The Sound—and the Curing When it comes to tinnitus treatment, research has pointed to benefits of cognitive-behavioral treatment. All Ears on Audiology
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All Ears on Audiology  |   September 01, 2017
The Sound—and the Curing
Author Notes
  • Dean Mark Thompson is psychology doctoral student at the National Institute for Health Research Nottingham Biomedical Research Centre in the United Kingdom. He is researching treatment for tinnitus and hyperacusis. dean.thompson@nottingham.ac.uk
    Dean Mark Thompson is psychology doctoral student at the National Institute for Health Research Nottingham Biomedical Research Centre in the United Kingdom. He is researching treatment for tinnitus and hyperacusis. dean.thompson@nottingham.ac.uk×
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Hearing Disorders / All Ears on Audiology
All Ears on Audiology   |   September 01, 2017
The Sound—and the Curing
The ASHA Leader, September 2017, Vol. 22, 16-17. doi:10.1044/leader.AEA.22092017.16
The ASHA Leader, September 2017, Vol. 22, 16-17. doi:10.1044/leader.AEA.22092017.16
The association between tinnitus and anxiety and depression cannot be denied.
People with anxiety and depression are more than twice as likely to report tinnitus, and patients with tinnitus report more anxiety and depression than the general population, according to epidemiological research (see sources below).
How, then, do we meet their needs?
The simple answer: Refer patients with tinnitus and a co-occurring mental health problem to a clinical psychologist, psychiatrist or other mental health professional. The problem: The number of people worldwide with anxiety and/or depression is around twice the size of the entire U.S. population, and mental health professionals are in short supply to meet demand. While a patients waits for a referral, the problem can often get worse before it gets better.
As a result, internationally we’re seeing growth in involvement of audiologists in mental health intervention with these patients. In the Netherlands, audiologists intervene early in the psychological care of tinnitus patients as standard practice, and in the U.K., we are exploring how to integrate psychoeducation and psychological techniques into audiologists’ clinical practice.
In the U.S., audiologists may integrate psychological techniques and fitting of hearing aid devices (that incorporate tinnitus noise-makers) into tinnitus treatment, as necessary. Depending on the case, they may also link patients with mental health services. What’s key in communications with patients is to recognize the complexity of the evidence on psychological treatments for tinnitus.
CBT and components
Perhaps the tinnitus intervention with the strongest supporting evidence is cognitive-behavioral therapy (CBT)—a talking therapy designed to identify and challenge negative automatic thoughts and modify unhelpful behavioral responses (see sources). More than one review of CBT for tinnitus indicates improvement in distress, anxiety, depression and quality of life (though not tinnitus loudness) over and above comparisons to education, sound therapy, relaxation and yoga (see sources).
CBT is one of the few tinnitus treatment options—alongside education, counseling and hearing aid evaluation—recommended in clinical practice guidelines from the American Academy of Otolaryngology. CBT is multifaceted: Earlier CBT from the 1980s tended to focus on attention-shifting techniques and relaxation. More recently, CBT for tinnitus has emphasized reducing avoidance of the tinnitus percept or distressing situations associated with it, such as social situations in which the tinnitus is distracting.
We need more research to identify the active ingredients that reduce tinnitus distress. Analyzing studies of depression treatment could be instructive for tinnitus treatment, given the association between these conditions. For example, depression treatment research by University of Washington’s Neil Jacobson and colleagues reveals roughly equivalent outcomes for CBT and its component of behavioral activation—aimed at re-establishing everyday activities that the patient may have begun to neglect due to low mood (there is some evidence that this also occurs in people with tinnitus).
In another study, Vendela Westin of Linköping University and colleagues found an apparent link between pursuit of day-to-day activities over 18 months and reduced tinnitus distress. These patients also showed an apparent reduction in depression and increase in quality of life. So, experiential avoidance may account for the depression and reduced quality of life commonly seen in tinnitus patients, and behavioral activation may help address these problems.
Another treatment strategy to consider is thought-stopping, which involves interrupting negative thinking, whether by shouting, “stop,” or by flicking an elastic band on the wrist. In a recent survey I and colleagues conducted of U.K. patients and audiologists (see sources), a third believed that thought-stopping may be important to consider including in psychological treatment for tinnitus.
However, thought suppression fell out of favor, particularly after social psychologist Daniel Wegner’s 1987 publication of a seminal study in which he asked participants not to think about a white bear. The result was a paradoxical rebound effect, in which the intrusive thought becomes more prominent. The combination of an absence of standardized tinnitus care and little training in tinnitus management in AuD courses highlights the importance of audiologists maintaining up-to-date knowledge of the efficacy of psychological interventions.

More exhaustive research will hopefully shed light on the little things we can do to help provide big tinnitus relief.

Accepting tinnitus
On the other end of the treatment spectrum from thought control and suppression is acceptance and commitment therapy (ACT). It seeks to ease tinnitus distress by targeting the linguistic processes implicated in poor mental health. One pillar of ACT is defusion techniques that attempt to “deliteralize” the language used in negative thoughts.
In practice, this can take several different forms. For example, patients can use “Titchener’s repetition” to verbally repeat the difficult thought until it appears to become an abstract assemblage of sounds. In theory, this provides the context for the thought to be stripped of its literal meaning, and there is some evidence to suggest that this technique is effective in people without anxiety and depression (see sources).
Many audiologists may already be implementing ACT defusion techniques without realizing it. For instance, when a patient expresses a negative thought, we may ask a patient, “What is that thought in service of?” to help them step outside of the content of the thought itself. Or we might repeatedly ask, “Why do you think that?” to demonstrate the shallowness of causal explanations. Or we may challenge the patient not to think about a specific worry about their tinnitus to demonstrate that trying to control our thoughts can be counterproductive.
There is little high-quality evidence involving use of ACT with tinnitus. However, there is some limited evidence to suggest that tinnitus is less likely to interfere with sleep when patients use verbal defusion early in treatment, saying statements such as, “The thoughts passed by me—I didn’t get hooked” or “It’s only a thought.”
Another potentially beneficial tinnitus-fighting technique is mindfulness: paying attention to the present moment, intentionally and without judgment. This may appear counterintuitive for people with tinnitus, so it can be helpful for them to first practice with something else, like the sensation of eating. Next steps are intentionally focusing on their tinnitus, catching when their attention lapses and reorienting toward the tinnitus without judgment. The aim is to demonstrate that the tinnitus sound is not as threatening in the here and now as fears about its future impact.
Much of the evidence on mindfulness for tinnitus distress has been limited by small sample sizes. However, it’s worth considering results of a study of 75 patients by University College London Hospitals psychologist Laurence McKenna and colleagues: Half received either mindfulness-based cognitive therapy or relaxation. Both conditions resulted in a reduction in tinnitus and psychological distress, as well as tinnitus loudness (contrary to many other studies of CBT). What’s more, the mindfulness group sustained these gains six months later.
As is apparent from this look at the research, there is, at present, a paucity of evidence-based treatment options for tinnitus. And, in the absence of intervention by a psychologist, even evidence-based interventions may not be sufficient to address all the various problems people with tinnitus experience.
However, the stronger the evidence for a technique, the more likely it is that the outcome will be positive. More exhaustive research will hopefully shed light on the little things we can do to help provide big tinnitus relief.
Sources
Cima, R. F. F., Maes, I. H., & Joore, M. A. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: A randomised controlled trial. The Lancet, 379, 1951-1959. [Article]
Cima, R. F. F., Maes, I. H., & Joore, M. A. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: A randomised controlled trial. The Lancet, 379, 1951-1959. [Article] ×
Cima, R., Andersson, G., & Schmidt, C. J. (2014). Cognitive-behavioral treatments for tinnitus: A review of the literature. Journal of the American Academy of Audiology, 25, 2961.
Cima, R., Andersson, G., & Schmidt, C. J. (2014). Cognitive-behavioral treatments for tinnitus: A review of the literature. Journal of the American Academy of Audiology, 25, 2961.×
Hayes, S., Strosahl, K. D. & Wilson, K. G. (2016). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. New York, Guilford Publications.
Hayes, S., Strosahl, K. D. & Wilson, K. G. (2016). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. New York, Guilford Publications.×
Hesser, H., Pereswetoff-Morath, C. E. & Andersson, G. (2009). Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology, 54(4), 381-389. [Article] [PubMed]
Hesser, H., Pereswetoff-Morath, C. E. & Andersson, G. (2009). Consequences of controlling background sounds: the effect of experiential avoidance on tinnitus interference. Rehabilitation Psychology, 54(4), 381-389. [Article] [PubMed]×
Hesser, H., Weise, C., & Westin, V.Z. (2011). A systematic review and meta-analysis of randomized controlled trials of cognitive–behavioral therapy for tinnitus distress. Clinical Psychology Review, 31, 545-553. [Article] [PubMed]
Hesser, H., Weise, C., & Westin, V.Z. (2011). A systematic review and meta-analysis of randomized controlled trials of cognitive–behavioral therapy for tinnitus distress. Clinical Psychology Review, 31, 545-553. [Article] [PubMed]×
Hoare, D.J., Kowalkowski, V.L., & Kang, S. (2011). Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. Laryngoscope, 121(7), 1555-1564. [Article] [PubMed]
Hoare, D.J., Kowalkowski, V.L., & Kang, S. (2011). Systematic review and meta-analyses of randomized controlled trials examining tinnitus management. Laryngoscope, 121(7), 1555-1564. [Article] [PubMed]×
Jacobson, N.S., Dobson, K.S., & Truax, P.A. (1996). A component analysis of cognitive-behavioural treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295-304. [Article] [PubMed]
Jacobson, N.S., Dobson, K.S., & Truax, P.A. (1996). A component analysis of cognitive-behavioural treatment for depression. Journal of Consulting and Clinical Psychology, 64(2), 295-304. [Article] [PubMed]×
Martinez-Devesa, P., Perera, R., & Theodoulou, M. (2010). Cognitive behavioural therapy for tinnitus. The Cochrane Database of Systemic Reviews, 9. doi: 10.1002/14651858.CD005233.pub3.
Martinez-Devesa, P., Perera, R., & Theodoulou, M. (2010). Cognitive behavioural therapy for tinnitus. The Cochrane Database of Systemic Reviews, 9. doi: 10.1002/14651858.CD005233.pub3.×
Masuda, A., Hayes, S. C., & Sacke, C. F. (2004). Cognitive defusion and self-relevant negative thoughts: Examining the impact of a ninety year old technique. Psychology Faculty Publications, Georgia State University. Paper 81. [Article] [PubMed] [PubMed]
Masuda, A., Hayes, S. C., & Sacke, C. F. (2004). Cognitive defusion and self-relevant negative thoughts: Examining the impact of a ninety year old technique. Psychology Faculty Publications, Georgia State University. Paper 81. [Article] [PubMed] [PubMed]×
Michalski, D., Mulvey, T. & Kohout, J. (2010). 2008: APA Survey of Psychology Health Service Providers. APA Center for Workforce Studies.
Michalski, D., Mulvey, T. & Kohout, J. (2010). 2008: APA Survey of Psychology Health Service Providers. APA Center for Workforce Studies.×
Pinto, P. C. L., Marcelos, C. M., & Mezzasalma, M. A. (2014). Tinnitus and its association with psychiatric disorders: systematic review. The Journal of Laryngology and Otology, 128, 660-664. [Article] [PubMed]
Pinto, P. C. L., Marcelos, C. M., & Mezzasalma, M. A. (2014). Tinnitus and its association with psychiatric disorders: systematic review. The Journal of Laryngology and Otology, 128, 660-664. [Article] [PubMed]×
Schaaf, H., Eichenberg, C., & Kastellis, G. (2010). Treatment of Tinnitus needs a combined neurootological and psychosomatic approach. Otolaryngologia Polska, 64(2), 78-82. [Article] [PubMed]
Schaaf, H., Eichenberg, C., & Kastellis, G. (2010). Treatment of Tinnitus needs a combined neurootological and psychosomatic approach. Otolaryngologia Polska, 64(2), 78-82. [Article] [PubMed]×
Taylor, J. A., Hall, D. A., Walker, D. M., McMurran, M., Casey, & A. Stockdale, D. (2017). A psychologically informed, audiologist-delivered, manualised intervention for tinnitus: protocol for a randomised controlled feasibility trial (Tin Man study). Pilot and Feasibility Studies, 3, 24. [Article] [PubMed]
Taylor, J. A., Hall, D. A., Walker, D. M., McMurran, M., Casey, & A. Stockdale, D. (2017). A psychologically informed, audiologist-delivered, manualised intervention for tinnitus: protocol for a randomised controlled feasibility trial (Tin Man study). Pilot and Feasibility Studies, 3, 24. [Article] [PubMed]×
Thompson, D. M., Hall, D. A., Walker, D. M. & Hoare, D. J. (2017) Psychological Therapy for People with Tinnitus: A Scoping Review of Treatment Components. Ear and Hearing, 38 (2), 149-158. [Article] [PubMed]
Thompson, D. M., Hall, D. A., Walker, D. M. & Hoare, D. J. (2017) Psychological Therapy for People with Tinnitus: A Scoping Review of Treatment Components. Ear and Hearing, 38 (2), 149-158. [Article] [PubMed]×
Thompson, D. M., Taylor, J. A., Hall, D. A., Walker, D. M., McMurran, M., & Casey, A. Patients’ and clinicians’ views of the psychological components of tinnitus treatment that could inform audiologists’ usual care: A Delphi survey. Ear and Hearing, in press.
Thompson, D. M., Taylor, J. A., Hall, D. A., Walker, D. M., McMurran, M., & Casey, A. Patients’ and clinicians’ views of the psychological components of tinnitus treatment that could inform audiologists’ usual care: A Delphi survey. Ear and Hearing, in press.×
Wegner, D.M., Schneider, D.J., Carter, S.R. & White, T.L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53(1), 5-13. [Article] [PubMed]
Wegner, D.M., Schneider, D.J., Carter, S.R. & White, T.L. (1987). Paradoxical effects of thought suppression. Journal of Personality and Social Psychology, 53(1), 5-13. [Article] [PubMed]×
Westin, V., Hayes, S. C. & Andersson, G. (2008). Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact. Behavior Research and Therapy, 46, 1259-1265. [Article]
Westin, V., Hayes, S. C. & Andersson, G. (2008). Is it the sound or your relationship to it? The role of acceptance in predicting tinnitus impact. Behavior Research and Therapy, 46, 1259-1265. [Article] ×
Westin, V. Z., Schulin, M., & Hesser, H. (2011). Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus: A randomised controlled trial. Behavior Research and Therapy, 49, 737-747. [Article]
Westin, V. Z., Schulin, M., & Hesser, H. (2011). Acceptance and Commitment Therapy versus Tinnitus Retraining Therapy in the treatment of tinnitus: A randomised controlled trial. Behavior Research and Therapy, 49, 737-747. [Article] ×
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September 2017
Volume 22, Issue 9