This document provides information on tinnitus and hyperacusis. It defines tinnitus as the perception of sound without an external stimulus. It discusses the prevalence, risk factors, pathophysiology, investigations, and treatments for both subjective and pulsatile tinnitus. A variety of mainstream and alternative treatment approaches are covered, including sound therapy, medications, and surgery. The document also examines hyperacusis and its relationship to tinnitus.

1. TINNITUS
&
HYPERACUSIS
DR.G.JOSHENI

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.  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.  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.  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. 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. 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. 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. 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.  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. 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. CALCIUM CHANNEL DYSFUNCTION
 Salicylates and quinine, affect intracellular calcium levels.
 Noise also affects the concentration of intracellular calcium

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. NOVEL SOUND THERAPIES
 Neuromonics
 Serenade
 Noise cancellation
 Acoustic CR neuromodulation
 Sound therapy with vagal nerve stimulation
 Mute button

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. 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. COMPLEMENTARY AND ALTERNATIVE MEDICINE

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. 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.  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.  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. 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. 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.  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. DIETARY SUPPLEMENTS

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. 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. 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. 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

45. 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

46.  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

47. 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

48. 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

49. 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

50. 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

51. 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

52. 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

53. IMMEDIATE SYMPTOMS
 Pain (most common)
 Otalgia
 Neck or jaw pain
 Facial pain.
 Tinnitus
 Balance disorders
 Hearing loss

54. DELAYED SYMPTOMS
 Hypervigilance
 Anxiety
 Sleep disorders
 Hyperacusis
 A feeling of aural fullness
 Normal symmetrical hearing

55. 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

56. 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

57. 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

58. 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

59. 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.

60. 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

61. 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

62. 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

63.  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

64. 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

65. 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

66. 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

67. 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

68. 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.

69. 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

70. 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

71. 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.

72. 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

73. PSYCHOSOCIAL FACTORS IN TINNITUS
 Emotional distress, insomnia and problems with sustained
concentration and cognitive functioning
 Personality traits, emotional state, psychiatric illness and cognitive
style

74. 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

75. 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

76.  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

77. 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

78.  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

79. 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

80. 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

81. 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

82. 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

83. 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’

84. 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

85. ‘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

86. 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

87. 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

88. 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