EMDR Therapy Quarterly

Introduction

Misophonia is a sound intolerance disorder characterised by severe aversive reactions, often manifesting as anger, panic or disgust, when confronted by certain repetitive auditory stimuli such as chewing or breathing (Jager et al., 2021; Jastreboff & Jastreboff, 2002). Other trigger sounds include common daily human-produced sounds, such as tapping, rustling, sniffing or throat clearing (Guetta et al., 2024).

Misophonia has been defined as an emotional response disorder that is poorly understood (Swedo et al., 2022). Köroğlu and Durat (2024, p254) state that, “Misophonia symptoms overlap with the emotional and autonomic response that can be seen in mental disorders such as PTSD, panic disorder and phobias.” Evidence suggests that the condition often presents alongside depressive and anxiety disorders, with additional, though less frequent, associations observed with obsessive-compulsive disorder, Tourette’s syndrome, attention-deficit/hyperactivity disorder, autism spectrum disorder, panic disorder, various personality disorders and suicidality (Mattson et al., 2023). The powerful aversive reactions lead to avoidance of certain situations, such as family meals or eating in restaurants. The associated sequelae of misophonia impact social and family relations (Jager et al., 2021).

The estimated prevalence of misophonia in the population is approximately 8 to 20% (Brennan et al., 2024). Some authors suggest symptoms typically start at age 13 (Jager et al., 2020; Schröder et al., 2013); however, in the service the study was based, children report symptoms of misophonia starting from as young as age six. “The onset of misophonia is often associated with early childhood experiences. Unpleasant childhood experiences can be remembered with misophonic triggers that reveal negative emotions in the person” (Edelstein et al., 2013; Claiborn et al., 2020, as cited in Köroğlu & Durat, 2024, p.252).

There is a limited evidence base for the treatment of misophonia, especially among adolescents. Some authors have noted that “exposure therapy is not widely accepted as a credible intervention among individuals with misophonia” (Mattson et al., 2023, p.7). Gregory (2024) suggested that exposure therapy may be ineffective, as emotions such as anger, disgust and shame may not habituate and could potentially increase symptoms rather than reduce them.

Cognitive behavioural therapy (CBT), incorporating various components, has been the most often utilised and effective treatment for reducing misophonia symptoms in one randomised trial and several case studies/series (Mattson et al., 2023). Of note, a case study by Muller et al. (2018) of a 14-year-old girl treated with CBT for misophonia found that significant tolerance of noise triggers occurred both within and between sessions. The patient achieved concurrent behavioural changes and tolerated a marked reduction in relevant avoidance behaviours. Self-reported and observed psychological and physiological distress diminished when confronted with identified trigger noises, both during conducted in vivo exposures and, more broadly, in the patient’s home and school environments.

Beyond CBT, other case studies suggested possible benefit from other treatment approaches. There is preliminary evidence that EMDR may help reduce the distress and impairment associated with misophonia (Jager et al., 2021). EMDR was originally developed to treat posttraumatic stress but has now been applied to many psychological conditions.

In a study conducted by Jager et al. (2021), participants were either on a waiting list for CBT or non-responders to CBT in a case series design. EMDR was focused on misophonia-related emotionally disturbing memories and was delivered over a mean of 2.6 sessions lasting 60 to 90 minutes each. Pre- and post-treatment, self-assessed ratings of misophonia symptoms were measured using AMISOS-R as the primary outcome. Jager et al. (2021) found a reduction in AMISOS-R scores in a sample of 10 adults and suggested that EMDR may be effective for patients with misophonia who do not respond to CBT. To date, there has been limited research evaluating the effectiveness of EMDR in adolescents with misophonia. Guetta et al. (2024) stated that future research samples should include children, adolescents and underrepresented groups. The current study aims to evaluate EMDR for adolescents experiencing misophonia as a potentially effective treatment approach.

Method

A case series of adolescents with a diagnosis of misophonia treated with EMDR was adopted to evaluate the impact of this intervention on the symptoms of misophonia.

Participant selection

A total of four patients were selected between August 2023 and August 2025 from the outpatient clinic at a national ear, nose and throat hospital. All the patients had been referred to the national specialist centre by local ENT clinicians for treatment of misophonia. Inclusion criteria were a diagnosis of misophonia, being between 12 and 16 years old and having a clear memory of past misophonia experiences. Exclusion criteria include the presence of depression and anxiety as a primary diagnosis, and substance misuse.

Hypotheses

It was hypothesised that a reduction in misophonia symptoms would occur following treatment with EMDR.

EMDR therapy

The EMDR therapy was conducted in accordance with Shapiro’s (2018) eight-phase protocol. Therefore Phase 1 involved history taking and formulation; Phase 2 included preparing and equipping the patient with resources; Phase 3 included identifying the target memory, along with positive and negative cognitions; Phase 4 included desensitisation and reprocessing; Phase 5 included installing more adaptive positive cognition; Phase 6 included a body scan to target any residual physical discomfort; Phase 7 involved closure and debriefing, and Phase 8 involved a re-evaluation, during the following session, to determine if any additional work was required.

Assessments

Participants were assessed at baseline (T1) and post-treatment (T2).

Measures

Misophonia symptoms were measured using the revised Amsterdam Misophonia Scale (AMISOS-R) (Schroder & Spape, 2014), which consists of 10 items with scores ranging from 0 to 40. Higher scores indicate greater symptom severity, classified as follows: 0–10 = normal to subclinical; 11–20 = mild misophonia; 21–30 = moderate to severe misophonia, and 31–40 = severe to extreme misophonia.

The perceived intensity of disturbance or distress associated with an image or an emotional memory being recalled was measured using the Subjective Units of Distress (SUD) scale. This score is indexed on an 11-point Likert-type scale, ranging from 0 (‘no disturbance at all’) to 10 (‘greatest level of disturbance’) (Shapiro, 2018). Participants indicated their SUD score verbally to the therapist for each identified event at the start, during and after EMDR therapy. The SUD scores are presented in Table 3.

Statistical analysis

Because this was a pilot study, no formal sample size calculations were performed. The decrease in symptom severity was tested using a paired t-test, with the AMISOS-R total score as the dependent variable and assessment time points (T1 and T2) as the independent factor. Analyses were based on two-tailed t-tests. For both co-primary and secondary outcomes, P<.05 was considered statistically significant. All results should be interpreted as exploratory. Data were analysed using SPSS Statistics (Version 30).

Participant characteristics

A total of four female patients aged between 12 and 16 years were included in the study.

Table 1. Participant characteristics

Participant	Sex	Age (years)	Age onset (years)	Co-existing diagnoses
1	F	16	9	No additional diagnosis
2	F	12	6	ADHD
3	F	16	10	OCD
4	F	15	12	No additional diagnosis

Primary outcomes

Table 2. Descriptive statistics for the mean changes between baseline and end of treatment in participants (n = 4)

Group	Pre MISO-R	Post MISO-R
Mean	16.25	10.00
SD	1.50	2.16
SEM	0.75	1.08
N	4	4

A paired t-test for the participants’ mean scores on the AMISOS-R showed significant improvement on the primary outcome, t (3) = .7529, p<.05. No adverse outcomes or side effects were reported by any of the participants.

Qualitative outcomes

After treatment, one participant said that their misophonia was not ‘front and centre’; it was now ‘in the background’. Further, she reported that her misophonia no longer bothered her in the same way, and that it had made a ‘huge difference’. She was now able to get a job as a waitress in a restaurant following treatment.

Another participant’s parent noticed they were better able to eat meals together as a family and that she would eat a meal with them in the room, whereas before she would eat separately.

Another participant was able to go on holiday with her girlfriends and sleep in the same room with her friends, when previously their breathing would have bothered her.

Table 3. EMDR treatment information of the four participants with misophonia 

Participant	Target  memories	SUD scores Pre	SUD scores post
1	Holocaust museum trip with primary school	8	0
	Friend chewing gum	10	1
	Mother’s breathing in the car	8	1
2	Teacher shouting	5	0
	Father vomiting	8	0.5
	Dance  competition	7	0
3	Mother’s family dinner table – eating food together	4	1
	Father’s family dinner table – eating food together	10	1
	Classroom students sniffing and cutting with scissors	4	0
	Hearing talking through the wall	9	0
4	Mother chewing at breakfast table	8	1
	Exam conditions at school – papers shuffling	8	1
	Sitting on a bus – man eating bread	9	0

Discussion

This is the first clinical case series to examine the feasibility and effectiveness of EMDR on adolescents with misophonia. The results demonstrated that EMDR targeting emotionally disturbing memories associated with the onset or exacerbation of misophonia symptoms led to a significant reduction in these symptoms. Our positive findings align with those of Jager et al. (2021), who also observed a reduction in misophonia symptoms following EMDR targeting misophonia-related memories. Similarly to the Jager et al. (2021) study used Shapiro’s (2018) future template to help patients successfully visualise themselves managing anticipated future events that involve misophonia triggers.

None of the participants reported any adverse reactions to therapy or side effects of treatment. This suggests that EMDR is an acceptable and tolerable treatment approach for adolescents. This is in contrast with Gregory’s (2024) suggestion that exposure therapy is not acceptable as a treatment approach for adults with misophonia.

Limitations and strengths

As this is a small case series without a control group, it, therefore, has several limitations. The absence of a control group prevents us from assessing the effects of time and non-specific factors on misophonia symptoms. In addition, the small sample size prevents generalisation of the findings.

All participants received EMDR from one therapist, and the evaluator was not blinded to treatment. The treatment fidelity measures were not carried out, possibly leading to bias.

Larger sample sizes with more sophisticated data analyses are needed to confirm the effectiveness of EMDR therapy for adolescents with misophonia, and it would be helpful to use longitudinal sampling to measure effects over a period of time.

However, despite these limitations, our study is, to the best of our knowledge, the first to examine EMDR in the treatment of misophonia in adolescents. A case series design was considered appropriate at this early stage of innovation. Importantly, these findings help to raise awareness within the EMDR and audio-vestibular medicine communities that EMDR may be a viable treatment for adolescents with misophonia.

This study provides preliminary evidence supporting EMDR as a viable and appropriate treatment for misophonia in the adolescent age group, and potentially extends the role of EMDR into the auditory field.

Acknowledgements

We sincerely appreciate the four adolescent participants who entrusted us with providing an alternative therapy approach. This case series underwent a clinical governance review and was approved as an audit within a national ear, nose and throat hospital. All participants received an information sheet and provided written informed consent prior to taking part in the audit.