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Case study: A novel application of mindfulness- and acceptance-based components to treat misophonia
Status:: #status/Bare-bones-review
Metadata
- Item Type: #journalArticle
- Authors: Rebecca L. Schneider, Joanna J. Arch
- Date: 04/2017
- Date Added: 2020-01-15
- URL: https://linkinghub.elsevier.com/retrieve/pii/S2212144717300285
- DOI: 10.1016/j.jcbs.2017.04.003
- Cite key: schneiderCaseStudyNovel2017
- Topics: primary Resources
- Tags: #Misophonia
- Local library
Abstract
Misophonia is an important, yet understudied, psychological condition characterized by feelings of extreme anger and disgust in response to specific human-generated sounds. Several promising case studies using cognitive behavioral therapy to treat misophonia have been published, but given the limited work to date, exploring additional treatment options and expanding the potential options available to clients and clinicians remains important. In order to target the high levels of anger and disgust, we treated a case of misophonia in a 17-year-old male using 10 (50-min) individual sessions based on mindfulness- and acceptance-based components drawn from dialectical behavior therapy and acceptance and commitment therapy. In particular, we focused on acceptance, mindfulness, opposite action, and nonjudgmentalness strategies. At 6-month follow-up, the client reported no significant difficulties and a continued decline in symptoms. Theoretical rationale and treatment implications are discussed.
Article Review table
| Background/Purpose | Background- • Misophonia is understudied and lacks validated treatments. • Prior interventions: • Tinnitus Retraining Therapy (TRT) – limited evidence; may reinforce avoidance via masking. • CBT case studies – promising but uncontrolled and exposure-focused. • Counterconditioning/neural repatterning – experimental; limited generalization. • No controlled trials of any psychological treatment. • Misophonia characterized more by anger and disgust than anxiety, suggesting traditional anxiety-focused exposure may not fully address phenomenology. • Many clinicians are reluctant to deliver exposure therapy optimally. Purpose- • Evaluate feasibility of a mindfulness- and acceptance-based treatment derived from ACT and DBT components. • Target: • Anger and disgust • Distress intolerance • Cognitive fusion • Behavioral avoidance • Provide first reported case of misophonia treated using ACT/DBT-based components. |
| Participants/samples | • “Michael” (pseudonym) • 17-year-old male high school senior. • Primary triggers: eating-related sounds. • Symptoms: • Immediate rage/anger. • Disgust. • Fight-or-flight activation. • Behavioral avoidance across school, family, and social domains. • Subthreshold OCD symptoms (not impairing). • Past major depressive episode (remitted). • No active depression/anxiety during treatment. |
| Measures | • Amsterdam Misophonia Scale (A-MISO-S) • Administered repeatedly across treatment and follow-ups. • Baseline: upper moderate range. • Trigger hierarchy with ratings of: • Strength of reaction. • Need to respond. • PHQ-9 (depression) – consistently minimal. • GAD-7 (anxiety) – consistently minimal. |
| Procedures | • 10 weekly 50-minute individual sessions with 1-week post-treatment and 6-month follow-up assessments. • Psychoeducation on misophonia, anger, and fight-or-flight response. • Trigger hierarchy development and self-monitoring of distress and reactions. • ACT components: • Values clarification (e.g., respect, connection). • Cognitive defusion exercises (e.g., “I’m having the thought that…”). • Acceptance of anger/disgust via mindfulness practices. • DBT components: • Chain analysis to identify maintaining factors. • Opposite action: physically relaxing instead of tensing in anticipation of triggers. • Nonjudgmental description of trigger situations (“just the facts”). • Mindfulness practice during exposure to eating sounds and in daily life. • Relapse prevention and anticipation of future triggers (e.g., transition to college). |
| Results | • Significant reductions in A-MISO-S scores across treatment. • Reduced strength of reaction and reduced urge to respond • Improvements maintained and further reduced at 6-month follow-up. • Notably: • One trigger (open-mouth chewing) returned to baseline reaction strength. • However, “need to do something” remained substantially lower, indicating improved distress tolerance. • Client reported near absence of problems at 2 months post-treatment. • No comorbid symptom changes (depression/anxiety remained low). |
| Discussion/Limits | Conclusion- • First documented case of misophonia treated using mindfulness- and acceptance-based components. • ACT + DBT-derived strategies appear: Feasible, Efficient (10 sessions), and Tolerable • Key mechanisms: • Increased psychological flexibility. • Reduced cognitive fusion. • Increased distress tolerance. • Reduced behavioral avoidance. • Opposite action via physical relaxation was particularly powerful. • Improvement reflects enhanced tolerance, not elimination of emotional reactions. |
| Limitations:: | • Single-case design. • Moderate baseline severity (unclear generalizability to severe cases). • No control condition. • Component-based approach (not manualized protocol). |
| Future Directions:: | • Randomized controlled trials. • Examination of treatment in severe misophonia. • Further exploration of muscle relaxation as mechanism. • Comparative studies with exposure-based CBT. |
| Relevance:: | • an old A case study where the use of mindfulness and acceptance therapy successfully treated misophonia |
Key Terms
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Misophonia – A condition characterized by extreme anger, disgust, and/or anxiety in response to specific human-generated sounds (e.g., chewing, slurping).
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Acceptance and Commitment Therapy (ACT) – A mindfulness- and acceptance-based behavioral therapy emphasizing psychological flexibility, cognitive defusion, acceptance of internal experiences, and values-based action.
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Dialectical Behavior Therapy (DBT) – A CBT-derived treatment emphasizing emotion regulation, distress tolerance, mindfulness, nonjudgmentalness, and opposite action.
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Cognitive defusion – An ACT technique aimed at altering one’s relationship to thoughts (e.g., “I’m having the thought that…”), reducing their behavioral control.
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Opposite action – A DBT skill involving engagement in behaviors opposite to an emotion’s action urge to weaken maladaptive emotional-behavioral links.
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Nonjudgmentalness – A DBT skill emphasizing factual description rather than evaluative judgments.
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Amsterdam Misophonia Scale (A-MISO-S) – A 6-item clinician-rated scale (0–24) adapted from the Y-BOCS assessing misophonia severity (time, interference, distress, resistance, control, avoidance).
Misc Notes
Mechanistic Insights
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Misophonia conceptualized as:
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Avoidance-driven disorder.
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Maintained by cognitive fusion and behavioral reactivity.
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Physiological tension may amplify emotional escalation.
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Relaxation disrupted escalation from annoyance → rage.
Theoretical Contribution
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Broadens treatment conceptualization beyond exposure.
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Suggests misophonia may benefit from:
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Acceptance-based frameworks.
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Emotion regulation targeting anger/disgust.
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Demonstrates overlap across CBT, ACT, DBT mechanisms.
Clinical Takeaway
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Targeting:
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Distress tolerance,
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Nonjudgmental stance,
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Defusion,
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Opposite action,
may be sufficient to substantially reduce functional impairment in misophonia without formal exposure hierarchies.
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