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Tinnitus

  1. 1. TINNITUS & HYPERACUSIS DR.G.JOSHENI
  2. 2. TINNITUS  The word tinnitus is derived from the Latin word tinnire (to ring)  McFadden’s described tinnitus as ‘the conscious expression of a sound that originates in an involuntary manner in the head of its owner, or may appear to him to do so’  Sensation of hearing a sound in the absence of an external stimulus or a sound sensation in the absence of an external or internal acoustical source or electric stimulation
  3. 3.  Pulsatile tinnitus is considered to be either synchronous or non- synchronous, depending on whether the sound is in synchrony with the patient’s arterial pulse  Subjective tinnitus - only the patient is aware of the sound sensation  Objective tinnitus - the sound can be perceived by others, either unaided, using a stethoscope or a microphone and amplifier
  4. 4.  Majority suffer from subjective idiopathic tinnitus  The tinnitus experienced is mainly simple sounds: whistling, humming, ringing or tones  The prevalence of persistent spontaneous tinnitus in the adult population was 10.1%  Defining persistent spontaneous tinnitus as tinnitus that arose spontaneously, not as a response to sound stimulus, and lasted for periods of 5 minutes or more at a time
  5. 5.  Women are more likely to perceive their tinnitus as a complex sound  A high frequency hearing deficit is a good predictor of tinnitus.  Previous noise exposure is also a good predictor  Left-sided tinnitus slightly more common than right-sided  Prevalence of tinnitus increases with age  Older people are more annoyed by their tinnitus than younger people
  6. 6. RISK FACTORS  Socioeconomic class, smoking, alcohol consumption  Other health issues such as previous head injuries, cardiovascular disease and hypertension  Specific otological conditions including Ménière’s disease, otosclerosis and vestibular schwannoma which is known as syndromic tinnitus  Drugs - salicylates, quinine, aminoglycoside antibiotics, and some antineoplastic agents, particularly the platinum based drugs  Type D personality
  7. 7. DIETARY FACTORS  Persistent tinnitus was associated with fruit, vegetable and bread consumption and dairy avoidance  Transient tinnitus reports increased with dairy avoidance and decreased with caffeinated coffee and brown bread consumption.  Bothersome tinnitus reports decreased with consumption of wholemeal, wholegrain bread  Higher caffeine consumption was associated with lower risk of developing tinnitus
  8. 8. COMORBIDITIES  Depression and anxiety  Temporomandibular joint dysfunction  Disorders of sound tolerance are commonly seen in association with tinnitus: 40% of people with tinnitus report some degree of hyperacusis  86% of people reporting hyperacusis also report tinnitus
  9. 9. PATHOPHYSIOLOGY  The most prevalent presentation of tinnitus in the general population is that of a subjective non-pulsatile sound  Many cochlear hair cells may be damaged before an apparent hearing loss is demonstrated using conventional pure-tone audiometry  Patients with tinnitus may demonstrate hearing loss at frequencies much higher than conventionally tested using standard methods
  10. 10.  Tinnitus can exist even if the auditory periphery has been completely destroyed or after the neural connections between ear and brain have been severed  The point at which the initial signal generation occurs has been dubbed the ignition site and the ensuing central mechanisms have been entitled promotion site  Any pathology that can potentially damage the auditory pathways has the potential to result in tinnitus
  11. 11. PERIPHERAL MECHANISMS DISCORDANT DAMAGE OF COCHLEAR HAIR CELLS  Outer hair cells have been shown to be more susceptible in noise and aminoglycoside antibiotics  In areas where outer hair cells have been damaged, tectorial membrane is no longer supported by the outer hair cells and can sag onto the inner hair cells, causing them to depolarize
  12. 12. CALCIUM CHANNEL DYSFUNCTION  Salicylates and quinine, affect intracellular calcium levels.  Noise also affects the concentration of intracellular calcium
  13. 13. GLUTAMATE RECEPTORS  Glutamate is the main excitatory neurotransmitter in the auditory system  AMPA receptors are the main receptors found on the auditory nerve fibres under the inner hair cell  Glutamate in large quantities is toxic to nerve fibres  NMDA receptors are also present in auditory nerve fibres  Pharmacological blockade of NMDA receptors can be protective against both salicylate-induced and noise-induced tinnitus in animal models
  14. 14. CENTRAL MECHANISMS INCREASED SPONTANEOUS FIRING  There is always a certain degree of electrical activity in the auditory system even when there is no sound input to the ear.  Damage to the ear results in reduced activity in the auditory nerve which in turn downregulates inhibitory processes in higher auditory centres, thereby potentially generating increased spontaneous activity in the auditory cortex that could be perceived as tinnitus
  15. 15. INCREASED CENTRAL NEURAL SYNCHRONY  Spontaneous neural activity in the auditory cortex is normally random and, when this activity becomes synchronized, this is the signal that a sound is present.  If the peripheral auditory system is damaged, spontaneous cortical activity tends to become more synchronized and there is speculation that this can give rise to tinnitus
  16. 16. REORGANIZATION OF THE CORTICAL AUDITORY MAP  The auditory system is tonotopically organized from cochlea to cortex: structures within the auditory system that deal with adjacent sound frequencies are situated beside each other  Neurons that received inputs from parts of the cochlea that have been damaged, tune in to the nearest adjacent frequency input that is still active  Overrepresentation of frequencies adjacent to areas of damage and increased neural activity at those frequencies
  17. 17. TINNITUS MODELS PSYCHOLOGICAL MODEL  There is some neurophysiological disturbance in the auditory system at any point between periphery and cortex  Normally the central auditory system should habituate to this activity  In certain situations such as high autonomic arousal, this process does not happen and the tinnitus activity can become intrusive  Relaxation therapy to reduce autonomic activity  Cognitive behavioural therapy to help change the emotional significance of the tinnitus
  18. 18. NEUROPHYSIOLOGICAL MODEL  In addition to events within the classical auditory system, tinnitus involved altered activity within the limbic system, reticular system and autonomic nervous system  This model stated the use of ‘tinnitus retraining therapy’ (TRT)
  19. 19. TINNITUS MODULATION  Many patients with tinnitus can modulate their symptom by touching their face clenching their teeth changing their gaze  This suggests the links between the auditory system and other somatosensory pathways
  20. 20. INVESTIGATION BASIC AUDIOMETRY  Pure-tune audiogram  Tympanometry TINNITUS-SPECIFIC AUDIOLOGICAL MEASUREMENTS  Loudness discomfort levels,  Tinnitus pitch matching,  Tinnitus loudness matching and  Minimal masking levels
  21. 21. IMAGING  Patients with unilateral tinnitus, an asymmetrical sensorineural hearing loss or associated neurological symptoms or signs require imaging to exclude the presence of a retrocochlear pathology such as a vestibular schwannoma.  The modality of choice is MRI
  22. 22. TINNITUS QUESTIONNAIRES  Tinnitus Handicap Questionnaire  Tinnitus Handicap Inventory (THI)  The Mini Tinnitus Questionnaire  Tinnitus Functional Index  Anxiety and depression with tinnitus-Hospital Anxiety Depression Scale (HADS)  Sleep disturbance - Insomnia Severity Index  Visual analogue scales
  23. 23. MAINSTREAM TREATMENTS  Many treatments may work via a placebo effect  General natural improvement in symptoms with time EXPLANATION AND REASSURANCE  An explanation of the condition and reassurance is a key initial step in the management of any patient with tinnitus  A negative counselling is damaging for patients with tinnitus and should always be avoided
  24. 24. HEARING AIDS  Hearing amplification may amplify external sounds and mask tinnitus, but indirect effects, such as improving communication, may reduce stress and anxiety that may be exacerbating the patient’s symptoms  Hearing amplification is considered to be the primary intervention
  25. 25. SOUND THERAPIES  Sound therapy can be used as part of TRT or as a standalone treatment.  It is possible to use sound to completely or partly suppress, or mask tinnitus  Complete masking is counterproductive as it may prevent habituation to the tinnitus signal  Sound should be used at very low levels at a point where the added sound is just below the perceived level of the tinnitus  This point is called the Mixing or blending point, which is supposed to facilitate the habituation process
  26. 26. TYPES OF HEARING DEVICES  Hearing aids that produce masking by amplifying ambient sound  Small ear level devices that generate wide-band sound (known as tinnitus maskers, sound generators, white noise generators or wide-band sound generators)  Combination device  Appliance that produces sound in the patient’s immediate environment. This is referred to as environmental sound enrichment
  27. 27. NOVEL SOUND THERAPIES  Neuromonics  Serenade  Noise cancellation  Acoustic CR neuromodulation  Sound therapy with vagal nerve stimulation  Mute button
  28. 28. ULTRASOUND  High- frequency sound is applied by a bone-conduction transducer  It stimulates the cochlea without interfering with the patient’s hearing for sounds occurring in the normal auditory spectrum
  29. 29. COMBINATION TREATMENT MODALITIES  Combined directive counselling and sound therapy to counteract the pathological positive feedback process and promote habituation to the tinnitus  Tinnitus retraining therapy (TRT) is much more effective as a treatment for patients with tinnitus than tinnitus masking  CBT resulted in no significant difference in tinnitus loudness, but CBT did result in a significant improvement in both depression scores and in quality of life scores  Mindfulness meditation and acceptance and commitment therapy
  30. 30. COMPLEMENTARY AND ALTERNATIVE MEDICINE
  31. 31. ELECTROMAGNETIC STIMULATION  Direct electrical stimulation of the ear has been shown to suppress tinnitus but delivering this stimulation is invasive and risks damage to the inner ear  High-powered rare earth magnets have been placed in the ear canal  Electromagnetism has been used in conjunction with functional imaging such as PET scanning or fMRI: pathologically active areas of brain are identified and electromagnetic therapy is then directed to this area.  Repetitive transcranial magnetic stimulation (rTMS)
  32. 32. SYSTEMIC DRUG TREATMENTS  Psychoactive drugs – for symptoms of psychological distress and because many of the receptors that psychoactive drugs act upon are also found within central auditory pathways.  Tricyclic antidepressant drugs  Selective serotonin reuptake inhibitor, paroxetine, showed no advantage over placebo  Benzodiazepines  Antiepileptic and antispasmodic drugs  Vasodilators and diuretics  Betahistine - no scientific rationale for this action.
  33. 33.  Local anaesthetic agents  Procaine caused temporary abatement of tinnitus in a patient undergoing nasal surgery  Bolus intravenous injection of lidocaine produced significant short- term tinnitus suppression  The antitinnitus effect of the local anaesthetic agent was central rather than peripheral
  34. 34.  Melatonin helps patients who have sleep disorders associated with tinnitus  Lack of oxygen secondary to vascular insufficiency is treated by application of hyperbaric oxygen therapy to increase the supply of oxygen to the ear and brain to reduce the severity of hearing loss and tinnitus  Glutamate is the main excitatory neurotransmitter in the auditory system  Its antagonist drugs, including memantine, flutirpine and neremexane  Carbamazepine can be effective in treating a variant of tinnitus that presents with an intermittent staccato quality, described as sounding like a typewriter or popping corn
  35. 35. REGIONAL DRUG TREATMENTS  Botulinum toxin for neuropathic pain and migraine.  With respect to migraine, botulinum toxin is thought not only to block acetylcholine but also to inhibit the release of other neurotransmitters and neuropeptides involved in the autonomic pathway  The drug is injected into soft tissues around the ear
  36. 36. INTRATYMPANIC DRUG TREATMENTS  Direct injection through the tympanic membrane was first utilized as a potential treatment for otosclerosis  Transtympanic administration of aminoglycosides in the treatment of Ménière’s disease  Transtympanic administration allows direct labyrinthine drug absorption which may offer improved labyrinthine metabolism  There is a small therapeutic time window between the pathological event in the ear and the development of permanent changes in the central auditory system
  37. 37.  In patients with sudden onset of tinnitus, there might be a short period when intratympanic treatments could be efficacious  Steroids, local anaesthetic agents, anticholinergic drugs, glutamate antagonists and antioxidant compounds  Esketamine, the S(+) enantiomer of ketamine, for acute ‘inner-ear’ tinnitus which acts as a non-competitive antagonist of the N-methyl-D-aspartate (NMDA) subgroup of glutamate receptors  Sustained-release formulation of another NMDA antagonist, gacyclidine
  38. 38. DIETARY SUPPLEMENTS
  39. 39. LASERS  Lasers were used to treat chronic pain  Low-power lasers have been used in the treatment of tinnitus, applied either transmeatally or to the mastoid process
  40. 40. SURGERY  Stapedectomy for otosclerosis  When tinnitus is associated with profound hearing loss, cochlear implantation  Destructive surgical procedures including VIIIth nerve neurectomy or selective cochlear neurectomy  Surgical treatments of Ménière’s disease
  41. 41. PREVENTION  Cochlear damage caused by exposure to agents including noise, ototoxic agents and cytotoxic drugs is recognized as a trigger for tinnitus  Inner ear damage is generally mediated by a process of apoptosis  Antioxidants including D-methionine (D-met), ebselen or a combination of beta carotene, vitamin C, vitamin E and magnesium (ACE Mg).  Stem-cell and gene therapies are also being investigated
  42. 42. PULSATILE TINNITUS SYNCHRONOUS PULSATILE TINNITUS PATHOPHYSIOLOGY  Synchronous pulsatile tinnitus may present as the direct result of abnormal vascular anatomy in the vicinity of the peripheral auditory system.  Systemic aberrations of the circulation, such as a hyperdynamic circulation may also produce tinnitus  Idiopathic intracranial hypertension, or pseudotumor cerebri tends to occur more often in young, overweight women
  43. 43. INVESTIGATION  Simple blood tests are considered helpful to exclude anaemia and thyrotoxicosis  If otoscopy reveals a retrotympanic mass, a contrast-enhanced CT of the temporal bone, brain and scalp is indicated  If atherosclerotic carotid artery disease is suspected, duplex carotid ultrasonography is done  The gold standard mode of imaging the vascular system of the temporal bone, brain and scalp is via formal angiographic imaging which is reserved for severe, recalcitrant cases
  44. 44.  If idiopathic intracranial hypertension is suspected Ophthalmological assessment Lumbar puncture Measurement of intracranial pressure and Diagnostic reduction of intracranial pressure by draining off some cerebrospinal fluid
  45. 45. TREATMENT  Supportive  Reassurance that there is no untoward pathology present  CBT or TRT  Sound therapies  Microvascular decompression of vascular loops  Vascular loops are commonly in close proximity to the cochlear nerves of patients with tinnitus  Laterally placed loops generate pulsatile tinnitus whereas vessels adjacent to the medial half of the nerve generate non-pulsatile tinnitus
  46. 46. NON-SYNCHRONOUS PULSATILE TINNITUS  Related to myoclonic activity resulting in repetitive contractions of the middle ear muscles - tensor tympani and/or stapedius muscle  The palatal muscles can also develop myoclonic contraction and this can produce clicking sound that is audible to others and is usually irregular with a frequency of one to two clicks per second  Inspecting the palate transorally or by visualizing the upper surface transnasally using a fibreoptic endoscope  Symptomatic palatal myoclonus - associated with lesions of the brainstem  Essential palatal myoclonus - usually idiopathic
  47. 47. INVESTIGATION  Middle ear myoclonus can be diagnosed based on history and impedance changes on long-time-based tympanometry  Palatal myoclonus usually produces an objective rhythmic sound that is associated with an involuntary movement of the soft palate and/or suprahyoid muscles  MRI is recommended to exclude a pathology with the triangle of Guillain–Mollaret
  48. 48. TREATMENT  Conservative treatment  Benzodiazepines, orphenadrine, carbamazepine, piracetam and botulinum toxin  Relaxation therapy, psychotherapy, tinnitus masking and biofeedback  In persistent cases, the surgical division of the middle ear tendons
  49. 49. ALLIED CONDITIONS MUSICAL HALLUCINATION  Common in women, the elderly and those with significant hearing impairment  Caused by deafferentiation, in which reduced input to the central auditory system causes increased gain within the associative auditory cortex  Brain misinterpreting background neuronal activity as music  For auditory hallucinations of mental illness, psychiatric opinion is essential  Musical hallucination can rarely be associated with epilepsy so a neurological opinion is prudent
  50. 50. ACOUSTIC SHOCK  It occurs when exposed to sudden unexpected sounds through their headsets or telephone handsets  Causative sounds had short rise times  Sounds that are generated close to the ear seem more likely to cause these symptoms than distant sounds  Cochlear and central auditory system mechanisms acoustic shock represents tonic contraction of the middle ear muscles – tonic tensor tympani syndrome
  51. 51. IMMEDIATE SYMPTOMS  Pain (most common)  Otalgia  Neck or jaw pain  Facial pain.  Tinnitus  Balance disorders  Hearing loss
  52. 52. DELAYED SYMPTOMS  Hypervigilance  Anxiety  Sleep disorders  Hyperacusis  A feeling of aural fullness  Normal symmetrical hearing
  53. 53. LOW-FREQUENCY NOISE COMPLAINT  It causes major disruption of normal activities and is often associated with sleep disturbance  They generally feel that the sound is a real external sound  In standard tinnitus, the person feels that the sound is within their own ears or head  Low-frequency sound levels are usually at or below hearing threshold  CBT  Counselling and sound therapy
  54. 54. EXPLODING HEAD SYNDROME  Exploding head syndrome is a parasomnia phenomenon characterized by the perception of a sudden loud noise in the head or ears that occurs during a transition of sleep stages  It is generally hypnagogic, occurring at the interface from wakefulness to sleep, but can be hypnopompic, presenting at the onset of wakefulness
  55. 55. ASSOCIATED FEATURES  Visual sensations in approximately 10% of cases  Feeling of heat or an electrical sensation which may be painless and has no serious medical sequelae  Feelings of shock and fear  Tachycardia and palpitations
  56. 56. EPIDEMIOLOGY  It is common in women and those over 50  Persistent over many years or can spontaneously remit  Exclude other conditions such as nocturnal epilepsy or subarachnoid haemorrhage TREATMENT  Education and reassurance  Tricyclic antidepressants, anticonvulsants and calcium-channel blockers
  57. 57. SPECIAL POPULATIONS MILITARY PERSONNEL  Military personnel experience both chronic noise exposure and sudden extreme noise exposure.  Even when wearing hearing protection, military personnel may be exposed to levels of sound that exceed safe limits  Service personnel may be exposed to ototoxic chemicals  Post-traumatic stress is high  Traumatic brain injury is also more common among military veterans and this may affect the central auditory system.
  58. 58. DISORDERS OF SOUND TOLERANCE DEFINITIONS AND CLASSIFICATION  Hyperacusis a dislike of loud sounds  Types of hyperacusis - Loudness hyperacusis, annoyance hyperacusis, fear hyperacusis and pain hyperacusis  Phonophobia a fear of particular sounds  Loudness recruitment a specific experience that is associated with cochlear hearing loss and specifically with dysfunction of the outer hair cells of the organ of corti  Misophonia a strong dislike of specific sounds
  59. 59. HYPERACUSIS DEFINITIONS  ‘Unusual tolerance to ordinary environmental sounds’  ‘Consistently exaggerated or inappropriate responses to sounds that are neither threatening nor uncomfortably loud to a typical person’ EPIDEMIOLOGY  Hyperacusis may be a precursor state for tinnitus
  60. 60. PATHOPHYSIOLOGY  Increased perception of sound intensity in the auditory cortex (hyperacusis) together with the perception of phantom sounds (tinnitus) results from a common trigger (hearing loss).  Central auditory system is playing the key role in setting auditory gain and perpetuating the perception of increased loudness
  61. 61.  Bell’s palsy and Ramsay Hunt syndrome - increased perception of sound intensity, secondary to an inefficient or absent stapedial reflex  Williams syndrome is a disorder characterized by deficits in conceptual reasoning, problem solving, motor control, arithmetical ability and special cognition and hyperacusis  Underlying dysfunction of 5-hydroxytryptamine (5-HT), migraine, depression and post-traumatic stress disorder, may lead to the increased auditory gain
  62. 62. INVESTIGATION  Measurement of loudness discomfort levels (ldls)  Thoroughly counselled beforehand and offered an opportunity to decline the investigation.  Stapedial reflex testing should be avoided because a loud test tone may be unpleasant or painful
  63. 63. TREATMENT  Ear protection in the form of ear plugs or ear defenders Sound deprivation worsens sound tolerance whereas enhancement of the acoustic background improves tolerance  TRT  CBT  Mindfulness meditation and ACT
  64. 64. MISOPHONIA DEFINITIONS  Dislike particular sounds irrespective of the level of the sound  Causative sounds included those of lip smacking, throat clearing, chewing or breathing.  Typical emotions included anger, disgust, irritation, anxiety, panic and avoidance behaviour. This was termed selective sound sensitivity syndrome.  Misophonia is associated with psychiatric conditions including obsessive– compulsive disorder, eating disorders and tourette syndrome
  65. 65. EPIDEMIOLOGY  The onset of the problem is generally peripubertal CLINICAL FEATURES  Sounds that trigger misophonia are generally sounds produced by other humans and in many cases the sound is produced by a specific person  Environmental sounds such as wind, rain or waves do not generally trigger misophonia  Coping strategies such as mimicking the causative sound
  66. 66. PATHOPHYSIOLOGY  Abnormal activation of the limbic and autonomic nervous systems  Psychological conditioning to repetitive events  A generalized hyper-reactivity condition  A defect in serotonin and dopamine utilization in the limbic system and basal ganglia  A variant of synaesthesia  The anatomical location of the problem is downstream from initial sound processing areas and may be situated in the inferior part of the temporal lobe where the nature of sounds or ‘what’ information is processed.
  67. 67. INVESTIGATION  Evoked-response audiometry  Skin conductance measurements - similar stimuli was unpleasant but the reaction demonstrated by the people with misophonia was greater than the reaction in the control group  Questionnaires  Amsterdam Misophonia Scale,  The Misophonia Questionnaire,  The Misophonia Assessment Questionnaire,  The Misophonia Coping Response Survey and  The Misophonia Trigger Survey
  68. 68. TREATMENT  Reassurance and education directed to both the patient and family  CBT  Sound therapy  TRT using a combination of counselling and sound therapy  Wear headphones when in the presence of their misophonia trigger
  69. 69. BEST CLINICAL PRACTICE  All patients with tinnitus should undergo a basic audiological assessment.  Further investigation those with pulsatile tinnitus; unilateral tinnitus; tinnitus in association with asymmetric hearing loss; tinnitus in association with significant vertigo; tinnitus in association with neurological symptoms and/or signs  Most people with tinnitus go through a process of habituation and the impact of the symptom gradually lessens with time.
  70. 70. THE BIOPSYCHOSOCIAL MODEL OF HEALTH AND ILLNESS  The biopsychosocial model places health and illness within the context of the psychological and social influences affecting an individual, together with their biology  The focus of treatment enables patients to manage tinnitus and its impact upon their life themselves, rather than being ‘cured’ of it  Chronic pain and chronic tinnitus  Both are linked to changes in the CNS after being triggered by peripheral changes  Both are associated with anxiety, depression, insomnia and reinforce each other within a vicious circle
  71. 71. PSYCHOSOCIAL FACTORS IN TINNITUS  Emotional distress, insomnia and problems with sustained concentration and cognitive functioning  Personality traits, emotional state, psychiatric illness and cognitive style
  72. 72. PERSONALITY FACTORS  How an individual reacts to tinnitus influences the degree of distress they experience  Traits of perfectionism, life satisfaction and anxiety sensitivity increase tinnitus severity.  Optimism is negatively associated with tinnitus distress  When tinnitus arises in people who are already emotionally strained, it is more likely to lead to distress
  73. 73. COGNITIVE VARIABLES RELATED TO TINNITUS  Distress arises because tinnitus is interpreted in a threatening way.  The most common themes in the thinking of distressed tinnitus patients reflect despair, persecution, hopelessness, loss of enjoyment, a desire for peace and quiet, and beliefs that others do not understand.  Catastrophic thoughts are associated with fear, which increases attention towards the tinnitus and reduces quality of life  Catastrophization in the early stages of the tinnitus experience appears to have a pivotal role in determining the long-term distress
  74. 74.  The perception of an illness is known to influence coping behaviours and outcomes in chronic illness  Internal locus of control in tinnitus is associated with habituation, reduced psychological distress and reduced severity  Illness perceptions are influenced by historical, social and cultural context  Patients will benefit from a hopeful but realistic assessment of tinnitus
  75. 75. EMOTIONAL CONSEQUENCES: ANXIETY AND DEPRESSION IN TINNITUS  Psychological distress in tinnitus patients can clearly be a reaction to the tinnitus, but emotional disorders can also act as a trigger for tinnitus  More distressed the patient becomes the more problematic the tinnitus  Severity of tinnitus relates to the severity of the depression.  Depressed tinnitus patients reported more psychological and somatic complaints than those who were not depressed
  76. 76.  Tinnitus patients report greater than average cognitive anxiety (worry and negative self-talk) and somatic anxiety (rapid heart rate and shortness of breath)  Depressed and anxious patients report more tinnitus distress and severity  Anxiety at onset predicts tinnitus distress 6 months later  Symptoms of PTSD and tinnitus are mutually aggravating
  77. 77. TINNITUS AND SUICIDE  It is not tinnitus per se that results in suicide but concomitant psychiatric conditions that amplify the effects of tinnitus on the individual patient  Psychological features known to increase the risk of suicide include hopelessness, helplessness, fear and anger
  78. 78. BEHAVIOURAL RESPONSES TO TINNITUS  Avoidant coping strategies and active coping styles are associated with worse tinnitus  Tinnitus-related fear-avoidance behaviour is highly correlated with anxiety and depressive symptoms and plays an important role in predicting tinnitus handicap  Concentration/attention problems - Tinnitus acts as a competing stimulus that attracts attention away from other things
  79. 79. SLEEP  Sleep disturbance is particularly prevalent among children with tinnitus  Insomnia is not an inevitable consequence of tinnitus, so tinnitus is probably not a specific sleep antagonist.  A premorbid sleep disturbance may create an opportunity to focus upon tinnitus, thus emphasizing a lack of sleep.  It may be the anxiety associated with the tinnitus that causes insomnia
  80. 80. FAMILY AND RELATIONSHIPS  Emotional distress or avoidance of situations as a result of tinnitus can adversely affect relationships  Other people’s responses to the patient can also have an impact by affecting their level of disability  Solicitous responses by spouses can also have a detrimental effect, with enquiries about tinnitus increasing distress  Helpful responses to tinnitus should thus be supportive, acknowledging the distress, without encouraging further distress-related behaviour
  81. 81. TREATMENTS FOR TINNITUS COGNITIVE BEHAVIOURAL THERAPY  CBT seeks to change overly negative thoughts and beliefs about tinnitus (and other issues causing distress), thus breaking unhelpful feedback cycles, reducing distress and improving habituation  In CBT, the patient is helped to recognize the link between thoughts, mood and behaviour and to identify and challenged ‘distorted’ or unhelpful thoughts.  CBT is time-limited (six to ten weekly sessions) and teaches skills that will enable the person to become their own ‘therapist’
  82. 82. SELF HELP AND THE INTERNET  CBT equips patients with skills that ultimately should allow them to cope with difficulties on their own  Bibliotherapy (self-help books or manuals) offers significant benefits, enhanced by minimal therapist support but attrition rates are higher and effect sizes smaller  Internet-based CBT therapist support provided over email. Outcomes are superior to self-help manuals
  83. 83. ‘THIRD WAVE’ THERAPEUTIC APPROACHES  CBT that has been developed and extended by increasing the emphasis upon accepting unwanted thoughts and feelings  Suffering is regarded as a normal part of life, and attempts to resist or change suffering can potentially perpetuate distress  Acceptance and commitment therapy (ACT) and Mindfulness-based therapies such as mindfulness-based cognitive therapy (MBCT)  ACT has been delivered effectively via the internet
  84. 84. HYPERACUSIS  Elevated levels of emotional and psychological distress, particularly anxiety  Behavioural responses in hyperacusis are characterized by avoidance and safety behaviours (avoiding noise and using ear protection)  If patients react to noise with avoidance, their capacity to engage in normal daily activities and effective interpersonal functioning will be inhibited
  85. 85. TREATMENT FOR HYPERACUSIS  Desensitization to sound involves the use of white noise generators with sound levels gradually increased over time  Talking therapies to reduce the distress that accompanies hyperacusis  CBT to reduce avoidance of noise  Psychoeducation  Applied relaxation  Exposure to sound and behavioural activation
  86. 86. SUMMARY  Psychological distress, particularly anxiety and depression, are common experiences among tinnitus and hyperacusis patients.  Negative thoughts (particularly catastrophic thoughts), avoidant behaviour and emotional distress also act as provocations for tinnitus and hyperacusis-related problems  Currently psychological treatments appear to offer the most effective remedy for patients.  The clinical environment will shape the thoughts, behaviours and emotions of patients and is of therapeutic benefit

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