Cognitive-behavioural treatment for tinnitus: A difficult case

Abstract

Tinnitus is a commonly seen and difficult to cure symptom of ear disease. This case study describes an example of cognitive-behavioural treatment for tinnitus. The patient was a 66-year-old woman with prior medical and psychiatric history. Cognitive-behavioural assessment revealed that her thoughts about the cause of her tinnitus made her focus on it and experience annoyance. The aim of treatment was to decrease the annoyance associated with the tinnitus and consisted of applied relaxation and cognitive distraction techniques. Daily registrations of tinnitus distress and annoyance, and general well-being were collected at pretreatment, mid-treatment and post-treatment on visual analogue scales. No clear effects were found on these measures, although loudness showed a slight tendency to decrease. The patient also completed a questionnaire at pretreatment and post-treatment on which no benefits were found. Verbal report and an in-session behavioural test showed positive effects of treatment, but were not mirrored in the self-reported results. The importance of reporting treatment failures is emphasized.     

Coping and Disputing with Neighbors1

A model based on the disputing process is discussed in the context of annoyances with neighbors. Results of a telephone survey (n= 198) which examined the cognitive and behavioral reactions of respondents to neighbor annoyances are presented. Most respondents handled neighbor annoyances through cognitive coping mechanisms. The intensity of annoyance and the cognitions reported in response to the annoyance, were related to whether respondents actively reacted to the annoyance (complained or disputed).     

"Learning to live with what you can't rise above": control beliefs, symptom control, and adjustment to tinnitus.

The relations between 3 types of perceived control, symptom severity, and 2 adaptational outcomes, depressive symptoms and psychological well-being, were examined in a sample of 319 people with tinnitus. Consistent with previous studies of control and adjustment to chronic health conditions, general health and symptom control were associated with better psychological adjustment, and retrospective control was associated with worse psychological adjustment. Only symptom control emerged as a significant moderator in the symptom severity-adjustment relationship, such that stronger beliefs in one's ability to control symptoms were most strongly associated with better adjustment among those with more severe tinnitus symptoms. These findings were consistent with coping perspectives and cognitive adaptation theory and suggest that symptom-related perceptions of control may be an effective coping resource to nurture in chronic health contexts with severe symptoms.     

Clients’ in-session acceptance and cognitive defusion behaviors in acceptance-based treatment of tinnitus distress

Cognitive-behavioral treatment (CBT) is considered to be an effective treatment of distress associated with tinnitus (perception of internal noises without any outer auditory stimulation), but the processes by which the therapy works remain unclear. Mindfulness and acceptance is receiving increased attention in the treatment literature for chronic medical conditions. However, few studies have examined these and related processes with behavioral or observer measures. In the present study 57 videotapes (a total of 1710 min) from 19 clients who participated in a controlled trial of an acceptance-based treatment for tinnitus distress, were coded for frequency and peak level of verbal behaviors expressing either acceptance or cognitive defusion. Frequency of cognitive defusion behaviors and peak level of cognitive defusion as well as peak level of acceptance rated in Session 2, predicted symptom reduction 6 month following treatment. These relationships were not accounted for by the improvement that had occurred prior to the measurement point of the process variables. Moreover, prior symptom changes could not predict process variables rated later in therapy (after most of the improvement in therapy had occurred). Thus, clients’ in-session acceptance and cognitive defusion behaviors appear to play an important role in the reduction of negative impact of tinnitus.     

Differences in baseline and process variables between non-responders and responders in Internet-based cognitive behavior therapy for chronic tinnitus

Although Internet-based cognitive behavior therapy (iCBT) is an effective treatment for chronic tinnitus, several patients do not improve. In the current study, baseline and process variables were compared between non-responders and responders. Data from patients participating in two randomized controlled trials on iCBT for chronic tinnitus were re-analyzed. Based on the literature, a pre-post difference on the “Tinnitus Handicap Inventory” (THI) of less than seven points improvement was used to operationalize non-response. Associations between non-response and baseline variables (age, gender, and questionnaire scores), patient progress (THI), the process of the therapeutic alliance (“Working Alliance Inventory-Short Revised”; WAI-SR), as well as other process variables (number of logins, amount of messages sent from therapists to patients) were investigated. The results showed that non-responders had a less favorable change on the THI than responders already at mid-treatment (p < .05). The alliance (WAI-SR) during iCBT was not associated with non-response. Non-responders showed more severe sleep disturbances, logged in less in the iCBT platform, and received fewer messages from the therapists than responders, but these differences were mostly not significant anymore when correcting for multiple testing. To conclude, no symptom change in the first half of iCBT for chronic tinnitus patients is a risk factor of not benefiting from iCBT.     

Anxiety Sensitivity in Patients with Chronic Tinnitus

Tinnitus is the perception of sounds (often ringing or buzzing) in the absence of any external auditory stimulation, hence sometimes called a ''phantom auditory perception''. Although most people tend to ignore their tinnitus, a significant proportion will show marked annoyance and reduced quality of life as a result of this complaint. It is difficult to predict those who are likely to develop severe problems with tinnitus, but psychosocial aspects such as anxiety and depression have been proposed as mediators. In this study we investigated the role of anxiety sensitivity defined as a trait tendency to fear anxietyrelated sensations. The study sample included 146 tinnitus patients with moderate to severe tinnitus. Results showed that anxiety sensitivity correlated significantly with tinnitus distress, but the association was significantly stronger in female participants who also displayed more signs of anxiety sensitivity. A multiple regression analysis revealed that anxiety sensitivity contributed to explained variance in tinnitus distress beyond audiological measures of tinnitus maskability and hearing thresholds. These results are discussed in light of related investigations on the role of anxiety sensitivity in somatic conditions.     

Autobiographical Memory in Patients with Tinnitus

Studies on psychiatric patients have found that their memories of the past are often unspecific and overgeneral, but the extent to which this is the case for patients with somatic problems has so far only been examined in patients with chronic pain and in patients with diabetes. The present study investigated autobiographical memories in 19 tinnitus patients and 19 controls without tinnitus. Participants were administered the autobiographical memory test (AMT), the Controlled word association test, and self-report measures of depression, anxiety, and tinnitus distress. Compared to control participants, tinnitus patients had difficulty retrieving specific memories and showed longer retrieval latencies. Additionally, tinnitus patients had fewer specific memories to positive cue words. While AMT responses were associated with depression scores, the difference between controls and patients remained significant for positive cue words after controlling for depression scores. Results suggest that cognitive components should be an integral element of the psychological management of tinnitus. The use in future studies of experimental methods such as AMT in health psychology is encouraged.     

CHRONIC NOISE AND PSYCHOLOGICAL STRESS

Abstract— This article illustrates the value of incorporating psychological principles into the environmental sciences Psycho physiological, cognitive, motivational, and affective indices of chronically exposed to aircraft noise We demonstrate for the first time that chronic noise exposure is associated with elevated neuroendocnne and cardiovascular measures, muted cardiovascular reactivity to a task presented under acute noise, deficits in a standardized reading test administered under quiet conditions, poorer long-term memory, and diminished quality of life on a standardized index Children in high-noise areas also showed evidence of poor persistence on challenging tasks and ambulation to auditory distraction on a signal-to-noise task They reported considerable annoyance with community noise levels, as measured utilizing a calibration procedure that adjusts for individual differences in rating criteria for annoyance judgments     

The Role of Fear-Avoidance Cognitions and Behaviors in Patients with Chronic Tinnitus

The current study investigated the role of fear-avoidance—a concept from chronic pain research—in chronic tinnitus. A self-report measure the “Tinnitus Fear-Avoidance Cognitions and Behaviors Scale (T-FAS)” was developed and validated. Furthermore, the role of fear-avoidance behavior as mediator of the relationship between anxiety sensitivity and tinnitus handicap was investigated. From a clinical setting, N = 373 patients with chronic tinnitus completed questionnaires assessing tinnitus handicap (Tinnitus Handicap Inventory), anxiety, depression (Hospital Anxiety and Depression Scale), anxiety sensitivity (Anxiety Sensitivity Index-3), personality factors (Big Five Inventory-10), and fear-avoidance. To analyze the psychometric properties, principal component analysis with parallel component extraction and correlational analyses were used. To examine a possible mediating effect, hierarchical regression analysis was applied. The principal component analysis resulted in a three-factor solution: Fear-avoidance Cognitions, Tinnitus-related Fear-Avoidance Behavior, and Ear-related Fear-Avoidance Behavior. Internal consistency was satisfactory for the total scale and all subscales. High correlations between tinnitus-related handicap scales, depressive and anxiety symptoms, and the T-FAS were found, whereas associations with personality factors were low. Moreover, results indicate a significant partial mediation of fear-avoidance behaviors in the relationship between anxiety sensitivity and the cognitive dimension of tinnitus handicap. Results show that fear-avoidance behavior plays an important role in tinnitus handicap. More attention should be paid to this concept in research and clinical practice of psychotherapy for chronic tinnitus.     

Headache and sensation seeking

According to the cognitive theory of sensation seeking, headache sufferers were predicted to score lower than controls on Zuckerman's Sensation Seeking Scale. 26 subjects who experienced chronic headaches scored significantly lower than a group of 26 controls. The relationships between the Sensation Seeking Scale and a number of personality tests are described. Replication of the findings on this scale with headache patients is encouraged as well as exploration of other personality dimensions which show significant relations with sensation seeking.     

Musiktherapie bei chronisch-tonalem Tinnitus

Tinnitus therapy according to the Heidelberg model of music therapy integrates psychological strategies in order to manage the perception and approaches to tinnitus aimed at curing the underlying somatic disorder. The specific musical therapeutic interventions as well as the postulated specific effective factors are explained. Several multidisciplinary studies support the effectiveness of this form of therapy. The results indicate that the therapy is highly advantageous in terms of treatment duration, effectiveness, and follow-up stability compared to customary interventions. Furthermore, the results of brain imaging strongly suggest the usefulness of further investigations and discussion in the realm of neuronal modeling of chronic tinnitus.     

The role of optimism in patients with tinnitus and in patients with hearing impairment

Abstract

Optimism was investigated in a sample of audiology clinic patients, consisting of one group of tinnitus sufferers (N = 30) and one group of hearing impaired subjects not experiencing tinnitus (N = 44). Optimism was measured by the Life Orientation Test (LOT). In the tinnitus group the LOT correlated significantly with measures of tinnitus related distress and in the hearing impaired group with measures of disability and emotional reactions due to the hearing impairment. Cronbach's alphas for the measures used were generally high. Principal components analysis of the LOT confirmed earlier findings by showing two separate factors; one with the positively worded LOT items reflecting the presence of optimism and one with the negatively worded LOT items reflecting the presence of pessimism. The results indicate that dispositional optimism is an usable concept in research with audiological samples, and that optimism is related with tinnitus distress and experienced disability and emotional reactions due to hearing impairment. Further research should investigate the possible role of personality factors in tinnitus and hearing impairment.     

Comparing the role of psychological flexibility and traditional pain management coping strategies in chronic pain treatment outcomes

Psychologically-based interventions for chronic pain traditionally include a mix of methods, including physical conditioning, training in relaxation or attention control, strategies to decrease irrational or dysfunctional thinking patterns, and activity management training. Recent developments suggest additional methods to promote acceptance, mindfulness, values-based action, and cognitive defusion (a cognitive process entailing change in the influences exerted by thoughts without necessarily changing their form or frequency). Collectively, these processes entail what is referred to as psychological flexibility. This study examined how changes in traditionally conceived methods of coping compare to changes in psychological flexibility in relation to improvements in functioning over the course of an interdisciplinary treatment program. Participants were 114 chronic pain sufferers. Results indicated that changes in the traditionally conceived methods were essentially unrelated to treatment improvements, while changes in psychological flexibility were consistently and significantly related to these improvements. We suggest that psychological flexibility appears highly relevant to the study of chronic pain and to future treatment developments. The utility of more traditionally conceived pain management strategies, on the other hand, may require a reappraisal.     

The evolution of chronic back pain problems: a longitudinal study.

A longitudinal evaluation of the recovery from an acute back pain episode was undertaken on 117 sufferers, with assessments at the onset, 3 and 6 months. The number of individuals still reporting pain at 6 months, and therefore qualifying for 'chronic pain', was considerably higher than expected (40%). At 6 months, the persisting pain problems were found to be moderate to severe in intensity in approx. 20% of cases. Despite the pain, the chronic sufferers showed gradual continuing adjustments to it, re-establishing activities despite pain. Most of the change in the pain components (cognitive, subjective, behavioral, depression, anxiety) occur in the first 3 months, after which considerable stability is evident in the residual problem. In contrast, the impact of the pain and the consequent disability decline more markedly and continue to do so right up to the 6 month point. There was no evidence of chronic pain evolving and growing, but rather of a persistence of the acute presentation.     

Multisensory Assessment of Acoustic Comfort Aboard Metros: a Virtual Reality Study

In this study, a multisensory methodology is used to assess acoustic comfort aboard different real‐world metros by means of subjective annoyance and cognitive performance measures. Two experimental conditions were compared: unimodal versus bimodal. Immersive virtual reality was used to simulate journeys aboard metro coaches. Participants performed four tasks (Rey Test, Verbal Fluency, Backward Counting and Auditory Words Discrimination) while listening to metro sounds (unimodal condition) or while listening to metro sounds within a virtual metro coach (bimodal condition). At the end of each journey, participants reported their degree of noise annoyance. The results showed that cognitive performances were worse in the bimodal than in the unimodal condition. Moreover, the bimodal condition affected negatively the capacity to discriminate words and to count backward. However, reported noise annoyance was higher in the unimodal than bimodal condition. The theoretical and practical implications of these findings are discussed. Copyright © 2012 John Wiley & Sons, Ltd.     

Stroop facilitation in tinnitus patients: an experiment conducted via the world wide web.

Cognitive mechanisms have been proposed to play an important role in tinnitus. In the present study, tinnitus participants were administered an emotional Stroop test via the Internet, incorporating words related to tinnitus concerns. In line with previous research using this Web-based version of the emotional Stroop test, faster color naming was demonstrated for concern-relevant words relative to neutral words. The present results thus provided support for a role for cognitive factors that are important for the understanding of tinnitus. However, future research is warranted in order to clarify the precise mechanisms involved in tinnitusrelated Stroop effects.     

Tinnitus und das Leiden am Tinnitus

Psychosomatic findings from 287 patients with tinnitus are presented in this article, who were seen by medical psychotherapists specialized in ENT for a period of 15 months. They were assigned to all of the therapeutic methods being offered. As relevant proved to be the neurootological professional competence, especially for recognizing and treating auditory limitations (in 41% of the patients) as well as noticing and treating the psychological comorbidity (in 45.3% of the patients). While neurophysiological and psychophysiological models interpret the subjective tinnitus stress as the failing of habituation, dysfunctional attention processes and assessments, from a psychodynamic view a symptom having pathological significance, such as the suffering from tinnitus (not the tinnitus itself) may develop if the defensive mechanisms are exhausted, a conflict cannot be resolved on the conscious level or traumatic experiences were made. It is recommended that an approach specifically matched with the disturbance is made taking into account both possible psychodynamic causes and sustaining factors in the cognitive behavioral sense, all on an audiologic background.     

Individual reactions to a multisensory immersive virtual environment: the impact of a wind farm on individuals

The aim of this study was to assess the impact of a wind farm on individuals by means of an audio-visual methodology that tried to simulate biologically plausible individual-environment interactions. To disentangle the effects of auditory and visual components on cognitive performances and subjective evaluations, unimodal (Audio or Video) and bimodal (Audio + Video) approaches were compared. Participants were assigned to three experimental conditions that reproduced a wind farm by means of an immersive virtual reality system: bimodal condition, reproducing scenarios with both acoustic and visual stimuli; unimodal visual condition, with only visual stimuli; unimodal auditory condition, with only auditory stimuli. While immersed in the virtual scenarios, participants performed tasks assessing verbal fluency, short-term verbal memory, backward counting, and distance estimations (egocentric: how far is the turbine from you?; allocentric: how far is the turbine from the target?). Afterwards, participants reported their degree of visual and noise annoyance. The results revealed that the presence of a visual scenario as compared to the only availability of auditory stimuli may exert a negative effect on resource-demanding cognitive tasks but a positive effect on perceived noise annoyance. This supports the idea that humans perceive the environment holistically and that auditory and visual features are processed in close interaction.     

Distinguishing obsessive features and worries: the role of thought-action fusion

Obsessions are a key feature of obsessive-compulsive disorder (OCD), and chronic worry is the cardinal feature of generalized anxiety disorder (GAD). However, these two cognitive processes are conceptually very similar, and there is a need to determine how they differ. Recent studies have attempted to identify cognitive processes that may be differentially related to obsessive features and worry. In the current study we proposed that (1) obsessive features and worry could be differentiated and that (2) a measure of the cognitive process thought-action fusion would distinguish between obsessive features and worry, being strongly related to obsessive features after controlling for the effects of worry. These hypotheses were supported in a sample of 173 undergraduate students. Thought-action fusion may be a valuable construct in differentiating between obsessive features and worry.     

An Evaluation of Two Types of Cognitive Intervention in the Management of Chronic Tinnitus

Abstract

Fifty-four subjects with chronic distressing tinnitus were randomly allocated to one of four experimental treatment conditions: (1) attention control and imagery training (AC1); (2) cognitive restructuring (CR); (3) combined attention control and imagery training plus cognitive restructuring (ACI + CR); and (4) a waiting list control (WLC). Significant overall improvements were found on measures of distress associated with tinnitus, and on a number of other measures of cognition and coping strategies. These improvements were maintained at the six-month follow-up. Relative to the WLC, the three treatment conditions (combined) were associated with improvements in tinnitus-related distress, reductions in tinnitus-related dysfunctional cognitions and an increase in the frequency of use of coping strategies. There was a significant effect in favour of the ACI group compared to the CR group on the measure of irrational beliefs. The analyses also revealed that the combined treatment condition (ACI + CR) showed significantly greater improvement on a measure of psychological distress and achieved a higher clinical response rate compared to the two single treatments. There were significant improvements from pretreatment to follow-up on some measures, although the mean scores revealed that some of the gains had been lost at this stage on the main measure of tinnitus-related distress. There were no significant group X time effects for any of the dependent variables at the six-month follow-up. The results were interpreted as supporting the practice of combining the two cognitive approaches.