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Reviewing Misophonia and its Treatment

  • Consilient Therapy

Abstract and Figures

Misophonia can be modelled as a process of five components initiated by a sensory experience. It is typified by an initial physical reflex followed by an undesirable emotional response. It may be present in as much as 18% of the population and is not simply an issue of sound sensitivity; the process being initiated by visual and kinaesthetic sensation in many cases. A number of approaches to treatment may be listed, each having its own proponents. The process of sequent repatterning has been developed by recognising the neuroscience that underpins both the condition itself and the changes necessary to successfully treat misophonia. Pragmatic choices have been made by recognising simply 'what works' and setting aside paradigms that do not. The result is a person-centred and scientifically-based therapy model that has proved itself durable and effective working with clients both face-to-face and remotely (online). The results of cases treated to date are reviewed and potential next steps considered.
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ISSUE 5, VOLUME 1 (2017) ISSN 2202-7653
Reviewing Misophonia and its
Christopher Pearson1
ABSTRACT Misophonia can be modelled as a process of five components initiated by a
sensory experience. It is typified by an initial physical reflex followed by an undesirable
emotional response. It may be present in as much as 18% of the population and is not simply an
issue of sound sensitivity; the process being initiated by visual and kinaesthetic sensation in
many cases.
A number of approaches to treatment may be listed, each having its own proponents.
The process of sequent repatterning has been developed by recognising the neuroscience that
underpins both the condition itself and the changes necessary to successfully treat misophonia.
Pragmatic choices have been made by recognising simply 'what works' and setting aside
paradigms that do not. The result is a person-centred and scientifically-based therapy model that
has proved itself durable and effective working with clients both face-to-face and remotely
The results of cases treated to date are reviewed and potential next steps considered.
1Correspondence concerning this article should be addressed to: Christopher Pearson, John Cox Health and
Physiotherapy Practice, 9, The High Street, Upton, West Yorkshire WF9 1HR, United Kingdom
Pearson, C. (2017). Reviewing Misophonia and its Treatment. International Journal of Neuropsychotherapy, 5(1), 2-10.
This piece begins with a review of the condition
that has come to be known as misophonia, its
neurological basis and its presentation. This text
then moves on to the treatment of misophonia: a
discussion of the therapeutic interventions that
were developed to provide genuine benefits to
clients. Considering effective therapy for
misophonia, the neuroscience underpinning the
step-wise approach of sequent repatterning is
described. There then follows a review of 197
cases completed to April 2017.
The term misophonia was applied to the condition
described by Jastreboff and Jastreboff (2001) as
“abnormally strong reactions of the autonomic
and limbic systems” but recognising it only in the
auditory domain (Jastreboff and Jastreboff, 2002).
Misophonia can be modelled as a process of five
components, with three key elements, initiated by
a sensory experience. It is typified by an initial
physical reflex, then followed by an undesirable
emotional response (Dozier, 2015). See Figure 1.
Misophonia is considered by some to be
uncommon and many members of misophonia
Facebook groups engaged with awareness
initiatives on Rare Disease Day (Rare Disease
Day, 2017) at the end of February 2017.
However, the condition may be present in at least
18% of the general population (Dozier 2015a). It
is certainly not simply an issue of sound
sensitivity. The process has been recognised as
being initiated by visual and kinaesthetic
sensation, in many cases over years. Some
therapists have noted clients having gustatory and
olfactory issues – I have recently encountered a
lady with a strong shame emotional response to
orange zest.
That sensory experience – what many refer to as a
trigger – begins a process that completes with a
negative emotion. Again, that emotion is often
typified as being rage or anger. Yet experience
demonstrates that it may be any of a range of
negative emotional experiences including the
prevalent anger and rage, but may be shame,
guilt, disgust, anxiety, too.
Between the experiential element – the trigger –
and the emotional element is the physical reflex
(Dozier, 2017). Indeed, this physical reflex has
been recognised by a number of researchers and
therapists as well as those experiencing
misophonia – it has led to some referring to
misophonia as a CARD, a conditioned aversive
reflex disorder, and referenced in the subtitle of
the first edition of Dozier's book in 2015, cf.
Although this reflexive phenomenon varies
between individuals it has been shown to be
present and detectable in at least 94% of
individuals with symptoms of misophonia and in
response to specific sensory stimulation. This
estimate was validated by a study conducted by
Morrison and Dozier in 2016 (Dozier, 2017).
The two remaining components are the
neurological links, one leading from stimulus to
reflex and the other from reflex to emotion: the
neural pathways.
It seems clear that if any one of the components is
removed or deactivated the process will not
complete and the symptom will be quenched.
The physical reflex can be a key to recognising
misophonia and certainly is a differentiator of this
We model the process of misophonia as an
activation of the limbic brain leading to an
activation of the H-P-A axis and down-regulation
of cognitive thinking processes. Some work has
been completed in imaging response in
misophonia and more formally establishing the
brain basis of the condition (Kumar, 2017).
A number of approaches to treatment may be
listed. Each has its own proponents. Some of
these, and in no particular order, are listed here:
CBT – cognitive behavioural therapy
DBT - dialectical behaviour therapy
TRT – tinnitus retraining therapy
Trigger tamer – dealing with each individual
auditory experience and based on Neural
Repatterning Technique (NRT)
Traditional, suggestion-based hypnotic work
Sequent repatterning
Others which promote well-being, reduce
stress and anxiety and some which rely upon
Of these, trigger tamer (Dozier, 2015b) and
sequent repatterning are two that have been
developed specifically with the treatment of
misophonia in mind.
The severity of misophonia and its response to
therapeutic intervention is often measured using
either or both of Misophonia Assessment
Questionnaire (MAQ-2) (Misophonia Assessment
Questionnaire, 2017) and Amsterdam Misophonia
Scale (A-MISO-S) (Amsterdam Misophonia
Scale, 2017).
Both assessment documents are based firmly in
the auditory domain although sensory-neutral
versions are presently in evaluation.
MAQ-2 and A-MISO-S are probably the only
generally accepted measures in international and
cross-disciplinary contexts.
Sequent repatterning is a bottom-up approach to
therapy. It is presented as a programme of
therapy usually planned over eight weekly
sessions. Misophonia does not appear in any
DSM and, almost exclusively, those we treat are
self-referred and fund therapy themselves. So
therapy that can be budgeted for is an important
start to the process. Making it affordable is
another key to accessibility.
Working with a programme allows us to define a
very clear structure for the therapeutic process – a
framework that begins with a linear process of
introduction, history-taking and explanation to
inform the client. We call this the pre-therapy
sequence. It is followed by a foundation session
that is all about safety, comfort and, very much,
the moment of now.
Sequent repatterning is often referred to as sequent
repatterning hypnotherapy for misophonia. It was
established some time ago that traditional,
suggestion-based hypnosis does not provide
enduring positive change in misophonia.
Hypnosis does, however, provide an ideal
platform from which neuropsychotherapeutic
change can be achieved. It allows individuals to
enter a nurturing, comfortable, and safe state of
mind in an enriched environment, receptive and
ideal for learning.
The therapist may also choose from a range of
useful hypnotic phenomena; in sound-response
misophonia, for instance, auditory hallucination
can be especially effective. It has been shown that
eliciting auditory hallucination in children
especially and in adults (Olness and Gardner,
1981, p. 28) is exceptionally straightforward and
can be beneficial in first learning sensory down-
regulation and then establishing enduring limbic
change in much the same way that virtual reality
interventions may be used.
Sequent repatterning consists five closely
integrated steps which match the elements of core
needs (Roussow, 2014, p. 57.) and which are
interpreted as shown in Figure 2
Inner world
Reframe and refocus
Outcomes – future pacing
In the first session, which follows pre-therapy
interaction, client and therapist make a joint
commitment to a programme of change. It is an
experience that quite clearly changes client and
therapist and leads towards the outcome the client
desires. It also provides an initial opportunity to
establish a hypnotic state and for the client to
experience its potential.
At this point we – client and therapist – consider
the road ahead. We can often talk to clients about
therapy as a journey but, in this context, I will
often suggest it is, perhaps, an expedition because
an expedition is not the same as a journey (where
there is likely a predetermined direction, with
familiar land-marks and reliable way-points). If
we think of those who sought the source of the
Nile, for example, they knew where they were:
standing by an estuary with the sea behind them
and a river in front of them. And they knew what
it was they were going to find: a hole in the
ground from which water sprang.
But they did not know how far they would travel,
they knew little of what they would encounter on
the way – mountains or valleys, forest or desert.
They had to gather all the resources they might
possibly need, whatever the circumstance. To do
that they first had to create a base camp. That is
exactly what the foundation session intends: to
build a base camp and identify the resources
needed for the expedition.
Only with this foundation firmly in place can we
begin to next address the elements of personal
change, firstly those emotions that are attached to
a client's uncomfortable response to specific
sensory events. I always will avoid using the
word, trigger, if I possibly can. As a word, it says
so much to a client that we should avoid bringing
to our conversation.
Table 1 summarises cases treated by me between
2013 and April 2017. Two documents used to
assess severity – A-MISO-S and MAQ-2 – were
used in assessment and progress monitoring. The
arithmetic average improvement, as measured by
MAQ-2, exceeds 50% reduction in symptoms.
Similar outcomes have been anecdotally reported
by other sequent repatterning practitioners. There
are some clients who have experienced a
transformational change of 100% symptom
Of 204 individuals committing to therapy, 197
completed a programme of sequent repatterning.
Seven (about 3%) dropped out and mostly early
on in the process.
A small number did not benefit significantly from
therapy: taking a 20% reduction in MAQ-2 as a
minimum for significance, 4% fall into that group,
of which 3% improved by less than 10%. That
said, this seems a low proportion of those treated
and none recorded a higher MAQ-2 on completion
than on initial assessment.
The therapy is planned over eight sessions
although the programme was extended to at least
ten consultations in slightly less than one third of
Because these are clinical interactions with clients,
consistency of follow up is determined by each
individual's willingness to respond to requests for
information. Of the 197 individuals completing
the programme, 101 returned MAQ-2 scores six
months later. The plot of results, showing all
cases in Figure 3 may be compared with Figure 4
which shows only results for clients who
completed therapy and also returned six-month
follow-up assessments.
The close correlation suggests that we might
reliably infer that the six-month data may be
representative of all cases.
While the table of outcomes (Table 1) provides a
summary of clients' progress and the box and
whisker plots (Figures 3 and 4) show numerical
measures of symptomatic change, we should be
clear that we are affecting the feelings of
individuals, their lives and the lives of those with
whom they interact. This review considers the
outcomes of a clinical process and not a research
study. Follow-up data at six months cf is useful. I
would prefer to have further follow-up data at one
year and two years. However, the rate of reply to
emails is very low over extended periods.
What we might expect in terms of response to
sequent repatterning is shown in Figure 5. It
shows that the Foundation Session – following on
from an engaging pre-therapy sequence – is often
followed by an immediate and significant
reduction in MAQ-2 sum score.
Parts Work, usually introduced during session
three, precedes a second and pivotal point in
therapeutic benefits. Parts Work, interacting with
emotional metaphors as some refer to this process,
is clearly the initiator of transformational change
in a number of cases.
Figure 5 should be viewed as being representative
of how a person might respond and may be
interpreted as confirmation that the sequence of
interventions employed in sequent repatterning is,
in this context, effective.
Sequent repatterning is subject to on-going
critique and its outcomes reviewed within a
community of therapists: its refinement and its
development continues as its deployment is
extended and further case data are collected.
I welcome opportunities to further study the onset
and ongoing pathology of misophonia and to
collaborate with others in research. I continue,
too, to support Misophonia Institute. The mission
of the Misophonia Institute is to improve
awareness in both general public and amongst
health-care professionals as well as encouraging
research, training and ethical practice.
Figure 1 - Misophonia modelled as a process of five components
Figure 2 – Meeting core needs in an integrated approach to therapy
Figure 3 – Results recorded in all cases treated with six-month follow-up data for 101 cases
Figure 4 – Results recorded in 101 cases with six-month follow-up data
Figure 5 – a typical response to sequent repatterning therapy
Assessment Preparation Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
MAQ Sum Sco res
MAQ Sum Score
Table 1 – Summary of results
Top-level summary of completed cases
Average change as MAQ-2 reduction
Case summary
Low responses
Less than 20% reduction in MAQ-2
Less than 10% reduction in MAQ-2
MAQ-2 increasing during therapy
Extended programme
Cases at 10 sessions
Amsterdam Misophonia Scale (A-MISO-S)*.
(n.d.). Retrieved July 2, 2017, from
Dozier, T. H. (2015a). Understanding and
overcoming misophonia: a conditioned aversive
reflex disorder. Livermore, CA: Misophonia
Treatment Institute.
Dozier, T. H. (2015). Treating the Initial Physical
Reflex of Misophonia With the Neural
Repatterning Technique: A Counterconditioning
Procedure. Psychological Thought, 8(2), 189-
210. doi:10.5964/psyct.v8i2.138
Dozier, T. H. (2017). Understanding and
overcoming misophonia: a conditioned aversive
reflex disorder (2nd ed). Livermore, CA:
Misophonia Treatment Institute.
Jastreboff, M. M. (n.d.), Hyperacusis, M.M.,
Jastreboff, P., Jastreboff, J. Retrieved July 03,
2017, from
Jastreboff, M. M., & Jastreboff, P. J. (2002).
Decreased sound tolerance and tinnitus
retraining therapy (TRT). Australian and New
Zealand Journal of Audiology, 24(2), 74-84.
Kumar, S., Tansley-Hancock, O., Sedley, W.,
Winston, J. S., Callaghan, M. F., Allen, M.,
Cope, Thomas E., Gander, Phillip E., Bamiou,
Doris-Eva, Griffiths, T. D. (2017). The Brain
Basis for Misophonia. Current Biology, 27(4),
QUESTIONNAIRE (MAQ). (n.d.). Retrieved
July 2, 2017, from
Olness, K., Duke, G., & Gardner, G. Gail (1981).
Hypnosis and hypnotherapy with children.
Philadelphia: Grune & Stratton.
Rare Disease Day. (n.d.). Retrieved June 29, 2017,
Rossouw, P. J. (2014) (Ed.). Neuropsychotherapy:
Theoretical underpinnings and clinical
applications. Brisbane, Qld: Mediros Pty Ltd.
ResearchGate has not been able to resolve any citations for this publication.
Full-text available
Misophonia is an affective sound-processing disorder characterized by the experience of strong negative emotions (anger and anxiety) in response to everyday sounds, such as those generated by other people eating, drinking, chewing, and breathing [1–8]. The commonplace nature of these sounds (often referred to as “trigger sounds”) makes misophonia a devastating disorder for sufferers and their families, and yet nothing is known about the underlying mechanism. Using functional and structural MRI coupled with physiological measurements, we demonstrate that misophonic subjects show specific trigger-sound-related responses in brain and body. Specifically, fMRI showed that in misophonic subjects, trigger sounds elicit greatly exaggerated blood-oxygen-level-dependent (BOLD) responses in the anterior insular cortex (AIC), a core hub of the “salience network” that is critical for perception of interoceptive signals and emotion processing. Trigger sounds in misophonics were associated with abnormal functional connectivity between AIC and a network of regions responsible for the processing and regulation of emotions, including ventromedial prefrontal cortex (vmPFC), posteromedial cortex (PMC), hippocampus, and amygdala. Trigger sounds elicited heightened heart rate (HR) and galvanic skin response (GSR) in misophonic subjects, which were mediated by AIC activity. Questionnaire analysis showed that misophonic subjects perceived their bodies differently: they scored higher on interoceptive sensibility than controls, consistent with abnormal functioning of AIC. Finally, brain structural measurements implied greater myelination within vmPFC in misophonic individuals. Overall, our results show that misophonia is a disorder in which abnormal salience is attributed to particular sounds based on the abnormal activation and functional connectivity of AIC.
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Does the sound of other people chewing fill you with rage? Do certain sights and sounds make you crazy when they don’t bother anyone else? If so, you are not alone. Although rarely known, misophonia is quite common, and there is hope. Misophonia is a neurological condition where a person has a strong emotional response of anger or disgust to specific sounds. For some, it might be hearing someone chewing. For others, it is the sound of sniffling or breathing. Many people also have the misophonic response to visual triggers such as seeing someone chew gum. With misophonia, a person has specific soft sounds (and sights) that they cannot tolerate. Misophonia can be upsetting and annoying, or it can be a debilitating condition. It may vary in intensity but generally gets worse with time. There are important management techniques that are helpful to almost everyone. Although there are no proven treatments that work for everyone, there are treatments that work for many. With proper management and treatment there is hope for reducing the horrible effects of this condition. This book will help you understand what this mysterious condition is doing to you, or help you understand what someone close to you is experiencing. It explains how misophonia develops and expands with time, and why those little sounds cause a person SO much distress. It also gives you many techniques that will help you manage this condition and explores the existing treatment options. With proper management and treatment, you can greatly reduce the effects of misophonia in your life. Developing misophonia has been a journey. Overcoming misophonia is also a journey, and it is a journey that can provide much relief for this horrible condition.
Full-text available
Misophonia is a condition in which a person has an acute emotional response of anger or disgust to a commonly occurring innocuous auditory or visual stimulus referred to as a trigger. This case details the effective treatment of misophonia in a young woman that included a counterconditioning treatment called the Neural Repatterning Technique (NRT), which combines a continuous positive stimulus and a reduced intensity, intermittent trigger. The treatment was delivered via the Misophonia Trigger Tamer smartphone app and all treatments were conducted independently by the patient. In this patient, the trigger elicited a physical reflex of contraction of the flexor digitorum profundus, which caused her to clench her fist. To enhance the effect of the NRT treatment, Progressive Muscle Relaxation was incorporated to increase her ability to deliberately relax the affected muscle during treatment. During NRT treatment sessions, the patient experienced a weak physical reflex to the reduced trigger stimulus but no emotional response. Her emotional response of misophonia was not treated, but when the physical reflex extinguished, the emotional response also extinguished. This case indicates that the misophonic response includes a Pavlovian-conditioned physical reflex. It is proposed that the trigger elicited the physical reflex and the physical reflex then elicited the conditioned emotional response that is characteristic of misophonia. Because of the conditioned reflex nature of misophonia, it is proposed that a more appropriate name for this disorder would be Conditioned Aversive Reflex Disorder.
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The main objective of Tinnitus Retraining Therapy (TRT) is habituation of activation of the autonomic nervous system, evoked by signals present in the auditory pathways. Sound therapy aims at decreasing the strength of these signals. The same systems in the brain are involved in tinnitus and decreased sound tolerance, and the same basic neurophysiological mechanisms are utilised for decreasing the tinnitusrelated neuronal activity and, in case of hyperacusis, abnormally enhanced activity induced by external sounds. The similarity of TRT treatment between tinnitus and misophonia is even closer, as in both situations the goal is to achieve extinction of functional connections between the auditory and the limbic and autonomic nervous systems. The increased gain within the auditory pathways that are presumably responsible for hyperacusis could enhance the tinnitus signal, thus it is possible to expect coexistence of tinnitus and hyperacusis, and the predisposition of hyperacusis patients to develop tinnitus. As such, for some patients tinnitus and hyperacusis may be considered the double manifestation of the same internal phenomenon.
In line with the heightened interest in child hypnotherapy, we discuss three broad topics in this book. First, we review the early history of therapeutic hypnosis with children, emphasizing the 19th-century literature so as to collect in one place those intriguing reports that predated modern scientific method. Second, we discuss issues related to child hypnosis, by which we mean a child can enter that altered state of consciousness that most people define as hypnosis. . . . Third, we review the broad topic of hypnotherapy with children, with chapters devoted to the treatment of psychological, medical, and surgical problems. (PsycINFO Database Record (c) 2012 APA, all rights reserved)