Jane (Qin) Chen, Ph.D. and Timothy C. Hain, MD. Hearing Page Page last modified: August 20, 2017
As medical treatment for tinnitus is so limited (Dobie, 1999), a common strategy to help tinnitus patient is to focus on decreasing their distress related to tinnitus. Tinnitus may be conceived as a failure to adapt to a stimulus. Some researchers also suggest that fear-avoidance behavior plays an important role in tinnitus handicap (Kleinstauber, Frank, & Weise, 2015). A wide range of therapies have been proposed for the treatment of Tinnitus symptoms. Medical treatments include drugs that decrease depression and anxiety. The most supported non-medical intervention for tinnitus related distress is Cognitive Behavioral Therapy (CBT).
Basic Assumptions and Focus of CBT
CBT was introduced by Aaron Beck in the 1960s. The basic premise of CBT is that our thoughts about ourselves, our world and our future are maintained by our core beliefs. The core beliefs, along with automatic thoughts and schema, affect the way we feel and how we behave. In the case of tinnitus, the external event, that is, the loud or/and annoying sound in the ear, is present, but how the patients manage the situation is determined largely by their perception of the situation. A common “core belief” among some tinnitus patients is that “life is ruined because of tinnitus”. Not surprisingly, this thought in and of itself creates distress and anxiety. The distress/anxiety gives rise to behavior and/or somatic symptoms that reinforce the dysfunctional core belief.
In order to help patients, CBT uses both behavioral and cognitive tasks to modify the patients’ cognitive distortions, that is, their dysfunctional responses such as fear and hyper-vigilance to the thought of an impending or increased volume of a sound and anticipation of the lack of control over their behavior once the sound starts to ring in their ears. Through intervention including psychoeducation about the nature of tinnitus, the therapists help to generate an understanding of the connection between thoughts, feeling and behavior. The goal is to replace negative thought patterns by raising cognitive accessibility of alternative belief formulations. The process of cognitive restructuring involves the patients to challenge the negative thinking patterns. These might include a tendency to allocate their attention to anticipating negative consequences and catastrophizing. For example, the therapist and the patient may examine the fearful thought of “life is ruined when the sound is there” as a hypothesis. They work together searching for discrepant evidence to disconfirm these pathogenic thoughts. The patient then learns to replace faulty thoughts with more functional one. Ultimately the patient establishes new and more functional behavior.
CBT is currently "in", and CBT enthusiasts suggest, somewhat implausibly, that CBT is effective for a number of disorders that are "hard wired" into the brain, such as OCD (obcessive compulsive disorder) and anxiety in general. In reality, CBT probably improves coping for these thinking patterns.
In tinnitus patients, CBT is often blended with other popular counseling protocols such as mindfullness, and acceptance and commitment therapy (ACT). Mindfullness trains the patient to be in the present. ACT emphasizes accepting that "it is what it is", instead of fighting tinnitus or fearing a future with tinnitus.
Assessment and Diagnosis of the Problem
Prior to seeing a psychotherapist for tinnitus, patients first undergo a medical assessment. This serves to exclude unusual patients with medically treatable tinnitus such as due to a tumor of the inner ear. Tinnitus is quantified by “tinnitus matching”, which simply is an organized attempt to find a sound judged by the patient as having the same frequency and loudness. Hyperacusis (intolerance to sound) is quantified by a similar procedure called “LDL” – loudness discomfort levels. Other tests are done to attempt to identify the cause of the tinnitus. If there is a significant hearing loss, a hearing aid may be helpful. Symptom inventories such as the “Tinnitus Handicap Inventory” are commonly used to gauge the impact of the tinnitus on the patient’s life. Given that there is significant impact and no medically treatable disease identified in the patient, they may then be referred for therapy. An example of such a case might be an individual who was exposed to loud noise at work for many years, and now is left with very strong ringing that is “driving him crazy”, hearing impairment on both sides, insomnia, and intolerance to moderately loud sounds.
Cognitive behavioral therapists often begin with an assessment using diagnostic tests. They typically use standard assessment tools to assess the extent of a symptom. For example, if depression is suspected, they might use the Beck Depression Inventory (BDI) to confirm and quantify or to rule out the condition. Patients with high tinnitus distress often have high scores on the BDI (Henry & Wilson, 1995).
CBT therapists focus on the specific problem areas and on the reasons the patients provide for their symptoms. To obtain a Problem List, the therapist collects data from multiple sources, including clinical interviews, structured diagnostic interviews, self-report scales, self-monitoring data provided by the patient, observations of the patient’s behavior, and if applicable, reports from the patient’s family members and other treatment providers.
A common tool frequently employed by both behavioral and cognitive therapists is functional analysis (FA), in which they find “triggers”, problem behaviors’ consequences, both negative positive consequences. As illustrated in a recent article (Magidson, Young, & Lejues, 2014), FA allows for illustration of necessary information pertaining to the patient’s behavior and thought/feeling. By being aware of the "antecedents" behind their behavior, patients are more likely to acquire better understand of what has been attributing to their distress. Through direct observation and systematic manipulation, the therapist helps to create a new, effective pattern in the clients that is beneficial toward their wants and needs.
CBT, in general, is also characterized by individualized case conceptualization. It is through case conceptualization that the therapist formulates a hypothesis about the mechanisms of what has caused and is maintaining the patient’s problems. Case conceptualization brings in several domains of assessment including symptoms and diagnosis, the patient’s weakness and strengths, contextual factors, and cognitive factors that influence diagnosis and treatment, such as automatic thoughts or schemas. The case formulation leads to a working hypothesis about the optimal course and focus of CBT. For example, a CBT therapist may formulate tinnitus as resulting from a combination of physical and psychological mechanisms: A physical internal noise is made more bothersome by distorted appraisals of stress incurred by the noise and stress causing events associated with the physical tinnitus sound, and behavioral and cognitive strategies, such as avoidance, that prevent the patients from correcting their faulty appraisals.
CBT approaches emphasize data, timely feedback and on-going assessment of behaviors and thoughts. Based on data, CBT therapists retest the hypotheses, and make adjustments to the treatment plan as appropriate. The therapists and the patients work collaboratively and continuously to frame their conclusions in the form of hypothesis testing.
The reports of CBT intervention for tinnitus are mainly of group CBT, typically manualized (Robinson et al., 2008). In psychology jargon, "manualized" means that treatments have exact steps, so that each person has relatively the same treatment. Of course, they are manualized so that one is not comparing apples with oranges. It should not be taken that "manualized" is necessarily better than being more flexible.
CBT approach is theoretically "collaborative". Collaborative is the psychology term for a teamwork approach between the therapist and patient. However, as CBT involves the therapist suggesting or exposing to the client the possibility that certain client thoughts are "dysfunctional", there is obviously the potential for a very directive approach.
CBT therapists work on recognizing automatic thoughts and schema, and attempts to reduce dysfunctional ones. In psychology jargon, a schema is a cognitive framework or concept that helps organize and interpret information. Thus a schema is a framework within which thoughts are generated.
A common practice is also to provide psychoeducation to the patient about interrelationships between behaviors/activities, thoughts, and mood. To help the patient understand the relationship between thought/feeling and behavior, CBT therapists often employ Socratic dialogue. This is another psychological jargon term - - meaning "question and answer".
Patients are also expected to actively practice new cognitive and behavioral skills when they are not in session. Aimed for testing beliefs and developing new skills in daily-life situations, homework is tailored to the patient’s specific problem and his/her style of information processing. Through homework assignments, a patient monitors his/her automatic thoughts, feeling and behavior in everyday settings. For example, a patient makes daily “thought records” of time, situation, emotion, automatic thoughts, response, and outcome. These recordings not only capture the automatic thoughts, but also channel attention to patterns of behavior and how the automatic thoughts undermine the likelihood of constructive responses, or otherwise bring about more functional outcome. Having patients continue hypothesis testing and actively modifying behavior on their own and at their own pace also promotes a sense of being in control. These assignments are discussed in later sessions with the therapist in order to maintain an on-going and prompt feedback for behavior monitoring, shaping, adjustment and encouragement. Whether it is case conceptualization, in-session discussion, psychoeducation or homework, what contributes to the central CBT change mechanisms is collaborative empiricism actualized through therapeutic collaboration between the therapist and the patient who collaboratively and systematically investigate empirical evidence to determine whether particular thoughts serve any useful purpose.
CBT emphasizes behavior modification. Main behavior techniques include actively scheduling, skill training, behavioral rehearsal, exposure therapy, systematic desensitization, relaxation and mindfulness training. Desensitization is complex in tinnitus therapy as there is a need to distinguish between real physiological changes that can increase sensitivity to sound in patients with ear damage – i.e. physical hyperacusis, and avoid of sound out of fear – i.e. phonophobia (Kleinstauber et al., 2013). Aside from the inconvenience factor, the problem with avoiding feared stimuli is that the patient misses the chance to overcome their fear. Avoiding fear often reinforces the fear. The idea of exposure therapy is that through repeated exposures, the patient gains an increasing sense of control. A “gentler” type of exposure therapy is systematic desensitization where the therapist starts from the least disturbing noise and works up from the hierarchy.
A recent trend is internet-based CBT therapy for tinnitus (ICBT). ICBT uses an online manual to handle tinnitus distress and related problems. The module typically starts with psychoeducation, including information about tinnitus. The subsequent modules describe how to cope with tinnitus: Attention diversion (including exposure and sound masking), cognitive restructuring, progressive muscle relaxation, positive imagery, general stress management and sleep management. Typically, one module focuses on a specific problem area and methods to manage it. There are instructions on how to practice and use the method, and finally online planning, registration, and reporting of homework. The manual also contains multiple-choice self-tests as well as exercises to check and reinforce understanding and build self-management skills. Most ICBT allows the participants complete modules at their own pace (Kaldo et al., 2013; Nyenhuis, Zastrutzki, Jager, & Kroner-Herwig, 2013). Other studies used fixed schedules (Hesser et al., 2012). Essentially ICBT approaches are self-help materials that are accessible electronically.
Hofmann et al (Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012) summarized the efficacy of CBT (in general) based on 269 meta-analytic studies. The problems included substance use disorder, schizophrenia, depression and dysthymia, bipolar disorder, anxiety, somatoform, eating disorders, insomnia, personality disorders, anger and aggression, criminal behaviors, and general stress. They also examined 11 studies that compared response rates between CBT and other treatments or control conditions. The evidence-base of CBT is very strong, especially for treating anxiety disorders. There is also strong support for CBT for somatoform disorders, bulimia, anger control problems, and general stress.
As mentioned above, it is implausible that CBT is a "Swiss army knife" that can cure organic disorders of the nervous system such as (for example), schizophrenia. It is also generally accepted that many other psychological disoders are "hard wired", or in other words, have a biochemical or neurological reason to manifest. One would suspect from this line of thought that CBT might be effective at helping people score more normally on psychological inventories. That is not necessarily a bad thing.
A recent article concerning CBT for depression reported that the effectiveness of CBT had declined steadily since its introduction (Johnsen and Friborg, 2015). The authors stated that "modern CBT clinical trials seemingly provided less relief from depressive symptoms as compared to the seminal trials". They cited studies suggesting that CBT is not superior to other techniques (for depression), and that CBT might not be so easy for clinicians to learn. Others have observed that the therapist is nine to 10 times more important to the outcome of therapy than the method (Miller, 2013). Wampold et al (2017), has suggested that the efficacy of CBT has been overemphasized, and that in reality, it is just another counseling technique. None of this data suggests that CBT is ineffective, but rather it suggests that CBT is no better than other techniques (in general). If this is the case for tinnitus as well, then the choice of psychotherapy for tinnitus would logically depend on who and what is available in your community.
A review of effectiveness of CBT in the management of patients suffering from tinnitus was provided by Martinez-Devesa and colleagues (Martinez-Devesa, Perera, Theodoulou, & Waddell, 2010), who studied 8 trials (with a total of 468 participants). There has been no evidence that therapy results in a significant difference in the subjective loudness of tinnitus. On the other hand, there is significant improvement in depression scores and in an increase in rating of quality of life.
A recent meta-analysis of “self-help” CBT interventions in tinnitus found no differences between self-help and group treatment regarding psychosomatic discomfort and in the effect of CBT in improving tinnitus related distress (Nyenhuis, Golm, & Kroner-Herwig, 2013). Regarding ICBT (internet), one study reported that it is just as effective as group CBT (Nyenhuis, Zastrutzki, et al., 2013). Comparing to usual care, there is also evidence that specialized multidisciplinary tinnitus treatment based on CBT is cost-effective (Maes et al., 2014). More studies and better controlled groups are needed to be certain of these initial findings.
While we have reviewed some conflicting studies here, it seems to us that CBT is a useful technique in tinnitus management, and that it is probably most effective when administered by a practitioner who is an expert in CBT as well as tinnitus, and who has enough personal "force" to convince clients to change their thinking for their own good.