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Id 84b5339e-b574-4b35-8bba-69a0f2d053f5
Year 2026
Abstract
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  • (Detroy & Norena, 2026)
Import Date 06-23-2026
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Notes Audited 2026-06-23T21:40:00
Audit Notes audited as review was done
Dv Authors N. Detroy, A.J. Norena,
Dv Initial Source Misophonia MOC
Dv Limitations • Designs were mostly uncontrolled, with small samples • Measurement heterogeneity across instruments (MQ, A-MISO-S, AMISOS-R, MAQ, MTS, MAS-1, S-Five, DMQ) complicates direct comparison across studies • Several reports with rich procedural description lack post-treatment severity scores on the same baseline instrument • Only a subset of studies prespecified response/remission thresholds or applied clinically significant change criteria; a smaller subset reported full statistics, confidence intervals, or session-by-session trajectories • Procedural detail (trigger source, response-prevention rules, homework prescriptions, family involvement/accommodation monitoring, adherence checks) variably reported across studies • Follow-up intervals, where provided, are short • No risk-of-bias ratings or meta-analysis were conducted; effects were not pooled
Dv Future Directions • Adopt a core outcome battery (e.g., AMISOS-R or A-MISO-S, MQ or DMQ, S-Five/S-Five-T, CGI-I, OASIS/ODSIS) with predefined response/remission criteria and transparent statistical reporting • Specify procedures at a granular level (stimuli provenance, dosing, response-prevention instructions, between-session practice templates) to support replication • Test whether particular ingredients (graded exposure with response prevention, counterconditioning, expectancy-violation strategies, attentional training, cognitive restructuring formats) contribute uniquely or in combination to clinically meaningful change • Pursue larger controlled trials, including confirmation of the transdiagnostic Unified Protocol adaptation • Investigate the distorted learning mechanisms specific to misophonia rather than assuming transfer of techniques developed for other disorders
Dv Relevance • a good review of literature around the use of CBT in Misophonia • most of the cited papers are already in my knowledge base, but this review gives a good recap and interpretation of those papers in the context of the larger field and would still be worth reading if I needed more context on this method of treatment.

•

Cognitive-Behavioural Therapy applied to Misophonia, a scoping review

Status:: #status/Bare-bones-review

Metadata

Abstract
Background/Purpose Background-
• Misophonia involves negative emotional, cognitive, and sometimes physical reactions to specific sounds, with severity dependent on context and meaning rather than acoustic intensity alone
• Triggers often produced by other people; response typically disproportionate to the sound itself
• Visual or tactile cues can also elicit misophonia-like reactions, sometimes independent of an auditory component
• Day-to-day impact includes routine restructuring, avoidance, and coping strategies that themselves carry costs
• Reactions are embedded in relationships; family members and partners adapt in ways that can either reduce conflict or, unintentionally, consolidate avoidance and preoccupation
• Prevalence estimates vary widely by sampling frame, measurement choice, and clinical-significance threshold
• Mattson et al. (2023) systematic review of 33 treatment studies found CBT the most frequently used modality (15/33) and the only modality tested in a randomised trial
• No consensus exists on underlying mechanisms of misophonia; cognitive-appraisal, conditioned-reflex, and neurophysiological frameworks each imply different protocol designs
• CBT integrates a behavioural tradition (classical/operant conditioning, exposure) and a cognitive tradition (appraisal modification)
• Third-wave approaches (ACT, DBT, MBCT) add emphasis on acceptance, mindfulness, and values-based action; a "fourth wave" label is used inconsistently

Purpose-
• To map, in clinical reports and trials, how CBT has specifically been applied to misophonia and how authors measured change when they did so
• To treat "CBT" as authors categorise their own interventions, encompassing graded exposure with response prevention, counterconditioning, behavioural experiments, attentional training, and emotion-regulation skills
• To map procedures and present outcomes using each study's own definitions, without pooling effects, given heterogeneity of designs/instruments/thresholds
Participants/samples • Scoping review of CBT applications to misophonia in clinical contexts, following PRISMA-ScR; not pre-registered in a protocol registry
• Searched PubMed, PsycINFO, and Google Scholar (last updated 17 November 2025) using five search strings combining condition and treatment terms
• PubMed returned 147 records, PsycINFO 142 records; Google Scholar screening of first 50 results per query yielded no unique additions; hand-search of reference lists added 4 records
• After de-duplication, 167 unique records entered title/abstract screening
• Inclusion criteria: delivery of a CBT-family procedure to people identified as having misophonia, in a clinical or research-clinical setting, with pre-to-post treatment measurement on at least one outcome instrument
• Exclusion criteria: theory-only papers, protocols without outcome data, purely audiological interventions, reviews/meta-analyses, misophonia not the primary treatment target, reports lacking implementational detail
• 72 full texts assessed; 42 excluded, yielding 30 included studies (2013–2025)
• 14 of 30 studies synthesised in depth (selected for novel protocols, greatest procedural detail, or forming part of a related series); remaining 16 summarised in a supplemental table
Measures • Across studies: MQ, A-MISO-S, AMISOS-R, MAQ, MTS, MAS-1, S-Five/S-Five-T, DMQ, SUDS, FASA, CGI-I, OASIS, ODSIS, MASC-2, CY-BOCS, ADIS-5
• For each included study, extracted setting/sample, delivery format, session number/spacing, main procedures, trigger identification/progression, within-session progression markers, homework structure, caregiver involvement, outcome instruments, study-defined response/remission criteria, and follow-up intervals
Procedures • No risk-of-bias ratings or meta-analysis conducted, given design/measurement heterogeneity
• Procedures and outcomes synthesised narratively, presenting each study's results using its own authors' definitions and thresholds
Results Common clinical ground

• Patients are typically treatment-seeking adults recruited from university-affiliated or tertiary-care services
• Case reports describe elevated self-imposed standards, conscientiousness, and intense anger/shame/worry about own reactions; larger samples confirm clinical perfectionism, rigid interpersonal standards, and emotion-regulation difficulties
• Age of onset typically falls between eight and thirteen years, a developmental window of rapidly increasing metacognitive capacity and social-evaluative sensitivity
• Distress gradient: family settings produce the most intense reactions, then friends, then strangers least
• Dominant emotional response sharpens along an anger–disgust axis, often followed by guilt/self-reproach
• Intrusive automatic thoughts oscillate between attributing hostility to the trigger person and self-blame
• Behavioural responses fall into avoidance and "active" coping classes, both maintaining the problem through different reinforcement pathways
• Somatic features (jaw clenching, fist tightening) reported in a minority of cases
• Triggers predominantly oral/feeding-related sounds; non-oral repetitive sounds can also acquire aversive salience
• Family accommodation reduces overt conflict short-term but deepens isolation/resentment long-term
• Programs typically begin with SUDS-based intensity mapping and psychoeducation for patients and families

ERP: single-case applications

• Four single-case reports adapted ERP to individual trigger profiles
• Hierarchies organised along source of sound (therapist/recorded toward family/trigger person) and amount of contact (duration, repetition, density)
• Response prevention suspends both overt avoidance and "active" coping responses
• Three of four reports include pre–post questionnaire data suggesting reduced misophonia-related distress/interference
• Unstructured exposure without scaffolding was associated with symptom worsening in one pilot observation
• Progression defined by functional behaviour during exposure rather than sound intensity alone; homework compliance strongly influences trajectory

Counterconditioning

• Single-case reports pair aversive triggers with a sustained positively valenced activity/state
• Dozier framework targets a conditioned physical reflex rather than the emotional response directly, with the emotional response expected to subside secondarily
• Rapid within-case decreases reported on general and trigger-specific severity indices across reports
• Improvements on a treated trigger do not necessarily transfer to untreated triggers, necessitating sequential trigger-by-trigger work
• Procedures combine positive-pairing with other CBT elements, limiting isolation of pairing's unique contribution

Inhibitory-learning-informed procedures

• Target expectancy violation and creation of new non-threat associations rather than within-session habituation
• Franck & McKay (2018) paired trigger sounds with incongruent positive/absurd behaviours and humorous compilations, embedding planned expectancy violations
• Authors emphasised feasibility/acceptability and patient-reported functional improvement without quantitative pre/post MQ analysis

Standardised and service-based programs

• Schröder et al. package combines attention-flexibility training, counterconditioning, self-relaxation, and stimulus manipulation in a fixed group format
• Jager et al. randomised waiting-list-controlled trial of the same package; treatment group improved on AMISOS-R/CGI-I, waitlist group did not change
• Gregory et al. service-based repertoire selects modules per patient need (inhibitory-learning exposure for all; attentional training, self-regulation, cognitive restructuring via Theory A/B/C, imagery rescripting, assertiveness training added as indicated)
• Service-based repertoire associated with clinically significant change in a majority of analysed cases per Jacobson & Truax criteria

Transdiagnostic protocol adaptation

• McMahon et al. adapted the Unified Protocol for misophonia, retaining core modules while rewriting examples/homework around misophonia-specific triggers and emotion-driven behaviours
• Exposures positioned within an inhibitory-learning frame (tolerability/function rather than pleasantness)
• Outcomes monitored via DMQ, OASIS, ODSIS; improvement reported during the treatment phase relative to baseline, with authors stressing preliminary status and heterogeneous effects

Single-case complement (adolescent UP-A)

• Tonarely-Busto et al. applied the adolescent Unified Protocol to a 16-year-old with ASD, misophonia, social anxiety, and specific phobia
• Combined blocked protective behaviour, in-session sound exposures, five-senses present-moment attention redirection, and parent non-accommodation coaching
• Movement reported across all measures used (MAQ, A-MISO-S, ADIS-5 severity, CGI-I)
Discussion/Limits Conclusion-
• Across reviewed designs, CBT-family procedures are generally feasible to deliver and, in many cases, coincide with symptom improvement on misophonia-specific and transdiagnostic measures
• Whether gains are driven primarily by method-specific ingredients or by common therapeutic factors remains undetermined
• Variability in response is expected and reflects a person × trigger × context model rather than a flaw specific to misophonia treatment
• Misophonia is distinguished from specific phobia by dominant emotion (anger/disgust alongside anxiety), low-intensity/recurrent/socially embedded stimulus class, and dependence on relationship/meaning/perceived control rather than proximity alone
• Misophonia is distinguished from hyperacusis by the context-dependence of reactions rather than tight linkage to acoustic intensity/spectral content alone
• Differential diagnosis between misophonia and hyperacusis is necessary because interventions effective for one are not established as effective for the other
• Recent evidence concludes that anxiety is not the primary core feature of misophonia and does not justify classifying it as an anxiety disorder
• Misophonia is not purely auditory; visual stimuli can elicit the same reaction cascade
• Standardised group packages offer scalability and predictable dosing but cannot accommodate every individual's trigger set or family context within fixed sessions; dropout is the central limitation
• Individualised programs match procedure to trigger ecology but are more time- and resource-intensive, with session counts varying widely across patients of comparable severity
• Service-based repertoires represent a middle path, preserving comparability while tailoring modules to indicated need
• CBT risks becoming a mechanistic "toolbox" detached from the inquiry that produced its techniques when methods designed for other disorders are applied to misophonia without adaptation
• Misophonia's distinctive features argue for a parallel investigative effort into its own distorted learning mechanisms, rather than assuming direct technique transfer from other disorders
• Therapeutic experiments that restore a sense of agency/optionality are framed as belief-tests that revise "inescapable" appraisals at the explicit level
• Imagery rescripting may be useful where misophonia is entangled with earlier humiliation/conflict/anger, but does not by itself loosen an overlearned cue–response link
Limitations:: • Designs were mostly uncontrolled, with small samples
• Measurement heterogeneity across instruments (MQ, A-MISO-S, AMISOS-R, MAQ, MTS, MAS-1, S-Five, DMQ) complicates direct comparison across studies
• Several reports with rich procedural description lack post-treatment severity scores on the same baseline instrument
• Only a subset of studies prespecified response/remission thresholds or applied clinically significant change criteria; a smaller subset reported full statistics, confidence intervals, or session-by-session trajectories
• Procedural detail (trigger source, response-prevention rules, homework prescriptions, family involvement/accommodation monitoring, adherence checks) variably reported across studies
• Follow-up intervals, where provided, are short
• No risk-of-bias ratings or meta-analysis were conducted; effects were not pooled
Future Directions:: • Adopt a core outcome battery (e.g., AMISOS-R or A-MISO-S, MQ or DMQ, S-Five/S-Five-T, CGI-I, OASIS/ODSIS) with predefined response/remission criteria and transparent statistical reporting
• Specify procedures at a granular level (stimuli provenance, dosing, response-prevention instructions, between-session practice templates) to support replication
• Test whether particular ingredients (graded exposure with response prevention, counterconditioning, expectancy-violation strategies, attentional training, cognitive restructuring formats) contribute uniquely or in combination to clinically meaningful change
• Pursue larger controlled trials, including confirmation of the transdiagnostic Unified Protocol adaptation
• Investigate the distorted learning mechanisms specific to misophonia rather than assuming transfer of techniques developed for other disorders
Relevance:: • a good review of literature around the use of CBT in Misophonia
• most of the cited papers are already in my knowledge base, but this review gives a good recap and interpretation of those papers in the context of the larger field and would still be worth reading if I needed more context on this method of treatment.

Notes

key terms and concepts

Misophonia – pattern of negative emotional, cognitive, and sometimes physical reactions to specific everyday sounds or associated stimuli, with severity shaped by context and meaning rather than acoustic intensity alone.

CBT (Cognitive-Behavioural Therapy) – integration of behavioural exposure-based procedures and cognitive procedures examining appraisals attached to triggers; treated in this review as authors categorise their own interventions, encompassing graded exposure, counterconditioning, behavioural experiments, attentional training, and emotion-regulation skills.

ERP (Exposure and Response Prevention) – method in which patients confront aversive trigger stimuli while refraining from avoidance, escape, or neutralising responses, used to weaken the learned trigger–emotion association.

Counterconditioning – pairing of an aversive trigger with a positively valenced stimulus, activity, or state to build competing associations; in Dozier's framework, targets a conditioned physical reflex rather than the emotional response directly.

Inhibitory-learning-oriented exposure – exposure procedures designed to violate threat expectancies and create new non-threat associations rather than to produce within-session habituation.

A-MISO-S (Amsterdam Misophonia Scale) – clinician-rated 6-item instrument adapted from the Y-BOCS, scored 0–24, with bands from subclinical to extreme.

AMISOS-R – revised 10-item version of the Amsterdam Misophonia Scale, scored 0–40.

MQ (Misophonia Questionnaire) – 17-item self-report measure with Symptom and Emotions/Behaviours subscales plus a single-item Severity rating.

MAQ (Misophonia Assessment Questionnaire) – 21-item self-report instrument scored 0–63, with mild/moderate/severe bands.

S-Five (Selective Sound Sensitivity Syndrome Scale) – 25-item, five-factor self-report measure (Internalising Appraisals, Externalising Appraisals, Perceived Threat/Avoidance, Outbursts, Impact), scored 0–250.

DMQ (Duke Misophonia Questionnaire) – 86-item self-report measure across nine subscales covering trigger frequency, affective/physiological/cognitive responses, coping, impairment, and beliefs.

SUDS (Subjective Units of Distress Scale) – patient-rated 0–10 or 0–100 scale anchoring distress to specific trigger situations, used to build exposure hierarchies.

Theory A/B/C – cognitive restructuring format structuring alternative explanations for misophonic reactions (other-blame, self-blame, treatable sensitivity).

Unified Protocol (UP) – transdiagnostic CBT program targeting cross-cutting emotion-regulation processes rather than disorder-specific symptom content; adapted for misophonia in two linked pilot studies.

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contextual statement

In a 2026 study, Detroy attempted to map how CBT-family procedures have been applied to misophonia in clinical reports and trials, and how authors measured change, by conducting a PRISMA-ScR scoping review of 30 publications (2013–2025) synthesising 14 in depth, using outcome measures including the MQ, A-MISO-S/AMISOS-R, MAQ, S-Five, and DMQ.

Zettelkasten

Scoping Review of CBT for Misophonia- Feasibility Established, Efficacy Not Yet

the waves of CBT in misophonia research

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