Getting Through Thanksgiving with Misophonia

This post is written for people with misophonia, a condition in which a person has an automatic, sometimes intensely unpleasant internal reaction to specific sounds.  Sounds that lead to this reaction are typically sounds from everyday life, such as others’ chewing food/gum, sniffling, or heavy breathing. For people with misophonia who struggle with eating-related sounds, holidays such as Thanksgiving can be a real challenge.  In addition to sit-down dinners, many people tend to “graze” between meals, so the chewing can be almost constant.  This can be really difficult. Many people with misophonia cope with the distress of being triggered by the sound of eating by leaving the situation or avoiding eating with others entirely. However, during the holidays this means that we are isolated from gatherings of friends and family that are commonplace.  

In light of this, I thought I’d share a few “tips” on surviving the upcoming holiday season when living with misophonia:

Things do to before you spend time with family:

  • Identify your values. Make a list of the family members with which you are most likely to see and/or those that you’ve been triggered by in the past.  Think about what is important to you about how you treat each person and write a sentence next to each name for how you’d like to act toward them. For instance, as a person with misophonia, my step-dad tends to trigger me when we share a meal together.  I know that what is important to me is treating him with respect, understanding, and kindness; when I do this I am being the daughter that I want to be.  It’s helpful to know that ahead of time so that when I feel triggered by him, I can consider how I want to respond rather than making angry comments. Remembering my value of being understanding allows me to respond in a way that is more accepting and gentle rather than judging him or assuming that he doesn’t care.
  • Practice acceptance. It’s very likely you will be triggered. Some people with misophonia have pretty constant anticipatory anxiety, meaning that they are anxiously scanning the environment while waiting for a trigger to happen.  This anticipatory anxiety can mean that we suffer more – since we suffer in waiting for the trigger and once the trigger has occurred.  Rather than scanning the environment for trigger sounds, accept that you will be triggered and know that you have control over how you respond.  Practice being in the present moment, rather than off in a future that hasn’t happened yet. For example, if you notice yourself anticipating that someone will start chewing again, you might label it as a thought, and bring your attention to things that are happening in the present, such as the sound of people talking around you, the faint sounds of music in the background, or the smell of pies baking in the oven.
  • Be mindful. Practice mindful breathing as a means of centering and grounding yourself.  The wonderful secondary effect one can get from mindfulness in general is a sense of calm and relaxation.  Your breath is a powerful tool that you carry around with you each day; it only needs you to engage it to begin to affect change in the moment.  The more we practice being mindful, the more skilled we are at focusing our attention on that which we choose.
  • Retire the “manners police.” A colleague of mine talks about how people with misophonia can sometimes slip into being the “manners police”.  Generally, once we are triggered we have judgmental thoughts about the person making the noise (for example, “Do they have to eat like that?” or “Didn’t anybody teach you to chew with your mouth closed?”); sometimes we verbalize these thoughts and sometimes not.  However, buying into those thoughts reinforces the idea that we are right and the other is wrong rather than it being about preference or opinion.  What I find helpful is to reframe the judgment into a statement of facts and consequences (“My opinion is that others should chew with their mouths closed.  This person is not closing their mouth when they chew and as a result I feel disturbed.”)  This tends to help me focus on what I can do vs. what they should do.

Things to do while spending time with family:

  • Practice mindful breathing.  Expand your mindfulness to that which is happening around you.  Notice sounds, smells, tastes, sights, and that which you can touch.  The nice thing about the holidays is that there are usually many sights, sounds, and tastes to behold.
  • Take a break. If you notice being triggered consider stepping outside and mindfully noticing the environment around you.  See if you can just observe the different ways your senses are being stimulated.
  • Do something that does not involve eating. Engage in an activity that does not require eating or around which eating would be difficult (e.g., board games, charades, knitting, coloring, etc.) and invite others to join you.  If needed, retreat to a more quiet area to engage in the activity.
  • Shift your attention. Offer to help with something that requires attention and focus and allows you a temporary break from trigger noises (e.g., help out with washing dishes-provided clanking dishes is not a trigger, take the dog for a walk, help with cooking).  It can be helpful to pour our energy into an activity and being of service, for some, can elicit positive emotion.
  • Stimulate your parasympathetic nervous system. When feeling particularly triggered, take a moment to go to the bathroom and splash very cold water on your face and if possible, hold a cold compress (wet washcloth with cold water, ice pack or bag of peas from the freezer, for example) over your eyes for about 15-20 seconds.  This helps to activate the parasympathetic nervous system, which in turn, creates a sense of calm in the body.  The effect is increased by standing up and bending over (as you might do at a sink) and holding your breath.  If you are using a cold compress, try standing, bending over, and holding your breath for 15-20 seconds.  I know this sounds weird, but it works! The effect of this strategy only lasts a short time, so once you feel calmer, it may help to use some of the other strategies listed above.
  • Practice self-compassion. Last, but not least:  practice being self-compassionate, especially for any internal experiences, such as feelings of rage or anxiety and judgment thoughts about others.  These are highly uncomfortable and normal responses to trigger sounds.  Remember, while you don’t get to choose how you feel inside once triggered, you do get to choose how you respond.  And if you happen to react in a way that doesn’t sit well with you, it’s even more important to be kind to yourself.  At times, I still react poorly to being triggered, and that provides me an opportunity to be understanding and validating of myself.

Vulnerability and Recovery

Because I work with people who struggle with addiction, I am particularly attuned to the ways that the public perceives people struggling with addiction and in recovery.  Too often, media portrayals of addiction dramatize or glamorize addiction in unrealistic ways.  These images contribute to a negative perception of addiction and recovery and lead to misunderstandings, fear, and stigma.

In my work, I’ve had the fortune to witness and be inspired by some of the many people who stop using alcohol or drugs each year. Based on this experience, I want to propose an alternative perspective on addiction — that most of us share a lot more experiences with folks struggling with addiction than we realize.

Think of a habit or behavior that you know is not so good for you or gets in the way of who you want to be.  This might take the form of a (more) socially approved of “addiction”.  Things like

  • chocolate,
  • shopping,
  • TV,
  • texting,
  • cell phone games

Have you ever tried to change that behavior?  Was it easy?

Have you noticed what happens when you start entertaining changing a habit?  If you are anything like me, your first thoughts might be something like “I could change if I wanted to,” and “it’s not a good time to change because…”  The truth is that changing is hard and would require being willing to experience a whole lot of difficult feelings and thoughts.

I experienced this recently when I quit eating sugar a few months ago.  For ten days I couldn’t concentrate, my emotions felt extreme and unpredictable, and my body ached in places that had not ever been injured.  I experienced triggers, urges, cravings – the whole nine yards.  I felt extremely sensitive, like a buffer between me and the difficult things that happen in my life had been removed. In the process of making this change, I encountered my own vulnerability.

In her now famous Ted Talk, Brene Brown talks about how she didn’t choose just one substance to retreat into to protect her from vulnerability, she used a failsafe combo: a couple of beers and a banana nut muffin.  Many of the behaviors that we do routinely may protect us from having to experience our own vulnerability.  But our vulnerability is a part of our humanity – and part of what connects us to each other. 

My admiration for folks in recovery comes from their willingness to experience their vulnerability in order to make a change.  Recovery usually involves giving up something that, at least at some level, feels like it keeps you safe and protected. Often it requires making changes to relationships, to daily routines, and to the things we use for comfort.  As if that weren’t vulnerable enough, it sometimes means making amends to people that you harmed in the past.  In my experience, recovery requires a courage of heart that is rarely required of most of us. 

Now I am aware that experiments in vulnerability, like choosing to give up sugar, TV, or your cell phone, or making other changes that disrupt our sense of safety, do not capture the experience of overcoming addiction. My intent is not to make light of the experience of addiction or recovery.  It is to suggest that making changes is hard for all of us and that we have more in common with those who struggle with addiction than we may realize.  In fact, I often think that stigma and judgements about others, including people who struggle with addiction, may be a way to distance ourselves from vulnerability. Unfortunately, this also restricts our connection to our humanity.

The truth is all of us humans experience very unpleasant sensations and feelings when we change our behavior — there is no permanent way to keep us safe from that.  We all have vulnerabilities we might prefer to avoid.  By noticing the ways in which we defend our vulnerability, we increase our empathy and humanity, and may even find a little of the courage of recovery in our own lives.

Fear of Fear Itself: Why Panic Isn’t Dangerous

Everyone has experienced intense fear at some point. Our hearts start racing when we realize we forgot to pick up the kids at school, our hands tremble and sweat as we struggle to unlock the door as a dark stranger looms in the shadows, or we feel dizzy and nauseous as we get up to present that speech we haven’t really prepared for. Whether a threat is great or small, the people and things we care about might get hurt if we don’t respond quickly.

We evolved the sympathetic nervous system to prepare us for threat

The physiological response we feel during intense fear and panic is a result of the body’s sympathetic nervous system. The sympathetic nervous system evolved to help us prepare to respond to dangerous situations.  Activation of the sympathetic nervous system leads to the kinds of biological changes we experience in fear and panic, including changes in heart rate, blood vessel dilation, breathing, digestion, and perspiration. These changes make us ready to face challenges to our safety through fighting (i.e., overpowering the threat), fleeing (i.e., getting away from the threat), and freezing (i.e., holding your breath and hiding by being still – think about the T-Rex in the movie Jurassic Park). Intense fear (i.e., panic) can be a real life saver, so be glad it’s there for you!

Panic involves an unnecessary but harmless misfiring of the sympathetic nervous system

The biological readiness we call panic mostly evolved to help us deal with immediate threats in the external environment (e.g., being chased by an actual lion), but in humans the same system can also get activated just by vividly imagining threats (e.g., anticipating having a heart attack or going crazy). It’s kind of like going to a scary movie – you can easily forget you’re actually in a nice safe theater and become so engrossed in the movie that you end up being afraid. When we get so caught up in our heads, it can start to feel (i.e., in our body) very much like we are in danger, when in fact we are safe. Even if there are “real dangers” in the distant future, such as dying of old age, actively anticipating them without a sense of perspective can make our bodies respond as if there were imminent danger right here and right now. This is where worry and anxiety come from – imagined threats. Nonhuman animals don’t worry and get anxious about things that aren’t actually happing right here and now – but people do. This ability to imagine future possibilitiess, plan for them, and feel emotions about them is an important part of what makes us human, but it also has this dark side.

In panic, people misinterpret normal bodily signs of anxiety as threatening

People who have recurrent and repeated problems with attacks of panic (sometimes called panic disorder) experience their bodily sensations of anxiety and fear as if there were an imminent threat happening here and now. That is, their minds accidentally interpret fear itself as a being a threat. A classic example is when someone interprets an elevated heart rate as evidence of a heart attack, and then takes this interpretation too seriously. The vividly imagined threat of a heart attack activates the sympathetic nervous system, which then further elevates the heart rate, which then provides more “evidence” of a heart attack, and so forth until the person is totally convinced that he or she is going to die. Feedback loops like this can lead to a major meltdown. A “panic attack” is just that – a catastrophic interpretation of otherwise harmless bodily sensations, leading to more and more fear and panic. The problem lies with how the sensations of fear and panic are interpreted, not with the sensations themselves.

The solution to panic attacks

Stop running and instead, feel the fear. Get warm and cozy with it. After all, panic is your good buddy who is trying to keep you safe, not an enemy looking to harm you. A friendly relationship with panic can be very counterintuitive at first – after all, panic doesn’t feel safe. You may be tempted to try to get rid of it with medications (fighting), or to try to stay away from situations in which you might panic (fleeing), or maybe if you just hunker down and wait it out it won’t happen again (freezing). See the problem here? That is all more panic! You can’t fight fire with more fire, but the good news is you don’t need to in the first place. If instead you learn to “hang out” with panic, you can learn that it is in fact perfectly safe despite how it feels.

This can of course be a fairly difficult thing to learn; a “just do it” approach to accepting panic sensations is often not helpful. Fortunately, you can find guidance in learning how to be less reactive to your own thoughts and feelings – a mindfulness practice is a great way to help gain perspective, and there are good self-help books out there that can be helpful. Furthermore, there are evidence-based psychotherapies that have been proven to help people with panic disorder – give me a call if you’d like to schedule an initial consultation.

If there is a real threat out there in the world – attack it, run from it, or hide! But your own sympathetic nervous system is not your enemy. You are safe with yourself.

Anxiety Treatment at Portland Psychotherapy

The Difficulties of Accessing Effective Treatment: OCD as an Example

I resonated with a recent article in Psychology Today about the difficulties people have in finding therapists who offer effective treatment. The authors Dean McKay and Scott Lilienfeld—especially Dr. Lilienfeld—have been extremely active in promoting science-based psychotherapies.

As an example, they offer the experience of “Jerry” (a pseudonym). Jerry struggled with obsessive-compulsive disorder (OCD). Having educated himself on OCD, Jerry knew that exposure and response (or ritual) prevention (ERP, for short) was the most researched and effective treatment for OCD. ERP involve systematically helping people with OCD learn to confront obsessions while resisting the urge to engage in compulsions or rituals.

Despite living in a major city, it took Jerry 3 years to find a therapist who offered and was proficient in ERP for OCD. Jerry’s experiences are similar to those of a Yale graduate student with OCD.

Many clients I’ve seen have similarly struggled. Some were misdiagnosed by prior therapists and did not even realize they had OCD until they did their own research. Some therapists correctly identified them as having OCD but when it came to treatment, they “just talked.”

Most people with OCD with whom I’ve worked have seen at least 1 or 2 therapists who have not been particularly helpful. Hair pulling (trichotillomania) and skin picking (excoriation) are two other problems that people with whom I’ve worked have struggled to find effective treatment.

The article by Drs. McKay and Lilienfeld provides a sober reminder that there are a number of people who would benefit from effective treatments such as ERP but cannot find therapists who practice it or are aware enough of their competency to refer out to a specialist. Unlike Jerry, many people with problems such as OCD, trichotillomania, and excoriation don’t even realize there’s a name for their struggles, let alone effective treatment, and they may drift in and out of therapists’ offices being misdiagnosed and receiving substandard treatment.

Drs. McKay and Lilienfeld recommend that:

The adoption of the new clinical practice guidelines is probably our field’s best hope for placing long overdue pressure on therapists to incorporate scientifically based approaches into their clinical practices. Practice guidelines would also assist mental health consumers with the daunting task of selecting more effective treatments.   


Sadly, there are many licensed therapists who do not believe in science-based approaches. For people with mild to moderate depression/anxiety, generic talk therapy and nonscientific approaches can offer some relief. For people like Jerry with OCD, these unscientific approaches are unlikely to be of much help.

I’m inspired that psychologists such as Drs. McKay and Lilienfeld take time from their busy schedules as full-time professors and respected researchers to promote scientific approaches. You can read their blog post here. I encourage readers to carefully research the therapists you or your loved ones see, and not to stay in therapy with someone who doesn’t seem to be very helpful.

Misophonia: what the heck is it and what’s a trigger?

Misophonia is a condition in which a person has an automatic, unpleasant internal reaction to specific sounds.  This reaction can vary from frustration to panic and even rage, and can be quite an intense experience for the sufferer.  Sounds that lead to this reaction are typically sounds from everyday life, such as others’ chewing food/gum, sniffling, or heavy breathing.  People with misophonia will often refer to “triggers”; a trigger, for someone with misophonia, refers to any sounds that produces the intense internal reaction.

Many people who have misophonia experience a lot of shame before they come to understand that this is a condition experienced by many others and that they are not alone in their struggles.  They can experience a lot of shame about both the intensity of the internal reaction and their response to those who have made a sound that is triggering.  I was one of those folks.

How I learned about my misophonia:

I learned about misophonia about 5 years ago.  I was talking with a colleague about my internal responses to certain noises and she noted that one of her clients had very similar experiences and told her that it was called misophonia.  I remember the first time I googled misophonia and found a video on YouTube, in which a man with misophonia was talking about his internal experiences of it.  After getting over the oddity of hearing this man talk about things I had never heard anyone else talk about, I began to feel so much more understood, by both myself and this larger community.  As I met others with misophonia, I discovered a community who could provide the sort of support that was difficult to garner from those who did not have misophonia.

Discovery and recovery:

Since discovering that I have misophonia, I have engaged with the misophonia community on a few different levels.  Given that I am a psychotherapist, I became interested in helping myself, and others with misophonia, learn to live with the condition and have relationships with others that thrive. I currently specialize in working with people with misophonia and am actively working on developing treatments that can help them to learn better ways to cope with the condition. I feel like being involved in the misophonia community and learning about the experiences of others has given me a lot of insight into the condition that I can share with others who are struggling. I feel grateful to have found this community and am thankful I get to pass on what I have learned to others.

Misophonia Treatment at Portland Psychotherapy