Advanced Casebook of Obsessive-Compulsive and Related Disorders

Conceptualizations and Treatment

Eric A. Storch,Dean Mckay,Jonathan S Abramowitz

• Publisher: Academic Press
• Year: 2019
• ISBN:
  9780128165577
• Topic: Psicología
• Subtopic: Psicología clínica

Advanced Casebook of Obsessive-Compulsive and Related Disorders: Conceptualizations and Treatment presents a synthesis of the emerging data across clinical phenomenology, assessment, psychological therapies and biologically-oriented therapies regarding obsessive compulsive disorders, including hoarding, skin picking, body dysmorphic and impulse control disorders. Following the re-classification of such disorders in the DSM-5, the book addresses recent advances in treatment, assessment, treatment augmentation and basic science of OCRDs. The second half of the book focuses on the treatment of OCRDs, covering both psychological therapies (e.g. inhibitory learning informed exposure, tech-based CBT applications) and biologically oriented therapies (e.g. neuromodulation).

• Includes psychosocial theoretical and intervention approaches
• Addresses newly proposed clinical entities, such as misophonia and orthorexia
• Examines neurobiological features of OCRDs across the lifespan

Chapter 1

Chew on this: considering misophonia and obsessive-compulsive disorder

Monica S. Wu, PhD¹, and Kelly N. Banneyer, PhD^{2 1}UCLA Semel Institute for Neuroscience and Human Behavior, Postdoctoral Scholar & Clinical Instructor, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, United States ²Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States

Abstract

Misophonia is a unique condition characterized by an extreme sensitivity to selective sounds. Individuals with this condition often display significant emotional distress in response to everyday noises (e.g., chewing, sniffing, tapping). These negative emotions often lead to avoidance and anger outbursts, ultimately resulting in decreased quality of life and increased functional impairment. Although misophonia is largely understudied, treatment literature supporting the use of exposure-based behavior therapy has been emerging. A summary of the extant research is presented, followed by a case report of an adolescent with misophonia, illustrating how to implement exposure and response prevention for this impairing disorder.

Keywords

Auditory; Misophonia; Sensitivity; Sensory; Sound

When listening to nails screech across a chalkboard, most individuals react universally; cringing, grimacing, covering ears, or trying to make the sound stop are all typical reactions. However, there are a subgroup of individuals who display similar visceral reactions to everyday auditory stimuli, irrespective of the frequency bands of the sound (Jastreboff, 2011). Indeed, seemingly innocuous sounds (or even the mere sight) of someone chewing, tapping their foot, or sniffing elicit considerable emotional and physical reactions in these individuals (Johnson et al., 2013). For some, it can become so unbearable that avoidance becomes the primary way of coping with the distress, leading to a limited lifestyle and decreased quality of life. This understudied, yet impairing, condition is called misophonia.

Background

What is misophonia?

Misophonia is a form of decreased sound tolerance that is characterized by a hypersensitivity to selective types of sounds. Common trigger sounds include the sound of people eating, repeated tapping, breathing noises, and throat sounds (Schröder, Vulink, & Denys, 2013; Wu, Lewin, Murphy, & Storch, 2014). When encountering the triggering auditory stimuli, individuals with misophonia often experience considerable emotional and physical arousal. The severity of the emotional reaction is sometimes dependent on the source of the sound (e.g., parent vs. stranger; McGuire, Wu, & Storch, 2015). In other cases, however, it is equally distressing regardless of the source, and individuals with misophonia may just be more effortful in controlling their emotional reactions around strangers in order to comply with social conventions (e.g., refraining from yelling at a stranger for chewing loudly).

With regard to specific emotions, anxiety, anger, and disgust are common negative reactions to these sounds (Ferreira, Harrison, & Fontenelle, 2013; Wu et al., 2014). Irritation and rage are often observed (Brout et al., 2018), sometimes resulting in verbal or physical aggression (Johnson et al., 2013; Schröder et al., 2013). It is noted, however, that anxiety may play a mediating role in the relationship between misophonia symptoms and rage outbursts (Wu et al., 2014; Zhou, Wu, & Storch, 2017), highlighting the importance of considering the unique role of anxiety in misophonia (Quek et al., 2018). Studies have also highlighted physical arousal in connection with triggering auditory stimuli (Edelstein, Brang, Rouw, & Ramachandran, 2013), specifically demonstrating higher levels of skin conductance responses (SCRs) when compared with a healthy control group. Additionally, a preliminary neuroimaging study revealed aberrant activation and functional connectivity in the anterior insular cortex (Kumar et al., 2017), which are thought to mediate physical responses (i.e., heart rate and SCRs) in the face of misophonia-related triggers.

Because of the emotional distress and physical arousal induced by the triggering sounds, individuals with misophonia often engage in avoidance behaviors in an attempt to escape from the upsetting auditory stimuli (Schröder et al., 2013; Webber, Johnson, & Storch, 2013). This can manifest as physically removing themselves from the source of the sound (e.g., leaving the room) or doing something to prevent themselves from hearing the sound (e.g., wearing headphones). These avoidance behaviors have immediate effects, such as preventing an individual from eating meals with loved ones for the fear of hearing chewing sounds or missing social events because of the possibility of hearing triggering noises. Avoidance also has deleterious long-term effects, as it is a slippery slope that often leads to more avoidance and decreased functioning in day-to-day life. As such, there is likely to be continued maintenance (and potential exacerbation) of the symptoms, given the negatively reinforcing nature of avoidance (see the section Theoretic models relevant to presentation for a more detailed explanation of this cycle). Other behavioral reactions to misophonia-related triggers include attempting to make the sound go away through their own actions, such as yelling at a person to stop making the noise. This can lead to frequent arguments and strained interpersonal relationships, especially if the sounds are coming from family members and other loved ones (McGuire et al., 2015). Collectively, individuals with misophonia experience a variety of negative emotional states and engage in different maladaptive behaviors in response to specific auditory stimuli, unfortunately resulting in decreased quality of life and functional impairment.

Who is affected by misophonia?

Misophonia often begins in childhood or early adolescence, with symptom severity worsening over time (Rouw & Erfanian, 2018). Why certain people develop misophonia and the exact cause of this condition are still unknown, with various putative causes being proposed in the emerging literature (Brout et al., 2018; Palumbo, Alsalman, De Ridder, Song, & Vanneste, 2018). Instead of resulting from damage to or overactivation of the auditory pathway, misophonia is thought to be associated with enhanced connections between the auditory, limbic, and autonomic nervous system (Jastreboff & Hazell, 2004; Jastreboff & Jastreboff, 2013). Additionally, enhanced functional connectivity between various brain regions tied to emotion regulation processes and interoception was observed in individuals with misophonia (Kumar et al., 2017), suggesting potential underlying neurobiological mechanisms.

Because research on this condition is still burgeoning, definitive incidence rates have been difficult to establish. When considering clinical samples of individuals presenting to audiologic clinics for tinnitus (a condition that is characterized by ringing of the ears, despite the lack of external auditory stimuli), an estimated 10%–60% of these patients are affected by misophonia as well (Hadjipavlou, Baer, Lau, & Howard, 2008; Sztuka, Pospiech, Gawron, & Dudek, 2010). Broader undergraduate samples in the United States and China have reported that 6%–20% of the participating students were affected by elevated, impairing levels of misophonia symptoms (Wu et al., 2014; Zhou et al., 2017). The remainder of studies examining misophonia are typically composed of case reports or use self-selected samples (e.g., from misophonia support groups), making it difficult to infer the true incidence rate. However, these preliminary estimates highlight the potentially high rate of occurrence of misophonia across cultures, suggesting its far-reaching impact.

With regard to the clinical characteristics of individuals with misophonia, various case reports and cross-sectional studies have highlighted clinical correlates and comorbidities. Higher numbers of misophonia symptoms have been linked with greater sensory sensitivities, with more moderate associations observed with depressive, anxiety, and obsessive-compulsive symptoms (Wu et al., 2014). Diagnostic criteria for misophonia have yet to be established, as it can be unclear whether the symptoms are better accounted for by other psychiatric disorders at times (Ferreira et al., 2013). However, given its moderate relationship with multiple psychiatric symptoms and a potentially unique cluster of symptoms characterizing the disorder, many consider misophonia to be a stand-alone condition that should have its own set of diagnostic criteria (Brout et al., 2018; Schröder et al., 2013).

Psychiatric comorbidities are often observed in individuals with misophonia. Specifically, the higher numbers of misophonia symptoms have been related to major depressive disorder and posttraumatic stress disorder (Erfanian, Brout, & Keshavarz, 2018; Rouw & Erfanian, 2018). Additionally, a case series suggested the possibility of a link between eating disorders and misophonia (Kluckow, Telfer, & Abraham, 2014), given the shared distress related to food and chewing. Interestingly, a cross-sectional study reported the co-occurrence of obsessive-compulsive personality disorder in approximately half of the sample (Schröder et al., 2013), with the authors suggesting that it may be either a risk factor for developing misophonia or a consequence of having it, but further research is needed to explore these hypotheses. However, perhaps the most researched and reported comorbidity for misophonia has been obsessive-compulsive disorder (OCD) and related conditions, such as Tourette syndrome (Hadjipavlou et al., 2008; Neal & Cavanna, 2013; Schwartz, Leyendecker, & Conlon, 2011). Consequently, clinicians and researchers alike have set forth notable efforts to further examine the similarities in the presentation and treatment of these conditions (Schröder et al., 2013), commonly viewing them within the same theoretic model.

Theoretic models relevant to the presentation

In describing the phenomenology and maintenance of the symptoms, misophonia can be viewed through the lens of a cognitive-behavioral model. Within this model, the triad of thoughts, feelings, and behaviors is thought to influence one another in a multidirectional manner (Kendall & Panichelli-Mindel, 1995). When presented with a trigger for misophonia, individuals typically have various thoughts that occur; they can think about how annoying the sound is, how much they want it to stop, and/or how much they dislike the person making the sound. The related feelings can be emotional or physical, including disgust, anger, anxiety (Brout et al., 201...