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Four Questions about Misophonia with Dr. Clair Robbins

We’ve been hearing more about misophonia lately but there’s still a lot of confusion about what it is and how to treat it. We sat down with Dr. Clair Robbins to learn more about misophonia. Before coming to TAP, Dr. Robbins worked at the Duke Center for Misophonia and Emotion Regulation so we are excited to learn more from her!

1. What is misophonia?

Misophonia is a condition in which people are extremely bothered by specific sounds. Most often, people with misophonia report sounds such as chewing or breathing are bothersome but people can experience misophonia in response to any sound including animal sounds or environmental sounds (clock ticking, air conditioners, etc.). People with misophonia sometimes report being bothered by other stimuli as well, such as seeing someone jiggle their leg repeatedly.

Importantly, misophonia is different from not liking a sound. Most people dislike some sounds. Misophonia involves an intense emotional and physiological reaction to specific sounds. For example, folks with misophonia often report experiencing fight or flight response (e.g., heart racing, sweating) and intense anger or anxiety when hearing these sounds. The experience of misophonia is unique to each person and this condition can be very impactful on peoples’ lives. People with misophonia often report avoiding misophonic sounds as much as possible or leaving situations when a sound occurs. They also report it can be extremely difficult to focus in the presence of these sounds making it difficult to attend work or school.

2. Is this a real condition and is there a diagnosis?

Great question! Misophonia is a very real condition. When I worked at Duke I talked to hundreds of people with misophonia and it had a very real impact on their lives.

While misophonia is a real condition, there is not currently an official medical or psychiatric diagnosis for it. So if you asked a doctor to diagnose you with misophonia they would not officially be able to do so. The reason it is not a diagnosis is that it is still a very new condition. It was first described in 2001 and has only started getting a lot of attention in the past decade. It takes a long time to create an official diagnosis and so it will probably be a while until we know whether this condition will become its own diagnosis. A lot of research is still needed to understand how to best describe this condition and what the diagnostic criteria for it would be.

That being said, just because something doesn’t have a formal diagnosis doesn’t mean it isn’t real and also doesn’t mean it can’t be treated.

3. What are the treatment options?

We’re still learning a lot about misophonia, so we usually recommend a multidisciplinary treatment approach. It is helpful to talk to different types of providers to find the treatment plan that will work best. Primary care doctors, psychologists, psychiatrists, audiologists, and occupational therapists, among others, can all be helpful. Each profession has a unique approach to treating misophonia.

Because I am a clinical psychologist, I’ll talk about how psychologists can help people with misophonia.

A lot of people with misophonia find that they have strong emotional reactions to misophonic sounds, notably anger, anxiety, and disgust. Often, they do not like these emotions and try to get them to go away as quickly as possible in ways that work in the short-term but backfire in the long-term. For example, they might yell at someone chewing which gets the person to stop, but leads to a fight. Or they might avoid eating with family which allows them to avoid the sounds, but they miss out on spending time with people who are important to them. When this is the case, evidence-based psychological treatments that teach skills for managing strong emotions can be really helpful. At TAP, I use the Unified Protocol and CBT to help people with misophonia. These treatments focus on helping people understand and manage their reactions to misophonic sounds in ways that work in both the short- and long-term.

In these treatments, we start by setting goals for treatment to get a sense of what each person is hoping to learn or change. Next, we learn skills for better understanding emotions and slowing down overwhelming emotional experiences to make them feel more manageable. With that strong foundation, we then learn skills like mindfulness, learning to consider different perspectives, and changing behavior, as ways to manage emotional responses to trigger sounds. Finally, we practice experiencing uncomfortable physical sensations and emotions as a way to really practice and hone the skills learned in treatment. Sometimes this is called exposure. Once we have done these things, we talk about how folks can maintain the progress they’ve made in treatment. Some people learn and use all these skills whereas others find they only need one or two skills to manage their reaction to sounds.

4. I’ve heard exposure therapy is bad for misophonia, is that true?

I’ve talked to a lot of people with misophonia who say exposure therapy did not help or even made things worse. However, in answering this question it is really important to know that there are different types of exposure therapy.

One type of exposure is called habituation-based exposure. In this kind of therapy, people with misophonia are asked to listen to the sounds that bother them over and over until the sound is no longer bothersome. There is no evidence to suggest this type of exposure is helpful.

Another type of exposure is called inhibitory learning. This type of exposure involves being in situations where there are misophonic sounds, using skills to manage the emotions that come up, and learning what happens. These types of exposure focus on what is learned in the situation regardless of whether distress goes down. Some people find the situations are not as bad as they expected. Others might find the situation is really difficult and they are able to cope better than expected. Still others learn what coping skills work best in different situations. Growing research suggests this type of exposure can be helpful for misophonia. I use this type of exposure in my own work and have found it to be really helpful.

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