Properties (7)

Id 1628f576-a598-4d16-89c0-228b70c78c82

Year 2025

Abstract Cognitive behavioural therapy (CBT) is an evidence-based intervention for managing distress associated with tinnitus, hyperacusis, and misophonia. This paper summarises key points from the 2025 Tonndorf Lecture presented at the third World Tinnitus Congress and the 14th International Tinnitus Seminar in Poland. The lecture addressed (1) the theoretical foundations of CBT for these conditions, (2) clinical evidence on CBT delivered by psychologists, audiologists, and digital self-help, and (3) the proportion of patients who may benefit from CBT. Research demonstrates that CBT can effectively reduce distress related to tinnitus, hyperacusis, and misophonia. Both psychologist- and audiologist-delivered CBT approaches have demonstrated significant improvements in reducing the impact of tinnitus, hyperacusis, and misophonia on patients’ quality of life, while guided internet-based CBT also demonstrates positive outcomes. Unguided internetbased CBT is also effective, though it faces challenges such as higher dropout rates. Despite these promising results, not all patients experience the same level of benefit. Some continue to experience distress even after completing CBT, highlighting the need for alternative or complementary interventions and ongoing support. This paper estimates that approximately 1 in 52 individuals with tinnitus require CBT, indicating that while tinnitus is relatively common, the need for intensive therapy is comparatively small. To enhance treatment outcomes, future research should compare the effectiveness of psychologist- and audiologist-delivered CBT, explore hybrid models that combine face-to-face and digital interventions, and address challenges with internet-based CBT, particularly for hyperacusis and misophonia. Furthermore, incorporating neuroimaging and physiological measures in future randomised controlled trials could provide objective insights into the neural mechanisms underlying symptom improvement, ultimately helping to refine CBT interventions. Identifying characteristics of non-responders to CBT may also guide the development of more tailored therapeutic approaches.

Cssclasses

purpleRed

Aliases

Cognitive Behavioural Therapy (CBT) for Managing Tinnitus, Hyperacusis, and Misophonia
(Aazh, 2026)

Import Date 09-02-2026

Initial Source

Misophonia

Cognitive Behavioural Therapy (CBT) for Managing Tinnitus, Hyperacusis, and Misophonia: The 2025 Tonndorf Lecture

Status:: #status/Bare-bones-review

Metadata

Item Type: #journalArticle
Authors:: Hashir Aazh,
Date:
Date Added: 1748831940000
URL: https://www.mdpi.com/2076-3425/15/5/526
DOI: 10.3390/brainsci15050526
Cite Key: aazhCognitiveBehaviouralTherapy2025
Tags:: #Misophonia, #literature-review, #Bare-bones-review-🦴, #tinnitus, #Hyperacusis, #CBT, #lecture,
PDF Attachments

Abstract


Background/Purpose	Background- • Misophonia involves strong negative emotional, physiological, and behavioral responses to specific trigger sounds, with symptoms reported by ~18% of UK adults. • Trigger exposure is associated with altered activity/connectivity across insular, limbic, amygdala, and salience networks. • Greater symptom severity is linked to reduced affective/cognitive flexibility and increased rumination. • Cognitive-behavioral models propose that maladaptive appraisals amplify distress, while avoidance and safety behaviors maintain symptoms by preventing corrective learning. • CBT approaches typically combine psychoeducation, cognitive restructuring, behavioral experiments, graded exposure, and reduction of avoidance/safety behaviors. • Evidence has progressed from case reports/open trials to an RCT showing significant improvement versus waiting list, alongside emerging transdiagnostic and telehealth approaches. • Despite recent reviews, key issues remain unclear, including outcome heterogeneity, variation in treatment delivery, residual symptoms, and their clinical implications. Purpose- • Critically evaluate current evidence on CBT for misophonia by synthesizing findings from clinical studies in children, adolescents, and adults regarding severity, emotional distress, functional impairment, anger reactions, and coping ability. • Describe therapeutic components and delivery formats, identify methodological limitations, and highlight priorities for future research on assessment, treatment development, and clinical implementation.
Participants/samples	N/A
Measures	N/A
Procedures	N/A
Results	• Studies (2015–2026) were mostly small, specialist clinical/academic samples; most involved adults, with two pediatric studies. • CBT was delivered by psychologists, trainees, and CBT-trained audiologists across individual/group, in-person, telehealth, and video formats. • Psychoeducation and exposure were most common, often supplemented by cognitive restructuring, attentional training, stimulus manipulation, counterconditioning, relaxation/mindfulness, psychomotor, or family-based components. • Treatment ranged from 8 weekly sessions to ~12 months, with follow-up extending to 1 year. • Samples varied substantially in psychiatric comorbidity, from relatively low to high rates across studies. • Diagnostic methods were heterogeneous, including structured interviews, study-specific assessments, clinical interviews, and the MQ. • CBT generally improved misophonia severity, distress, anger, impairment, and coping; RCTs showed the strongest and most durable effects. • However, clinically significant residual symptoms/impairment remained common in some samples. • Outcome measurement was also heterogeneous; only the Amsterdam Misophonia Scale family appeared in multiple studies, and one study used an anger measure rather than a misophonia-specific outcome.
Discussion/Limits	Conclusion- • CBT may reduce misophonia severity, distress, anger, and functional impairment across varied settings and formats. • Evidence remains limited and heterogeneous, with many small, uncontrolled studies and potential publication bias. • Lewin et al. (2026) is difficult to interpret because the psychoeducation/relaxation comparator contained active therapeutic elements that may have reduced between-group differences. • Recovery appears continuous rather than a simple responder/non-responder distinction. • Persistent disability after treatment warrants better assessment frameworks and access to appropriate accommodations. • Treatments for CBT non-responders require further study, including taVNS/neuromodulation, pharmacological, acceptance-based, family-based, and multidisciplinary approaches. • Outcome measures vary in focus and format, underscoring the need for a standardized core outcome set. • Heavy reliance on self-report/clinician ratings limits understanding of mechanisms; physiological and neurophysiological measures may help distinguish process change from altered appraisal. • Given frequent psychiatric comorbidity, clinicians should use comprehensive assessment and individualized formulation while balancing accommodations with intervention to avoid reinforcing avoidance.
Limitations::	• Three included studies were case reports or small case series (<5 participants), limiting generalizability and robust effectiveness estimates. • Only two RCTs identified; remainder used observational, open-label, or uncontrolled designs. • Heterogeneity across participant characteristics, protocols, duration, therapist backgrounds, and outcome measures precluded direct comparisons. • Comorbid tinnitus/hyperacusis and concurrent psychological/pharmacological treatments in several studies made it difficult to isolate CBT effects. • Most studies were conducted in specialist clinical settings, limiting generalizability to routine practice. • Predominance of case reports, uncontrolled studies, and specialist-clinic samples introduces recognized selection, performance, and reporting biases. • Publication bias and selective reporting cannot be excluded as all included studies reported positive outcomes. • Literature search was restricted to PubMed/MEDLINE and title-based terms; relevant studies in other databases or using different terminology may have been missed.
Future Directions::	• Utilize validated misophonia-specific outcome measures and develop a core outcome set for future clinical trials. • Incorporate objective physiological and neurophysiological markers (fMRI, EEG, skin conductance, heart rate variability) alongside self-report and clinician-rated outcomes. • Conduct process research and dismantling studies to identify which therapeutic components, patient characteristics, and contextual factors predict response and long-term outcomes. • Attend to treatment fidelity, including therapist adherence, treatment integrity, and protocol compliance. • Investigate predictors of treatment response and evaluate interventions for treatment-resistant misophonia. • Compare CBT with interventions from alternative theoretical frameworks (person-centered counselling, supportive therapy, symptom-management) to clarify specific vs. common therapeutic factors. • Investigate whether treatment response, mechanisms of change, and optimal strategies differ across the lifespan. • Develop criteria for clinically significant disability associated with misophonia to support decision-making, service planning, accommodations, and future research on severe/treatment-resistant cases.
Relevance::	• a recap from a lecture given at a 2025 tinnitus seminar that talks about the application of CBT to treating tinnitus, hyperacusis and Misophonia • unsurprisingly found good results from CBT for Misophonia , though nots not all people responded to treatment. • a a good source for more in depth info on the specifics of CBT as a method and its application to Misophonia , tinnitus, and hyperacusis.

Notes

key terms and concepts

Misophonia – a disorder of decreased tolerance to specific sounds (trigger sounds) that evoke disproportionately strong emotional, physiological, and behavioral reactions.
Trigger sounds – often human-generated sounds (chewing, breathing, sniffing, coughing, tapping, slurping) or repetitive environmental sounds that evoke misophonic reactions.
Cognitive behavioural therapy (CBT) – intervention aiming to identify and modify maladaptive thoughts, beliefs, attentional processes, emotional reactions, and behavioral responses associated with trigger sounds.
Transdiagnostic CBT – broader CBT approach targeting emotional regulation, cognitive flexibility, coping skills, and behavioral responses to distress rather than a single disorder.
Task concentration training – attentional technique designed to reduce hyperfocus on trigger sounds.
Treatment responder – participant meeting a predefined improvement criterion (e.g., ≥30% A-MISO-S reduction combined with CGI-I score of 1 or 2).

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contextual statement

In a 2026 study, Aazh attempted to critically evaluate the current evidence on CBT for misophonia by conducting a systematic narrative review of PubMed/MEDLINE from database inception to June 2026, screening 12 records and synthesising seven included case reports, observational studies, open clinical trials, and randomised controlled trials that used misophonia-specific outcome measures such as the A-MISO-S, AMISOS-R, MIQ, SSSQ, 4C-M, and CGI.

summary statement

In a 2026 study, Aazh evaluated the current evidence on CBT for misophonia by conducting a systematic narrative review of seven clinical studies identified through PubMed/MEDLINE. They found that CBT was generally associated with improvements in misophonia severity, emotional distress, anger reactions, functional impairment, and coping ability, with the strongest evidence from RCTs showing large treatment effects and maintenance of gains, though substantial heterogeneity in participants, protocols, and outcome measures was observed and a meaningful proportion of participants continued to report clinically significant symptoms after treatment. From this they concluded that CBT is a promising intervention for misophonia but the evidence base remains at an early stage, and further work is needed on validated outcome measures, mechanisms of change, disability frameworks, and interventions for treatment-resistant cases.

Atoms

review of variability in dx criteria across Misophonia CBT studies

review of variability in outcome measures across Misophonia CBT studies

Review of variability in treatment outcomes across Misophonia CBT studies

review of clinical implications across Misophonia CBT studies

speechify summary

Overview of Cognitive Behavioural Therapy for Misophonia

Definition of Misophonia: Misophonia is characterized by disproportionately strong negative emotional, physiological, and behavioral reactions to specific "trigger sounds"—commonly human-generated noises like chewing or breathing. These reactions often include anger, anxiety, and disgust, leading to social withdrawal and avoidance behaviors.
Scope of the Review: This systematic narrative review, published in June 2026, evaluated the efficacy, delivery methods, and clinical outcomes of Cognitive Behavioural Therapy (CBT) across seven studies involving children, adolescents, and adults.

Key Findings on CBT Effectiveness

Clinical Improvements: Across the examined studies, CBT was generally associated with reduced symptom severity, decreased emotional distress, and improved coping skills.
Evidence Quality:
- Strongest Evidence: Randomized controlled trials (RCTs) reported large treatment effects and the maintenance of gains over follow-up periods.
- Heterogeneity: The existing evidence base is limited by substantial variation in intervention protocols, participant demographics, and the presence of comorbid psychiatric conditions.
Treatment Delivery: CBT for misophonia has been successfully delivered through diverse formats, including:
1. Individual sessions.
2. Group therapy.
3. Telehealth and video-based platforms.
4. Specialist-led interventions, including those delivered by trained audiologists.

Methodological Limitations and Future Directions

Persistent Symptoms: A significant finding is that some patients continue to report clinically significant impairment despite completing a course of CBT, suggesting that treatment success exists on a continuum.
Diagnostic and Measurement Variability: There is a lack of consensus on diagnostic criteria and outcome measures, with studies relying on a mix of self-report questionnaires and clinician-rated scales.
Recommendations for Research:
- Standardization: Future research should prioritize the establishment of a "core outcome set" to improve data consistency.
- Multi-modal Assessment: Greater integration of objective physiological and neurophysiological measures (e.g., heart rate variability, brain imaging) is needed alongside traditional psychological assessments.
- Treatment for Non-responders: Further investigation is required into alternative, adjunctive, or specialized interventions for individuals who remain symptomatic after standard CBT.
- Disability Frameworks: Developing clinical criteria for "disabling misophonia" is necessary to help patients access appropriate educational, occupational, and social accommodations.

In summary, CBT represents a promising and evidence-supported intervention for managing misophonia by targeting maladaptive thoughts and behaviors. While outcomes are generally positive, the field remains at an early developmental stage, requiring more rigorous research to address clinical heterogeneity and support those who do not achieve full symptom remission.