| کلیدواژههای انگلیسی مقاله |
Misophonia, Cognitive-behavioral therapy, Anger, Sound, What&,rsquo s Known Misophonia is triggered by auditory stimuli and characterized by an extreme emotional response (e.g., anxiety, agitation, and annoyance) to specific patterns of sound. Despite the adverse effects of misophonia on patients&,rsquo quality of life, only a few studies have addressed the effect of psychological treatments on its symptoms. What&,rsquo s New The effectiveness of cognitive-behavioral therapy on anger, as the main symptom of individuals with misophonia, was investigated. Effectiveness of psychological interventions in treating misophonic individuals was confirmed. IntroductionThe term misophonia was introduced by Jastreboff and others in 2001. 1,, 2, It describes a condition that causes individuals to experience a negative emotional reaction (e.g., anxiety, agitation, and annoyance) to specific patterns of sound in certain situations, despite tolerance for other louder sounds. 3, Triggered by auditory stimuli, anger, and rage are the most common emotional reactions of misophonic individuals. 4, Anger is a normal human reaction in response to stress and hostility and is usually associated with involuntary responses such as increased blood pressure, heartbeat, sweat, and blood sugar. 5, The feeling is provoked by various real or imaginary conditions such as frustration, injuries, humiliations, or injustices. Typically, an individual with misophonia will react with body language, e.g., stare or a verbal response to the source of the noise. In general, those in direct contact with such individuals such as family and friends tend to avoid making irritating sounds while eating (slurping and chewing). 6, Physical aggression by individuals with misophonia has also been reported. A previous study among 42 such patients reported the incidence of verbal abuse (28.6%), throwing of objects (16.7%), and physical aggression (11.9%). 7, Various studies have addressed the effectiveness of cognitive-behavioral therapy (CBT) on anger management. 5,, 8,, 9, However, there are no controlled studies on the treatment of anger in individuals with misophonia, and the publications are limited to a few case studies. In a study in 90 patients with misophonia, eight CBT group sessions were performed every two weeks resulting in a significant reduction of the symptoms in 48% of the patients. 10, A couple of other studies also reported the effectiveness of CBT. 11,, 12, An article in a medical journal indicated that CBT may help individuals with misophonia to manage their emotions, when exposed to irritating noise. 13, Individuals with misophonia find trigger noises produced by their close relatives more distressing than by strangers. 11, An interesting study examined the effect of misophonia on students living in dormitories. 14, They showed that a switch from living in a home environment to dormitories could interfere with their adaptation to misophonia with other roommates. This was particularly the case in female students, as they are more sensitive to environmental factors and are more vulnerable to psychological problems.Most clinical studies on misophonia have been conducted in female patients, 11,, 15,- 17, but there is no information about the prevalence of the disorder. It has been shown that misophonia is not an auditory impairment caused by anatomical anomalies, instead, it is due to a highly sensitive association between the limbic and sympathetic nervous systems. 18,, 19, Such excessive sensitivity of the sympathetic nervous system leads to alteration of cognition and behavior. The main objective of the present study was to investigate the effectiveness of CBT on anger in female students with misophonia.Materials and MethodsA study based on a non-concurrent multiple baseline single-case experimental design was conducted in 2018 at the School of Education and Psychology, Shahid Chamran University of Ahvaz, Ahvaz, Iran (Ethical code, 49752). The target population was female students living in dormitories of Ahvaz University of Medical Sciences (Ahvaz, Iran). The sample size was determined in accordance with the Krejcie and Morgan table. 20, Based on the multi-stage random sampling method, 320 female students living in the dormitories were recruited. To identify students with misophonia, we made a random selection of the dormitories (two out of six), two floors in each dormitory, and 15 rooms per floor. For the initial diagnosis, the misophonia questionnaire (MQ) was handed out to the female students. Out of the 320 students, 65 students achieved the score &,ge 7 (cut off point based on a previous study 21, ). These students were approached for an interview, however, the majority either did not respond to phone calls, refused to fill in the required information, or did not attend the meeting. Eventually, 27 students were enrolled for the interview in accordance with the diagnostic criteria of Schroder and others. 7, The inclusion criteria were misophonia score &,ge 7, diagnosed with misophonia, and willingness to participate in the study. The exclusion criteria were psychiatric or psychotropic drug consumption at the start of or during the last six months prior to the study and attending psychotherapy sessions. Out of the 27 students, 11 fulfilled the criteria, among which four students were randomly selected for participation. During the study, one student decided to withdraw and the remaining students (n=3) followed the study stages, namely baseline, intervention, and follow-up sessions. The Novaco anger questionnaire was used during the baseline sessions, intervention sessions (sessions three, six, and eight), and six weeks follow-up (two, four, and six weeks after the last intervention session). 22, Based on the study design, the participants entered the baseline stage at the same time, but each followed the intervention stage with a one-week interval. The intervention sessions were conducted weekly over eight weeks period, each lasting 60 minutes. The assignments and exercises of the sessions were mainly in accordance with the technique proposed by Schroder and colleagues (relaxation, task concentration exercise, audio clips, and cognitive-behavioral therapy). 10,, 23, The content of the therapeutic sessions was,Baseline, Familiarization with the topic and exchange of information, interviewing in accordance with Schroder criteria, 7, and filling out the questionnaires for baseline assessment. Session 1, Introduction to misophonia and intervention methodology, description of intervention goals, defining a systematic hierarchical system to examine a range of auditory stimuli triggers, and homework. Session 2, Homework review, open discussion on the personal experiences with misophonia, and participants&,rsquo moral values related to misophonic triggers, identifying adaptive and maladaptive coping strategies, task concentration exercise, and homework. Session 3, Homework review, relaxation and breathing training, and homework. Session 4, Introduction to manipulation of auditory stimuli and instruction on how to manipulate auditory misophonic triggers by altering the pitch or interval of audio clips. Sessions 5-7, Homework review and direct exposure to aversive sounds (i.e., dining with family members or those who produce such sounds). Session 8, Homework review, assessment of therapeutic effects, and guidelines for additional exercises. Prior to the study, written informed consent was obtained from the participants.InstrumentsMisophonia Questionnaire (MQ)MQ is a self-report questionnaire developed by Wu and colleagues. 21, It consists of three scales, namely a 7-item misophonia symptom scale (MSS), 10-item misophonia emotions and behaviors scale (MEBS), and a single item misophonia severity scale. The misophonia severity scale is based on a modified version of the National Institute of Mental Health Global Obsessive-compulsive Scale, 24, which evaluates the overall severity of misophonia symptoms. The reliability by Cronbach&,rsquo s alpha of the MSS, MEBS, and the total scale was 0.86, 0.86, and 0.89, respectively. 21, A previous study in Iran examined the psychometric properties of the MQ on 350 students and the reported reliability by Cronbach&,rsquo s alpha for MSS, MEBS, and the total scale was 0.80, 0.89, and 0.90, respectively. 25, In the present study, the reliability by Cronbach&,rsquo s alpha for the total scale was 0.90, and for the MSS and MEBS was 0.75 and 0.90, respectively.Novaco Anger Scale (NAS) This tool consists of 25 items and rated on a 5-point scale from 0 to 4. The total score ranges from 0 to 100. The reported validity and reliability of the scale were 0.86 and 0.96, respectively. 26, A previous study in Iran correlated NAS with the Buss-Perry aggression questionnaire and reported a correlation coefficient of 0.78. The reliability of NAS by Cronbach&,rsquo s alpha was 0.86 whereas by test-retest was 0.73. 22, In the present study, the reliability of NAS by Cronbach&,rsquo s alpha was 0.91.In addition to the above-mentioned instruments, a clinical interview with the participants was conducted. The diagnostic criteria for misophonia as described by Schroder and colleagues 7, were used to better understand the underlying reasons for misophonia, i.e., obsessive-compulsive disorder (OCD) or post-traumatic stress disorder (PTSD).Data Analysis Since the study was based on a single-case design, data obtained from the three participants during the baseline, intervention, and follow-up stages were analyzed using descriptive statistical methods. The data were analyzed using visual analysis, recovery percentage formula, and reliability change index (RCI). RCI was calculated to determine the clinical significance of the results and the cut-off score. In addition, trends of stability indices, and the percentage of non-overlapping and overlapping data points were calculated.ResultsThe effectiveness of CBT on anger scores of the participants is listed in table 1,. During the follow-up stage, the anger score of each participant reduced with fluctuations. After the baseline stage, the mean anger score of the first, second, and third participants was 73.0, 65.25, and 48.4, respectively. After the intervention, these scores were 41.0, 37.66, and 44.0 and in the follow-up stage were 21.33, 28.33, and 45.66, respectively. Overall, the results showed that the intensity of anger in the first and second participants decreased after the intervention and follow-up stages. However, in the case of the third participant, at the start of the intervention stage, the trend of anger reduction was slow with fewer fluctuations than the other two participants. Surprisingly, the score increased during the follow-up stage. Stages Participant 1Participant 2Participant 3Intervention |