Quick Case Study

Auditory Sensory Over-responsivity in a Young Woman

For years, a young woman with cognitive impairment, neurodevelopmental delays, auditory sensory over-responsivity, and parasuicidal behavior tried various pharmaceutical agents and behavioral therapies without success. When she and her parents read about the over-responsivity research of M. Zachary Rosenthal, PhD, at Duke, they consulted him to see if he could offer another approach for their daughter.

Question: What was Rosenthal’s diagnosis, and how did he manage her condition?

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Answer: After ruling out borderline personality disorder (BPD), Rosenthal diagnosed the patient with misophonia and anxiety. He began dialectical behavior therapy (DBT).


The decision to use DBT, which was originally developed to treat patients with BPD, was based on the symptom of self-harm. “It doesn’t matter what else is going on with a patient. Self-harm is the first thing we target,” Rosenthal says. “Once self-harm is no longer there, we can move on to making longer-lasting changes.”

Through weekly skills sessions, the patient has been learning the 4 modules of DBT: mindfulness, interpersonal effectiveness, distress tolerance, and emotional regulation. The skills sessions have helped her learn to accept auditory cues from the environment (eg, aversive noises her family members make) without immediately responding and have taught her how to ask for what she needs instead of turning to self-harm. She also attends weekly individual therapy sessions with Rosenthal that afford her the opportunity to problem-solve and practice her new skills.

After 4 months, Rosenthal reports the patient is no longer engaging in self-harm and is better able to control her reaction to misophonic sounds.

Addressing self-harm first reflects the hierarchical treatment targets of DBT, Rosenthal explains, with therapy-interfering behaviors, followed by behavior that interferes with quality of life, as the next priorities. DBT is designed to be a comprehensive approach to help “the person fully live a life that’s worth living,” Rosenthal says.

Their weekly sessions now focus on addressing the patient’s therapy-interfering behaviors, including her cognitive impairment, which makes it difficult for her to learn and remember new skills. Rosenthal is also working with the patient to change longstanding dysfunctional patterns of eating as part of helping her develop self-confidence and build healthy social relationships.

“I’m excited about using evidence-based treatment to help target behavioral problems outside of the diagnosis that the treatment was originally developed for,” says Rosenthal. “I’m most excited about doing that specifically for a patient who is presenting with longstanding auditory sensory over-responsivity or, in this case, misophonia because we don’t really have any known treatments.”