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Cognitive behavioural therapy for tinnitus: Protocols
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects and safety of CBT for tinnitus in adults. © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
... Although, there is an existing Cochrane review (Martinez-Devesa et al. 2010) it is now outdated and does not include all cognitive, and/ or behavioural interventions (Acceptance and Commitment Therapy (ACT) and Mindfulness-based therapies, described as different "waves" of CBT). A Cochrane review examining all cognitive and behavioural approaches for tinnitus is currently ongoing (Fuller et al. 2017a). ...
... The scoping exercise described here has already resulted in the expedited production of two Cochrane systematic reviews (Sereda et al. 2018;Wegner et al. 2018) in part to inform the NICE guideline on tinnitus which is currently under development. A further three priority reviews are currently in progress (Fuller et al. 2017a;Hoare et al. 2015;Sereda et al., 2019). ...
Objective: To develop an innovative prioritisation process to identify topics for new or updated systematic reviews of tinnitus research.
Design: A two-stage prioritisation process was devised. First, a scoping review assessed the amount of randomized controlled trial-level evidence available. This enabled development of selection criteria for future reviews, aided the design of template protocol and suggested the scale of work that would be required to conduct these reviews. Second, using the pre-defined primary and secondary criteria, interventions were prioritised for systematic review.
Study sample: Searches identified 1080 records. After removal of duplicates and out of scope works, 437 records remained for full data charting.
Results: The process was tested, using subjective tinnitus as the clinical condition and using Cochrane as the systematic review platform. The criteria produced by this process identified three high priority reviews: (1) Sound therapy using amplification devices and/or sound generators; (2) Betahistine and (3) Cognitive behaviour therapy. Further secondary priorities were: (4) Gingko biloba, (5) Anxiolytics, (6) Hypnotics, (7) Antiepileptics and (8) Neuromodulation.
Conclusions: A process was developed which successfully identified priority areas for Cochrane systematic reviews of interventions for subjective tinnitus. This technique could easily be transferred to other conditions and other types of systematic reviews.
... Cognitive behavioral therapy, recommended in the American tinnitus guidelines, has shown positive therapeutic effects in terms of improving quality of life and reducing the adverse effects of tinnitus. However, its effectiveness may be limited in cases of severe or prolonged tinnitus 7 . Sound therapy, assessed through subjective evaluations, has demonstrated effectiveness in tinnitus management. ...
Idiopathic tinnitus is a common and complex disorder with no established cure. The CAABT (Cochleural Alternating Acoustic Beam Therapy CAABT), is a personalized sound therapy designed to target specific tinnitus frequencies and effectively intervene in tinnitus according to clinical tinnitus assessment. This study aimed to compare the effectiveness of the CAABT and Traditional Sound Therapy (TST) in managing chronic idiopathic tinnitus. This was a randomized, double-blind, parallel-group, single-center prospective study. Sixty adult patients with tinnitus were recruited and randomly assigned to the CAABT or TST group in a 1:1 ratio using a computer-generated randomization. The treatment lasted for 12 weeks, and participants underwent assessments using the tinnitus handicap inventory (THI), visual analog scale (VAS), tinnitus loudness measurements, and resting-state functional magnetic resonance imaging (rs-fMRI). Both groups showed significant reductions in THI scores, VAS scores, and tinnitus loudness after treatment. However, CAABT showed superiority to TST in THI Functional (p = 0.018), THI Emotional (p = 0.015), THI Catastrophic (p = 0.022), THI total score (p = 0.005) as well as VAS score (p = 0.022). More interesting, CAABT showed superiority to TST in the changes of THI scores, and VAS scores from baseline. The rs-fMRI results showed significant changes in the precuneus before and after treatment in both groups. Moreover, the CAABT group showed more changes in brain regions compared to the TST. No side effects were observed. These findings suggest that CAABT may be a promising treatment option for chronic idiopathic tinnitus, providing significant improvements in tinnitus-related symptoms and brain activity.
Trial registration: ClinicalTrials.gov:NCT02774122.
... On average, each phenotype showed mainly improved variables scores after the multimodal treatment program that aimed to relieve distress attributed to chronic tinnitus, confirming the effectiveness of psychologically anchored approaches as gold standard for alleviating tinnitus-related distress 5,31 . The findings both confirm and expand previous findings on the effectiveness of the here-investigated intensive, multimodal seven-day program. ...
The clinical heterogeneity of chronic tinnitus poses major challenges to patient management and prompts the identification of distinct patient subgroups (or phenotypes) that respond more predictable to a particular treatment. We model heterogeneity in treatment response among phenotypes of tinnitus patients concerning their change in self-reported health burden, psychological characteristics, and tinnitus characteristics. Before and after a 7-day multimodal treatment, 989 tinnitus patients completed 14 assessment questionnaires, from which 64 variables measured general tinnitus characteristics, quality of life, pain experiences, somatic expressions, affective symptoms, tinnitus-related distress, internal resources, and perceived stress. Our approach encompasses mechanisms for patient phenotyping, visualizations of the phenotypes and their change with treatment in a projected space, and the extraction of patient subgroups based on their change with treatment. On average, all four distinct phenotypes identified at the pre-intervention baseline showed improved values for nearly all the considered variables following the intervention. However, a considerable intra-phenotype heterogeneity was noted. Five clusters of change reflected variations in the observed improvements among individuals. These patterns of treatment effects were identified to be associated with baseline phenotypes. Our exploratory approach establishes a groundwork for future studies incorporating control groups to pinpoint patient subgroups that are more likely to benefit from specific treatments. This strategy not only has the potential to advance personalized medicine but can also be extended to a broader spectrum of patients with various chronic conditions.
... The European tinnitus guideline recommends Cognitive Behavioral Therapy (CBT) or sound therapies. However, many more treatment options are available, such as but not limited to, pharmacological therapy, Transcranial Magnetic Stimulation (TMS) and complementary therapies (1,3). ...
Introduction: The therapeutic rationale varies among tinnitus therapies. A recent study identified which outcome measures should be used for different types of interventions. What patients consider the most important outcome measure in tinnitus therapy is unclear.
Objectives: To study the preference of the tinnitus patient for different outcome measures in tinnitus therapy.
Methods: A discrete choice experiment was conducted. Participants were provided with two alternatives per choice set (nine choice sets total). Each choice-set consisted of four attributes (tinnitus loudness, tinnitus acceptance, quality of sleep and concentration). With a difference in one of three levels (increased, similar or decreased after treatment) between the alternatives. Results were analyzed with a mixed logit model. Preference heterogeneity was explored with covariates, correlating attributes and a latent class analysis.
Results: One hundred and twenty-seven participants took part. In the mixed logit models we found that the choice for a tinnitus therapy was significantly affected by all levels of the outcomes, except for a similar level in concentration and tinnitus acceptance. Tinnitus loudness was considered the most important outcome measure relative to the other attributes. Preference heterogeneity was not explained by correlating attributes. The latent class analysis identified two classes. The first class was similar to the mixed logit analysis, except for a non-significance of similar quality of sleep and tinnitus acceptance. The second class showed a statistical significant preference only for increased tinnitus acceptance and similar quality of sleep.
Conclusion: Based on this study, tinnitus patients consider loudness the most important outcome measure. However, there is a variance in preference as indicated by the latent class analysis. This study underlines the importance of research into tinnitus heterogeneity. Next, this study highlights the need for research into tinnitus therapies that focus on diminishing tinnitus loudness.
... Prosocial behavior is supposed to be a by-product of individual counseling to young people because of the potency of individual counseling and the amenability of prosocial behavior. Individual counseling can be influential in many ways and can operate in many modes, such as behaviorist, cognitive-behavioral, cognitivist, emotion-focused, humanistic, psychoanalytic, and rationalemotive-behavioral modes (Fall et al., 2004;Gray, 2000;Izzard, 2000;Wampold, 2007). The behaviorist mode includes therapeutic strategies such as reinforcement, modeling, diversion, and desensitization. ...
Promoting the prosocial behavior of young people is desirable. The individual counseling sessions held in schools and in youth centers can effectively promote prosocial behavior among the youth. Given the lack of relevant research on this topic, this study aims to examine how individual counseling in a natural setting contributes to the formation of prosocial behavior among the youth after four and ten months. Data from 1735 and 1490 young people came from a two-wave panel survey. The individual counseling sessions held in both schools and youth centers demonstrated significant positive effects on the prosocial behavior of young people after four and ten months. However, such an effect was weaker on those young people recruited from youth centers. These results indicate that the contributions of individual counseling are both generic and attenuated because of the abundance of functions provided in youth centers.
Tinnitus is a heterogeneous condition not only in terms of nature of the sound, but also in co-morbidities such as mental health issues. Prevalence number range widely between 5 and 43%. Even though the etiologic pathway between tinnitus and its comorbidities remains unclear, in this study we aim to assess whether people with tinnitus use more primary health care than people without tinnitus. To compare primary healthcare consumption between patients with tinnitus and people without tinnitus. In this cross-sectional study, data on number of consultations with the general practitioner or nurse practitioner mental health services were obtained from Nivel (Netherlands Institute for Health Service Research) Primary Care Database in 2018 (n = 963,880 people). People with an open tinnitus episode (n = 8050) were defined as a patient with tinnitus and compared to all other people. Percentages, means, ranges and mean differences were calculated for the total number of consultations and for organ specific diagnoses registered as ICPC-1 code on the day of consultation. Secondary, the total number of referrals to medical specialists and number of drug prescriptions was collected. Logistic regressions were performed to predict having one or more contacts, referrals, and prescriptions,with having tinnitus, this was corrected for age and gender. Patients with tinnitus had a mean of 9.8 (SD 10.9) primary care consultations in 2018, compared to 5.7 (SD 7.9) for people without tinnitus. More patients with tinnitus had more than one referral to medical specialists (47%) compared to people without tinnitus (25%). Patients with tinnitus have 1.2 (mean difference) more drug prescriptions than people without tinnitus. Compared to people without tinnitus, patients with tinnitus were more likely to have one or more of primary healthcare contact, independent of age group and gender. Patients with tinnitus had more consultations in primary health care than people without tinnitus. They are more often referred to medical specialists and receive more drug prescriptions. The causal relationship between tinnitus and the higher healthcare consumption remains to be researched.
Background:
Tinnitus affects up to 21% of the adult population with an estimated 1% to 3% experiencing severe problems. Cognitive behavioural therapy (CBT) is a collection of psychological treatments based on the cognitive and behavioural traditions in psychology and often used to treat people suffering from tinnitus.
Objectives:
To assess the effects and safety of CBT for tinnitus in adults.
Search methods:
The Cochrane ENT Information Specialist searched the ENT Trials Register; CENTRAL (2019, Issue 11); Ovid MEDLINE; Ovid Embase; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 November 2019.
Selection criteria:
Randomised controlled trials (RCTs) of CBT versus no intervention, audiological care, tinnitus retraining therapy or any other active treatment in adult participants with tinnitus.
Data collection and analysis:
We used the standard methodological procedures expected by Cochrane. Our primary outcomes were the impact of tinnitus on disease-specific quality of life and serious adverse effects. Our secondary outcomes were: depression, anxiety, general health-related quality of life, negatively biased interpretations of tinnitus and other adverse effects. We used GRADE to assess the certainty of evidence for each outcome.
Main results:
We included 28 studies (mostly from Europe) with a total of 2733 participants. All participants had had tinnitus for at least three months and their average age ranged from 43 to 70 years. The duration of the CBT ranged from 3 to 22 weeks and it was mostly conducted in hospitals or online. There were four comparisons and we were interested in outcomes at end of treatment, and 6 and 12 months follow-up. The results below only refer to outcomes at end of treatment due to an absence of evidence at the other follow-up time points. CBT versus no intervention/wait list control Fourteen studies compared CBT with no intervention/wait list control. For the primary outcome, CBT may reduce the impact of tinnitus on quality of life at treatment end (standardised mean difference (SMD) -0.56, 95% confidence interval (CI) -0.83 to -0.30; 10 studies; 537 participants; low certainty). Re-expressed as a score on the Tinnitus Handicap Inventory (THI; range 0 to 100) this is equivalent to a score 10.91 points lower in the CBT group, with an estimated minimal clinically important difference (MCID) for this scale being 7 points. Seven studies, rated as moderate certainty, either reported or informed us via personal communication about serious adverse effects. CBT probably results in little or no difference in adverse effects: six studies reported none and in one study one participant in the CBT condition worsened (risk ratio (RR) 3.00, 95% CI 0.13 to 69.87). For the secondary outcomes, CBT may result in a slight reduction in depression (SMD -0.34, 95% CI-0.60 to -0.08; 8 studies; 502 participants; low certainty). However, we are uncertain whether CBT reduces anxiety, improves health-related quality of life or reduces negatively biased interpretations of tinnitus (all very low certainty). From seven studies, no other adverse effects were reported (moderate certainty). CBT versus audiological care Three studies compared CBT with audiological care. CBT probably reduces the impact of tinnitus on quality of life when compared with audiological care as measured by the THI (range 0 to 100; mean difference (MD) -5.65, 95% CI -9.79 to -1.50; 3 studies; 444 participants) (moderate certainty; MCID = 7 points). No serious adverse effects occurred in the two included studies reporting these, thus risk ratios were not calculated (moderate certainty). The evidence suggests that CBT may slightly reduce depression but may result in little or no difference in anxiety or health-related quality of life (all low certainty) when compared with audiological care. CBT may reduce negatively biased interpretations of tinnitus when compared with audiological care (low certainty). No other adverse effects were reported for either group (moderate certainty). CBT versus tinnitus retraining therapy (TRT) One study compared CBT with TRT (including bilateral sound generators as per TRT protocol). CBT may reduce the impact of tinnitus on quality of life as measured by the THI when compared with TRT (range 0 to 100) (MD -15.79, 95% CI -27.91 to -3.67; 1 study; 42 participants; low certainty). For serious adverse effects three participants deteriorated during the study: one in the CBT (n = 22) and two in the TRT group (n = 20) (RR 0.45, 95% CI 0.04 to 4.64; low certainty). We are uncertain whether CBT reduces depression and anxiety or improves health-related quality of life (low certainty). CBT may reduce negatively biased interpretations of tinnitus. No data were available for other adverse effects. CBT versus other active control Sixteen studies compared CBT with another active control (e.g. relaxation, information, Internet-based discussion forums). CBT may reduce the impact of tinnitus on quality of life when compared with other active treatments (SMD -0.30, 95% CI -0.55 to -0.05; 12 studies; 966 participants; low certainty). Re-expressed as a THI score this is equivalent to 5.84 points lower in the CBT group than the other active control group (MCID = 7 points). One study reported that three participants deteriorated: one in the CBT and two in the information only group (RR 1.70, 95% CI 0.16 to 18.36; low certainty). CBT may reduce depression and anxiety (both low certainty). We are uncertain whether CBT improves health-related quality of life compared with other control. CBT probably reduces negatively biased interpretations of tinnitus compared with other treatments. No data were available for other adverse effects.
Authors' conclusions:
CBT may be effective in reducing the negative impact that tinnitus can have on quality of life. There is, however, an absence of evidence at 6 or 12 months follow-up. There is also some evidence that adverse effects may be rare in adults with tinnitus receiving CBT, but this could be further investigated. CBT for tinnitus may have small additional benefit in reducing symptoms of depression although uncertainty remains due to concerns about the quality of the evidence. Overall, there is limited evidence for CBT for tinnitus improving anxiety, health-related quality of life or negatively biased interpretations of tinnitus.
Objective:
To evaluate the efficacy of cognitive and/or behavioral therapies in improving health-related quality of life (HRQOL), depression, and anxiety associated with tinnitus.
Data sources:
EMBASE, MEDLINE, PubMed, PsycINFO, and the Cochrane Registry were used to identify English studies from database inception until February 2018.
Study selection:
Randomized controlled trials (RCTs) comparing cognitive and/or behavioral therapies to one another or to waitlist controls for the treatment of tinnitus were included.
Data extraction:
Quality and risk were assessed using GRADE and Cochrane's Risk of Bias tool respectively.
Data synthesis:
Pairwise meta-analysis (12 RCTs: 1,144 patients) compared psychological interventions to waitlist controls. Outcomes were measured using standardized mean differences (SMDs) and 95% confidence intervals (CI). I and subgroup analyses were used to assess heterogeneity. Network meta-analysis (NMA) (19 RCTS: 1,543 patients) compared psychological therapies head-to-head. Treatment effects were presented by network diagrams, interval plots, and ranking diagrams indicating SMDs with 95% CI. Direct and indirect results were further assessed by inconsistency plots.
Conclusions:
Results are consistent with previously published guidelines indicating that CBT is an effective therapy for tinnitus. While guided self-administered forms of CBT had larger effect sizes (SMD: 3.44; 95% CI: -0.022, 7.09; I: 99%) on tinnitus HRQOL, only face-to-face CBT was shown to make statistically significant improvements (SMD: 0.75; 95% CI: 0.53, 0.97; I: 0%). Guided self-administered CBT had the highest likelihood of being ranked first in improving tinnitus HRQOL (75%), depression (83%), and anxiety (87%), though statistically insignificant. This NMA is the first of its kind in this therapeutic area and provides new insights on the effects of different forms of cognitive and/or behavioral therapies for tinnitus.
Purpose
The selection and design of control conditions are critical factors in minimizing the influence of unwanted variables in randomized controlled trials (RCTs). This article describes the rationale, design, and content of a standard of care control condition in a Phase III RCT of tinnitus retraining therapy.
Method
Existing tinnitus practices at military hospitals were identified and aligned with the American Speech-Language-Hearing Association's (2006) preferred practice patterns for tinnitus management and counseling and embedded in a patient-centered protocol to ensure uniformity and treatment fidelity.
Results
For those involved in the design of behavioral RCTs, the article identifies options and methods to consider in the selection and design of control conditions.
Conclusion
For those who provide tinnitus services, the standard of care protocol developed for the tinnitus retraining therapy trial constitutes a patient-centered approach to intervention that can be implemented clinically.
Supplemental Material
https://doi.org/10.23641/asha.9342503
Background: Though clinical guidelines for assessment and treatment of chronic subjective tinnitus do exist, a comprehensive review of those guidelines has not been performed. The objective of this review was to identify current clinical guidelines, and compare their recommendations for the assessment and treatment of subjective tinnitus in adults.
Method: We systematically searched a range of sources for clinical guidelines (as defined by the Institute of Medicine, United States) for the assessment and/or treatment of subjective tinnitus in adults. No restrictions on language or year of publication were applied to guidelines.
Results: Clinical guidelines from Denmark, Germany, Sweden, The Netherlands, and the United States were included in the review. There was a high level of consistency across the guidelines with regard to recommendations for audiometric assessment, physical examination, use of a validated questionnaire(s) to assess tinnitus related distress, and referral to a psychologist when required. Cognitive behavioral treatment for tinnitus related distress, use of hearing aids in instances of hearing loss and recommendations against the use of medicines were consistent across the included guidelines. Differences between the guidelines centered on the use of imaging in assessment procedures and sound therapy as a form of treatment for tinnitus distress respectively.
Conclusion: Given the level of commonality across tinnitus guidelines from different countries the development of a European guideline for the assessment and treatment of subjective tinnitus in adults seems feasible. This guideline would have the potential to benefit the large number of clinicians in countries where clinical guidelines do not yet exist, and would support standardization of treatment for patients across Europe.
Background: Tinnitus is associated with depression and anxiety disorders, severely and adversely affecting the quality of life and functional health status for some people. With the dearth of clinical psychologists embedded in audiology services and the cessation of training for hearing therapists in the UK, it is left to audiologists to meet the psychological needs of many patients with tinnitus. However, there is no universally standardized training or manualized intervention specifically for audiologists across the whole UK public healthcare system and similar systems elsewhere across the world.
Objectives: The primary aim of this scoping review was to catalog the components of psychological therapies for people with tinnitus, which have been used or tested by psychologists, so that they might inform the development of a standardized audiologist-delivered psychological intervention. Secondary aims of this article were to identify the types of psychological therapy for people with tinnitus, who were reported but not tested in any clinical trial, as well as the job roles of clinicians who delivered psychological therapy for people with tinnitus in the literature.
Design: The authors searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; Cochrane Central Register of Controlled Trials; PubMed; EMBASE; CINAHL; LILACS; KoreaMed; IndMed; PakMediNet; CAB Abstracts; Web of Science; BIOSIS Previews; ISRCTN; ClinicalTrials.gov; IC-TRP; and Google Scholar. In addition, the authors searched the gray literature including conference abstracts, dissertations, and editorials. No records were excluded on the basis of controls used, outcomes reached, timing, setting, or study design (except for reviews-of the search results. Records were included in which a psychological therapy intervention was reported to address adults (<=18 years) tinnitus-related distress. No restrictive criteria were placed upon the term tinnitus. Records were excluded in which the intervention included biofeedback, habituation, hypnosis, or relaxation as necessary parts of the treatment.
Results: A total of 5043 records were retrieved of which 64 were retained. Twenty-five themes of components that have been included within a psychological therapy were identified, including tinnitus education, psychoeducation, evaluation treatment rationale, treatment planning, problem-solving behavioral intervention, thought identification, thought challenging, worry time, emotions, social comparison, interpersonal skills, self-concept, lifestyle advice, acceptance and defusion, mindfulness, attention, relaxation, sleep, sound enrichment, comorbidity, treatment reflection, relapse prevention, and common therapeutic skills. The most frequently reported psychological therapies were cognitive behavioral therapy, tinnitus education, and internet-delivered cognitive behavioral therapy. No records reported that an audiologist delivered any of these psychological therapies in the context of an empirical trial in which their role was clearly delineated from that of other clinicians.
Conclusions: Scoping review methodology does not attempt to appraise the quality of evidence or synthesize the included records. Further research should therefore determine the relative importance of these different components of psychological therapies from the perspective of the patient and the clinician.
Background
There is no evidence-based guidance to facilitate design decisions for confirmatory trials or systematic reviews investigating treatment efficacy for adults with tinnitus. This systematic review therefore seeks to ascertain the current status of trial designs by identifying and evaluating the reporting of outcome domains and instruments in the treatment of adults with tinnitus. Methods
Records were identified by searching PubMed, EMBASE CINAHL, EBSCO, and CENTRAL clinical trial registries (ClinicalTrials.gov, ISRCTN, ICTRP) and the Cochrane Database of Systematic Reviews. Eligible records were those published from 1 July 2006 to 12 March 2015. Included studies were those reporting adults aged 18 years or older who reported tinnitus as a primary complaint, and who were enrolled into a randomised controlled trial, a before and after study, a non-randomised controlled trial, a case-controlled study or a cohort study, and written in English. Studies with fewer than 20 participants were excluded. ResultsTwo hundred and twenty-eight studies were included. Thirty-five different primary outcome domains were identified spanning seven categories (tinnitus percept, impact of tinnitus, co-occurring complaints, quality of life, body structures and function, treatment-related outcomes and unclear or not specified). Over half the studies (55 %) did not clearly define the complaint of interest. Tinnitus loudness was the domain most often reported (14 %), followed by tinnitus distress (7 %). Seventy-eight different primary outcome instruments were identified. Instruments assessing multiple attributes of the impact of tinnitus were most common (34 %). Overall, 24 different patient-reported tools were used, predominantly the Tinnitus Handicap Inventory (15 %). Loudness was measured in diverse ways including a numerical rating scale (8 %), loudness matching (4 %), minimum masking level (1 %) and loudness discomfort level (1 %). Ten percent of studies did not clearly report the instrument used. Conclusions
Our findings indicate poor appreciation of the basic principles of good trial design, particularly the importance of specifying what aspect of therapeutic benefit is the main outcome. No single outcome was reported in all studies and there was a broad diversity of outcome instruments. PROSPERO registrationThe systematic review protocol is registered on PROSPERO (International Prospective Register of Systematic Reviews): CRD42015017525. Registered on 12 March 2015 revised on 15 March 2016.
To measure tinnitus induced by sodium salicylate injections, 84 rats were used in a conditioned suppression paradigm. In Exp 1, Ss were trained with a conditioned stimulus/stimuli (CS) consisting of the offset of a continuous background noise. One group began salicylate injections before Pavlovian training, a 2nd group started injections after training, and a control group received daily saline injections. Resistance to extinction was profound when injections started before training but minimal when initiated after training, suggesting that salicylate-induced effects acquired differential conditioned value. In Exp 2, salicylate treatments were mimicked by substituting a 7 kHz tone in place of respective injections, resulting in effects equivalent to salicylate-induced behavior. A 3rd experiment included a 3 kHz CS, and again replicated the salicylate findings. In Exp 4, we decreased the motivational level, and the sequential relation between salicylate-induced effects and suppression training was retained. Findings support the demonstration of phantom auditory sensations in animals. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Tinnitus is a phantom auditory sensation that reduces quality of life for millions of people worldwide, and for which there is no medical cure. Most cases of tinnitus are associated with hearing loss caused by ageing or noise exposure. Exposure to loud recreational sound is common among the young, and this group are at increasing risk of developing tinnitus. Head or neck injuries can also trigger the development of tinnitus, as altered somatosensory input can affect auditory pathways and lead to tinnitus or modulate its intensity. Emotional and attentional state could be involved in the development and maintenance of tinnitus via top-down mechanisms. Thus, military personnel in combat are particularly at risk owing to combined risk factors (hearing loss, somatosensory system disturbances and emotional stress). Animal model studies have identified tinnitus-associated neural changes that commence at the cochlear nucleus and extend to the auditory cortex and other brain regions. Maladaptive neural plasticity seems to underlie these changes: it results in increased spontaneous firing rates and synchrony among neurons in central auditory structures, possibly generating the phantom percept. This Review highlights the links between animal and human studies, and discusses several therapeutic approaches that have been developed to target the neuroplastic changes underlying tinnitus.
Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field [1],[2], and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research [3], and some health care journals are moving in this direction [4]. As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews.
Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in four leading medical journals in 1985 and 1986 and found that none met all eight explicit scientific criteria, such as a quality assessment of included studies [5]. In 1987, Sacks and colleagues [6] evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in six domains. Reporting was generally poor; between one and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement [7].
In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials [8]. In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1).
Box 1: Conceptual Issues in the Evolution from QUOROM to PRISMA
Completing a Systematic Review Is an Iterative Process
The conduct of a systematic review depends heavily on the scope and quality of included studies: thus systematic reviewers may need to modify their original review protocol during its conduct. Any systematic review reporting guideline should recommend that such changes can be reported and explained without suggesting that they are inappropriate. The PRISMA Statement (Items 5, 11, 16, and 23) acknowledges this iterative process. Aside from Cochrane reviews, all of which should have a protocol, only about 10% of systematic reviewers report working from a protocol [22]. Without a protocol that is publicly accessible, it is difficult to judge between appropriate and inappropriate modifications.
Tinnitus is the perception of phantom sound in the absence of a corresponding external source. It is a highly prevalent disorder, and most cases are caused by cochlear injury that leads to peripheral deafferentation, which results in adaptive changes in the CNS. In this article we critically assess the recent neuroimaging studies in individuals with tinnitus that suggest that the disorder is accompanied by functional and structural brain abnormalities in distributed auditory and non-auditory brain regions. Moreover, we consider how the identification of the neuronal mechanisms underlying the different forms of tinnitus would benefit from larger studies, replication and comprehensive clinical assessment of patients.
Limited, outdated, and poor quality data are available on the prevalence of tinnitus, particularly in Italy.
A face-to-face survey was conducted in 2014 on 2,952 individuals, who represented the Italian population aged 18 or more (50.6 million). Any tinnitus was defined as the presence of ringing or buzzing in the ears lasting for at least 5 min in the previous 12 months.
Any tinnitus was reported by 6.2% of Italian adults, chronic tinnitus (i.e. for more than 3 months) by 4.8%, and severe tinnitus (i.e. which constitutes a big or very big problem) by 1.2%. The corresponding estimates for the population aged ≥45 years were 8.7, 7.4 and 2.0%, respectively. Multivariable analysis on population aged ≥45 years revealed that old age (odds ratio (OR) = 4.49 for ≥75 vs. 45-54 years) and obesity (OR = 2.14 compared to normal weight) were directly related to any tinnitus, and high monthly family income (OR = 0.50) and moderate alcohol consumption (OR = 0.59 for <7 drinks/week vs. non-drinking) were inversely related.
This is the first study on tinnitus prevalence among the general Italian adult population. It indicates that in Italy tinnitus affects more than 3 million adults and is felt as a major problem by more than 600,000 Italians, mostly aged 45 years or more. © 2015 S. Karger AG, Basel.
Tinnitus is a common condition in adults; however, the pathophysiology of tinnitus remains unclear, and no large population-based study has assessed the associated risk factors. The aim of this study was to analyze the prevalence and associated risk factors of tinnitus.
We conducted a cross-sectional study using data from the Korea National Health and Nutrition Examination Survey, with 19,290 participants ranging in age from 20 to 98 years old, between 2009 and 2012. We investigated the prevalence of tinnitus using a questionnaire and analyzed various possible factors associated with tinnitus using simple and multiple logistic regression analysis with complex sampling.
The prevalence of tinnitus was 20.7%, and the rates of tinnitus associated with no discomfort, moderate annoyance, and severe annoyance were 69.2%, 27.9%, and 3.0%, respectively. The prevalence of tinnitus and the rates of annoying tinnitus increased with age. The adjusted odds ratio (AOR) of tinnitus was higher for females, those with a smoking history, those reporting less sleep (≤ 6 h), those with more stress, those in smaller households, those with a history of hyperlipidemia osteoarthritis, rheumatoid arthritis, asthma, depression, thyroid disease, an abnormal tympanic membrane, unilateral hearing loss, bilateral hearing loss, noise exposure from earphones, noise exposure at the workplace, noise exposure outside the workplace, and brief noise exposure. Additionally, unemployed individuals and soldiers had higher AORs for tinnitus. The AOR of annoying tinnitus increased with age, stress, history of hyperlipidemia, unilateral hearing loss, and bilateral hearing loss.
Tinnitus is very common in the general population and is associated with gender, smoking, stress, sleep, hearing loss, hyperlipidemia, osteoarthritis, rheumatoid arthritis, asthma, depression, and thyroid disease history.
The importance of psychological factors in tinnitus distress has been formally recognized for almost three decades. The psychological understanding of why tinnitus can be a distressing condition posits that it becomes problematic when it acquires an emotive significance through cognitive processes. Principle therapeutic efforts are directed at reducing or removing the cognitive (and behavioral) obstacles to habituation. Here, the evidence relevant to a new psychological model of tinnitus is critically reviewed. The model posits that patients’ interpretations of tinnitus and the changes in behavior that result are given a central role in creating and maintaining distress. The importance of selective attention and the possibility that this leads to distorted perception of tinnitus is highlighted. From this body of evidence, we propose a coherent cognitive-behavioral model of tinnitus distress that is more in keeping with contemporary psychological theories of clinical problems (particularly that of insomnia) and which postulates a number of behavioral processes that are seen as cognitively mediated. This new model provides testable hypotheses to guide future research to unravel the complex mechanisms underpinning tinnitus distress. It is also well suited to define individual symptomatology and to provide a framework for the delivery of cognitive-behavioral therapy.
Chronic tinnitus (ringing of the ears) is a medically untreatable condition that reduces quality of life for millions of individuals worldwide. Most cases are associated with hearing loss that may be detected by the audiogram or by more sensitive measures. Converging evidence from animal models and studies of human tinnitus sufferers indicates that, while cochlear damage is a trigger, most cases of tinnitus are not generated by irritative processes persisting in the cochlea but by changes that take place in central auditory pathways when auditory neurons lose their input from the ear. Forms of neural plasticity underlie these neural changes, which include increased spontaneous activity and neural gain in deafferented central auditory structures, increased synchronous activity in these structures, alterations in the tonotopic organization of auditory cortex, and changes in network behavior in nonauditory brain regions detected by functional imaging of individuals with tinnitus and corroborated by animal investigations. Research on the molecular mechanisms that underlie neural changes in tinnitus is in its infancy and represents a frontier for investigation.
Background:
Tinnitus can be defined as the perception of an auditory sensation, perceivable without the presence of an external sound.
Purpose:
The aim of this article is to systematically review the peer-reviewed literature on treatment approaches for tinnitus based on cognitive-behavioral therapy (CBT) and to provide a historical overview of developments within these approaches.
Research design:
Experimental studies, (randomized) trials, follow-up assessments, and reviews assessing educational, counseling, psychological, and CBT treatment approaches were identified as a result of an electronic database metasearch.
Results:
A total of 31 (of the initial 75 studies) were included in the review. Results confirm that CBT treatment for tinnitus management is the most evidence-based treatment option so far. Though studied protocols are diverse and are usually a combination of different treatment elements, and tinnitus diagnostics and outcome assessments vary over investigations, a common ground of therapeutic elements was established, and evidence was found to be robust enough to guide clinical practice.
Conclusions:
Treatment strategy might best be CBT-based, moving toward a more multidisciplinary approach. There is room for the involvement of different disciplines, using a stepped-care approach. This may provide brief and effective treatment for a larger group of tinnitus patients, and additional treatment steps can be provided for those suffering on a more severe level.
Objective:
Subjective tinnitus is a frequent symptom characterized by perception of sound in the absence of a corresponding external stimulus. Although many people learn to live with tinnitus, some find it severely debilitating. Why tinnitus is debilitating in some patients, but not in others, is still incompletely understood. We aimed to assess the influence of different aspects of psychological distress on perceived tinnitus severity.
Methods:
Three hundred seventeen patients diagnosed with chronic subjective tinnitus at two university clinics completed the Tinnitus Handicap Inventory (THI), the Tinnitus Questionnaire (TQ) and the Symptom Check List-90-Revised. The influence of the different dimensions of psychological distress on perceived tinnitus severity was statistically evaluated.
Results:
Both THI and TQ scores were significantly influenced by gender, site and the dimension "depression". In addition, TQ scores were significantly influenced by age and "somatization," whereas "hostility" had an impact on THI scores only.
Conclusion:
Psychological aspects as well as sociodemographic variables had a significant influence on both TQ scores. However, our results indicate, that these scales reflect emotional distress of tinnitus sufferers differently. This should be taken into consideration in the use of these scales as screening tools for assessment of tinnitus handicap.
Background:
CONSORT guidelines call for precise reporting of behavior change interventions: we need rigorous methods of characterizing active content of interventions with precision and specificity.
Objectives:
The objective of this study is to develop an extensive, consensually agreed hierarchically structured taxonomy of techniques [behavior change techniques (BCTs)] used in behavior change interventions.
Methods:
In a Delphi-type exercise, 14 experts rated labels and definitions of 124 BCTs from six published classification systems. Another 18 experts grouped BCTs according to similarity of active ingredients in an open-sort task. Inter-rater agreement amongst six researchers coding 85 intervention descriptions by BCTs was assessed.
Results:
This resulted in 93 BCTs clustered into 16 groups. Of the 26 BCTs occurring at least five times, 23 had adjusted kappas of 0.60 or above.
Conclusions:
"BCT taxonomy v1," an extensive taxonomy of 93 consensually agreed, distinct BCTs, offers a step change as a method for specifying interventions, but we anticipate further development and evaluation based on international, interdisciplinary consensus.
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.
The symptoms and signs of severe tinnitus and chronic pain have many similarities and similar hypotheses have been presented regarding how the symptoms are generated. Pain and tinnitus have many different forms. The severity of the symptoms of both varies within wide limits, and it is not likely that all forms have the same pathology. Some individuals with severe tinnitus perceive sounds to be unpleasant or painful. This may be similar to what is known as allodynia, which is a painful sensation of normally innocuous stimulation of the skin. Many individuals with chronic pain experience a worsening of their pain from repeated stimulation (the "wind-up" phenomenon). This is similar to the increasingly unpleasant feeling from sounds that are repeated that many individuals with severe tinnitus experience. There are also similarities in the hypotheses about the generation of pain and tinnitus. Although less severe tinnitus may be generated in the ear, it is believed that severe tinnitus in many cases is caused by changes in the nervous system that occur as a result of neural plasticity. Acute pain caused by tissue injury is generated at the site of injury but chronic pain is often generated in the central nervous system, yet another similarity between chronic pain and severe tinnitus. The changes in the nervous system consist of altered synaptic efficacy including opening of dormant synapses. For pain, this is believed to occur in the wide dynamic range neurons of the spinal cord and brain stem. Less is known about the anatomic location of the changes that cause severe tinnitus but there are indications that it may be the inferior colliculus. It is also possible that other auditory systems than the classical ascending pathways may be involved in severe tinnitus.
Abbreviations: DRG = dorsal root ganglion, GABA = gamma amino butyric acid, HFS = hemifacial spasm, HTM = high threshold mechanoreceptors, IC = inferior colliculus, LTM = low threshold mechanoreceptor, TGN = trigeminal neuralgia, WDR = wide dynamic range neurons
Tinnitus: A Multidisciplinary Approach provides a broad account of tinnitus and hyperacusis, detailing the latest research and developments in clinical management, incorporating insights from audiology, otology, psychology, psychiatry and auditory neuroscience. It promotes a collaborative approach to treatment that will benefit patients and clinicians alike. The 2nd edition has been thoroughly updated and revised in line with the very latest developments in the field. The book contains 40% new material including two brand new chapters on neurophysiological models of tinnitus and emerging treatments; and the addition of a glossary as well as appendices detailing treatment protocols for use in an audiology and psychology context respectively.
Loudness functions and frequency difference limens (DLFs) were measured in five subjects with steeply sloping high-frequency sensorineural hearing loss. The stimuli were pulsed pure tones encompassing a range of frequencies. Loudness data were obtained using a 2AFC matching procedure with a 500-Hz reference presented at a number of levels. DLFs were measured using a 3AFC procedure with intensities randomized within 6 dB around an equal-loudness level. Results showed significantly shallower loudness functions near the cutoff frequency of the loss than at a lower frequency, where hearing thresholds were near normal. DLFs were elevated, on average, relative to DLFs measured using the same procedure in five normally hearing subjects, but showed a local reduction near the cutoff frequency in most subjects with high-frequency loss. The loudness data are generally consistent with recent models that describe loudness perception in terms of peripheral excitation patterns that are presumably restricted by a steeply sloping hearing loss. However, the DLF data are interpreted with reference to animal experiments that have shown reorganization in the auditory cortex following the introduction of restricted cochlear lesions. Such reorganization results in an increase in the spatial representation of lesion-edge frequencies, and is comparable with the functional reorganization observed in animals following frequency-discrimination training. It is suggested that similar effects may occur in humans with steeply sloping high-frequency hearing loss, and therefore, the local reduction in DLFs in our data may reflect neural plasticity.
Emotional stress is a constant companion of tinnitus patients, since this phantom sound can unfortunately be a very effective stressor. However, the mechanism of stress contribution to the onset or progression of tinnitus remains unknown. Here, we review the pathways induced by emotional stress and the outcome of their induction: corticosteroid-dependent changes in gene expression, epigenetic modulations, and impact of stress on neuronal plasticity and neurotransmission. Using clinical examples, we demonstrate the presence of emotional stress among tinnitus patients and we present methods to measure the degree of stress. The evidence causally linking emotional stress with tinnitus is still indirect-the main difficulty lies in the inaccessibility of human auditory tissues and the inability to directly measure tinnitus-induced psychological distress in animal models. However, we believe that translational research is the future way of filling this gap, finding the answers, and thereby improving both the diagnosis and treatment of tinnitus patients.
An ACT Approach Chapter 1. What is Acceptance and Commitment Therapy? Steven C. Hayes, Kirk D. Strosahl, Kara Bunting, Michael Twohig, and Kelly G. Wilson Chapter 2. An ACT Primer: Core Therapy Processes, Intervention Strategies, and Therapist Competencies. Kirk D. Strosahl, Steven C. Hayes, Kelly G. Wilson and Elizabeth V. Gifford Chapter 3. ACT Case Formulation. Steven C. Hayes, Kirk D. Strosahl, Jayson Luoma, Alethea A. Smith, and Kelly G. Wilson ACT with Behavior Problems Chapter 4. ACT with Affective Disorders. Robert D. Zettle Chapter 5. ACT with Anxiety Disorders. Susan M. Orsillo, Lizabeth Roemer, Jennifer Block-Lerner, Chad LeJeune, and James D. Herbert Chapter 6. ACT with Posttraumatic Stress Disorder. Alethea A. Smith and Victoria M. Follette Chapter 7. ACT for Substance Abuse and Dependence. Kelly G. Wilson and Michelle R. Byrd Chapter 8. ACT with the Seriously Mentally Ill. Patricia Bach Chapter 9. ACT with the Multi-Problem Patient. Kirk D. Strosahl ACT with Special Populations, Settings, and Methods Chapter 10. ACT with Children, Adolescents, and their Parents. Amy R. Murrell, Lisa W. Coyne, & Kelly G. Wilson Chapter 11. ACT for Stress. Frank Bond. Chapter 12. ACT in Medical Settings. Patricia Robinson, Jennifer Gregg, JoAnne Dahl, & Tobias Lundgren Chapter 13. ACT with Chronic Pain Patients. Patricia Robinson, Rikard K. Wicksell, Gunnar L. Olsson Chapter 14. ACT in Group Format. Robyn D. Walser and Jacqueline Pistorello
Objectives
To present a neuroradiographic imaging algorithm for patients presenting with pulsatile tinnitus.
Methods
This was a retrospective review of patients presenting to a tertiary care academic medical center from 1993 to 2007 with a chief complaint of pulsatile tinnitus. Clinical presentation and diagnostic imaging data were analyzed.
Results
Of the 108 patients identified, 93 patients had subjective pulsatile tinnitus and 15 patients presented with objective pulsatile tinnitus. In patients with subjective pulsatile tinnitus, 27/93 (29%) had positive radiologic findings, with 71% of cerebral angiogram studies and 57% of MR studies revealing anatomic abnormalities responsible for the pulsatile tinnitus. In patients with objective pulsatile tinnitus, 9/15 (60%) had positive radiologic findings, with 80% of cerebral angiogram studies and 57% of MR studies revealing anatomic abnormalities responsible for the pulsatile tinnitus. Magnetic resonance sensitivity in subjective and objective pulsatile tinnitus was 67% and 57% respectively.
Conclusions
Magnetic resonance is an excellent first-line diagnostic imaging modality in the assessment of pulsatile tinnitus. However, regardless of the subjective or objective nature of pulsatile tinnitus, cerebral angiography should be considered in patients with a negative MR and disabling pulsatile tinnitus.
To evaluate the cost-effectiveness of specialized multidisciplinary tinnitus treatment based on cognitive behavioral therapy, compared with care as usual.
Randomized controlled trial including an economic evaluation from a health-care and societal perspective, using a one-year time horizon.
Audiologic center.
A referred sample of 626 patients with tinnitus were eligible for participation. Approximately 492 patients were included in the study. Eighty-six (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.
Quality adjusted life years (QALYs) as measured with the Health Utilities Index Mark III and cost in US dollars.
Compared with patients receiving usual care, patients who received specialized care gained on average 0.015 QALYs (95% bootstrapped confidence interval [BCI], -0.03 to 0.06). The incremental costs from a societal perspective are 1,034 to 24,580. The probability that SC is cost-effective from a societal perspective is 58% for a willingness to pay for a QALY of $45,000.
Specialized multidisciplinary tinnitus treatment based on cognitive behavioral therapy is cost-effective as compared with usual care. Although uncertainty surrounding the incremental costs and effects is considerable, sensitivity analysis indicated that cost-effectiveness results were robust.
Tinnitus is described as the perception of sound or noise in the absence of real acoustic stimulation. In the current absence of a cure for tinnitus, clinical management typically focuses on reducing the effects of co-morbid symptoms such as distress or hearing loss. Hearing loss is commonly co-morbid with tinnitus and so logic implies that amplification of external sounds by hearing aids will reduce perception of the tinnitus sound and the distress associated with it.
To assess the effects of hearing aids specifically in terms of tinnitus benefit in patients with tinnitus and co-existing hearing loss.
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 19 August 2013.
Randomised controlled trials and non-randomised controlled trials recruiting adults with subjective tinnitus and some degree of hearing loss, where the intervention involves amplification with hearing aids and this is compared to interventions involving other medical devices, other forms of standard or complementary therapy, or combinations of therapies, no intervention or placebo interventions.
Three authors independently screened all selected abstracts. Two authors independently extracted data and assessed those potentially suitable studies for risk of bias. For studies meeting the inclusion criteria, we used the mean difference (MD) to compare hearing aids with other interventions and controls.
One randomised controlled trial (91 participants) was included in this review. We judged the trial to have a low risk of bias for method of randomisation and outcome reporting, and an unclear risk of bias for other criteria. No non-randomised controlled trials meeting our inclusion criteria were identified. The included study measured change in tinnitus severity (primary measure of interest) using a tinnitus questionnaire measure, and change in tinnitus loudness (secondary measure of interest) on a visual analogue scale. Other secondary outcome measures of interest, namely change in the psychoacoustic characteristics of tinnitus, change in self reported anxiety, depression and quality of life, and change in neurophysiological measures, were not investigated in this study. The included study compared hearing aid use to sound generator use. The estimated effect on change in tinnitus loudness or severity as measured by the Tinnitus Handicap Inventory score was compatible with benefits for both hearing aids or sound generators but no difference was found between the two alternative treatments (MD -0.90, 95% confidence interval (CI) -7.92 to 6.12) (100-point scale); moderate quality evidence. No negative or adverse events were reported.
The current evidence base for hearing aid prescription for tinnitus is limited. To be useful, future studies should make appropriate use of blinding and be consistent in their use of outcome measures. Whilst hearing aids are sometimes prescribed as part of tinnitus management, there is currently no evidence to support or refute their use as a more routine intervention for tinnitus.
Tinnitus is the perception of sound in the absence of a corresponding external acoustic stimulus. With prevalence ranging from 10% to 15%, tinnitus is a common disorder. Many people habituate to the phantom sound, but tinnitus severely impairs quality of life of about 1-2% of all people. Tinnitus has traditionally been regarded as an otological disorder, but advances in neuroimaging methods and development of animal models have increasingly shifted the perspective towards its neuronal correlates. Increased neuronal firing rate, enhanced neuronal synchrony, and changes in the tonotopic organisation are recorded in central auditory pathways in reaction to deprived auditory input and represent-together with changes in non-auditory brain areas-the neuronal correlate of tinnitus. Assessment of patients includes a detailed case history, measurement of hearing function, quantification of tinnitus severity, and identification of causal factors, associated symptoms, and comorbidities. Most widely used treatments for tinnitus involve counselling, and best evidence is available for cognitive behavioural therapy. New pathophysiological insights have prompted the development of innovative brain-based treatment approaches to directly target the neuronal correlates of tinnitus.
This paper discusses the two main approaches to tinnitus management: the ‘psychological’ approach that seeks to understand and treat tinnitus within a cognitive behavioural model, and the ‘neurophysiological’ approach that suggests that tinnitus distress can be understood within a classical conditioning paradigm. Both models, and their corresponding approaches to therapy, have strong followings, and this has given rise to debate about their relative merits. However, there is some confusion among practitioners over points of similarity and differences between the two approaches. The psychological model proposes that autonomic nervous system (ANS) arousal is involved, but highlights the importance of cognitive processes in the tinnitus experience. The neurophysiological model also contends that ANS and brain processes play a fundamental role in the perception of tinnitus; it suggests that tinnitus becomes problematic because it becomes associated with something negative. This model stresses the importance of unconscious conditioning over conscious cognitive processes. Both models represent a major departure from an earlier focus on cochlear mechanisms. Both propose that habituation is a key process in attenuating tinnitus distress. There is an overlap in the evidence cited in support of each model but they differ in the emphasis they give to the role of cognition and classical conditioning within the process of tinnitus perception, suffering and treatment. This difference indicates that they derive from different philosophical traditions. The similarities and differences between the models and the theories underpinning them are discussed. Questions concerning the models are raised. The need for more evidence in support of the habituation hypothesis is discussed. The relevance of the classical conditioning paradigm, and therefore the neurophysiological model, to the human experience of tinnitus is questioned. In questioning the psychological approach, the need for a more elaborate cognitive model is highlighted. The models need stronger experimental support than they currently enjoy, but either of them provides a more clinically relevant account of tinnitus than the older cochlear models. They have both led to practitioners offering at least some help to people for whom tinnitus is problematic. However, neither gives a complete picture, and a more comprehensive model of tinnitus that seeks to elucidate the mind‐body interaction is still needed.
Objective: Using a randomized group design, the efficacy of an outpatient cognitive–behavioral Tinnitus Coping Training (TCT) was compared to two minimal-contact (MC) interventions. Methods: TCT was conducted in a group format with 11 sessions (total n=43). One MC [MC-E (education), n=16] consisted of two group sessions in which education on tinnitus was presented and self-help strategies were introduced. The second MC [MC-R (relaxation), n=16] comprised four sessions. Besides education, music-supported relaxation was suggested as self-help strategy and audiotapes with relaxing music were provided. Furthermore, a waiting-list control group was installed (WC, n=20). Data were assessed at baseline (pretherapy) and at posttherapy period. Only TCT was additionally evaluated at a 6-month and a 12-month follow-up. Several outcome variables (e.g., awareness of tinnitus) were recorded in a tinnitus diary. Tinnitus coping and disability due to tinnitus were assessed by questionnaires. Subjective ratings of improvement were also requested from the patients. Furthermore, inventories of psychopathology were given to the patients. Results: Findings reveal highly significant improvements in TCT in comparison to the control group (WC). MC interventions do not differ significantly from each other, but are superior to WC in a few domains of outcome. Outcome in TCT is somewhat superior to combined MC interventions in two domains of data, but not regarding disability reduction. Effect sizes, nevertheless, indicate distinct differences in degree of improvement, with TCT achieving the best results. Conclusions: A sequential scheme for the treatment of chronic tinnitus is discussed on the basis of cost-effectiveness considerations.
Neuroimaging studies of tinnitus suggest the involvement of wide-spread neural networks for perceptual, attentional, memory, and emotional processes encompassing auditory, frontal, parietal, and limbic areas. Despite sparse findings for tinnitus duration and laterality, tinnitus distress has been shown to be related to changes in non-auditory cortical areas. The aim of this study was to correlate tinnitus characteristics with grey matter volume in two large samples of tinnitus patients. High-resolution brain images were obtained using a 1.5 T magnetic resonance imaging scanner and analysed by means of voxel-based morphometry. In sample one (n = 257), tinnitus distress correlated negatively with grey matter volume in bilateral auditory areas including the Heschl's gyrus and insula, that is, the higher the tinnitus distress the lower the grey matter volume. The effects of this correlation were small, but stable after correction for potential confounders such as age, gender, and audiometric parameters. This negative correlation was replicated in a second independent sample (n = 78). Our results support the notion that the role of the auditory cortex in tinnitus is not restricted to perceptual aspects. The distress observed was dependent on grey matter alterations in the auditory cortex, which could reflect reverberations between perceptual and distress networks.
Purpose:
Known association between tinnitus and psychological distress prompted us to examine patients with chronic tinnitus by using the Composite International Diagnostic Interview (CIDI), which is a standardized and reliable method used for the diagnosis of mental disorders.
Methods:
One hundred patients with chronic tinnitus admitted to the Tinnitus Center, Charité-Universitätsmedizin Berlin, were included in this study. Data were collected between February 2008 and February 2009. Besides CIDI, the Tinnitus Questionnaire according to Goebel and Hiller, the Hospital Anxiety Depression Scale, and the General Anxiety Disorder-7 were used.
Results:
Using CIDI, we have identified one or more mental disorders in 46 tinnitus patients. In that group, we found persistent affective disorders (37 %), anxiety disorders (32 %), and somatoform disorders (27 %). Those patients who had affective or anxiety disorders were more distressed by tinnitus and were more anxious and more depressed than tinnitus patients without mental disorders. Psychological impairment positively correlated with tinnitus distress: Patients with decompensated tinnitus had significantly more affective and anxiety disorders than patients with compensated tinnitus.
Conclusions:
In the present study, we have detected a high rate (almost half of the cases) of psychological disorders occurring in patients with chronic tinnitus. The patients diagnosed with psychological disorders were predominantly affected by affective and anxiety disorders. Psychological disorders were associated with severity of tinnitus distress. Our findings imply a need for routine comprehensive screening of mental disorders in patients with chronic tinnitus.
Traces the development of the cognitive approach to psychopathology and psy hotherapy from common-sense observations and folk wisdom, to a more sophisticated understanding of the emotional disorders, and finally to the application of rational techniques to correct the misconceptions and conceptual distortions that form the matrix of the neuroses. The importance of engaging the patient in exploration of his inner world and of obtaining a sharp delineation of specific thoughts and underlying assumptions is emphasized. (91/4 p ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
This text describes the principles of learning and behavior by emphasizing the intellectual context in which the important ideas and topics were developed. In addition to explaining the important facts and theories and describing the latest research, the book tries to honor where the facts and theories came from. The book starts simply, and builds. Chapter 1 begins with a short history--what the field is currently about, how it got this way, and what it can offer to our general understanding of psychology and behavior in the real world. Chapter 2 then turns to the functions of both instrumental and Pavlovian learning. Chapter 3 then examines the nuts and bolts of Pavlovian learning; the basic facts that one needs to know before applying it to phenomena in the world outside of the lab, and in order to understand it theoretically. Chapter 4 follows with an explanation of the modern theories of conditioning beginning with the Rescorla-Wagner model. Chapter 5 then complements Chapter 4 by exploring how learning is translated into behavior; it reviews work on remembering and forgetting, extinction, occasion setting, and behavior systems, for example. In many ways, Chapters 4 and 5 provide the theoretical heart of the book. In Chapter 6, I consider the challenge (first provided by the discovery of taste aversion learning) that such a theoretical heart, established so carefully in the lab, might not generalize that well to other examples of learning. This chapter takes the reader through more important learning phenomena, and then ultimately examines conditioning in honeybees and categorization and causal learning in humans. The last four chapters cover voluntary behavior--that is, behavior that is represented in instrumental or operant conditioning. Chapter 7 considers work that followed Skinner's analysis and covers how behavior is related to its consequences. Chapter 8, which covers stimulus control and animal cognition, begins with a fairly extensive discussion of categorization in pigeons, and then presents some basic generalization and discrimination phenomena that are necessary tools for understanding the more complex topics. From there, the narrative turns to topics from an information-processing perspective and then on to the cognition of timing and spatial learning. Chapter 9 turns to the motivation of instrumental behavior, a topic that is fascinating and important--but is rarely considered in its own right in contemporary textbooks on learning and behavior. The final chapter provides what I believe is the current "synthetic" approach to instrumental behavior. It tells a story about avoidance learning, learned helplessness, misbehavior in appetitive learning, and the contemporary "cognitive" analysis of instrumental learning. This all provides a vehicle to reconsider and integrate many of the most important themes presented in previous chapters: evolution, cognition, motivation, and the interrelations between Pavlovian and operant learning. I hope this chapter will allow the reader to walk away from the book with a review and integration of the different topics firmly situated in his or her mind. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The present volume includes many of the important papers and chapters on RET [rational emotive therapy] that have appeared since 1977. We . . . think that readers of this volume will readily see that RET and CBT [cognitive behavior therapy] are still notably advancing in theory, in techniques, in research studies, and in influence. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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The aim of this study was to outline the psycho-pathological characteristics of a population of outpatients affected by tinnitus and to consider its impact on their mental state and ability to function in major areas of their lives. Seventy-five consecutive tinnitus patients were enrolled on their first visit to the outpatients clinic of the Audiology Department of the 'Federico IF University of Naples, for audiological and psychiatric evaluation. A series of audiometric and vestibular tests was performed for tinnitus rating assessment, and further information was obtained from the patient via a semi-structural interview. For the psychopathological examination, patients underwent the Mini International Neuropsy-chiatric Interview (MINI), by means of which a multiaxial diagnosis (five axes) was expressed, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). For a better understanding of the personality aspects, the Minnesota Multiphasic Personality Inventory (MMPI) test was administered to a subgroup of 55 subjects whose cultural background permitted their full cooperation. The results of the study show that 58 subjects (77% of the total) met the criteria for psychiatric disorder diagnosis, according to the DSM-IV system: Axis I comprises anxiety, affective and somatoform disorders and psychoses; Axis II comprises personality disorders. Multiple diagnoses were expressed in some subjects. The findings of the examination via MMPI show a high percentage of depression, hysteria, and hypochondria. Although we are not seeking to establish a cause-effect relationship between the unpleasant experience of tinnitus and psychopathological disorders, our findings are consistent with those of other authors. Tinnitus can indeed have severe consequences for the subject's ability to function in many areas of their life. In this paper, the implications of such results for the diagnosis and therapy of tinnitus are discussed. Sumario: El objetivo de este cstudio fue determinar las características psicopatológicas de una población de pacientes externos afectados por tinnitus para considerar el impacto del mismo en su condición mental y sus habilidades para funcionar en las áreas importantes de sus vidas. Se incluycron 75 pacientes con tinnitus que acudieron en orden consecutivo a una primera visita en la consulta externa del Departamento de Audiología de la Universidad “Federico II” de Nápoles para evaluaeión audiológica y psiquiátrica. Se llevó a cabo una serie de estudios audiométricos y vestibulares para evaluar el grado de tinnitus además de obtener información adicional del paciente por medio de una entrevista semi-estructurada. Para la evaluaeión psicopato-lógica se utilizó la Entrevista Neuropsiquiátrica Internacional Mini (MINI) por medio de la cual se expresa un diagnóstico multiaxial (cinco ejes) de acuerdo con los criterios del Manual Diagnóstico y Estadistico de Trastornos Mentales (DSM-IV). Para una mejor comprensión de los aspectos de la personalidad, se administró la prueba del Inventario de Personalidad Multifásica de Minnesota (MMPI) a un subgrupo de 55 sujetos cuyos antecedentes culturales permitian su total cooperación. Los resultados del estudio muestran que 58 sujetos (77% del total) reunieron los criterios para establecer un diagnóstico de trastorno psiquiátrico, de acuerdo con el sistema DSM-IV El eje I comprende ansiedad, afectividad y trastornos somáticos además de psicosis. El Eje II incluye trastornos de la personalidad. En algunos sujetos se establecieron diagnósticos mültiples. Los hallazgos del examen por medio del MMPI muestran un alto porcentaje de depresión, histeria e hipocondria. A pesar de que no estamos en posición de establecer una relación de causa-efecto, entre la desagradable experiencia del tinnitus y los trastornos psicopatológicos, nuestros hallazgos son consistentes con los encontrados por otros autores. El tinnitus puede con seguridad tener severas consecuencias en el funcionamiento del sujeto en muchas áreas de su vida. En este trabajo, se discuten las implicaciones de esos resultados para el diagnóstico y el tratamiento del tinnitus.