206. EMOTION REGULATION: Misophonia, DBT, Reactivity, & More feat. Dr. Mark Zachary Rosenthal

Dec 2

listen to this episode:

Today's guest is Dr. Mark Zachary Rosenthal—a clinical psychologist and an Associate Professor in the Psychiatry & Behavioral Sciences department and the Psychology & Neuroscience department at Duke University. He is also the director of the Duke Center for Misophonia and Emotion Regulation (CMER), where he pioneers research on misophonia, emotional functioning, borderline personality disorder, virtual reality, digital health, and behavioral therapies. We are also joined by Grace Heppes, the Outreach and Education Coordinator for CMER.

In this episode, we discuss:

+ How our body generates emotions & the purpose of our emotions

+ Reasons that certain people have dysregulated emotions

+ Why dialectical behavioral therapy (DBT) is so unique & its key principles

+ A hack for finding a qualified, DBT-based clinician

+ The connection between suicidal ideation & emotion dysregulation

+ What misophonia is & how people's views of it have changed over time

+ How people react to misophonia triggers & why this ties to emotion regulation

+ The realities of living with misophonia

+ Tools to help people struggling with misophonia

+ so much more!

Mentioned In The Episode…

+ CMER Website

+ CMER Instagram

SHOP GUEST RECOMMENDATIONS: https://amzn.to/3A69GOC

About She Persisted (formerly Nevertheless, She Persisted)

After a year and a half of intensive treatment for severe depression and anxiety, 18-year-old Sadie recounts her journey by interviewing family members, professionals, and fellow teens to offer self-improvement tips, DBT education, and personal experiences. She Persisted is the reminder that someone else has been there too and your inspiration to live your life worth living.

a note: this is an automated transcription so please ignore any accidental misspellings!

Sadie: Welcome to She Persisted. I'm your host, Sadie Sutton, a 19 year old from the Bay Area studying psychology at the University of Penn. She Persisted is the Teen Mental Health Podcast made for teenagers by a teen. In each episode, I'll bring you authentic, accessible, and relatable conversations about every aspect of mental wellness.

You can expect evidence-based, teen approved resources, coping skills, including lots of D B T insights and education in. Each piece of content you consume, she persisted, Offers you a safe space to feel validated and understood in your struggle, while encouraging you to take ownership of your journey and build your life worth living.

So let's dive in this week on She persisted.

Rosenthal: the therapist and the patient, are working together, moving in the same speed, in the same direction, like two trains leaving a station on two separate tracks, Are we going the same speed and the same direction to the same next train station? That's therapeutic alliance. It's that real shared collaborative, we're doing this together, two humans, two flawed humans. Therapists included, right? we're going to help you figure out how do we get there together?

Sadie: Hello, hello, and welcome back to another episode of She Persisted. I am really excited for you guys to listen to this one. I went in person to interview Dr. Rosenthal and Grace At the Duke Center for Misophonia and Emotion Regulation, and we talked about everything you could want to know, both with emotion regulation and misophonia.

Dr. Zachary Rosenthal is an expert in DBT and misophonia research. He is a clinical psychologist at Duke University. and Grace Hepps is the outreach and education coordinator at their lab. And so we talk a lot about her lived experience, how you can someone struggling with misophonia and how the treatment and research landscape has changed.

We start by talking with Dr. Rosenthal about emotion regulation, emotion dysregulation, how this shows up in DBT. what this cycle of emotion looks like because it shows up in a lot of different ways, especially misophonia and people that find dbt to be effective. So, if you are interested in learning more about emotion reactivity, regulation, recovery, DBT, misophonia, all the things, this is an episode you will absolutely enjoy. And if you guys haven't heard of misophonia, I'll give you a quick little definition that we do touch on it in this episode.

It's a chronic condition that causes people to have extreme emotional reactions to specific sounds. So, we talk about why we have different emotional reactions to things, how we can cope with them, and then also, specifically with misophonia, which is a new area of research and is a really interesting way to apply a lot of this knowledge about emotion regulation and the emotion cycle itself.

So, I really hope you guys enjoy this conversation with Dr. Rosenthal and Grace. I had an incredible time so with that, let's dive in.

I love

it.

Well, guys so much for joining me today on She Persisted. I'm so incredibly excited to have you on the podcast and to talk about DBT and emotion regulation and misophonia. Really important conversation that we were talking off air that not a lot of people are having, but I think a lot of people could benefit from.

So I'm really excited to have you both here today. It

Rosenthal: is wonderful to be here with you, and what a pleasure to be in person here with you at Duke. Thank you for coming here.

Sadie: We're coming to you guys from North Carolina, which is different from my normal podcasting setup in Philadelphia. So, exciting, and I'm just so glad to do this.

So, to get things started, I wanted to start with kind of laying a bit of a framework for this episode, which is that we're really talking about emotion regulation, and with that comes reactivity and recovery, which is a very complex topic, and it's something that we all navigate and go through, but we probably don't have the vocabulary or understanding to be like, here are the phases that I'm going through when I experience an emotion, or I'm in a stressful environment.

And so, I was wondering if you could give that insight and definition to listeners about what that cycle and process looks like when we experience emotions, why we experience them differently, how we regulate them, and then what that looks like after the fact, that like recovery cycle.

Rosenthal: Yeah, absolutely.

And I'll do my best to not sound like a really boring professor doing this. I promise. And I may fail. , apologies in advance if I do, but here's the thing. All responses we have in the world always start with sensory input. We always do. Everything we experience starts with what we see, or we smell, or we taste, or touch, or what we hear.

And what happens is that our brain, super complicated organ, probably roughly around a three pound organ, and its basic function, boil it all down, is survival. So what our brain is doing in taking in sensory information is it's trying to make sense of it in a way that gives it, gives us. An idea about how to respond, to stay away from danger, to stay away from threat, to kind of move through the world in a way that feels safe to us.

So this is the first thing to understand is like, there's a lot coming at us every single day, all sorts of sensory input, and that's the trigger, if you will, for, and then how we make sense of the sensory input, which we can think of as our thinking, so that sensory input plus the way we make sense of it together is going to impact Our biology, our body, and I mean throughout our whole body.

Our nervous system is way complicated. There's lots of moving parts and what happens is the sensation, the cognition, all this stuff comes together and poof, instantly, like milliseconds instantly, we react. And what we call that reaction, we call it an emotion, right? We say, ooh, I'm having this emotion. The emotion itself is a word.

And it's a word we learn, it's a word we learn from the way we grow up. So people from different parts of the world have some different emotions that they might experience in similar situations. So it's actually really, really complicated. But what happens at the end of the day is we get emotions throughout the day, every day.

We react, we have them, we experience them. Now we may not be aware, we may not put good words to them, but we have them. Sometimes they're small, sometimes they're big. And they last just a few seconds. This is a wild thing. Emotions last seconds. And then they sometimes get triggered again. And now they last more than a few seconds.

And now you start stringing them together with more and more and more firing of emotions. Now we start having minutes of emotional experiences or hours even. Some people might report days of experiencing this. And now this is where we really start to see struggle. and distress, and so on. Whether we're talking about shame, fear, anxiety, disgust, sadness, etc.,

etc., Now the emotion's there. It's intense. Now how do we cope with it? Right? This is the real key in understanding once the emotion is triggered and we react, how long it takes to come back down to where we started is mostly going to be due to how we regulate. How we regulate. And that is a complicated next topic.

Sadie: Yeah, I think there's this misconception, especially when you're struggling with your mental health, that the way you, quote unquote, should be experiencing life is like, no emotion, or very little emotion, or maybe just positive emotions, and that idea that if you were Regulating your emotions properly or you could better tolerate your distress that You wouldn't be having those initial experiences and I think that's not necessarily the case.

It's

Rosenthal: absolutely wrong It's completely wrong. Emotions are there for reasons evolutionarily speaking. They make sense. They make total sense again Our brains and our bodies they're they're engineered really really well to help keep us going Keep us alive. Keep us moving. Keep us out of harm's way. And so when we feel an emotion It's a signal It means something, and we need to kind of recognize what that is in the moment, try to make sense of it, which is hard,

Sadie: hard

Rosenthal: to do, that's a big part of emotion regulation.

Try to make sense of what does that mean about what I'm experiencing.

Sadie: And

Rosenthal: it's a kind of self validation, if you think about it. It's like, it's, the emotion itself is a communication to you about what's going on with you in that moment. So we've got to listen to it. The other thing that emotions do that's really important, whether we're talking pleasant or unpleasant or whatever, not only do they tell us something, but we use the emotions to tell other people things.

So emotions function as communication to others. Our faces communicate, our fists, our shoulders, our hands, the way we hold our bodies. Our words, all of it communicates to others, and we need that to be able to function, right, to be able to have the type of relationships and day to day functioning that we all are striving to have.

So, then the third piece that emotions do is they motivate, right? They motivate actions. They motivate. If we listen to our emotions, they motivate us to do something. Now, is that something skillful and effective, or is that something that might get us into trouble? That's a whole other distinction to make, but they motivate us.

Sadie: I think it's a lot of people, when we think about emotions, our mind immediately goes to ways when they're being ineffective, like when we think about struggles with emotion regulation or emotion dysregulation. We think about these really extreme examples where maybe that's not going how it should be and maybe that's , populations that DBT is really effective for, whether it's borderline personality disorder or depression, anxiety in some cases.

It's not so much that day to day cycle that you talked about, which is that our emotions come up, they're telling us something. We probably respond to that same. Signal hopefully effectively and then we regulate the emotion and it's kind of just passes without a second thought, but we do have these Individuals and populations where that doesn't happen effectively and like you were saying maybe the emotional signal is lasting for hours or days Or it's more consistent.

I Don't want to say something's going like quote unquote wrong in that situation But it's not that typical cycle that maybe most of us experience when we're Just navigating our day to day lives with these smaller stressors. So when we think about that, reaction, regulating, recovery, at what point is that cycle not being as effective as it could be when we see this extreme emotion dysregulation?

Rosenthal: Yeah, that's a really good question and probably different for different people, right? And different settings for the same person. , what's complicated about emotion and emotion regulation is that there's a whole bunch of other intersecting processes that come together to give us what we call emotion or emotion regulation.

And so someone might be really distressed and having a really, really hard time functionally. Maybe they're like not hanging with their friends or they're not able to go to school or do well in school. , or maybe they're having a hard time with their family or work, whatever. So there's, there's this kind of.

Impairment is kind of like jargon we would use in my world. We'd say there's impairment with day to day functioning That's consistent and it's related to this really intense big overwhelm set of emotions Yeah, but here's the thing inside of those emotions There's a whole bunch of other stuff that we can help people try to unpack and understand to change all of that So whether it's what they're attending to with their attention Or whether it's what they're automatically doing with their actions.

Sadie: Yeah

Rosenthal: before They get triggered anticipating they're going to be triggered or whether it's when they do respond to some sort of really kind of intense emotional type of situation. What are they doing with their actions? Right? Are they approaching? Are they avoiding? Are they escaping? Are they confronting?

Are they right? There's all these sort of behavioral things that we can help people with. , what are they thinking?

Sadie: Yeah.

Rosenthal: Before, during and after the emotional.

stimulus, if you will, before the thing triggers them. What are the different types of thought processes? Because we can help people change those.

There's really good evidence based ways, as you know, to change patterns of thinking, and that can be before somebody's triggered, while they're in that intense distress, or after. We also can help people with how they communicate, again, before, during, And those communication patterns also, if they change, can change how people think or what they do or how they feel.

And then lastly we have what's going on in people's bodies, right? So that, of course, also can be something we can target changing before, during, or after. So I think it's really interesting because all these things come together kind of like in a network, kind of like holistically, right?

Like what you feel, what you think, what you do, what's going on in your body, how you communicate. Those things are not separate from each other. They're all interrelated. And so if you change one, you can actually change some of the others, all in an effort to regulate

Sadie: mm hmm. You mentioned different interventions that we can do to be more effective or target these things.

DBT or dialectical behavioral therapy is a big one for emotion dysregulation and distress tolerance. I would love to talk to you a bit about the training process for that, because what makes DBT really unique is that if you're doing, like, DBT adherence, treatment and you're working with someone who's gone through the training process and, , they have their board of clinicians that they're working with.

You're going to group, you're going through the different, , phases of treatment. Your outcomes are pretty consistent statistically versus when you go to a normal Psychotherapy appointment the number one determinant is your relationship with that therapist Which is really interesting because dbt does lean so much on that Skills group part of things and these things that are really set in stone whether it's phone coaching or we start with phase one Like therapy interfering behaviors or life interfering behaviors and work through this hierarchy what is it about the training process and What are you guys doing to lead to those outcomes that are so consistent, , and adhering to this original protocol?

Rosenthal: Well, the number one thing, in my opinion, with training someone in DBT is, and I've been training people for decades. I train people around the world, , in China, , in, in the U. S., , a lot in North Carolina and here at Duke. Okay. I've done this for a long time and train a lot of people, and I think the number one thing if I take a step back with this question, it's really about helping people have and express compassion from the heart for the person in front of them, but to do that in a way that is aligned with principles of behavior change, including acceptance based and change based strategies for change.

I think it's actually a false distinction to say that there's either, you know, kind of the relationship that accounts for outcomes in psychotherapy or there are things like skills or, or in DBT or other treatments, I actually think it's, it's both. It's definitely, and go figure, I'm dialectical here, so on the one hand there's this, on the other hand there's that.

The way I tend to think of things is how do we integrate and synthesize so we get a both and instead of an either or. And the both and is that that's what we're trying to train people to do, right? It's to really have strong therapeutic relationship in a DBT context, strong therapeutic alliance, and then the third piece is strong ability to do these really specific kind of DBT principles and skills and so on.

That's like a three tier layer cake or three layers to a cake. The relationship is not the same thing as alliance. Alliance is the degree to which two People, the therapist and the patient, are working together, moving in the same speed, in the same direction, like two trains leaving a station on two separate tracks, right?

Are we going the same speed and the same direction to the same next train station? That's therapeutic alliance. It's that real shared collaborative, we're doing this together, two humans, two flawed humans. Therapists included, right? We're real people, but we, we're going to help you figure out how do we get there together?

And that's on top of this really, really strong compassion driven, humane, deeply humane relationship that's expressed. So training people on how to do that and honestly how to get out of their own way to do that really well, that leads to therapeutic alliance. And then our third kind of like covering of the cake, if you will, what you see, the icing, the flowers, the.

Happy birthday letters, right? What you see on top of the cake. That's the skills, right? That's the like, let's do a chain analysis Let's do dear man, and let's do the stop and the tip skill, that stuff's necessary, too But your question is about training.

Sadie: Mm

Rosenthal: hmm. I want to train people who want and really deeply care about others But they lost they want to learn how to channel that in a compassionate way that also includes You Using these evidence based strategies.

It's not either or, it's both.

Sadie: Yeah. Can we talk about some of those principles? Because I think people that have been in traditional psychotherapy versus when you enter DBT therapy, it's like a very stark difference. And Well, I think that idea of teamwork is very clear your first session. You're like, wow, we're on this team together they're in my corner, which for a lot of patients You're like I've never felt this way before you get to the session and they're like, okay We've got to change this behavior and DBT.

It's like, what do you want to work on? what are we focusing on and obviously there's some like We've got to kind of work on this better so we can get to that later thing that you want to do. , but there really is that idea of collaboration. And I think the compassion piece as well, which also can sometimes feel really foreign, especially when your behaviors aren't making sense to those around you.

And I liked what you said about getting out of your own way to be able to support someone that's in a position that they're struggling. And I think that's relevant to parents. It's relevant to peers, especially when you want to support a friend. , and there's these really specific philosophies that DBT has, like, the patient is doing their best, but they can also do better.

And you mentioned therapists and people too. And, not but. Did I say but? Yeah. Oh no, and. That's the number one DBT thing. Not but. , the dialectic. , and so I'm wondering, , are there any of those. philosophies or ways that people can be more compassionate and understanding and open to get out of their own ways And support people that are struggling in a way that they don't necessarily Understand or it seems really out of left field or foreign.

Yeah.

Rosenthal: that's a really good question There's a couple things that come to my mind. I love the question I'll answer it this way first. So the beating heart of DBT as a clinician, the beating heart that I experience week to week is my team of therapists that are the community of therapists working with me and I'm with them and we're all working together in a way to try to serve all of our patients and clients.

Yeah. Right? So that beating heart of, there's a community of people helping to support each other. And when, the way we do that is we essentially do therapy for the therapist, that's what we call it. So on our treatment teams, we are doing mindfulness practice every week. We are paying attention to how fatigued we are, how difficult things are in our personal lives.

We are supporting each other. We're helping each other get out of our own way, of our own tendencies to do this or that, right? So we have this. It's a group of therapists that are really providing a type of love and care for each other and they're doing that in a way to help support doing DBT by the book.

The patient is not lost in this, the patient is at the core of this. But to help the patient, what we recognize is we've got to make sure we are full, we are nurtured, That's not a thing you see in other treatment approaches. The reason we do that is because these are hard people to work with and this is a hard treatment.

So we have to create structures around us to take care of us. So we can take the best care of the treatment and most importantly, our patient.

Sadie: I think that's really important and very applicable to parents and just the everyday individual that you can't help others until you can help yourself. And you're going to be able to support them more effectively if you.

Done everything possible to be able to get your needs met and so that you're not pouring from an empty cup, which is common

Rosenthal: That's right. We have to be aware because we're flawed humans. We're just clinicians, right? We're just people we're and this is a DBT way to think and talk about this, right that we are people with some expertise.

That's true But we also are we're real people we have our own Lives and our own stuff and we want to make sure that we don't let that So, , when, when hard things happen in our lives, , we talk about it. I recently lost my mother, , not too long ago. And that's been really, really hard. It was really, really hard losing my, my mother.

I talk about that with my team.

Sadie: Yeah.

Rosenthal: Because I don't want that next patient who has anything that reminds me of my mother. I don't want any of that to interfere with care for that patient.

Sadie: Yeah.

Rosenthal: And it might still anyway, but I want to try to make it be kind of above board and help me be as aware as possible about

Sadie: that.

Rosenthal: So again, we're paying attention, we're looking out for each other, and parents, listening. You know the one I'm about to say is true, because you've struggled with this. When you are trying to find care for your teenage kids or your grown kids, or even your late childhood kids, if you're trying to find care that is DBT or DBT based.

You know how difficult it is to know the quality of the clinician by looking at a website. You know this. You know this really, really hard. So here's a hack. A trick is you can ask them if they're part of a DBT therapist consultation team. You can find that out, and the answer is not going to be maybe, it's going to be yes or no, right?

And those that are, are likely going to have the type of support around them that is DBT, and is part of really truly doing an adherent full model DBT program. And the vast majority of those people in America, and I would say probably everywhere, who say they're doing DBT are probably just doing DBT group.

DBT skills training. Yeah, which quite frankly is the least DBT thing about DBT.

Sadie: Just

Rosenthal: the skills.

Sadie: Yeah.

Rosenthal: Literally, Marsha, when she made the skill, she collected, , like, it's like she took a basket and walked around the world and picked up skill after skill. Yeah,

Sadie: attachment theories. Does anybody think that

Rosenthal: Marsha invented mindfulness?

I mean, this is, this is, like, really, truly, like, a, I mean, we could say what we want about it, but it's like, it's a 3, 000 year old practice. She didn't make it up. She's taken it and she's made it secular to some extent. It's still Zen Buddhist to some extent, but she's really secularized it, modernized it, put it into a, an evidence based psychological, , treatment.

She didn't make it up. She didn't make up chain analysis.

Sadie: This is behavioral analysis. This

Rosenthal: is stuff from the 1960s.

Sadie: Please skills are not new. Please skills are not new. We have helped.

Rosenthal: Yeah, like so you got to kind of like think about the skills themselves are fabulous. They're skills for probably everybody.

I use the skills regularly. But skills alone are not a way to live every day. It's certainly not, well, maybe more specifically, distress tolerance skills alone are not a way to live every day. These, some skills like the distress tolerance skills, these are good in certain moments, but we wouldn't all like every day want to live just doing stop skill and, you know, tip skill all day long.

It would be not such a rewarding life. , so takeaway here is that the skills themselves are probably what you're most likely to find at , parents listening and patients listening. And they might be really, really helpful. They can be helpful for anybody. But if what you're looking for is sort of full model DBT, ask if the therapist is on a therapist consultation team.

Sadie: We touched on this a little bit, but I want to circle back, which is that, A lot of these ideas aren't new, like having a lot of compassion for the patient and working together as a team and these skills that come from a lot of different psychological theories. These aren't brand new ideas. And yet it was kind of revolutionary to see these kinds of outcomes in this.

demographic, and you've done some work on this, but there's this mechanism of change that's taking place here, and so I'm curious, obviously it's going to be dialectic in a number of things, , but do you feel strongly that it's like that therapist patient relationship, it's these basic beliefs and principles we talked about, , like these dialectics that are at the core.

What do you kind of see as that mechanism for change that makes DBT so different for so many patients compared to trying the skills by themselves at home or just working with an individual therapist?

Rosenthal: I

Sadie: think

Rosenthal: it, gonna answer this two ways. Yeah. The first is simpler, which is that it's the ability to live your life with more intention, more purpose, more awareness, and more flexibility.

Which means lots and lots of things. But that's the short answer, right? It's that ability to do all of those things. A longer way to answer your question is that I think it's the wrong question. And what I mean by that is that I don't think there is a mechanism across all people.

Sadie: I

Rosenthal: think that that's actually not the way to think.

The way to think about it and the question to ask is For which people are which mechanisms of which treatment most likely to be helpful and why?

Sadie: Yeah,

Rosenthal: right. So if you if you approach it from that framework Allows you to look at each person a little bit more flexibly a little bit more like really truly treating each person differently and Understanding how people really are different and their patterns are different.

Their backgrounds are different. Their traumas are different You Their family histories are different, their brains are different, and so on and so on and so on. So much is different.

Sadie: Yeah,

Rosenthal: so much is so different about each person. So what may help one person really change in DBT may not actually be the same mechanism, singular speaking, as the next person.

And that's okay. I think we can look at mechanisms at different levels. So there might be interpersonal mechanisms. There might be more physiological mechanisms. There might be more behavioral mechanisms. There might be more attentional mechanisms. All of these things, if we boil them down to one, I think come back to like being more flexible, more skillful, if you will, to use dbt language would be more flexible from a place of intention and awareness.

Sadie: We talked about trying to be compassionate with. with behaviors or feelings that we maybe can't empathize with. We can sympathize and be like, I can see you're really struggling, I can see you're in a lot of pain, but I don't understand it. And then it's challenging to take that compassionate and as a peer or a parent or a therapist, be a team member and help someone work towards this goal, , of working towards maybe like phase two or phase three or whatever it is.

And I think an example of that is suicidal ideation. A lot of people don't understand. Why people are having those thoughts, or what would cause them to think that way, or why that's the response to their environment that they're maybe living in the same environment as someone else. And so I'm curious if you can unpack that a little bit and explain, especially from the emotion regulation piece, why there is that strong relationship between struggling to regulate emotions and then suicidal ideation, which a lot of people don't experience in their lifetimes.

There's a lot of confusion and misunderstanding.

Rosenthal: When somebody has extraordinary suffering, they imagine doing anything they possibly can to end it, to stop it, because it's so extraordinary. I mean, the experience of being deeply in what feels like hell, like really truly feels unbearable, leads one to imagine what they can do to stop it.

Yeah. And when each successive attempt to try to stop it, solution after solution, does not seem to stop the pain, ultimately the person starts to think about ending their life as a type of way to end. And so it becomes this imagined solution. what can happen for some people is that even thinking about this solution, even thinking about harming themselves or thinking about killing themselves, in the moment they do that can take the edge off of the emotion they're feeling in that moment.

And that's relief in that moment.

In a more sort of jargony way, it's negative reinforcement.

Sadie: It's

Rosenthal: the reduction of something unpleasant. And anything that reduces something unpleasant for us is likely to be reinforced, meaning it's likely to happen again.

Sadie: Yeah. And

Rosenthal: again, it's the reason why, when we shut our doors to our cars and the annoying ding ding ding ding ding happens with our we do?

Put

Sadie: on our seatbelts. We put on our seatbelts. Yeah.

Rosenthal: Why? In that moment, why?

Sadie: We stop the annoying, distressing stimuli. It's just that. Yeah.

Rosenthal: It's exactly that. you can think of suicidal ideation or suicidal behavior as a behavior, even thinking, you can think of it as a type of behavior that has a function.

Sadie: Yeah.

Rosenthal: That actually works in the moment, that actually really does work. And therapists that seek to understand that and lean into that with compassion. Well, they might be good DBT therapists, because that's really dialectically how we might think

Sadie: about it.

Rosenthal: It doesn't mean we're going to support it or want it, but it's about an understanding and acknowledging the function, the reason why this is happening, is it has some effect that works.

So it's going to then happen again.

Sadie: Shifting gears a little bit into misophonia and people listening to the podcast who are interested in mental health and engaged in some way online have probably heard of misophonia before. It's becoming more popular and more mainstream for people to talk about. , we hear these conversations online, , this is where people are getting their information, and we sometimes have misinformation, , because we're not coming at it from a research lens, we're not coming at it from really trying to understand what we objectively know about, , the lived experience, and also how we can break it down and understand it in more of a research context.

So I'd love to understand, , what the current definition of misophonia is, and also how that shows up in, , the day to day, so we can shift. Sure. Sure. So

Rosenthal: misophonia is a recently defined disorder of decreased sound tolerance, but it's really more complicated than that. You can think of it as an unusually strong reaction, unpleasant reaction, to really particular sounds and other.

cues or stimuli that are related to those sounds. So the word translates literally into dislike of sounds, and that's kind of what it is. It's this strong reaction to particular sounds. Now the sounds we often call them triggers, even though I don't love that word. Yeah, that's just the word that's used.

And, , typical triggers are mouth or nose or face kinds of triggers. So sneezing, snorting, chewing, crunching, lip smacking, eating, swallowing, slurping, , sniffing, throat clearing, apologies to anybody out there that's getting a reaction even to those words. I know. It's like there's

Sadie: a lot of them. There's a lot of them.

There's a

Rosenthal: lot. They tend to break down into noises that people. make repetitively, , in their nose or their mouth or their throat. And there are other, there are other trigger sounds that are common, , that are not nose or mouth or throat, , pens, clicking keyboards, typing, , environmental noises that are repetitive.

But in the research studies of people with misophonia, most of the people report having among their primary triggers. Eating sounds, chewing sounds, and, or any of those nasal or, or throat sounds.

Sadie: Yeah.

Rosenthal: And the reactions to these sounds vary quite a bit, , but the way you can think about it is that this is not being bothered by sounds.

This is an extreme reaction. think of it this way, it's kind of like, you know, if you're listening right now and you're kind of tuning me out, here's the thing, think about this. You feel anxiety sometimes. Most everybody does. Thanks. If you never feel anxiety, there's maybe, maybe something else we should talk about.

Maybe see someone. Right, but everybody feels anxious from time to time and that's probably good, but not everybody has an anxiety disorder,

Sadie: right?

Rosenthal: We can do the same thing if we want with depression. We can say, most everybody could say they've felt sad before, but that doesn't mean you have major depression.

Right. Some people think about things a lot. They might obsess, but that doesn't mean they have OCD, right? So misophonia, think of it as sort of like that. It's the extreme end of sound sensitivity where the sensitivity leads to really strong and very distressing and very, very impairing reactions. And the reactions are anger, irritation, disgust, anxiety, really a wide array of different negative emotions.

The emotions are hard to regulate because they're unwanted, they're automatic, they're intense, they're disabling in the moment. The student can't focus in class. The student's not being manipulative. They can't actually focus. And there's research studies that have looked at this, that in the brains of people with misophonia, when they're triggered, They lose the ability to learn, to pay attention, to remember, to do the kinds of things we want people to do when they're in classrooms, for example.

So these triggers come, they elicit these really big reactions and responses in the brain, in the brain and throughout the nervous system. And that can then lead to behavioral reactions, often needing to leave the room, to escape, to avoid, or to confront somebody, or to seek out that sound source and try to, you know, Understand it if you're still not clear what I'm talking about These are the people who look at you sideways on the airplane or the bus They look at you sideways when you open up that bag of potato chips and you start crinkling that bag and you pull up that potato chip and you put it in your mouth and you make that crunching noise.

These are the folks that might look over at you

Sadie: and

Rosenthal: there's daggers coming out of their eyes because they're really intensely triggered. I mean, this is not a dislike. This is really, really unbearable nervous system reaction that is automatic and really, really distressing.

Sadie: I would love to hear a little bit about the lived experience of that.

We have an objective definition of how that can show up, but I imagine one of the biggest areas would also be interpersonal relationships, because a lot of those triggers are outside of your control, and You have to employ some relationship skills to be able to alleviate the distress or get out of that situation.

I'm sure there's a lot of setting intentional boundaries, but how does that show up, , in your day to day with regard to engaging in relationships? Things like class, like you guys mentioned, is a really big factor. I can imagine things like eating out or going out with friends. Can you speak to that a little bit?

Grace: Yes, so I've been reflecting on this a lot in the past week because we got the chance to go to the Misophonia Research Fund meeting last week and It was funny for, to hear you say that, like, if you're online and you've probably heard of this thing.

That was never, I never thought I'd hear that sentence in my life.

Sadie: Maybe I'm too deep on TikTok.

Grace: But, but I think that it is, the awareness is increasing so rapidly. Like I, so I'm, I turned 23 today. Another reason why I'm reflecting a lot is because I started at 13 is when I started to experience symptoms of misophonia.

So it's been 10 years now. And. Back then, , that wasn't in our vocabulary. Yeah. And eventually, my mom and my older sister found that word out, and when you look it up, everything is negative. It's parents blogging about how their child is suffering so much and they can't do anything.

Sadie: Mm hmm.

Grace: So, I actually refused to look up the word for years, because there was nothing positive. It was, you're getting no help, and I can't believe how fast that is changing right now. And when we went last week, , there were 21 studies being presented, ongoing studies, and I, I cried several times during the meeting because I couldn't believe that there was so much work being done and all around the world too.

There are people from Poland, . There are being studies being done with people in South Korea. It was just I couldn't believe it something that I didn't think I would see and not in within 10 years at least and Just can't believe that hearing you say You've probably heard of this. Yeah. It really does blow my mind.

, and I'm so grateful that people are finally learning what it is and I get, I don't have Tik Tok, but my, friends send me the links to them all the time and people, whenever someone mentions misophonia, my phone blows up because everyone I know sends me that Tik , and it really does warm my heart that people are finally finding out I've been talking about relationships.

something I've been thinking about a lot recently is the relationship I have with my parents and we spent years going to different doctors. I grew up in New York. We would drive in Jersey and different parts of the state just to find someone who could help me and. It was a nightmare. I would go to these doctors and they would be asking me what misophonia was.

And I would just immediately break down on the spot. And I would get upset with my parents because I feel like I needed to put the blame on someone. And I would be upset. Why are you bringing me to these people? And they don't even know what this is. And I have to, I'm, I'm a child and I have to explain this to them.

And I'm asking them for help. And why are you bringing me to these people? And Looking back on it now, like I have so much empathy for what my parents went through during that time of, they just wanted to help me and I was so frustrated they were too, but there was nothing there. There was no one saying we can help, or if they were, there was no evidence behind it.

And, I really feel for my mom and dad looking back now. , And it's hard to see it in that moment when you are dealing with so much. And I was so overstimulated all the time of trying to, I couldn't even, I wore headphones all the time in my own home because my walls were thin. I shared a room with my sister until I was like 15 and I felt like there was no escape.

And that definitely affected my relationship with my parents because they're also my biggest triggers. I can't even hear my dad breathe. it's really hard to be in the same room as my parents, unfortunately, if there's not some sort of background noise. And I love them so dearly and they've done nothing wrong.

But I can't stand being in the same room as them sometimes. And going out to eat, I Growing up, I just felt like this annoying teenager because I would have my headphones in and I'd be like in the corner of the booth not looking at anyone. The waitress would come up and I would like not even see them come up and I'd be like they probably think that I'm just this annoying bratty teenager who's listening to her music and has having these hormonal changes, is being dramatic.

I'm the youngest of four as well, so that was also something I heard a lot was. Get over it. Like, what are you doing? When I would get upset at dinner. And one time my oldest sister said to me, she was, she's like eight years older than me, so she was away at college for a lot of this time, a lot of when the onset happened and didn't really see my day to day difficulties as my other siblings did.

And she came home for break once and said, you haven't gotten over this yet. even my other sister was like, Oh, she shouldn't have said that. , so that even just getting that understanding within my own household took a long time, let alone outside of it. I was so afraid to tell anyone outside of my house.

, the first time I told my friends, I was at a sleepover with two of them and they were eating pretzels. And I just. I hadn't told anyone about it, and they immediately were like, What is wrong? And it took me a while to even get the words out. And they were so supportive, and made sure that they didn't do those things around me.

And that, that allowed me that experience, because I was so afraid people wouldn't believe me. Because there's, there was nothing on it, and no one knew what this was, and it was just, I It was embarrassing, and I felt guilty for telling people to stop eating, which is something that everyone has to do, and that's also something that I would hear in my house, too, in like the very beginning, was, well, I have to eat, and my dad said that to me, actually, last year, and that, it brought me back, like, it's how, you know, devastating that time period was for me really came back to me in that moment of like I got this like rush of just oh my god of me being kind of grateful that I don't experience that day to day anymore, but also like It is so frustrating to hear things like that and Someone asked me last night actually well, what's the difference between just being annoying and And I was in a social setting and I feel like I've been, because I work here now, I'm in this setting where people are understanding me and I don't have to explain myself to people.

And I just kind of shut down because I felt like my 13 year old self again, of not being able to explain things and feeling like no one's going to believe me. And I'm just so grateful that the research is happening and that people are hearing this word now. And. Sometimes when I ask people if they've heard of it, some people are saying yes now and they never did.

They never did. I always had to explain it. , or at least they're like, Oh, it's something with sounds. Right. And then I'm able to build off of that, but it's really, really hard day to day and having to decide what social events I'm going to go to or how I'm going to handle them. And even going to a meeting yesterday here, knowing that it was going to be during lunch.

And having to decide whether I was going to risk going down there, and I did, and it was hard. , but, I knew that I had the option of walking out if I needed to because I'm in an understanding environment. But in other situations it's not like that, where you feel like you have to explain yourself. And, just feel like no one's going to believe

Sadie: you.

Yeah.

Grace: When I was in high school, there was a class that I was in and one of my classmates was given permission to eat their lunch.

And I Told my teacher like I need to leave because I had a 504 plan to be able to leave if I needed to And he looked me in the eye and said, Do you actually have to? And I was like, Whoa. You're not allowed to ask that. Yeah, that was, that was wild. , and I went home very upset, and my mom sent this like six paragraph email to all my teachers, and she said, If one of the kids in your class had a peanut allergy, you would not let someone eat peanuts.

I'm not going to go into anaphylactic shock, obviously, but I am suffering when I hear those sounds. It's debilitating. I can't pay attention. What's the point of me sitting there? And it's so harmful, and I remember when, my memories actually of the onset are very foggy because it was such a dark time for me and very confusing.

It's so confusing. And I just remember sitting at the dinner table bawling my eyes out, just not understanding why I felt so tortured just by hearing my family eat. And just this feeling inside my chest of like, I am in so much danger right now when I'm actually not. And that it's, I just had the need to leave.

Mhm. And I, I just, yeah, it's, it's so hard to explain in the feeling in words, but that I think danger is, is probably one of the best.

Rosenthal: I once had a patient tell me that it's like having a grizzly bear suddenly out of nowhere unpredictably sitting next to you. And in terms of how your body feels, it's that really intense, sudden, Surge of threat is present threat.

There's something and that's what's happening biologically in the brain is The sound pathways seem to be intersecting with the emotion pathways and eliciting this really automatic overwhelming There's danger there's threat and then the threat reactions behaviorally and cognitively follow.

Sadie: Yeah Yeah, you mentioned headphones, background noise.

There were some things that were incredibly invalidating as responses, but you said more recently it's been different in a positive way. What has been helpful, , as far as boundaries being set, skills being used, even just having a more nuanced understanding of the experience itself, I imagine is really helpful.

What has been helpful in your journey?

Grace: I think the, the validation of even just being in the meeting last week, of seeing so many people working on it, and that there are people putting in this effort to help us, because think all of us felt so alone for so long, and, I think having those papers being published and all these things, and, , Moving towards a place where we can better understand it, I think does make me feel better.

And, I think I also have different expectations of people too, and that applies to my triggers. And, I think that's, Might be part of why people get more triggered by their family as they expect them to understand and stuff like that. They

Sadie: also have no boundaries though. Siblings especially, it's like you don't expect the decorum at the table.

There's like, you're not using manner, so it's so much worse. Right.

Grace: No, you're right. So it is, it's that and I don't really know because I I did go, I've gone to therapy, but I don't really know if we used any, like, I don't, it wasn't DBT, I don't know what, I didn't find it helpful in the beginning, but it was helpful to talk to someone.

Yeah. And, I think just over time, Learning to regulate my emotions as I grew up as well and being in different environments, being in more understanding environments as well. Like at work, I don't have to worry at all. Yeah. Because we're working with Ms. Phony, people understand. And at home, it's much better now that if I need to step out, people aren't yelling at me or judging me and aren't upset by it.

So I think it's, it's still very difficult with strangers. They trigger me less. I still have that feeling of embarrassment and guilt.

Sadie: Yeah. Yeah. I think DBT especially comes from this lens of like, you always have the choice and I think you have a more nuanced understanding of that as you get older, where yes, there's things we have to do and we have to go through and be in certain environments, but you do have a lot of autonomy and choice over who you surround yourself with and the boundaries you set and who you're choosing to put in your circle to support you. And whether that's in high school or college, you just have a lot more choice there than I think we initially think, especially because as we're younger, so many of those relationships are defined for us.

Parents and siblings and family, friends and the classroom you're in. But you really do have a lot of autonomy to Build that community to set you up for success.

Grace: Right. And I think that that's also the difference is I'm so much more in control of my own life right now. , I don't live in the same home as my, my family members now.

And college, like you said, you can choose your friends. Yeah. High school, you're like. Told where to go. You're told where to go. you have this set schedule every single day. And You have to ask to go to the bathroom. Like, there's these set rules that you have to follow, and you've been following them for 13 years.

So it's, it's much more structured, and you have no control over it. So that's also a really hard part of being a teenager, is feeling like you have less control over things, but , I hope that there will be more education and people will be able to allow teenagers to have more control over, especially with mental health and misophonia, in accommodating them and making their own decisions that would help them.

Sadie: Absolutely.

Rosenthal: So two thoughts on this part of the dialogue. One is that, , As people age, they tend to be able to, generally speaking, kind of get a little bit better at regulating emotions. It's really, really hard to do that when you're a teenager. It's hardest, probably, in general, to do that when you're younger. , And you learn.

You learn in lots of ways. And life, hopefully, allows you privileges to help you be able to learn more easily how to be in control of what you feel and who you're around. The environment and so on so all of that and therapies you might do or whatever you might do all sorts of things to develop Really good coping strategies to deal with with hard stuff.

So that's generally true for everyone. I think this question about teens and misophonia and the environments, I really think about this dialectically And maybe that's because I'm a DBT person. I don't know maybe probably that's probably why I think about it this way I think that on the one hand We probably do need to provide more support, more structural support in school systems and in environments.

I mean, probably we need to think about noise and noise generally for all people as an irritant and as something that is a stressor. And this is scientifically shown in lots of studies around the world that just noise, lots and lots of noise is kind of like not great.

Sadie: Why do we take tests in quiet?

Because people need to focus. Right, exactly.

Rosenthal: So I think on the one hand systems. Whether they're school or whether it's work or whether it's wherever, systems do need to accommodate better around noise and around noise sensitivity for everyone and especially for people on the tail end of this distribution who have misophonia or other sound intolerance disorders.

So I think that's true. They do need to. However, I think on the other hand, the person themself also needs to accommodate the environment that they're in. There's a little bit of a dialectic here, is that we can't expect the world to completely accommodate all people with misophonia. That's just not realistic.

It's not. It's not realistic for anybody with any condition to be accommodated by all people everywhere all the time. Right? That's just not real.

Sadie: Yeah.

Rosenthal: But we can strive in that direction as long as we're balanced by and what can that person do that's reasonable, that's feasible, that's skillful, that's effective for them, given their culture, Given their identities, given their context, right, given who they are, what can they do, right?

And I think that's, that's really hard. That's a hard thing. And this is something that therapists can help people sort through. Therapists can help be reasonable and flexible, , and therapists can also support people with misophonia by Helping to write letters of support for them to for requests at school and accommodations and such So finding that balance and finding that that blend I think is really an important way to look at this

Sadie: Yeah, and you mentioned blame and shame is huge being like those really strong initial emotions, I think there's so much benefit and talking through those really intense emotions, especially when they've been building up for years.

And therapy can be a helpful setting for that because you don't move through those overnight. And once you're back in those dynamics or relationships, it can continue to arise. And so Even getting to that point of like, I want to implement skills or I want to accommodate the environment while also requesting that the environment accommodates me, having someone to support you through that process to even get in that headspace is really important too and doesn't happen overnight and takes a lot of work for sure.

You guys are putting out a lot of information in media, and you guys mentioned there's a lot of research still coming out, so if people want to follow along with that or keep up with you guys and your lab, where can they do that?

Grace: , our website, www. missifonia. duke. edu, and our Instagram, Duke Center for Missifonia.

Sadie: Amazing. I'll put that in the show notes, and thank you guys so much for coming on the show. Thank you.

Rosenthal: for having us.

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