Download Tinnitus Patient Management - Kansas Speech-Language

Tinnitus Patient Management
Robert W. Sweetow, Ph.D.
University of California, San Francisco
San Francisco, California
[email protected]
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Agenda
• Tinnitus (in general)
• Available treatments
– Acoustic therapies
– Counseling
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Limitations
Integrated Approach
Cognitive Behavioral Intervention
Amplification and Zen
Relaxation exercises and sleep management
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Why treat tinnitus patients?
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These patients are already in your office
Approximately 15% of the world’s population has tinnitus.
More than 70% of hearing impaired individuals have had
tinnitus at some point
80-90% of tinnitus patients have some evidence of
hearing loss
10 - 20% of tinnitus sufferers seek medical attention
Reaffirms your expertise
Additional source of new patients
It’s the ethical thing to do
It doesn’t have to be complicated!
(though it’s not for everyone)
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Famous People with Tinnitus
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Joan of Arc
Ludwig Van Beethoven
Charles Darwin
Michangelo
Vincent Van Gogh
Thomas Edison
Eric Clapton
Barbara Streisand
Phil Collins
Bob Dylan
Cher
Ozzy Osborne
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Peter Frampton
Leonard Nimoy
Willie Mays
David Letterman
Ronald Reagan
Bill Clinton
William Shatner
Huey Lewis
Pete Townsend
will. i. am
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Popular theories of tinnitus origin (apologies to those I’m omitting)
• Disruption of auditory input (e.g., hearing loss) and resultant increased gain
(activity) within the central auditory system (including the dorsal cochlear
nucleus and auditory cortex)
• Homeostasis: Neurons that have lost sensory input become more excitable
and fire spontaneously, primarily because they have “homeostatic”
mechanisms to maintain their overall firing rate constant (Bao, et al 2011)
• Decrease in inhibitory (efferent) function
• Over-representation of edge-frequencies (cortical plasticity)
• Correlated activity across nerves by phase locking - ephaptic transmission;
Extralemniscal neurons, particularly in dorsal cochlear nucleus and AII area,
receiving input from somasthetic system
• Association with fear and threat (limbic system)
• Increased attention related to reticular activating system involvement
• Dysfunctional gating in basal ganglia; thalamic reticular nucleus
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Tinnitus and Hearing Loss
Odds of Having Tinnitus
0
10
20
30
10-19 dB
20-29 dB
30-39 dB
40-49 dB
HL at 4k Hz
50-59 dB
60-69 dB
70-79 dB
> 80 dB
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Lack of correlation between tinnitus severity and
auditory threshold
Tinnitus symptom severity and best
hearing threshold
Best hearing threshold at
FREQmax
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70
60
50
40
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20
10
0
0
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40
60
80
100
120
Tinnitus Handicap Inventory Score
Tsai, Cheung, and
Sweetow, Laryngoscope,
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2012
Correlation between tinnitus loudness SL and subjective
loudness
Bauer,
2009
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Research supporting central location
• Dandy, 1940
• Heller and Bergman, 1953
• Andersson, et al 1997; Baguley et al, 1992
(translabyrinthine surgery)…
• Lockwood and Salvi, 1998; Burkard, 2001 (PET)
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Tinnitus is associated with abnormal EEG-patterns,
showing enhanced activity in the δ band and
reduced activity in the α band (Weisz, Moratti, Meinzer,
Dohrmann, & Elbert, 2005)
MEG data indicating that subjects with tinnitus
< 4 years have gamma network predominantly in
the temporal cortex; but subjects with tinnitus of
a longer duration show a widely distributed
gamma network into the frontal and parietal
regions (deRidder, 2011)
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Functional connectivity
• (Maudoux et al, 2012a,
• Tinnitus individuals showed increased connectivity in the
brainstem, basal ganglia, cerebellum, parahippocampal,
right prefrontal, parietal, and sensorimotor areas and
decreased connectivity in the right primary auditory cortex,
left prefrontal, left fusiform gyrus, and bilateral occipital
regions.
• The presence of tinnitus was able to modify functional
connectivity in networks which encompass memory,
attention, and emotion.
Psychological contributions
– Cognition: maladaptive cognitive strategies “The
reaction is the key to whether a person with tinnitus
becomes a tinnitus patient” (Sweetow, 1986; 2000)
– Habituation: intolerance results from individual’s
failure to adapt (Hallam et al, 1984; 2006)
– Attention: failure to shift attention away from tinnitus
(Hallam and McKenna, 2006)
– Enhanced tinnitus perception is learned response
resulting from “negative” emotional reinforcement
involving limbic system and autonomic activation
(Hallum;Jastreboff and Hazell, 1993; McKenna,
2004)…..de-emphasizes connection with peripheral
hearing loss
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Tinnitus and Emotional Processing
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Using fMRI and affective sounds, examined emotional processing in 3 groups
(HL with tinnitus, HL without tinnitus, NH without tinnitus.
Faster response times to emotional sounds for TIN and NH groups, but not HL
group.
Amygdalar response detected only in the NH group.
Results revealed increased insular and parahippocampal response in TIN
subjects.
Such compensatory changes may affect processing of external emotional
stimuli.
Results suggest that the emotional processing network is altered in tinnitus to
rely on the parahippocampus and insula, rather than the amygdala, and this
alteration may maintain a select advantage for the rapid processing of
affective stimuli despite the hearing loss.
– Alterations of the emotional processing system may underlie preserved rapid reaction
time in tinnitus
– Carpenter-Thompson, Akrofi, Schmidt, Dolcos, Husain
– Brain Research, 2014
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Revised habituation model
(after Jastreboff and Hazell, 1993)
Perception & Evaluation
Auditory and Other Cortical Centers
Detection
(Subcortical)
Abnormal
gating
Emotional Associations --limbic system, frontal
lobe, cerebellum, etc.
Annoyance
Enabler
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Dashed lines represent neutral interpretation of tinnitus percept.
Most common difficulties
attributed to tinnitus
• Sleep
• Persistence
• Speech
understanding
• Despair,
frustration,
depression
• Annoyance,
irritation, stress
• Concentration,
confusion
• Drug
dependence
• Pain/headaches
Tyler and Baker, 1983
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Sleep deprivation
– 53% of tinnitus patients report sleep disturbance
(Meikle and Taylor-Walsh (1984)
– 2/3 require more than 30 minutes to fall asleep
– (less frequently a problem for people with normal
hearing (Hallum 1996)
– Alster, et al 1993) indicate tinnitus severity
increases with sleep problems
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Influence of noise and stress on probability of
having tinnitus
• N = 12, 166 ; N with tinnitus) = 2,024 (16%)
• Each year of age increased the odds ratio of tinnitus by
about 3%.
• Men generally showed a higher risk for tinnitus compared
with women.
• Exposure to noise and stress were important for the
probability and level of discomfort from tinnitus. However,
for the transition from mild to severe tinnitus, stress turned
out to be more important.
• Reduction of likelihood of tinnitus if noise is removed =
27%, if stress is removed =19%), if both removed = 42%.
• Conclusions: Stress management strategies should be
included in hearing conservation programs, especially for
individuals with mild tinnitus who report a high stress load.
– Baigi, et al; Ear and Hearing 2011. 32, 6:787-789
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Associated with Tinnitus?
 Hyperacusis: everyday noises seem unbearably or painful
loud. Examples: turning newspaper pages, running water in
the sink, placing plates in the cabinet,
 Misophonia: everyday normal sounds become annoying and
intolerable. Examples: throat clearing, cough, chewing,
tapping nails on computer keyboard, sound of planes or
motorcycles.
 Phonophobia: generalized fear of sound
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Tinnitus Therapies
Reduce Contrast
Mask Phantom Percept
Suppress Hyperactivity
Reclassify Phantom Percept
Reduce Saliency
Mitigate Emotional Distress
Examples
Examples
Maskers
o Hearing Aids
o “Neuromonics”
o “Zen” Fractal tones
o“Sound Cure” S tones
o“Cochlear Implants
Tinnitus Retraining Therapy
o Neuromonics
o Zen Therapy
o Cognitive-behavioral
intervention
o Mindfulness Based Stress
Reduction
oAntidepressants
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Auditory-Striatal-Limbic Connectivity
Disrupt Information Conveyance
Avoid Interference with Audition
Examples
Striatal Neuromodulation
o Vagal nerve stimulation
o Cortical Stimulation (rTMS)
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o Drug therapies (i.e. DCN potassium channel alteration with retigabine)
o
Progressive Tinnitus Management (Henry, et al)
– hearing aids, masking, TRT, and CBT.
– key features are that it is a stepped-care
approach, (telephone screen, informational
counseling, intake assessment, treatment,
extended treatment) leading to self efficacy
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Caffeine reduces likelihood of tinnitus
by 15%
• Brigham and Women’s Hospital, Curhan, et al; American
Journal of Medicine, 2014
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Tinnitus Retraining Therapy
• directive counseling
• auditory (low level noise) therapy
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Basic assumptions
The brain can sort out meaningful
stimuli from those which are not
• Attention is directed toward
"salient" or information-bearing
stimuli
•
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Habituation
• the process of "ignoring" (or becoming
accustomed to) a stimulus without exerting
any conscious effort.
• from a psychological perspective, it is defined
as the adaptation, or decline of a conditioned
response, to a stimulus following repeated
exposure to that stimulus.
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Examples of normal habituation
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Ring on your finger
Clothing
Refrigerator humming
Rear end (buttocks) in your chair
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The Limbic System
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How sensory systems suppress stimuli
• Somatosensory
• Auditory
• How brain (limbic system) determines
importance of external stimuli
– Thunder versus soft, unexpected sound
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A simple structure for remembering the
sequence of the brain’s analysis of the tinnitus
1. The auditory cortex analyzes
2. The hippocampus identifies
3. The amygdala determines salience
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Current sound treatments
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Maskers
Noise generators
Music (unfiltered, filtered, fractal)
Hearing aids (effective in over 60% of cases)
Combination instruments
Home based sounds
CDs/internet
• Some numbers to consider
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SOUND GENERATORS FOR TINNITUS
AMPLISOUND ( formerly UHS)
SOLACE
GHI (General Hearing Instruments)
TRANQUIL
Digital sound generator –adjustable
Broadband white or broadband pink noise
HANSATON
WAVE
Digital noise generator
NEUROMONICS
OASIS AND SANCTUARY
Four tracks of music adjusted to hearing
SOUND CURE
SERENADE
Four tracks -2 “S” tones (customized
amplitude and frequency modulated
tones), NBN and white noise
Considerations
• Reported success numbers
– i.e. in Goddard, et al 2009 reported 78% success with
Neuromonics; but only 14 of initial 47 subjects completed
the study
– If 100 subjects enroll, but only 60 complete the study, and
40 of those 60 are successful, what is the success rate,
66%, or 40%?
• Research design
– Risk of bias assessment tools consist of five domains:
population, outcome, exposure,
statistical analysis, and, for Random Control Trials,
randomization, blinding, and withdrawals
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Methodological risk of bias criteria of randomized
controlled trials for the sound technology interventions
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Evaluation and Treatment of Tinnitus: A Comparative
Effectiveness Review; Pichora-Fuller, et al, in press
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Cochrane Review
• Sound Generators:
– The limited data from the included studies failed
to show strong evidence of the efficacy of sound
therapy in tinnitus management.
– The absence of conclusive evidence should not be
interpreted as evidence of lack of effectiveness.
– “The lack of quality research in this area, in
addition to the common use of combined
approaches (hearing therapy plus counseling) in
the management of tinnitus are, in part,
responsible for the lack of conclusive evidence.
• (Hobson, Chisholm, El Rafaie, 2010)
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Conclusions of Kochkin, et al; 2011
• Of the nine tinnitus treatment methods assessed, none were tried
by more than 7% of the subjects.
• Treatment methods rated with substantial tinnitus amelioration
were hearing aids (34%) and music (30%).
• Subjects who had their hearing aids fit by professionals using
comprehensive hearing aid fitting protocols are nearly twice as
likely to experience tinnitus relief than respondents fit by hearing
care professionals using minimalist hearing aid fitting protocols.
• This study confirms that the provision of hearing aids offers
substantial benefit to a significant number of people suffering
from tinnitus. This fact should be more widely acknowledged in
both the audiological and medical communities.
– Kochkin S., Tyler R., Born J. MarkeTrak VIII: The Prevalence of Tinnitus
in the United States and the Self-reported Efficacy of Various
Treatments Hearing Review. 2011;18(12):10-27.
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Why hearing aids may help tinnitus patients
• Greater neural activity allows brain to correct for
abnormal reduced inhibition
• Enriched sound environment may prevent
maladaptive cortical reorganization
• Alter production peripherally and/or centrally
• Reduce contrast to quiet
• Partially mask tinnitus
• Fatigue and stress is reduced allowing more resources
to be allocated to tinnitus fight
• All of the above may facilitate habituation
and
• The majority of tinnitus sufferers have at least some
degree of hearing loss
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TINNITUS INSTRUMENTS
(HEARING AID PLUS SOUND GENERATOR)
• WIDEX– Zen (all models)
• PHONAK - Audeo Q
• STARKEY– Xino
• RESOUND– Verso TS (Alera TS )
• SIEMENS - Ace ™, Pure®,Life™,
Pure Carat®
• Fractal tones plus white noise
Additional Zen therapy guide with
relaxation exercises
• Adjustable tinnitus balance noise
generator - App of sounds and
music for smart phones
• Adjustable sound generator –
patient can customize sound using
sound point
• Adjustable sound generator – can
customize for sound preference
• Adjustable signal generator with 4
preprogrammed sounds: white
noise, pink noise, speech noise, and
high-tone noise
What are the objectives of sound
therapy?
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Complete masking
Partial masking
Mix
Habituate
Distract
Suppress
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Counseling only
= 3 worse, 6
same, 6 better
(40%)
Masking = 2
same, 4 better
(66%)
Retraining = 5
same, 6 better
(54%)
NOTE: none
used hearing
aids
Tyler, 2010, 2012
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Issues relating to sound therapy
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Mixing point
Spectral characteristics
Dynamic characteristics
Temporal factors
• Amplification characteristics
– Kneepoint
– Bandwidth
– Verification
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Conclusions
• Subjects who experienced suppression reported
louder tinnitus (db SL) at baseline
• Best stimuli were amplitude modulated pure
tones with carrier frequencies between 6K and
9K
• White noise is ineffective as a suppressor
• For subjects with any suppression, AM and FM
pure tones were more likely to yield total
suppression compared to un-modulated pure
tones
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A perfect example of an auditory disorder
closely related to stress:
Tinnitus
The Vicious Cycle
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Acoustic therapy considerations
• If tinnitus is related to an increase in synchrony,
would the use of a dynamic signal as opposed to
a steady state signal alter the response?
• Given the widespread effect of tinnitus in the
brain, doesn't it make sense to use acoustic
stimuli that activate widespread regions?
• Given the impact of stress on tinnitus (and vice
versa), shouldn’t the acoustic signal be relaxation
inducing?
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• Music has been shown to activate the limbic
system and other brain structures (including
the frontal lobe and cerebellum) and has been
shown to produce physiologic changes
associated with relaxation and stress relief.
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Where is music processed?
Frontal
Lobe
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How is music used?
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Home
Work
Celebrations
Advertising
Romance
Movies
Athletic locker rooms
Shopping malls
Hospitals
Therapies
Relaxation
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Modes of Delivery
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Home stereo
iPod
Neuromonics
Hearing aids
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“Rules” of music and emotions
• Slow onset, long, quiet sounds – calming
• Music with a slow tempo (i.e. near natural heart rate
(60 – 72 beats per minute) - relaxing
• Repetition - emotionally satisfying
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Categorical Expectations
• We don’t like the unexpected
• But certain rules have to be followed
• Active listening may arouse, passive listening
may soothe
• For tinnitus patients, active listening may draw
attention to the tinnitus, passive listening may
facilitate habituation
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Music suggestions
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evokes positive feelings
without vocals
no pronounced bass beat
pleasant, but not too interesting or compelling (though
for short term relief attention capturing music can be
beneficial)
• induces relaxation while reducing tinnitus audibility
(best for long term relief)
• Play at low levels where music blends with tinnitus
– Hann D, Searchfield G, Sanders M, Wise K (2008) Strategies
for the slection of music in the short-term management of
mild tinnitus.
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Selecting the right sounds
Sounds (including music) affects people in different
ways, due to inherent, learned (and cultural)
preferences
Thus it is appropriate to use relaxing background
sounds (that activate the parasympathetic division of
the autonomic nervous system) and minimize
exposure to alerting, negative, or annoying sounds
(that activate the sympathetic division)
Cultural preferences (Bolero)
Earworms?
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Earworms
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Nearly 98% of people have had songs stuck in their head, Kellaris reported at the recent
meeting of the Society for Consumer Psychology. The 559 students -- at an average age of 23
-- had lots of trouble with the Chili's "Baby Back Ribs" Jingle and with the Baha Men song
"Who Let the Dogs Out." But Kellaris found that most often, each person tends to be haunted
by their own demon tunes.
"Songs with lyrics are reported as most frequently stuck (74%), followed by commercial
jingles (15%) and instrumental tunes without words (11%)," Kellaris writes in his study
abstract. "On average, the episodes last over a few hours and occur 'frequently' or 'very
frequently' among 61.5% of the sample."
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Top 10 earworm list:
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Chili's "Baby Back Ribs" jingle.
"Who Let the Dogs Out"
"We Will Rock You"
Kit-Kat candy-bar jingle ("Gimme a Break ...")
"Mission Impossible" theme
"YMCA"
"Whoomp, There It Is"
"The Lion Sleeps Tonight"
"It's a Small World After All"
•
Kellaris, 2003
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Fractal tones
• dynamically varying signals with semi-random
temporal modulations
• fractal tones create a melodic chain of tones
that repeat enough to sound familiar and
follow appropriate rules, but vary enough to
not be predictable.
• fractal technology ensures that no sudden
changes appear in tonality or tempo
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An Integrated Approach to Tinnitus
Management
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Tinnitus Management Team
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Audiologist
Otolaryngologist
Psychologist
Psychiatrist
Neurologist
Pharmacologist
Nutritionist
TMJ Specialist
Physical Therapist
Biofeedback Specialist
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Which "red flags" suggest the need for
immediate referral?
• Patients presenting with any of the following symptoms
or diagnostic findings should be referred to a physician
(particularly an otolaryngologist) before beginning Widex
Zen Therapy because they may either be treatable or may
indicate the presence of a serious medical condition:
• sudden hearing loss
• unexplained unilateral hearing loss
• pulsatile tinnitus
• tinnitus accompanied by dizziness or vertigo
• tinnitus with conductive hearing loss previously not
diagnosed
• depression, anxiety, or uncontrolled and extreme stress
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When to treat?
• For patients who require extensive treatment,
it is generally true that once the medical
evaluation has been conducted to rule out
treatable or systemic etiologies, the earlier
therapy can begin, the better.
• However, even patients who have had tinnitus
for many years, can still achieve success.
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Subjective scale measures
Why use them?
Establish baseline score
Identify how tinnitus is affecting
quality of life.
Helps establish individualized goals.
Track progress
Assessment Inventories
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Tinnitus Severity Scale – Sweetow and Levy
Tinnitus Handicap Inventory - Newman et al
Tinnitus Handicap Questionnaire - Kuk, et al
Tinnitus Effects Questionnaire - Hallam, et al
Tinnitus Reaction Questionnaire - Wilson, et al
Tinnitus Cognitive Questionnaire (TCQ) - Wilson and
Henry
• Tinnitus Functional Index – Miekle,et al, 2012
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Tinnitus Functional Index (TFI)
http://www.ohsu.edu/xd/health/services/ent/services/tinnitusclinic/tinnitus-functional-index.cfm
• 25 items designed to address 8 important domains of
negative tinnitus impact:
– intrusiveness, reduced sense of control, cognitive interference,
sleep disturbance, auditory difficulties attributed to tinnitus,
interference with relaxation, quality of life reduced and
emotional distress.
• Each of the 8 subscales consist of 3 items except for the
quality of life subscale which consist of 4 items.
• All items are scored using a percentage score or a 0-10
scale giving a maximum possible score of 250 (which is then
divided by 25 and multiplied by 10 for a max score of 100).
• The TFI is useful for scaling the severity and negative
impact of tinnitus, for use in intake assessment and for
measuring treatment-related changes in tinnitus.
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60
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Tinnitus Questionnaire
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Otologic
Medical
Audiologic
Diet
Exercise
Emotional Pattern
Sleep
Previous Treatments
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Potentially useful diagnostic procedures
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audiogram
assessment (severity) scales
psychological profiles
tinnitus matching (do loudness match first)
loudness discomfort levels
minimum masking levels
OAEs
ultra high frequency testing
immittance/reflexes/decay
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Initial Interview
Once the intake has been completed, the initial interview is
performed in order to:
• review the findings,
• educate the patient regarding the probable cause and course of
the tinnitus,
• provide appropriate reassurance that the tinnitus does not
represent a grave illness or a progressive condition (established
based on the previously conducted medical examination,
• Discuss results of subjective assessment scale (TFI)
Suggestion: whenever possible, try to involve a patient's family
member. Like hearing loss, tinnitus can have a profound effect not
only on the patient, but on the entire family. Bringing in a family
member or friend can not only provide emotional support but can
help motivate the patient to comply with your recommendations.
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Tinnitus triggers
• Physical (viral, medication, hearing
loss (imbalance between excitatory
and inhibitory neurons), neurotoxicity
from noise, somatic influences)
• psychological
• retirement syndrome
• stress related
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Defining the tinnitus problem
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•
•
•
time
behaviors affected
attitudes and thoughts
what affects the tinnitus?
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SURVEY
• 1. Please estimate the percentage of your mini
BTE RIC instant dome patients who have lateral
migration issues (defined as the earpiece working
its way out partially out of the ear canal), or
needing to frequently push the earpiece back into
at least one of their ear canals.
• Please estimate the percentage of your mini BTE
RIC instant dome patients whose physical fit
creates a gap between the thin wire and the side
of the head.
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Disclosure
68
Widex Zen Therapy
• an integrated program addressing all 3 major
components of tinnitus distress; auditory, attention, and
emotion; as well as stress and sleep management
• many patients will be adequately served by counseling
and sound therapy (hearing aids, fractal tones, or noise)
alone;
• patients with negative reactions treated with a
comprehensive program integrating cognitivebehavioral concepts and relaxation exercises along with
the counseling, sleep management, and acoustic tools.
69
Components
1. Counseling to educate the patient and assist the limbic
system to alter its negative interpretation of the tinnitus via
cognitive and behavioral intervention;
2. Amplification (binaurally, when appropriate) to stimulate
the ears and brain in order to discourage increased in
central activity (overcompensation) and maladaptive
cortical reorganization;
3. Fractal tones binaurally delivered to the patient in a
discreet, inconspicuous and convenient manner, designed
to both relax and provide acoustic stimulation;
4. Relaxation strategy program highlighted by behavioral
exercises and sleep management strategies.
70
Level 5:
77+
TFI, THI,THQ, TRQ
Level 4:
58-76
Level 3:
37-57
Level 2:
18-36
Level 1:
0-17
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Level I: Minimal or no negative tinnitus reaction.
• Instructional Counseling
• Amplification (when hearing loss exists)
• (Zen might be useful for quiet environments)
Level II: mild negative tinnitus reaction
• Level I components PLUS.....
• Zen for quiet environments
Level III: Moderate negative tinnitus reaction
• Level I and II comppnents PLUS.....
• Cognitive behavioral Intervention
• Amplification/avoidance of silence
• Zen all day
• (Relaxation exercises might be useful)
Level IV: Severe negative tinnitus reaction
• Level I, II, and III components PLUS,,,,,
• Cognitive behavioral intervention
• Relaxation exercises
Level V: Catastrophic tinnitus reaction with or without hearing loss
• Level I, II, III, and IV comppnents PLUS.....
• Relaxation exercises 2-3 times a day
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Counseling
• Instructional
• Adjustment-based
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Counseling
• Instructional counseling helps educate the
patient about aspects of the tinnitus itself. For
example, it addresses…………..
– the basic anatomy and physiology of the auditory
(and central nervous) system,
– why the tinnitus is present (particularly when it is a
normal consequence of having a hearing loss),
– what the logical course of the tinnitus might be,
– how the limbic system affects the tinnitus perception
and how the patient’s reaction impacts the ability to
cope with or habituate to the tinnitus.
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Adjustment based counseling…
• Helps the patient recognize aspects about how the
tinnitus is affecting him or her, and the cognitive and
behavioral implications. It is designed to :
• address the emotional sequelae of tinnitus, including
fear, anxiety and depression;
• identify and correct maladaptive thoughts and
behaviors;
• understand the relationship between tinnitus, stress,
fear, behaviors, thoughts, and quality of life.
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Most reactions are learned processes
• Subject to behavioral and cognitive
modifications
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Cognitive-Behavior Therapy
(Beck, Meichenbaum)
• The therapeutic effort to modify maladaptive
thoughts and behaviors by applying systematic,
measurable implementation of strategies designed
to alter unproductive actions
• CBT gives patients hypotheses that can be selftested
• focuses on using a wide range of strategies to help
clients overcome maladaptive thoughts and
behaviors
– cognitive restructuring, dissociation of negative
emotional association, attention directing, modification
of avoidance behavior, journaling, role-playing, thought
stopping, relaxation techniques, and mental
distractions, coping strategies
Cognitive theory
Common Misunderstanding
Cognitive Theory
Event
Emotion
Common misunderstanding:
An event causes an emotion
The CBI model:
Event-Thought-Emotion
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Events?
Thoughts?
Emotions?
Sad
Parties are fun
Emotion
Thought
TheTHIS
noise
level
is high
NOISE
IS
TO
Thought
MUCH
Reading a
book
Grateful
I can’t
concentrate
Event
Emotion
Thought
A party
invitation
Annoyance
At a café
with friends
Event
Emotion
Event
79
Example of cognitive theory
Someone
grabs your
arm from
behind
“it’s a
thief!”
FEAR!
EVENT
THOUGHT
EMOTION
80
But what if ….
A person
grabs your
arm from
behind
“it’s a
friend”
EVENT
THOUGHT
Happines
s
EMOTION
81
Cognitive behavioral intervention….
• is designed to identify the unwanted thoughts and behaviors
hindering natural habituation, challenge their validity, and
replace them with alternative and logical thoughts and
behaviors.
• the objective is to remove inappropriate beliefs, anxieties
and fears and to help the patient recognize that it is not the
tinnitus itself that is producing these beliefs, it is the
patient's reaction (and all reactions are subject to
modification).
The basic processes in cognitive-behavioral intervention are :
• identify behaviors and thoughts affected by the tinnitus;
• list maladaptive strategies and cognitive distortions
currently employed;
• challenge the patient to identify negative thoughts;
• identify alternate thoughts, behaviors, and strategies.
82
Introducing the patient to CBI
•
•
•
•
Explaining the rationale for CBI to the patient
How many visits
How long should each session be
What can be done at home versus face to face
The basic process of CBI
Address the emotions of tinnitus
Explain the relationship between tinnitus, thoughts and emotions
Identify maladaptive thoughts and behaviors
Provide strategies for alternative thoughts and behaviors
Disclaimer: The suggested CBI activities are not intended to replace the
services of a mental health professional.
Flipchart & CBI Worksheets
84
Awareness of tinnitus
Cognitions (Automatic thoughts)
Emotional state
(anger, depression, anxiety)
Emotional response is the result of the
thoughts, not the event (awareness of the
tinnitus) itself.
85
CHARACTERISTICS OF
AUTOMATIC THOUGHTS
Examples on Thought errors
Mind
reading
Overgeneralizatio
n
Jumping to
conclusions
All or
nothing
thinking
Should
statements
Mental
filter
Catastrophizing
Disqualifying
the positive
Emotional
reasoning
All or nothing thinking
• If a situation falls short of perfection, you see it as a
total failure.
• When a young woman on a diet ate a spoonful of ice
cream, she told herself, “I have just completely
blown my diet”.
• Pattern of seeing only one “truth” as valid; no room
for two sides of the story; no moderation or grey
area; context is made irrelevant.
Tinnitus examples?
Overgeneralization
• Drawing broad and general conclusions from a
limited amount of information.
• You see a simple negative event as a never
ending pattern of defeat by using words such
as “always” or “never” when you think about
it.
Tinnitus examples?
Mental filter
• We tend to confirm our pre-existing
assumptions. Whatever information doesn’t
fit our beliefs gets filtered out, ignored, or
explained away as insignificant
• You pick out a single negative detail and focus
on it, exclusively so that your vision of all
reality becomes darkened .
Tinnitus examples?
Discounting the positive
• You reject positive experiences by insisting
they don’t count.
• If you do a good job, you may tell yourself it
wasn’t good enough or “anyone could do it”.
• This discounting takes the joy out of life and
makes you feel inadequate and unrewarded.
Tinnitus examples?
Jumping to conclusions
• A pattern of making premature conclusions
based on incomplete or ambiguous
information
Tinnitus examples?
Jumping to conclusions
Tinnitus examples?
Magnification
• You react to the imagined worst case scenario
as if it was actually happening.
• You exaggerate the importance of your
problems and shortcomings or you minimize
the importance of your desirable qualities.
Tinnitus examples?
Emotional reasoning
• You think based on emotions.
• Your emotions create “facts” in your mind.
• “I am terrified of airplanes. It is dangerous to
fly.”
• “I feel sad. This proves I’m being treated
unfairly.”
Tinnitus examples?
Should statements
• You tell yourself that things should be the way you
expected them to be.
• “I shouldn’t have made so many errors.”
• “He shouldn’t be so stubborn and argumentative.”
• Should statements directed against yourself lead to
guilt and frustration.
• Should statements directed against other people
lead to anger and frustration.
Tinnitus examples?
Labelling
• Complex human beings are taken out of
context and reduced to an overgeneralized
characteristic.
• Labelling is an extreme form of all or nothing
thinking. Instead of saying, “I made a mistake”,
you attach a negative label to yourself.
• “I am a loser.”
Tinnitus examples?
Personalization and blame
• Causes of negative events are attributed to
ourselves rather than to context or situations.
• When a woman received a note that her child
was having difficulties at school, she told
herself “this shows what a lousy mother I am”
instead of trying to establish the true cause of
the problem.
Tinnitus examples?
The “Columbo Technique”
TOOLS TO USE WITH CBI
Analyzing perceived problems
Perceived problem
Realistic assessment
My tinnitus keeps me awake all night
I fall asleep relatively easily but then I
awaken twice each night and it takes
about an hour to fall back
asleep.
The tinnitus drives me crazy
I am finding it difficult to concentrate
when I can’t find any quiet time and I am
frustrated, but I am not crazy!
Tinnitus is ruining my life
I am really stressed because I don’t have
enough time to juggle work, family and
leisure, and I tend to blame the tinnitus
for my problems
Tools to use with
CBI
Negative thought Thought error
Alternative
thought
My life used to be
perfect before I had
tinnitus, now it is
horrible
All or nothing thinking
Life is never perfect, I
had some problems
before, and I still have
some good things
about my life now (like
my grandchildren)
My tinnitus makes me
feel hopeless
Emotional reasoning
Other people have
survived tinnitus, I can
too
Tools to use with
CBI
Event
Thought
Emotion
Invitation to a social
gathering
I can’t go. My tinnitus
will get worse
Hopelessness, despair,
frustration
Inability to hear what
was said during a party
People think I’m stupid
when I ask them to
repeat things I don’t
hear
Depression, suicidal
feelings
TOOLS TO USE WITH CBI
Maladaptive behavior
Alternative strategy
When I hear my tinnitus in the
morning, I stay in
bed all day, avoiding sound, and
feeling depressed
Being active makes me think less
about my tinnitus. I should
go to a mall, put on other sounds in
my house so that the tinnitus
isn’t so apparent, and do anything
except nothing!
I have trouble falling asleep so I lay in
bed worrying
about how I will feel tomorrow
If I can’t sleep in 30 minutes, I will get
up and read on the
sofa, or will watch some quiet TV
show, or get some extra
work done that I have been putting
off
Similarities between WZT and TRT:
– Event (awareness of tinnitus) leads to Cognitions
(automatic thoughts) which lead to Emotional
state (depression, anger, anxiety)
• - Automatic thoughts may arise with little awareness,
are highly believable, and appear to be out of direct
control
– Combination of sound therapy and counseling
• (but counseling is different)
With both approaches, tinnitus remains, but coping skills
improve
105
Differences between TRT and WZT
• Categorization
• Sound therapy
• Use of relaxation and sleep management
106
Differences between TRT and Cognitive
Therapies
• CT is intensive and collaborative designed for
8-12 weekly sessions and direct testing of
hypotheses
• TRT uses directive counseling with 4-6
sessions over 18 month period
• CBT teaches coping, TRT does not
107
More differences between TRT and cognitive
therapies
• WZT emphasizes a collaborative interaction versus directive
counseling
• WZT emphasizes flexibility with multiple components
• WZT more short term (with greater load in front (coincident
with amplification)
• WZT more active in counseling aspects, passive in sound
therapy
• WZT aims to help patient develop coping strategies, TRT
promotes concept of habituation is natural and coping
strategies aren’t vital
• A critical segment of WZT is relaxation and sleep
management; these are not part of TRT
• WZT is constantly evolving, it is not static!
108
Strengths, limitations, and comparison
of existing approaches
• CBT, which can increase realistic, logical and
rational thinking and is believed to relieve
distress and reduce maladaptive behaviors, does
not call for the use of sound enrichment, though
practitioners have noted anecdotally that success
using CBT may be enhanced when amplification is
employed.
• In addition, it is frequently delivered by
psychologists, who may not have an
understanding of the nature of the ear or
impaired auditory system.
109
• Henry and Wilson, 2001 “encourage
audiologists to adopt CBT” and have written a
book for audiologists promoting this effort
–
110
Summary of Cima, et al results
• 86 (35%) of 247 patients in the usual care group and 74 (30%) of 245
patients in the specialized care group were lost to follow up by month
12. Reasons for nonresponse seemed unrelated to treatment content.
• Health-related quality of life increased with specialized care compared
with usual care at 8 months and 12 months).
• Tinnitus severity and impairment related to tinnitus were reduced by
specialized care compared with usual care at all three follow-ups
• Specialized care reduced negative affect at 8 months and 12 months, and
tinnitus catastrophising and fear related to tinnitus at all three followups.
• The difference between specialized care and usual care that occurred by
8 months seemed to persist to 12 months, and was larger than that
noted at 3 months.
• Patients with mild or severe tinnitus seemed to benefit equally
111
Cochrane Reviews
• TRT
– Only one study, involving 123 participants, matched the
inclusion criteria for this review (five were excluded because
they used a “modified” version). Although this study suggested
considerable benefit for TRT in the treatment of tinnitus the
study quality was not good enough to draw firm conclusions.
– Phillips, McPherran, 2010
• CBT
– Found no evidence of a significant difference in the subjective
loudness of tinnitus.
– However, found a significant improvement in depression score
(in six studies) and quality of life (decrease of global tinnitus
severity) in another five studies, suggesting that CBT has a
positive effect on the management (reduction of annoyance and
distress) of tinnitus.
– Martinez-Devesa, et al 2010
112
Why amplification may help tinnitus patients
• Greater neural activity allows brain to correct for
abnormal reduced inhibition
• Enriched sound environment may prevent
maladaptive cortical reorganization
• Alter production peripherally and/or centrally
• Reduce contrast to quiet
• Partially mask tinnitus
• Fatigue and stress is reduced allowing more
resources to be allocated to tinnitus fight
• All of the above may facilitate habituation
and
• The majority of tinnitus sufferers have at least some
degree of hearing loss
113
Amplification
• While most well fitted, high quality hearing
aids can help tinnitus patients with hearing
loss, hearing aids containing low compression
thresholds, broad bandwidth, precision in
fitting procedure (Sensogram), and in situ
verification (Sound Tracker) are particularly
effective.
114
Zen
• An optional listening program in certain (Passion, Mind, and
Clear) Widex hearing aids that plays adjustable, continuous,
chime-like tone complexes using fractal algorithms.
• The chimes are generated based on an understanding of the
properties of music that would be most relaxing (Robb et al.,
1995):
•
•
•
•
•
•
•
Ability to self select music.
Tempo near or below resting heart rate (60-72 bpm).
Fluid melodic movement.
Variety of pitches
No rapid amplitude changes
Element of uncertainty (Beauvous 2007)
Passive listening
115
Frequency response and amplitude settings are based on in-situ audiogram.
A filtered broad band noise can be used as a separate program or in combination with the fractal tones.
Signals are dichotic
116
• Each Zen program can be individually adjusted
to loudness, pitch and tempo preferences
• The fractal tones (or the noise) should be
audible, but relatively soft
• It should never interfere with conversational
speech
• The annoyance level of the tinnitus should just
begin to decrease (i.e., tinnitus can still be
audible)
117
Zen sound stimulation
Zen fractals can be used alone or mixed with broadband
noise
Zen fractal tones can be individualized
Zen helps reduce the contrast between the tinnitus and
the surrounding sound environment
Zen is relaxing to listen to
Zen promotes habituation
118
Evidence of effectiveness
• Sweetow & Henderson-Sabes, The use of acoustic
stimuli in tinnitus management. JAAA 21,7, 461473, 2010
• Kuk F, Peeters H, Lau CL. The efficacy of fractal
music employed in hearing aids for tinnitus
management. Hearing Review. 2010;17(10):3242.
• Herzfeld and Kuk, Hearing Review, 2011; 18,(11),
50-55.
119
•14 subjects with severe, uncompensated
tinnitus, 6 non-tinnitus subjects. 2 subjects
dropped out.
• All subjects had tinnitus for at least one
year and had received no active treatments
(including counseling) for at least three
months prior to the start of the experiment.
0
20
dB HL
• All tinnitus subjects had been seen at
UCSF for tinnitus treatment at least 3 mos.
prior to the study – completed tinnitus
counseling and other therapies but were
still significantly bothered (average THI
entering study = 58.7).
40
60
80
100
500
1000
2000
4000
8000
Frequency (Hz)
• Battery of questionnaires = THI, TRQ,
stress, annoyance, and relaxation measures.
120
Study Questions
• Would fractal tones (and/or noise) delivered
through hearing aids be:
– Perceived as relaxing to tinnitus patients?
– Reduce short term tinnitus annoyance in the lab?
– Lower subjective tinnitus handicap and reaction
scores in a 6 month field trial?
121
Zen fractal stimuli
•
•
•
•
•
Aqua
Coral
Green
Lavender
Sand
• and noise
122
Relaxation ratings
1 – very relaxing, 2 – somewhat relaxing, 3 – neither relaxing nor stressful,
4 – somewhat tensing, 5 – very tensing
5
Relaxation Rating
4
3
2
1
More Relaxed
0
Aqua
Coral
Lavender
Green
123
Relaxation ratings
1 – very relaxing, 2 – somewhat relaxing, 3 – neither relaxing nor stressful,
4 – somewhat tensing, 5 – very tensing
5
Relaxation Rating
4
3
2
1
More Relaxed
0
Zen alone
Zen+Master
Zen+Master+Noise
124
Tinnitus annoyance
0 – no annoyance, 1 – just slightly annoying, 2 – mildly annoying, 3- moderately annoying,
4 – very annoying, 5 – extremely annoying, 6 – worst possible annoyance
6
Tinnitus Annoyance Rating
5
4
3
2
1
0
Less Annoying
-1
Unaided Master
Aqua
Coral
Lavender Green
Noise
125
Tinnitus Handicap Inventory
126
Weakness of group data and randomization
• Group analysis assumes all are the same
• Some individuals show large changes, but
these are diluted in group analysis
• There is not likely a single treatment which
confers universal benefit
• Subjects who do not want a device, but who
are randomized to a device group are less
likely to show benefit
• Tyler, 2010
127
Herzfield and Kuk, 2011 (48 subjects receiving counseling plus
128
Summary of findings
• Fractal tones were effective as a tool in
promoting relaxation and reducing
annoyance from tinnitus
• Both fractal tones and noise reduced tinnitus
annoyance, but the fractal tones were
preferred by subjects for longer term use
129
Binaural fitting considerations
If tinnitus and hearing loss is present in both ears:
• Use binaural amplification. Monaural amplification may
draw attention to the tinnitus in the non-amplified ear.
If tinnitus is present in one ear and hearing loss in both ears:
• Use binaural amplification. Previously undetected tinnitus
may become apparent in the unamplified ear when it is
suppressed in the amplified ear, In addition, an unpleasant
imbalance in hearing may occur if only one hearing aid is
used.
If tinnitus is present in both ears and hearing loss in only one
ear:
• Your patient may benefit from binaural devices, but turn off
the microphone in the normal hearing ear when Zen + is
selected. This arrangement will still allow the patient to
obtain the dichotic fractal tone experience (and will ensure
stimulation of both cortical hemispheres).
130
Binaural considerations (continued)
If tinnitus is present but hearing is not sufficiently impaired to
warrant hearing aids:
• Your patient may benefit from binaural devices with the
Zen+ option. Use an open fitting and turn off the
microphone in Zen+ so outside sounds are not being
amplified.
If tinnitus and hearing loss are present in only one ear:
• Use binaural hearing aids. Select Zen + and turn off the
microphone in the normal hearing ear. Leave the fractal
tones on in both ears to stimulate both hemispheres.
131
Demonstrating Zen in your
office
• Demonstrate Zen through hearing
aids
– Hearing loss taken into account
– Stereophonic effect
• Demonstrating Zen through
loudspeakers
– No true stereophonic dichotic effect
– Sounds may not be adequately
filtered to hearing needs
– Patient may reject it before truly
experiencing it
132
Breaking the cycle & enabling
habituation
• Overcoming auditory
deprivation
• Acoustic distraction
• Relaxation
• Improving sleep
• Lifestyle modifications
• Alternative ways of thinking
about and reacting to tinnitus
133
Relaxation/Meditation/self hypnosis, MBSR, etc
These techniques can:
• increase Alpha (8-13 Hz or cycles per second) production;
• increase Theta (4-7 Hz) production;
• increase high Beta (20-40 Hz) activity (with experienced meditaters)
Alpha patterns are associated with calm and focused attention;
Theta patterns are associated with reverie, imagery, and creativity;
high Beta activity is associated with highly focused concentration.
It was therefore argued that meditation contributed to a calm,
creative, and focused pattern of brain activity which resulted in a
person with these same qualities.
Other early research indicated that meditation produced an
increased hemispheric synchrony
Differences
•
•
•
Transcendental meditation is a technique of meditation of Hindu origin that promotes deep relaxation
through the use of a mantra. A mantra is a verbal formula that is repeated in meditation to maintain
concentration while not focusing intensely.
Concentrative meditation focuses the attention on the breath, an image, or a sound (mantra), in order to
still the mind and allow a greater awareness and clarity to emerge. The simplest form of concentrative
meditation is to sit quietly and focus the attention on the breath. Breathing provides a natural object of
meditation. There is a direct correlation between breathing and the state of mind. The breath is typically
shallow, rapid, and uneven when a person is anxious, frightened, agitated, or distracted, whereas it tends to
be slow, deep, and regular when the mind is calm, focused, and composed. By letting the mind become
absorbed in the rhythm of inhalation and exhalation, your breathing will become slower and deeper, and the
mind becomes more tranquil and aware.
Mindful meditation involves broadening your attention to become aware of the continuously changing
external sensations and feelings, images, thoughts, sounds, and smells without becoming involved in
thinking about them. Sitting quietly and simply witnessing whatever goes through your mind, not reacting or
becoming involved with thoughts, memories, worries, or images trains the mind to be non-reactive and
helps in the attainment of inner peace. This process is analogous to providing advice for a friend who is
overwhelmed by problems. As a detached observer who is not affected emotionally by your friend's state of
mind, you can provide new perspectives for looking at the problems and reach more objective and logical
decisions. Similarly, the non-reactive state of mind from mindful meditation gives you the ability to become
aware of the multitude of factors that surround you, and you became more calm from having a broader
perspective
135
Relaxation Exercises
• Progressive Muscle Relaxation
• Deep breathing
• Guided imagery
136
General suggestions for the relaxation
exercises:
• Perform the exercises while sitting in a comfortable
chair in a quiet place with no distractions;
• Do the exercises while listening to the Zen tones, but
if you are too distracted, turn off the tones;
• Remove your shoes and wear loose, comfortable
clothing;
• Don't worry if you fall asleep;
• After finishing the exercise, close your eyes, relax for
a few minutes, breathe deeply and rise up slowly.
• * NOTE: IF YOU HAVE MEDICAL CONDITIONS THAT
MAY CAUSE YOU TO EXPERIENCE DISCOMFORT ASK
YOUR PHYSICIAN BEFORE DOING THESE EXERCISES
137
Progressive Muscle Relaxation (PMR):
•
PMR consists of alternating deliberately tensing muscle groups and then releasing the
tension. Focus on the muscle group; for example, your right foot. Then inhale and simply
tighten the muscles as hard as you can for about 8 seconds. Try to only tense the muscle
group that you are concentrating on. Feel the tension. Then release by suddenly letting go.
Let the tightness and pain flow out of the muscles while you slowly exhale. Focus on the
difference between tension and relaxation.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
head (facial grimace)
neck and shoulders
chest
stomach
right upper arm
right hand
left upper arm
left hand
buttocks
right upper leg
right foot
left upper leg
left foot
Relax for about 10-15 seconds and repeat the progression. The entire exercise should take about 5
minutes.
•
DO NOT DO IF YOU HAVE HIGH BLOOD PRESSURE
138
Deep breathing:
• This is the simplest of the relaxation procedures. It simply
requires you to follow the five suggestions above and to
add deep, rhythmic breathing. Specifically, you should
complete the following cycle 20 times:
• Exhale completely through your mouth;
• Inhale through your nose for four seconds (count "one
thousand one, one thousand two, one thousand three,
one thousand four");
• Hold your breath for seven seconds;
• Exhale through your mouth for eight seconds;
• Repeat the cycle 20 times
• The entire process will take approximately 7 minutes.
139
• Deep breathing compresses polyvagal nerve
140
Sleep suggestions (partial list)
• Maintain a standard bedtime for each day.
• Set your alarm for the same time each day.
• Walk or exercise for ten minutes a day, but not right before going
to sleep.
• Set thermostat for a comfortable bedroom temperature.
• Use a fan or white noise machine to interfere with your tinnitus.
• Close your curtains/drapes and maintain a bedroom dark enough
to sleep.
• Change the number of pillows you use. This also may impact
somatic contributors to tinnitus.
• Don't watch TV, eat or read in bed. Use your bed for sleep and sex.
• Sleep on your back or on your side, try to avoid sleeping on your
stomach.
• Take prescription medicines as directed, but only if required.
141
The manual…….
…..helps establish realistic, time-based
expectations, provides methods of assessing
progress, and creates a follow up schedule.
In addition, the information is demonstrated
with the use of case examples.
142
Improvement
• Subjective scales
• Reduction in the number of episodes of awareness
• Increase in the intervals between episodes of
awareness
• Increase in quality of life
• Not necessarily a reduction in perceived loudness
• Effect may NOT be immediate
• Establish realistic, time-based expectations
Counsel about the following:
•
•
•
•
Tinnitus is not unique to that one patient.
Tinnitus is not a sign of insanity or grave illness.
Tinnitus may be a “normal” consequence of hearing loss
Tinnitus probably is not a sign of impending
deafness.
• There is no evidence to suggest the tinnitus will get
worse.
• Tinnitus does not have to result in a lack of control.
• Patients who can sleep can best manage their tinnitus.
144
Counsel about the following:
•
Tinnitus is real, and not imagined.
• Tinnitus may be permanent.
• Reaction to the tinnitus is the source of the problem.
• Reaction to the symptom is manageable and subject to
modification.
• If significance and threat is removed, habituation or
"gating" of attention can be achieved.
• Stay off the internet!
145
Additional suggestions….
• Ask “what will make this encounter or therapy
successful in your mind?”
• Remember that tinnitus patient management
is a journey, remind patients of the ups and
downs to be expected
• Tell patient that 1st thought upon recognizing
tinnitus should be…..
146
Conclusions
• Tinnitus patients with hearing loss may best
be served by amplification that incorporates
low compression thresholds, a broad
frequency response, and flexible options for
acoustic stimuli
• Tailor the therapy to the patient’s functional
and financial needs
• Sound therapy without counseling is not likely
to work
147
Thanks for listening
[email protected]
148