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Psychological
disorders combined with tinnitus
Tinnitus from the perspective of the psychologist
Karoline V. Greimel, PhD (Salzburg University Hospital)
Birgit Kroener-Herwig, PhD (University of Goettingen, Department of Clinical
Psychology & Psychotherapy
The
psychological perspective on tinnitus
Tinnitus always has to be regarded as being both a medical
and a psychological phenomenon. Even if there is a medical reason for
the emergence of tinnitus (e.g., hair cell damage) it is the brain that
generates the inner noise when interpreting an altered pattern of nerve
signals. This "abnormal" perception is further processed by the brain
and then psychological factors come in and play an important role regarding
how the tinnitus is evaluated and coped with. Nevertheless, when proposing
a "psychological dimension" of tinnitus, it does not mean that tinnitus
is a mental disorder. To classify patients with tinnitus on the basis
of hypothesized underlying medical conditions as "organic" or "non-organic"
(respectively "psychogenic") is not reasonable, either. Likewise, it is
not at all advisable to attempt to modify the patient's personality. Instead,
the consequences of tinnitus (i.e., behaviour and cognitions regarding
tinnitus) must be made the central issue in psychological assessment and
intervention.
Due to the fact that tinnitus is not verifiable by any objective measurement,
patients easily get the feeling that their sensations are not taken seriously.
They are afraid that their symptoms are considered as imagined, not real,
or feigned. For that reason it is important to emphasize the validity
of tinnitus as a sensory experience to the patients.
Psychological approaches: assessment,
psychoeducation/counseling, psychological treatment
The primary goal of psychological interventions is to improve
the patient's ability to reduce the impact of tinnitus on quality of life,
i.e. to teach and improve coping strategies. Psychological approaches
can offer assessment and management of tinnitus.
Psychological assessment
A comprehensive assessment is essential before the implementation
of a therapy. Apart from medical and audiological parameters, perceptual,
attentional, emotional and behavioral aspects have to be equally considered.
Topics of psychological assessment include characteristics of tinnitus
(loudness, localization, pitch of sound) and the progression of tinnitus
(onset, duration, intensity, increasing and decreasing factors). Beyond
that, cognitive-emotional evaluation and coping (e.g., catastrophic thinking,
helplessness, anger, sadness, etc.), psychological impairments related
to tinnitus (depression, irritability, sleeping problems and so on), effects
of tinnitus on life (e.g., work, social interactions), sources of stress
apart from tinnitus (e.g., live events, daily hassles), operant factors
(e.g., avoidance behavior), comorbidity (e.g., mental disorders, hearing
loss), treatment history and treatment expectations.
In addition, sometimes it might be important to disentangle
connections between tinnitus and other afflictions, preventing tinnitus
from becoming a scapegoat for all other problems. Assessment of tinnitus
also includes the patient's view of his/her problem: Although from a psychological
perspective, the etiology of tinnitus can be neglected most of the time,
the way in which patients interpret the cause for tinnitus can be essential
for coping efforts. Patients may indicate that intensity or loudness of
their tinnitus causes difficulties in the areas of sleep, concentration,
hearing, social relationships or work and is therefore made responsible
for their increasing anxiety and depression. However, as research shows,
there appears to be little correlation between the subjective loudness
of the tinnitus and the degree to which a person is impaired by it (Coles
and Baskill, 1995; Traserra et al., 1995). Tinnitus distress can not be
regarded as dependent on the severity of the tinnitus sensation or as
a function of "loudness". A variety of features of tinnitus, together
with characteristics of the individual, have to be considered in assessing
tinnitus related distress. It is the patient's reaction to tinnitus rather
than the symptom itself that separates the individual who simply "experiences"
tinnitus from the individual who seeks medical or psychological help because
of tinnitus (Sweetow, 1986).
Psychological assessment is accomplished through interviews, questionnaires,
severity rating and so on. Sometimes diaries are used for documenting
frequency, duration, intensity and other parameters of tinnitus impairment.
The introduction of diaries arouses the fear in some patients that it
might cause exacerbation of tinnitus, because attention is focused on
it. However, this is not harmful, on the contrary, it rather might be
an opportunity to make patients aware of the alliance between attention
direction and perception.
Psychoeducation/psychological counseling
An understanding of the assumed neurobiological basis of tinnitus and
its cognitive, emotional and behavioral factors is essential for successful
coping. Knowledge about tinnitus ought to be enhanced and patients are
led to take psychological aspects of tinnitus into account. Educational
programs cover topics like assumptions about causes of tinnitus information
about exacerbating factors and the prognosis, and give an overview of
treatment possibilities, etc. Many patients are afraid that tinnitus might
become worse over time, that they will go deaf, and they consider tinnitus
to be a severe illness. Such beliefs and concerns shift attention to tinnitus
and increase its awareness. Patients need to be taught about the relationship
between selective attention on tinnitus and its cognitive-emotional and
behavioral consequences.
It is also important to inform patients that a large number of individuals
are not impaired at all and are able to cope effectively with tinnitus.
Poor coping has been found to be associated with lack of control over
sound and failure to habituate (Hallam et al., 1988). Besides the perception
of noises, various other problems may contribute to a negative emotional
status and patients may incorrectly attribute it entirely to tinnitus.
In addition, patients often are worried that tinnitus becomes worse over
time. However, research has shown quite the opposite: the number of complaints
tends to decline the longer the tinnitus has been present (Tyler & Baker,
1983; Andersson et al., 2001).
Instead of focusing on the unrealistic goal of tinnitus elimination, modifying
the ways of coping with tinnitus is a more realistic goal. However, this
can be challenging and involves assisting patients in the identification
of aggravating factors and dealing with negative emotions (e.g., anxiety,
anger, depression), sleeping problems, interferences with social and recreational
activities, concentration dysfunctions and deterioration of performance.
Sometimes patients also need help avoiding countless ineffective treatments
and considerable costs.
Psychological treatment
Treatment has to be tailored to the specific needs of patients, and patients
should become active participants in all assessment and treatment procedures.
Psychological approaches depend on the working alliance between therapist
and patient rather than on so-called "compliance". Psychological treatment
is a collaborative, rather than directive approach (Wilson & Henry, 2000)
Before beginning any psychological treatment, a therapeutic rationale
has to be developed and offered to the patient. A general hypothetical
model of tinnitus tolerance was first developed by Hallam et al. (1984)
and enhanced by Kroener-Herwig (1997).
This model of tinnitus tolerance described by Hallam (1987) suggests that
tinnitus can be equated with any other auditory stimulus to which a person
may or may not attend and that habituation to tinnitus noises and development
of tolerance is the normal response, even though this process may take
time. Habituation takes place when an originally new stimulus becomes
"well known" and has no relevance for taking any actions. Habituation
fails if the stimulus is endowed with a negative evaluation (threat, impairment,
anxiety). Attention to the inner noise is correlated with distress since
it is associated with negative thoughts (e.g., catastrophizing and worrying)
and may also interfere with other activities (e.g., falling asleep, reading
a book).
In this model suffering from tinnitus is explained as a failure of habituation
or adaptation. At least three classes of variables are considered influential
to the process.
These variables can be divided into:
1. Sensory factors: The characteristics of the stimulus (i.e., intensity
and quality). It is assumed that noises which are more salient and show
a more variable and irregular pattern require a longer period of habituation.
2. Perceptual factors: Environmental conditions (e.g., intensity of
other stimuli and the competing demands on attention). For some patients
masking by natural sounds will frequently occur. Different activities
and competing sensory perceptions ought to distract attention from tinnitus.
3. Psychological factors: It is assumed that the more meaningful, especially
the more threatening, a stimulus is, the more attention it will receive,
which creates a positive feedback loop: the more tinnitus is attended
to the more the person is involved in negative cognitive emotional processing.
High levels of cortical arousal are supposed to delay habituation. A
patient's style of information processing and general distractibility
may influence habituation as well. Furthermore, CNS pathology affecting
the neural pathways involved in attention, habituation and appraisal
has to be considered as well.
Psychological therapies aim to assist patients in controlling
attention by learning to direct attention away from tinnitus (attention-control
techniques) and in bringing negative cognitive processes under self-control
(cognitive restructuring techniques). Behaviour modification techniques
aim at the reduction of avoidance behavior motivated by tinnitus and increase
in adaptive problem solving. In addition, different forms of relaxation
training, including biofeedback, are offered to find a way of coping with
tension related to tinnitus, sleeping difficulties or other sources of
stress (see chapter CBT).
General recommendations
regarding treatment protocols
Psychological interventions should be an integral part of tinnitus management
and not be based on the existence of a mental disorder, despite the fact
that in some cases anxiety or depressive disorders can accompany tinnitus
attributed distress. Early referrals to a psychologist are desirable to
undertake an assessment of tinnitus related complaints, identification
of psychiatric comorbidity and to undertake a comprehensive functional
analysis of the problem. Referrals to psychologists after various medical
and audiological treatments have failed in removing or diminishing tinnitus
are counterproductive. And simply telling the patient to accept and ignore
the ringing in their ear is not enough, - if it were, they would have
already done so. Giving the information that "nothing more can be done"
and that the tinnitus might be "psychogenic" is often interpreted by patients
as uncaring and insensitive. Such sentiments hamper the search for and
acceptance of psychotherapeutic help.
McFadden (1982) stated that "treatment of psychological
factors without adequate preparation of the patient often results in confusion
and alienation." It is vital to inform the patient that while the tinnitus
is "real", the maladaptive response is creating the distress and this
is where patient themselves can intervene. Moreover, cognitive-behavioural
therapy, albeit a primarily psychological approach, may have significant
neurophysiological consequences as suggested by the principles of neuroplasticity
and cortical reorganization (Kilgard & Merzenich, 1998; Rauschecker,1999;
Moeller, 2003). Resistance is often minimized when the patient recognizes
that this approach works on the biological level as well.
When tinnitus is experienced, a patient will very likely consult his or
her doctor first. From the very beginning, physicians, audiologists and
psychologists should work together as partners. Medical assessments and
interventions prevail at that the beginning. Psychological assessment,
counseling and treatment should become more significant over the course
of time.
While medical interventions attempt to remove ("to cure") tinnitus, psychological
intervention rather supports patients in learning to tolerate the noises
and handle tinnitus related impairments ("to manage"). The patient role
is very different in medical and psychological settings as well. While
doctors "treat" a disease and patients are more or less passive recipients
of treatment, patients have to participate actively in psychological approaches.
The collaborative style maximizes patient involvement, encourages the
patient to take responsibility, and minimizes the feeling that the therapist
is imposing his or her own view on the patient.
The time of referral to a psychologist and psychotherapist has to be planned
carefully as well. Often Psychological factors are neglected. Patients
expect that tinnitus is being removed by medical interventions. When this
goal fails (which is the case in chronic tinnitus most of the time) patients
increasingly get disappointed and frustrated. In response, they might
visit other doctors ("doctor-shopping") or become desperate and hopeless.
The medical expert should be helpful in deciding when is the right moment
for seeking the cooperation of a psychologist by assessing the cognitive-emotional
and behavioral impact of tinnitus on the patient early and repeatedly.
Sometimes the patient is referred to a psychologist, without (or insufficiently)
performing medical and audiological assessments. In this case, tinnitus
is considered exclusively "psychogenic" and medical and audiological factors
are ignored. Both ways have their shortcomings in the long run. In any
medical condition which is predisposed to become chronic, medical as well
as behavioral variables have to be considered equally. It is mainly the
cognitive, emotional and behavioral response to tinnitus that separates
patients experiencing tinnitus from patients who are suffering from tinnitus,
and behavior can be changed at any time. Due to that, psychologists play
an important role in tinnitus management regardless of the existence of
psychiatric disorders.
References:
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follow-up of tinnitus complaints. Arch. Otolaryngol. Head Neck Surg.
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Coles, RRA and JL. Baskill. Absolute loudness of tinnitus. Tinnitus
clinic data. Proceedings of the Fifth International Tinnitus Seminar
Portland, Oregon, American Tinnitus Association; 1995: 135-141.
Hallam, RS. Psychological aspects of tinnitus. Contributions to medical
psychology. S. Rachmann (Ed.). Oxford, Pergamon Press; 1984: 31-53.
Hallam, RS. Psychological Approaches to the evaluation and management
of tinnitus distress. Tinnitus. J. Hazell (Ed.). Edinburgh, Churchill
Livingstone; 1987: 156-175.
Hallam, RS., Jakes, SC. and R. Hinchcliffe. Cognitive variables in
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213-222.
Kilgard, MP. and MM Merzenich. Plasticity of temporal information processing
in the primary auditory cortex. Nature Neuroscience 1998; 1: 727-731.
Kroener-Herwig, B. (Hrg.). Die Psychologische Behandlung des chronischen
Tinnitus. Weinheim, Beltz; 1997.
McFadden, D. Tinnitus: Facts, theories and treatments. Washington
D.C., National Academy Press; 1982.
Moeller, AR. Pathophysiology of tinnitus. Otolaryngol Clin North Am
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Rauschecker JP. Auditory cortical plasticity: a comparison with other
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Sweetow, RW. Cognitive aspects of tinnitus-patient management. Ear
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Traserra, J., Doménech, J., Fusté, J., Carulla, M. & Traserra-Coderch,
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Posted
2012-01-09
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