As an illustration of the misophonia model we use the case conceptualization of an actual patient given the anonymized name of "Charlotte." This patient meets all criteria proposed by the Amsterdam UMC in 2020. The revised Amsterdam Misophonia Scale [AMISOS-R; ] indicates she has severe to extreme misophonia (range 31-40). The labels in parentheses are links to the main elements of Figure 3.
Charlotte is a 37-year-old woman, who works as a lawyer and has a family with two children. Charlotte signed up for treatment, because she wants to avoid a divorce. She considers treatment as "her last straw to save her marriage." Charlotte developed her symptoms at the age of 12, when she started puberty. She has always had high standards as a child (personality), but she started judging people who made more eating sounds and even disliked them. Now she considers people who make eating sounds as "people who have a defect" and refuses to interact with them. Her parents do not have misophonia, but she found out her father's mother had similar symptoms (genetic disposition). Charlotte grew up in a prosperous family as an only child. Her first and main trigger sound was the sound of food chewing her mother made. During her adolescence all joint meals were in a tense atmosphere, with her mother expressing she was hurt by the non-verbal aggression of Charlotte, and her father "trying to mediate between them." Sometimes Charlotte was allowed to listen to a portable music player during dinners, but more often she was told by her father to stay at the table and control herself. This made her feel extremely powerless and she felt guilty for ruining dinner (learning history). During holidays, without her busy schedule of extracurricular activities, misophonia symptoms were less present. With lower stress and, as such, less sensitivity to misophonic triggers, she could enjoy her mother's company more (environment). Later in life she felt annoyed by nearby eating behaviors of students or colleagues, but misophonia symptoms were not disabling, because she could avoid her major triggers. When she visited her parents however, misophonia symptoms returned to levels that were present at puberty. The first 6 years of her relationship with her husband, she did not experience him as a misophonia trigger. But during the pregnancy of their firstborn child, she started to respond with disgust and aggression (emotion) to his eating sounds and breathing or snoring. She also had a strong reaction to the sounds of doors closing loudly, whispering, sniffing, "s" and "t" sounds, glasses being put on the table, ringing keys and the dishwasher during nighttime (trigger sound). She developed a strong focus on these sounds, which made it impossible to engage in social interaction or sleep during these sounds (hyper focus). Subsequently Charlotte avoided eating together with her family and started sleeping alone. She tried to correct her husband when he was eating, even though she realized he did not produce too much sound, and she picked many fights about his breathing sounds (coping).
Results of the protocol are illustrated by the case study of Charlotte. Even though Charlotte was anxious at first to adopt new triggers from other patients, she did not. After treatment she experienced a large reduction in misophonia symptoms. Although she was still experiencing some symptoms, the relationship with her husband improved significantly. After treatment Charlotte was able to eat and sleep together again. She could make jokes with her husband about her misophonia (for example saying "Just breathe!," when she got annoyed) and the tension at home decreased. She lost the hyper focus on most trigger sounds. The eating sounds of her mother remained a trigger for Charlotte, but she no longer avoided eating with her parents. She was able to cope in a functional manner when an emotional reaction was provoked. Charlotte stated she felt more relaxed and free in social interactions with other people.
At session 1, 4, 7, and 8 progress was monitored by two questionnaires; the AMISOS-R and SCL-90. Charlotte started treatment with severe to extreme misophonia (range 31-40) and at the end of treatment her symptoms were reduced to mild misophonia (range 11-20). Also, general psychopathology decreased from a very high level to a level above average (see Figure 6).