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Tinnitus Patient Management Robert W. Sweetow, Ph.D. University of California, San Francisco San Francisco, California [email protected] 1 Agenda • Tinnitus (in general) • Available treatments – Acoustic therapies – Counseling • • • • • Limitations Integrated Approach Cognitive Behavioral Intervention Amplification and Zen Relaxation exercises and sleep management 2 Why treat tinnitus patients? • • • • 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) 3 Famous People with Tinnitus 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 Peter Frampton Leonard Nimoy Willie Mays David Letterman Ronald Reagan Bill Clinton William Shatner Huey Lewis Pete Townsend will. i. am 4 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 5 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 6 Lack of correlation between tinnitus severity and auditory threshold Tinnitus symptom severity and best hearing threshold Best hearing threshold at FREQmax 80 70 60 50 40 30 20 10 0 0 20 40 60 80 100 120 Tinnitus Handicap Inventory Score Tsai, Cheung, and Sweetow, Laryngoscope, 7 2012 Correlation between tinnitus loudness SL and subjective loudness Bauer, 2009 8 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) 9 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) 10 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 12 Tinnitus and Emotional Processing • • • • • • 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 13 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 14 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 15 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 16 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 17 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 18 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 o o Auditory-Striatal-Limbic Connectivity Disrupt Information Conveyance Avoid Interference with Audition Examples Striatal Neuromodulation o Vagal nerve stimulation o Cortical Stimulation (rTMS) 19 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 20 Caffeine reduces likelihood of tinnitus by 15% • Brigham and Women’s Hospital, Curhan, et al; American Journal of Medicine, 2014 21 Tinnitus Retraining Therapy • directive counseling • auditory (low level noise) therapy 22 Basic assumptions The brain can sort out meaningful stimuli from those which are not • Attention is directed toward "salient" or information-bearing stimuli • 23 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. 24 Examples of normal habituation • • • • Ring on your finger Clothing Refrigerator humming Rear end (buttocks) in your chair 25 The Limbic System 26 How sensory systems suppress stimuli • Somatosensory • Auditory • How brain (limbic system) determines importance of external stimuli – Thunder versus soft, unexpected sound 27 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 28 Current sound treatments • • • • • • • 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 29 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 31 Methodological risk of bias criteria of randomized controlled trials for the sound technology interventions * * * * * Evaluation and Treatment of Tinnitus: A Comparative Effectiveness Review; Pichora-Fuller, et al, in press 32 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) 33 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. 34 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 35 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? • • • • • • Complete masking Partial masking Mix Habituate Distract Suppress 37 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 38 Issues relating to sound therapy • • • • Mixing point Spectral characteristics Dynamic characteristics Temporal factors • Amplification characteristics – Kneepoint – Bandwidth – Verification 39 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 40 A perfect example of an auditory disorder closely related to stress: Tinnitus The Vicious Cycle 41 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? 42 • 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. 43 Where is music processed? Frontal Lobe 44 How is music used? • • • • • • • • • • • Home Work Celebrations Advertising Romance Movies Athletic locker rooms Shopping malls Hospitals Therapies Relaxation 45 Modes of Delivery • • • • Home stereo iPod Neuromonics Hearing aids 46 “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 47 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 48 Music suggestions • • • • 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. 49 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? 50 Earworms • • 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." • Top 10 earworm list: • • • • • • • • • 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 51 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 52 An Integrated Approach to Tinnitus Management 53 Tinnitus Management Team • • • • • • • • • • Audiologist Otolaryngologist Psychologist Psychiatrist Neurologist Pharmacologist Nutritionist TMJ Specialist Physical Therapist Biofeedback Specialist 54 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 55 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. 56 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 • • • • • • 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 58 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. 59 60 61 Tinnitus Questionnaire • • • • • • • • Otologic Medical Audiologic Diet Exercise Emotional Pattern Sleep Previous Treatments 62 Potentially useful diagnostic procedures • • • • • • • • • 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 63 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. 64 Tinnitus triggers • Physical (viral, medication, hearing loss (imbalance between excitatory and inhibitory neurons), neurotoxicity from noise, somatic influences) • psychological • retirement syndrome • stress related 65 Defining the tinnitus problem • • • • time behaviors affected attitudes and thoughts what affects the tinnitus? 66 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. 67 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 71 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 72 Counseling • Instructional • Adjustment-based 73 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. 74 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. 75 Most reactions are learned processes • Subject to behavioral and cognitive modifications 76 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 78 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