- Email: [email protected]
Toward a theoretical model of misophonia
Letters to the Editor
Collaborative care dissemination is growing, including the Depression Improvement Across Minnesota (DIAMOND) program in over 80 primary care clinics throughout Minnesota and the Washington state Mental Health Integration Program, in which major insurance companies agreed to implement and pay for collaborative care in over 100 community health clinics and 30 community mental health centers [5]. However, health policy changes will be necessary to widely implement this evidence-based model. Several recent policies could improve depression quality of care. These include mental health policies, such as the Medicare Improvements for Patients and Providers Act of 2008 [which eliminated by 2014 unequal copayments previously required for psychotherapy (50%) and other medical services in Medicare (20%)], the Mental Health Parity and Addiction Equity Act of 2008 (which prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits), and broader health policies included in the ACA: Medicaid expansion, employer mandate, health insurance exchanges with low income subsidies, PCMHs, Medicaid health homes, ACOs, and inclusion of mental health in essential benefits packages. Some policies have a greater likelihood than others to improve depression care. For example, mental health parity and insurance expansion alone are unlikely to solve the problem, as challenges with access to mental health services, which is already difficult, are likely to worsen (i.e., demand will increase but provider supply will not). However, some policy changes, such as credentialing requirements based on 2014 National Committee for Quality Assurance criteria for PCMH designation, incentivize integrated models with population-based requirements, CM requirements, and ways to better integrate mental health as key components to achieve level 3 credentialing, which will lead to better payments from many insurers. Demonstration models such as the Comprehensive Primary Care initiative provide financial incentives as well as educational opportunities and technical assistance to encourage integrated care practices. ACOs incentivize decreasing emergency room visits and hospitalizations, and people with comorbid mental and physical illness are disproportionately represented in these populations. Increasing evidence demonstrates that depression predicts 30-day rehospitalizations and ambulatory care-sensitive hospitalizations. CMS tracks and penalizes hospitals in the bottom 25% of 30-day rehospitalizations. CMS also recently finalized a separate payment, outside of a face-to-face visit, for managing care of Medicare patients with two or more chronic conditions (which could include depression) beginning in 2015. One might question how new policies could improve depression outcomes, particularly due to limited focus of broader policies on mental health conditions (e.g., only 1 of 33 ACO quality measures focuses on mental health with depression screening). However, strengths of recent policies may lie in encouraging more thoughtful applications of integrating evidence-based models to enhance depression treatment. These policies potentially incentivize a more nuanced, systematic, and integrated approach to depression management. Financial incentives provided by policies generate motivation for clinicians and healthcare systems to engage in the practice redesign work to identify which patients have depression, what treatments are needed, how treatments fit into overall treatment plans (rather than addressing mental and physical disorders separately), and provide increased intensity of care and systematic follow-up for patients with persistent symptoms. We recommend that to enhance integration of this evidence-based model, payers need to develop billing codes for care management contacts, including phone contacts and in-person contacts, codes for weekly psychiatrist systematic caseload review, and incentives for process measures tightly linked to depressive outcomes (e.g., changing ineffective treatments by 8 weeks) and improved outcomes (e.g., percent of patients reaching at least a 50% symptom reduction by 8 weeks and 6 months) [5]. Quality indicators or fidelity measures are needed to provide either a financial disincentive for systems that have attempted to
369
implement care managed with little fidelity to evidence-based models or to provide an incentive for systems implementing higher fidelity models. Incentives should also be provided for groups to participate in collaborative endeavors to improve the dissemination process and create more sustainable improvements. Both performance criteria and outcomes monitoring are important. Don Berwick said that the American system gets what it pays for by incentivizing high-cost procedures and tests rather than care quality and time with practitioners. It is time to change financial incentives to improve quality of care and outcomes for depression using evidencebased ways to deliver treatments. Kara Zivin, PhD Department of Veterans Affairs, Center for Clinical Management Research Ann Arbor, MI, USA Department of Psychiatry, University of Michigan Medical School Ann Arbor, MI, USA Corresponding author. University of Michigan North Campus Research Complex, 2800 Plymouth Road, Building 16, 228W, Ann Arbor, MI 48109-2800, USA. Tel.: +1-734-222-7417 E-mail address: [email protected] Wayne Katon, MD Department of Psychiatry, University of Washington Medical School Seattle, WA, USA Deceased, 3/1/2015 http://dx.doi.org/10.1016/j.genhosppsych.2015.04.004
References [1] Grembowski DE, Martin D, Patrick DL, Diehr P, Katon W, Williams B, et al. Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. J Gen Intern Med 2002;17:258–69. [2] Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:1–277 [CD006525]. [3] Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies Press; 2012. [4] Sederer LI. What does it take for primary care practices to truly deliver behavioral health care? JAMA Psychiatry 2014;71:485–6. [5] Unützer J, Chan Y-F, Hafer E, Knaster J, Shields A, Powers D, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health 2012;102:e41–5.
Toward a theoretical model of misophonia To the Editor, Misophonia, literally translated into “hatred of sound” [1], is characterized by intense emotional responses to hearing specific sounds (i.e., triggers or auditory cues) as well as observing certain movements. Commonly reported triggers include chewing, breathing and sounds emitted from movements (e.g., foot or pen tapping) [2,3]. Those with misophonic symptoms often experience significant impairment across occupational/academic, familial/home-based and social functioning in response to the disgust, anger and distress caused by auditory cues [3]. The primary behavioral response to triggers is avoidance, although other behaviors have been reported [2,4]. Over the past several years, case studies have brought attention to the incidence of misophonic symptoms across certain clinical populations [5–8], but there have been few treatment studies or empirical reports that contribute to the development of a theoretical model for understanding misophonia and related phenomena, or its treatment. For future efforts to develop effective treatments for misophonic
370
Letters to the Editor
symptoms, a cohesive theoretical model and diagnostic classification system is needed. Schröder et al. [2] proposed a diagnostic classification system that categorizes misophonia as an obsessive–compulsive spectrum disorder (OCSD). OCSDs are all thought to include some element of obsessions and compulsions [9]. Indeed, misophonia shares many clinical characteristics with OCSDs, such as intrusive and unwanted preoccupation with a stimulus and distress-reducing avoidance [10,11]. There is also evidence that misophonic symptoms and sensory overresponsivity (SOR) are comorbid with OCSDs [2,6,12]. Other clinical characteristics include significant distress in response to repetitive visual movements [2,11]. However, it is unclear what factors contribute to individual differences in the form of triggers and what explains the large variability in severity of responses to misophonic triggers. Family accommodation has been observed in case reports of misophonia and may contribute in part to this variability [5]. Future research that identifies factors would deepen our understanding of the phenomenology of misophonia and may contribute to identification of effective treatment strategies. A significant complication in identifying treatments concerns the lack of a coherent theoretical and etiological framework. Given that misophonia is phenomenologically similar to OCSDs, anxiety/distress may account for this overlap. Indeed, the theoretical model for OCSDs maps on to misophonia quite well. In this model, triggers (e.g., auditory or visual cues) lead to a negative emotional reaction (e.g., distress, anger or anxiety) that is negatively reinforced by a behavioral response. Although this model fits the presentation of misophonia, it is imperative that, as with tinnitus, physical causes be ruled out [1]. It is also unclear how other psychological variables that are associated with characteristics of misophonia (e.g., emotion regulation and SOR) influence misophonia [13]. Unfortunately, there are too few empirical studies that have examined the mechanisms underlying misophonic symptoms, and extant findings require replication and extension. As such, there is yet to be a coherent theoretical framework that accounts for misophonic symptoms. Because our understanding of the processes underlying misophonic symptoms is limited, no evidence-based treatment options exist. While the only published treatment studies for misophonia have utilized psychoeducation and habituation via sound therapy [14] or exposure and response prevention [15,16], these data are limited in scope, methodological rigor and number of treated individuals. The variability in misophonic symptom presentation suggests that treatment may not be best characterized as “one size fits all,” such that one treatment may not be effective for all patients. Cognitive behavior therapy involving exposure and response prevention may fit best for those that experience anxiety/ distress in response to triggers. Alternatively, patients that experience severe anger (or rage) in response to triggers may benefit most from cognitive restructuring or stress inoculation [17], although it remains unclear if this should be in conjunction with other approaches (e.g., exposure therapy). Thus, it is critical that treatment plans be individualized to best address patients’ needs. Clearly, the literature on misophonia is in its infancy although growing. There are several areas that require immediate attention. First, in order to understand more about the phenomenology of misophonia, there is a need for large studies with qualitative and quantitative measures. Second, psychometrically sound measures of misophonia need to be developed. Initial efforts are promising [2,3], but optimally informative measures must include indices on the nature, impairment and frequency of triggers. Third, exploration of modularized treatment protocols in large, clinically diverse samples is needed to identify core treatment components, treatment predictors and mediators. Such research would have a profound effect on the scientific understanding of misophonia and may dramatically benefit those suffering from misophonic symptoms.
Troy A. Webber, MA Department of Psychology, University of South Florida, Tampa, FL Corresponding author. Department of Psychology, University of South Florida, 4202 East Fowler Ave, PCD3103, Tampa, FL 33620 E-mail address: [email protected] Eric A. Storch, PhD Department of Psychology, University of South Florida, Tampa, FL Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL Department of Health Policy and Management, University of South Florida Tampa, FL Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL Rogers Behavioral Health – Tampa Bay, Tampa, FL All Children’s Hospital – Johns Hopkins Medicine, St. Petersburg, FL http://dx.doi.org/10.1016/j.genhosppsych.2015.03.019
References [1] Jastreboff PJ. Tinnitus habituation therapy (THT) and tinnitus retraining therapy (TRT). In: Tyler RS, editor. Tinnitus handbook. San Diego: Singular, Thomson Learning; 2000. p. 357–76. [2] Schröder A, Vulink N, Denys D. Misophonia: diagnostic criteria for a new psychiatric disorder. PLoS One 2013;8(1):e54706. [3] Wu MS, Lewin AB, Murphy TK, Storch EA. Misophonia: incidence, phenomenology, and clinical correlates in an undergraduate student sample. J Clin Psychol 2014; 70(10):994–1007. [4] Edelstein M, Brang D, Rouw R, Ramachandran VS. Misophonia: physiological investigations and case descriptions. Front Hum Neurosci 2013;7. [5] Johnson PL, Webber TA, Wu MS, Lewin AB, Murphy TK, Storch EA. When selective audiovisual stimuli become unbearable: a case series on pediatric misophonia. Neuropsychiatry 2013;3(6):569–75. [6] Neal M, Cavanna AE. Selective sound sensitivity syndrome (misophonia) in a patient with Tourette syndrome. J Neuropsychiatry Clin Neurosci 2013;25(1):E01. [7] Schwartz P, Leyendecker J, Conlon M. Hyperacusis and misophonia: the lesserknown siblings of tinnitus. Minn Med 2011;94:42–3. [8] Veale D. A compelling desire for deafness. J Deaf Stud Deaf Educ 2006;11(3):369–72. [9] Hollander E, Wong CM. Obsessive–compulsive spectrum disorders. J Clin Psychiatry 1995(Suppl. 4):3–6. [10] Hadjipavlou G, Baer S, Lau A, Howard A. Selective sound intolerance and emotional distress: what every clinician should hear. Psychosom Med 2008;70(6): 739–40. [11] Webber TA, Johnson PL, Storch EA. Pediatric misophonia with comorbid obsessive– compulsive spectrum disorders. Gen Hosp Psychiatry 2014;36(2):231-e1. [12] Lewin AB, Wu MS, Murphy TK, Storch EA. Sensory over-responsivity in pediatric obsessive compulsive disorder. J Psychopathol Behav Assess 2014;1–10. [13] Green SA, Ben-Sasson A. Anxiety disorders and sensory over-responsivity in children with autism spectrum disorders: is there a causal relationship? J Autism Dev Disord 2010;40(12):1495–504. [14] Jastreboff MM, Jastreboff PJ. Decreased sound tolerance and tinnitus retraining therapy (TRT). Aust N Z J Audiol 2002;24(2):74–84. [15] Bernstein RE, Angell KL, Dehle CM. A brief course of cognitive behavioural therapy for the treatment of misophonia: a case example. Cogn Behav Ther 2013;6:e10–3. [16] McGuire JF, Wu MS, & Storch EA. Cognitive–behavioral therapy for two youth with misophonia. J Clin Psychiatry [in press]. [17] Beck R, Fernandez E. Cognitive–behavioral therapy in the treatment of anger: a metaanalysis. Cogn Ther Res 1998;22(1):63–74.
Letter to the editor: Potential treatment targets for misophonia To the Editor, Misophonia, a condition characterized by extreme sensitivity to select sounds, has recently been proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1]. Individuals with this disorder respond with irritation, disgust, anger
Collaborative care dissemination is growing, including the Depression Improvement Across Minnesota (DIAMOND) program in over 80 primary care clinics throughout Minnesota and the Washington state Mental Health Integration Program, in which major insurance companies agreed to implement and pay for collaborative care in over 100 community health clinics and 30 community mental health centers [5]. However, health policy changes will be necessary to widely implement this evidence-based model. Several recent policies could improve depression quality of care. These include mental health policies, such as the Medicare Improvements for Patients and Providers Act of 2008 [which eliminated by 2014 unequal copayments previously required for psychotherapy (50%) and other medical services in Medicare (20%)], the Mental Health Parity and Addiction Equity Act of 2008 (which prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits), and broader health policies included in the ACA: Medicaid expansion, employer mandate, health insurance exchanges with low income subsidies, PCMHs, Medicaid health homes, ACOs, and inclusion of mental health in essential benefits packages. Some policies have a greater likelihood than others to improve depression care. For example, mental health parity and insurance expansion alone are unlikely to solve the problem, as challenges with access to mental health services, which is already difficult, are likely to worsen (i.e., demand will increase but provider supply will not). However, some policy changes, such as credentialing requirements based on 2014 National Committee for Quality Assurance criteria for PCMH designation, incentivize integrated models with population-based requirements, CM requirements, and ways to better integrate mental health as key components to achieve level 3 credentialing, which will lead to better payments from many insurers. Demonstration models such as the Comprehensive Primary Care initiative provide financial incentives as well as educational opportunities and technical assistance to encourage integrated care practices. ACOs incentivize decreasing emergency room visits and hospitalizations, and people with comorbid mental and physical illness are disproportionately represented in these populations. Increasing evidence demonstrates that depression predicts 30-day rehospitalizations and ambulatory care-sensitive hospitalizations. CMS tracks and penalizes hospitals in the bottom 25% of 30-day rehospitalizations. CMS also recently finalized a separate payment, outside of a face-to-face visit, for managing care of Medicare patients with two or more chronic conditions (which could include depression) beginning in 2015. One might question how new policies could improve depression outcomes, particularly due to limited focus of broader policies on mental health conditions (e.g., only 1 of 33 ACO quality measures focuses on mental health with depression screening). However, strengths of recent policies may lie in encouraging more thoughtful applications of integrating evidence-based models to enhance depression treatment. These policies potentially incentivize a more nuanced, systematic, and integrated approach to depression management. Financial incentives provided by policies generate motivation for clinicians and healthcare systems to engage in the practice redesign work to identify which patients have depression, what treatments are needed, how treatments fit into overall treatment plans (rather than addressing mental and physical disorders separately), and provide increased intensity of care and systematic follow-up for patients with persistent symptoms. We recommend that to enhance integration of this evidence-based model, payers need to develop billing codes for care management contacts, including phone contacts and in-person contacts, codes for weekly psychiatrist systematic caseload review, and incentives for process measures tightly linked to depressive outcomes (e.g., changing ineffective treatments by 8 weeks) and improved outcomes (e.g., percent of patients reaching at least a 50% symptom reduction by 8 weeks and 6 months) [5]. Quality indicators or fidelity measures are needed to provide either a financial disincentive for systems that have attempted to
369
implement care managed with little fidelity to evidence-based models or to provide an incentive for systems implementing higher fidelity models. Incentives should also be provided for groups to participate in collaborative endeavors to improve the dissemination process and create more sustainable improvements. Both performance criteria and outcomes monitoring are important. Don Berwick said that the American system gets what it pays for by incentivizing high-cost procedures and tests rather than care quality and time with practitioners. It is time to change financial incentives to improve quality of care and outcomes for depression using evidencebased ways to deliver treatments. Kara Zivin, PhD Department of Veterans Affairs, Center for Clinical Management Research Ann Arbor, MI, USA Department of Psychiatry, University of Michigan Medical School Ann Arbor, MI, USA Corresponding author. University of Michigan North Campus Research Complex, 2800 Plymouth Road, Building 16, 228W, Ann Arbor, MI 48109-2800, USA. Tel.: +1-734-222-7417 E-mail address: [email protected] Wayne Katon, MD Department of Psychiatry, University of Washington Medical School Seattle, WA, USA Deceased, 3/1/2015 http://dx.doi.org/10.1016/j.genhosppsych.2015.04.004
References [1] Grembowski DE, Martin D, Patrick DL, Diehr P, Katon W, Williams B, et al. Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. J Gen Intern Med 2002;17:258–69. [2] Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:1–277 [CD006525]. [3] Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies Press; 2012. [4] Sederer LI. What does it take for primary care practices to truly deliver behavioral health care? JAMA Psychiatry 2014;71:485–6. [5] Unützer J, Chan Y-F, Hafer E, Knaster J, Shields A, Powers D, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health 2012;102:e41–5.
Toward a theoretical model of misophonia To the Editor, Misophonia, literally translated into “hatred of sound” [1], is characterized by intense emotional responses to hearing specific sounds (i.e., triggers or auditory cues) as well as observing certain movements. Commonly reported triggers include chewing, breathing and sounds emitted from movements (e.g., foot or pen tapping) [2,3]. Those with misophonic symptoms often experience significant impairment across occupational/academic, familial/home-based and social functioning in response to the disgust, anger and distress caused by auditory cues [3]. The primary behavioral response to triggers is avoidance, although other behaviors have been reported [2,4]. Over the past several years, case studies have brought attention to the incidence of misophonic symptoms across certain clinical populations [5–8], but there have been few treatment studies or empirical reports that contribute to the development of a theoretical model for understanding misophonia and related phenomena, or its treatment. For future efforts to develop effective treatments for misophonic
370
Letters to the Editor
symptoms, a cohesive theoretical model and diagnostic classification system is needed. Schröder et al. [2] proposed a diagnostic classification system that categorizes misophonia as an obsessive–compulsive spectrum disorder (OCSD). OCSDs are all thought to include some element of obsessions and compulsions [9]. Indeed, misophonia shares many clinical characteristics with OCSDs, such as intrusive and unwanted preoccupation with a stimulus and distress-reducing avoidance [10,11]. There is also evidence that misophonic symptoms and sensory overresponsivity (SOR) are comorbid with OCSDs [2,6,12]. Other clinical characteristics include significant distress in response to repetitive visual movements [2,11]. However, it is unclear what factors contribute to individual differences in the form of triggers and what explains the large variability in severity of responses to misophonic triggers. Family accommodation has been observed in case reports of misophonia and may contribute in part to this variability [5]. Future research that identifies factors would deepen our understanding of the phenomenology of misophonia and may contribute to identification of effective treatment strategies. A significant complication in identifying treatments concerns the lack of a coherent theoretical and etiological framework. Given that misophonia is phenomenologically similar to OCSDs, anxiety/distress may account for this overlap. Indeed, the theoretical model for OCSDs maps on to misophonia quite well. In this model, triggers (e.g., auditory or visual cues) lead to a negative emotional reaction (e.g., distress, anger or anxiety) that is negatively reinforced by a behavioral response. Although this model fits the presentation of misophonia, it is imperative that, as with tinnitus, physical causes be ruled out [1]. It is also unclear how other psychological variables that are associated with characteristics of misophonia (e.g., emotion regulation and SOR) influence misophonia [13]. Unfortunately, there are too few empirical studies that have examined the mechanisms underlying misophonic symptoms, and extant findings require replication and extension. As such, there is yet to be a coherent theoretical framework that accounts for misophonic symptoms. Because our understanding of the processes underlying misophonic symptoms is limited, no evidence-based treatment options exist. While the only published treatment studies for misophonia have utilized psychoeducation and habituation via sound therapy [14] or exposure and response prevention [15,16], these data are limited in scope, methodological rigor and number of treated individuals. The variability in misophonic symptom presentation suggests that treatment may not be best characterized as “one size fits all,” such that one treatment may not be effective for all patients. Cognitive behavior therapy involving exposure and response prevention may fit best for those that experience anxiety/ distress in response to triggers. Alternatively, patients that experience severe anger (or rage) in response to triggers may benefit most from cognitive restructuring or stress inoculation [17], although it remains unclear if this should be in conjunction with other approaches (e.g., exposure therapy). Thus, it is critical that treatment plans be individualized to best address patients’ needs. Clearly, the literature on misophonia is in its infancy although growing. There are several areas that require immediate attention. First, in order to understand more about the phenomenology of misophonia, there is a need for large studies with qualitative and quantitative measures. Second, psychometrically sound measures of misophonia need to be developed. Initial efforts are promising [2,3], but optimally informative measures must include indices on the nature, impairment and frequency of triggers. Third, exploration of modularized treatment protocols in large, clinically diverse samples is needed to identify core treatment components, treatment predictors and mediators. Such research would have a profound effect on the scientific understanding of misophonia and may dramatically benefit those suffering from misophonic symptoms.
Troy A. Webber, MA Department of Psychology, University of South Florida, Tampa, FL Corresponding author. Department of Psychology, University of South Florida, 4202 East Fowler Ave, PCD3103, Tampa, FL 33620 E-mail address: [email protected] Eric A. Storch, PhD Department of Psychology, University of South Florida, Tampa, FL Department of Pediatrics, University of South Florida Morsani College of Medicine, Tampa, FL Department of Health Policy and Management, University of South Florida Tampa, FL Department of Psychiatry and Behavioral Neurosciences, University of South Florida Morsani College of Medicine, Tampa, FL Rogers Behavioral Health – Tampa Bay, Tampa, FL All Children’s Hospital – Johns Hopkins Medicine, St. Petersburg, FL http://dx.doi.org/10.1016/j.genhosppsych.2015.03.019
References [1] Jastreboff PJ. Tinnitus habituation therapy (THT) and tinnitus retraining therapy (TRT). In: Tyler RS, editor. Tinnitus handbook. San Diego: Singular, Thomson Learning; 2000. p. 357–76. [2] Schröder A, Vulink N, Denys D. Misophonia: diagnostic criteria for a new psychiatric disorder. PLoS One 2013;8(1):e54706. [3] Wu MS, Lewin AB, Murphy TK, Storch EA. Misophonia: incidence, phenomenology, and clinical correlates in an undergraduate student sample. J Clin Psychol 2014; 70(10):994–1007. [4] Edelstein M, Brang D, Rouw R, Ramachandran VS. Misophonia: physiological investigations and case descriptions. Front Hum Neurosci 2013;7. [5] Johnson PL, Webber TA, Wu MS, Lewin AB, Murphy TK, Storch EA. When selective audiovisual stimuli become unbearable: a case series on pediatric misophonia. Neuropsychiatry 2013;3(6):569–75. [6] Neal M, Cavanna AE. Selective sound sensitivity syndrome (misophonia) in a patient with Tourette syndrome. J Neuropsychiatry Clin Neurosci 2013;25(1):E01. [7] Schwartz P, Leyendecker J, Conlon M. Hyperacusis and misophonia: the lesserknown siblings of tinnitus. Minn Med 2011;94:42–3. [8] Veale D. A compelling desire for deafness. J Deaf Stud Deaf Educ 2006;11(3):369–72. [9] Hollander E, Wong CM. Obsessive–compulsive spectrum disorders. J Clin Psychiatry 1995(Suppl. 4):3–6. [10] Hadjipavlou G, Baer S, Lau A, Howard A. Selective sound intolerance and emotional distress: what every clinician should hear. Psychosom Med 2008;70(6): 739–40. [11] Webber TA, Johnson PL, Storch EA. Pediatric misophonia with comorbid obsessive– compulsive spectrum disorders. Gen Hosp Psychiatry 2014;36(2):231-e1. [12] Lewin AB, Wu MS, Murphy TK, Storch EA. Sensory over-responsivity in pediatric obsessive compulsive disorder. J Psychopathol Behav Assess 2014;1–10. [13] Green SA, Ben-Sasson A. Anxiety disorders and sensory over-responsivity in children with autism spectrum disorders: is there a causal relationship? J Autism Dev Disord 2010;40(12):1495–504. [14] Jastreboff MM, Jastreboff PJ. Decreased sound tolerance and tinnitus retraining therapy (TRT). Aust N Z J Audiol 2002;24(2):74–84. [15] Bernstein RE, Angell KL, Dehle CM. A brief course of cognitive behavioural therapy for the treatment of misophonia: a case example. Cogn Behav Ther 2013;6:e10–3. [16] McGuire JF, Wu MS, & Storch EA. Cognitive–behavioral therapy for two youth with misophonia. J Clin Psychiatry [in press]. [17] Beck R, Fernandez E. Cognitive–behavioral therapy in the treatment of anger: a metaanalysis. Cogn Ther Res 1998;22(1):63–74.
Letter to the editor: Potential treatment targets for misophonia To the Editor, Misophonia, a condition characterized by extreme sensitivity to select sounds, has recently been proposed for inclusion in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [1]. Individuals with this disorder respond with irritation, disgust, anger