by which Liz could offer feedback when she was triggered. Liz reported
that she did not have to do so, however, as she had not noticed a single instance of being
bothered that week.
10 R. E. Bernstein et al.
Despite these major gains, Liz reported some uncertainties about her improvement and fears
about getting better, namely, that (1) now that the ‘big stuff’ was no longer bothering her, ‘the
little things’ (like crunching) would become bothersome; (2) that by talking to people more
candidly about her symptoms and becoming more mindful of their oral noises, they might
develop misophonia; (3) that by continuing to initiate anxiety-provoking conversations about
her symptoms she might ‘use up’ her complaint ‘allowance’ on this issue, and would ‘not be
able to get upset about other things like not washing dishes’; and (4) that the progress she
made might be due to the weekly reinforcement of therapy, and that she might relapse without
The therapist responded by examining the evidence for each of her concerns. Regarding
the ﬁrst concerns, Liz admitted that she had not yet experienced any such change. Without
supporting evidence, this fear became less concerning. Regarding her second worry, she
reported that two people had reported being more bothered by eating noises since Liz had
discussed her symptoms with them. Through Socratic questioning, Liz was able to distinguish
‘normal’ displeasure in hearing noises generally considered unattractive and rude from a
misophonia sufferer’s discomfort and rage. She concluded that other people’s increased
distaste for such sounds was less likely indicative of contagion and more likely due to an
increased mindfulness towards its impoliteness. Still, Liz decided she did not want to tell
others with whom she was not close, and felt that confrontation in those cases was not worth
the effort, time, or embarrassment.
Regarding her third fear, Liz conﬁrmed that her aversion to confrontation generalizes across
domains, and that ‘in any situation, [she is]always the one to concede and let other people’s
needs come before [hers]’. Although being confrontational had been universally difﬁcult, she
reported generally feeling good about its outcome. Liz noticed her conﬁdence growing, and
she felt more assertive in other domains. She attributed this to the conversation she had with
her housemates about the importance of honesty and open communication. Her fourth concern
prompted a discussion about treatment termination and relapse prevention. The therapist
suggested that they meet in 2 weeks to test whether Liz could maintain her healthy attitude
without ‘weekly reminders’. At that time, they would discuss criteria for ending treatment,
including Liz’s perceived readiness, and strategize around relapse prevention.
Homework. (1) Track the number of times she felt bothered or irritated by misophonia to
determine if her irritation escalated as more time passed from her last therapy session, and (2)
continue with exercise, communication, behaviour coping.
Session 6: Termination
Liz reported that the last 2 weeks had ‘ﬂown by’. She reported noticing only a few instances
of loud chewing at a recent function, but explained they had not escalated into any strong
emotional reaction. She reported that she no longer felt symptomatic as her coping had
become ‘automatic’. She found different coping strategies to be helpful in different situations.
With close others, she asked them to stop (despite any awkwardness); within group settings,
she redirected her attention to background sounds or music.
Liz and the therapist reﬂected that she had entered therapy with a very speciﬁc goal, and that
it appeared that she was happy with the progress she had made. Her fears about other problems
Cognitive behavioural treatment of misophonia 11
had subsided, and she no longer felt her progress was dependent on attending therapy. She had
the tools she needed moving forward. Hence, Liz and her therapist terminated therapy.
Treatment summary and conclusions
Throughout treatment, Liz was timely, cooperative, honest, motivated, articulate, and
consistently worked on, if not completed her homework. The therapeutic relationship was
collaborative and strong. The intervention was experimental, but was clearly outlined to the
client before treatment began. Progress was linear although not well measured by traditional
symptom inventories, and relied instead on reports of distress and functional interference by
the patient. Liz’s treatment entailed physiological, cognitive, and behavioural interventions.
Physiological interventions used exercise before expected exposure to triggers in an effort to
reduce the HPA axis threshold in sound reactivity. Because HPA activation was not directly
measured, it is unknown whether this occurred.
Cognitive intervention was central to Liz’s course of treatment. Detailed four-column
tracking and the therapist’s Socratic questioning enabled identiﬁcation and subsequent
modiﬁcation of the maladaptive thoughts that contributed to Liz’s high levels of distress. More
speciﬁcally, Liz came to realize that her rage was not a response to the auditory input itself
as much as a reaction to an underlying core belief that her needs were not important to those
close to her. Prior to treatment, Liz had assumed that because close others had not responded to
her non-speciﬁc covert signals, they were imperceptive, selﬁsh, uncaring, unaccommodating,
and dismissive of her needs – beliefs that led to feelings of rage and resentment. Because
these feelings were inconsistent with her self-identity as a compassionate and loving person,
they perpetuated secondary feelings of shame and a core belief of helplessness regarding her
Also central to treatment was Liz and the therapist’s identiﬁcation and critical consideration
of intermediate assumptions (i.e. ‘if I am assertive, others will reject me’; ‘disgust and
rage are intolerable’), and the automatic thoughts that reinforced them (e.g. ‘I have to
leave now’) to reduce Liz’s affective responses and maladaptive behaviours to auditory
triggers. Using Socratic questioning, the therapist repeatedly challenged Liz to examine the
effectiveness of her passive communication style and aversion of confrontation to suggest
changes that might reduce her symptoms. The therapist identiﬁed evidence of being met with
patient understanding and earnest efforts at accommodation when she honestly and openly
communicated with others.
Behavioural interventions included identifying existing pre-emptive and restorative
strategies, outlining the contexts in which they worked best, discussing the ways in which
they might be improved, and articulating novel methods. Effective coping strategies included
regular exercise, redirecting her attention towards other ambient or self-made sounds, and
focusing on people over their eating sounds. Ineffective behavioural strategies (e.g. sighing,
eye rolling, glaring) were extinguished. Additionally, therapist modelling and client–therapist
role-plays allowed Liz to observe and practice new forms of sensitive assertiveness. Learning
how to broach sensitive matters emerged as an important skill, as candid conversations with
others led to signiﬁcant symptom reduction in the context of those relationships.
At end of treatment, Liz still found chewing noises unpleasant, but these triggers no
longer impaired her social or occupational functioning. She felt able to assert her needs and
communicate effectively, and knew how to implement effective coping techniques ﬂexibly
12 R. E. Bernstein et al.
and automatically. Her GAF was assessed at 85, representing absent to minimal symptoms,
high life satisfaction, and good functioning across domains. These gains appeared stable for at
least the 4 months following treatment, as Liz reported no symptoms of relapse at a follow-up
meeting regarding the present case study, Liz’s success with a brief course of CBT provides
promising preliminary support for its use in treating misophonia. Future case studies and
empirical work will be needed to conﬁrm that CBT is an effective treatment for misophonia,
and to identify the most ‘active ingredients’ of the multidimensional approach described here.
The authors thank Liz for her consent and input, and the University of Oregon Psychology
Clinic’s practicum student cohort of 2010–2011 for their helpful discussions and support.
Declaration of Interest
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(1) Become familiar with misophonia and the current empirical literature on its
(2) Be able to formulate a CBT case conceptualization and treatment plan for
symptoms of misophonia.
(3) Identify cognitive, behavioural, and physiological interventions intended to address
symptoms of misophonia.