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18.05.2014

Tinnitus causes and clinical management, bipolar disorder manic depressive illness - For Begninners

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The versatility of the Siemens tinnitus therapy feature makes it easy to work with the tinnitus protocol of your choice.
This webinar will serve as an introduction to the CONNEXX 7.4 software, with a focus on programming and adjusting hearing instruments featuring the binax platform. Tinnitus can be devastating for many patients, causing emotional, hearing, sleep and concentration problems.
The leading causes of traumatic brain injury (TBI) in civilians are motor vehicle accidents, falls, and assaults. While the nature and outcomes of brain injuries resulting from blast exposure are not yet fully understood, it is known that TBI causes both acute and delayed symptoms. We have described audiologic tinnitus management (ATM) previously (Henry, Zaugg, & Schechter, 2005a, 2005b). PATM uses therapeutic sound as the primary intervention modality, and it is distinguished from other sound-based methods (neuromonics tinnitus treatment, tinnitus masking, and tinnitus retraining therapy) in that the sound-management protocol is adaptive to address patients' unique needs. The focus of patient education is to provide patients with the knowledge and skills to use sound in adaptive ways to manage their tinnitus in any life situation disrupted by tinnitus. The Tinnitus Pyramid illustrated in Figure 1 is a way of visualizing how people who experience chronic tinnitus are affected differently.
The overall goal of PATM's hierarchical approach is to minimize the impact of tinnitus on patients' lives as efficiently as possible. Level 1 is for referring patients at the initial point of contact-usually by nonaudiologist clinicians. Because tinnitus can affect many aspects of health, a team approach to tinnitus management is the ideal. Both TBI and tinnitus often are associated with mental health disorders, including PTSD, depression, and anxiety.
The PATM model was developed primarily as the result of a series of clinical studies conducted at the National Center for Rehabilitative Auditory Research (NCRAR).
Some tinnitus patients present with behaviors that indicate the need for an evaluation by a psychiatrist, psychologist, or other licensed mental health professional.
Tinnitus is a symptom of dysfunction within the auditory system and usually is associated with some degree of hearing loss.
The Level 2 evaluation includes a standard audiologic evaluation and brief written questionnaires to assess the relative impact of hearing problems and tinnitus problems. The advantages of a group education format include the following: (a) Education and support can be provided to more patients in less time-maximizing available resources. For each of the three types of sound for managing tinnitus (soothing, background, and interesting), patients are taught that environmental sound, music, or speech can be applied.
Intervention with PATM focuses on assisting patients in learning how to self-manage their tinnitus using therapeutic sound in adaptive ways.
Caution should be used when discussing the use of psychological interventions with patients due to the stigma of mental illness and negative connotations of seeing a psychologist. CBT has been shown to be effective in reducing the annoyance of tinnitus and is an adjunct to the sound-based PATM counseling to address emotional difficulties by teaching patients to learn ways to change their thoughts and feelings about tinnitus.
Each participant uses a worksheet to develop an individualized "plan of action" to change their negative thoughts and feelings about tinnitus-see Figure 6, PATM Changing Thoughts and Feelings Worksheet [PDF]. Most patients can satisfactorily self-manage their tinnitus after participating in Level 3-Group Education. Following completion of the Level 4-Tinnitus Evaluation, patients must meet certain criteria to be considered for Level 5-Individualized Management, namely (a) Levels 1-4 of PATM have not met their needs, and (b) they have been evaluated and referred to other health care providers as warranted. Blast-related TBI is a major problem among returning veterans of the wars in Iraq and Afghanistan. No program currently exists to provide clinical management for military personnel and veterans who have tinnitus associated with TBI. The PATM model is designed for implementation at any audiology clinic that desires to optimize resourcefulness, cost efficiency, and expedience in its practice of tinnitus management. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. For more details about the diagnosis and treatment of TBI, see Veterans Health Initiative, Traumatic Brain Injury: A CME Program [PDF]. James Henry, PhD, has been working at the VA at the National Center for Rehabilitative Auditory Research (NCRAR) in Portland, Oregon, for the past 22 years and has conducted tinnitus research for 16 years. The ASHA Action Center welcomes questions and requests for information from members and non-members. A quick Introduction to Tinnitus is designed to increase awareness of people regarding Tinnitus. Powers received her undergraduate degree from Northern Illinois University, her graduate degree from RUSH University in Chicago, and her Doctorate from A.T. Despite that, only a small percentage of practicing audiologists routinely employ this useful technology in their clinical routine. Psychophysical procedures, questionnaires, sound therapies and counseling are helpful to reduce the reactions to tinnitus. This course offers a practical and evidence-based approach for non-medical treatment of bothersome tinnitus. Displaying posters and handouts on TBI, PTSD, and signs of depression in your clinic can help increase awareness about the conditions and can be a helpful source of information. The ATM method provided specific guidelines for audiologists to implement a well-defined program of tinnitus management. The management program is goal-oriented with a focus on individualized management, patient and family education, counseling, and support.
This is accomplished by helping patients develop and implement custom sound-based management plans to address their unique needs.
A Clinician Guidelines Handbook and an online training course (consisting of 19 comprehensive Web modules of training) have been developed to provide detailed clinical education, guides, and tools to conduct PATM (Henry, Zaugg, Myers, & Schecter, 2008c).
The base of the pyramid reveals that most persons who experience tinnitus are not bothered by it or only require some rudimentary information about tinnitus.


Because the impact of tinnitus varies widely for these patients, their management needs vary accordingly.
Unless there is a medical or psychiatric emergency, all patients who complain of tinnitus should be referred to an audiologist for a Level 2 Audiologic Evaluation.
If left untreated, these mental health conditions can impede any rehabilitation efforts, including the clinical management of tinnitus. The model is designed to be maximally efficient to have the least impact on clinical resources, while still addressing the needs of all patients who complain about tinnitus.
These providers may be unaware of tinnitus management resources that are available to help these patients. When indicated, the Level 2 evaluation can also include a brief structured tinnitus interview and brief written questionnaires to assess appropriateness of referral to a mental health clinic.
During the first session, the principles of using sound to manage tinnitus are explained, and each participant uses a worksheet that is located in the self-management workbook provided at the Level 2 Audiologic Evaluation to develop an individualized "sound plan" to manage their most bothersome tinnitus situation—see Figure 5, PATM Sound Plan Worksheet [PDF]. Thus, the therapeutic use of sound with PATM can involve all nine combinations of the three types of sound and environmental sound, music, or speech.
Some patients with problematic tinnitus, however, require psychological intervention to alter negative reactions to tinnitus and to aid in coping with tinnitus.
Specifically, patients are taught that relaxation techniques such as deep breathing and imagery can reduce stress and tension caused by tinnitus, and changing how they think about their tinnitus can help them change how they feel about it.
Patients who need more support and education than are available at Level 3 can progress to the PATM Level 4-Tinnitus Evaluation to determine their needs for further intervention.
Level 5-Individualized Management uses a standardized, individualized counseling flip chart to provide directed counseling as well as discussion of sound management and relaxation strategies. A pilot study funded by VA RR&D using a national, centralized tinnitus management counseling program via telephone that is thus accessible to individuals from any geographic location is currently being formally evaluated. Also, PATM has been adapted to quickly identify and meet the unique tinnitus management needs of veterans and military members with TBI. Paula Myers is Chief of the Audiology Section and Cochlear Implant Coordinator at the James A.
His research focuses on developing standardized protocols for clinical assessment and management of tinnitus, and conducting randomized clinical trials to assess outcomes of different methods of tinnitus intervention. Zaugg, AuD, is a licensed, certified, and clinically privileged research audiologist employed at the NCRAR, in Portland, Oregon. Kendall, PhD, is a research psychologist at the VA Connecticut Healthcare System in West Haven, Connecticut, and associate research scientist at Yale University. Manager of Education and Training for Siemens Hearing Instruments where she is responsible for the planning and implementation of customer and employee product meetings.
Magnetic stimulation of the brain can also suppress tinnitus in some patients, but its clinical application is uncertain.
The intensified use of explosive devices and mines in warfare and noise from weapons have resulted in auditory dysfunction, tinnitus, TBI, mental health conditions, and pain complaints among members of the military. Mild TBI can cause cognitive deficits in speed of information processing, attention, and memory in the immediate postinjury period.
The invisibility of closed head injury, hearing loss, and tinnitus heighten the importance of screening for TBI, PTSD, depression, hearing impairment, and tinnitus in those service members exposed to blast injury. Our subsequent tinnitus clinical research pointed to the need to provide tinnitus clinical services in a hierarchical manner, that is, to provide services only to the degree necessary to meet patients' individual needs. Therapeutic sound can be used in a variety of ways with PATM, which is necessary because patients encounter different situations that differentially affect how they react to their tinnitus.
Development of these action plans may be facilitated by the clinician, but the ultimate goal is that patients learn how to devise and implement the plans on their own.
These materials were developed in conjunction with a randomized clinical trial unded by the VA Rehabilitation Research and Development (RR&D) Service. Epidemiological studies generally reveal that about 80% of people who experience tinnitus are not particularly bothered by it.
Whenever possible, mental health professionals should have expertise in the management of tinnitus, or at least be familiar with the nature of tinnitus within the context of coexistent psychological problems.
Audiologists also should refer patients out to other clinics as necessary, as highlighted in Figure 3. Figure 4, the PATM flowchart [PDF], shows the five levels of progressive tinnitus management.
The triaging guidelines that we developed (shown in Figure 4) are designed mainly for nonaudiologists who encounter patients complaining of tinnitus.
Tinnitus patients who require amplification are fitted with hearing aids, which often can result in satisfactory tinnitus management with minimal education and support specific to tinnitus. Patients are instructed to use the sound plan that they developed during the first meeting until the next meeting, at which time they discuss their experiences using the plan and its effectiveness. This psychological component is particularly important for tinnitus patients who also experience PTSD, depression, anxiety, or other mental health problems.
Rather, psychologists can assist patients cope with tinnitus using CBT, which is a specific modality of psychotherapy shown to be effective in treating many health conditions.
The Level 4-Tinnitus Evaluation includes an intake interview and a tinnitus psychoacoustic assessment. If individualized management is not effective after about 6 months, then different forms of tinnitus intervention such as neuromonics tinnitus treatment, tinnitus masking, tinnitus retraining therapy, and tinnitus focused CBT should be considered. Tinnitus can occur not only as a direct consequence of the injury causing TBI but also as a side effect of medications commonly used to treat cognitive, emotional, and pain problems associated with TBI.
The program is based on the educational counseling methods of PATM with modifications to include individualized brief telephone interventions with an audiologist and a psychologist; also, patients receive via mail a supplemental self-management workbook and DVD consisting of use of therapeutic sound, relaxation techniques to include deep breathing, guided imagery, sleep hygiene tips, and changing thoughts and feelings.
This modified centralized approach to tinnitus management allows for frequent and brief intervention to accommodate the needs of people with impaired memory, limited concentration, and other cognitive difficulties often associated with TBI.
VHA Directive 2007-013: Screening and evaluation of possible traumatic brain injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans.
Through her involvement in tinnitus clinical trials over the last 8 years at the NCRAR, she has developed considerable expertise in tinnitus assessment and management, and in the training of audiologists to perform tinnitus management.


Her research interest focuses on the psychological interventions for tinnitus and the comorbidities of mental health disorders with tinnitus. A brief information about Neuromonics, the latest invention to Tinnitus was discussed in one slide. Finally, there is now a greater appreciation that there are different subgroups of tinnitus patients, and the careful selection of subgroups is now being applied to new drug trials. Symptoms of mild TBI or concussion frequently include tinnitus, which can occur not only as a direct consequence of the injury causing TBI but also as a side effect of medications commonly used to treat cognitive, emotional, and pain problems associated with TBI.
In addition, we saw a need to make numerous changes to the ATM assessment and intervention methodologies to improve the effectiveness and efficiency of the clinical protocol.
The materials currently are being edited and reviewed for distribution to all VA medical centers-for utilization primarily by audiologists but also by other clinicians. The remaining 20% are bothered, but to different degrees-as depicted by people with "progressively more severe tinnitus problems" toward the top of the pyramid.
Tinnitus patients with these problems should be referred for evaluation by a mental health professional.
It is sometimes also appropriate to screen for the presence of mental health symptoms and to refer patients to a mental health clinic because these symptoms can interfere with successful self-management of tinnitus. Any patient found to have problematic tinnitus receives "How to Manage Your Tinnitus: A Step-by-Step Workbook" and is invited to attend Level 3-Group Education. Recent evidence supports the use of group education as a basic form of tinnitus intervention. Psychological intervention can be an important component of an overall approach to tinnitus management for patients with mild TBI. Administration of the intake interview is the primary means of determining whether one-on-one individualized tinnitus management is needed. The audiologist should support the patient and family and provide education and training for real-world success in self-management.
While a brief overview, this article provides the essential elements of PATM and the problematic overlap of mental health factors and TBI. Her research focuses on the development of patient health education programs and materials, standardized protocols for clinical assessment and management of tinnitus, and blast injury and auditory dysfunction. The unique occurrence and strong associations between the physical, cognitive, behavioral, and emotional sequelae involved with TBI require audiologists to work as a team with several services. ATM therefore was completely revamped, resulting in a five-level hierarchical program of tinnitus management that we refer to as progressive audiologic tinnitus management (PATM). These situations also change over time, and the use of sound likewise must adapt to these changes.
Although this method has been developed and evaluated for veterans with tinnitus, PATM protocols can be applied to any adult with problematic tinnitus. The tip of the pyramid contains the relatively few patients who have the most severe tinnitus condition, that is, those who are debilitated by their tinnitus. A handout that audiologists can share with their health care provider referral sources is found in Tinnitus Triage Guidelines—intended to be provided to nonaudiologist clinicians with patients who complain of bothersome tinnitus.
Patients should also be referred immediately to a mental health professional if they report suicidal ideation, or if they have bizarre thoughts or perceptions such as "hearing voices." Patients with PTSD and severe tinnitus may require test protocol modifications and referrals to mental health that address the powerful limbic system responses. The workbook, written at the sixth-grade reading level, contains information on using sound to manage tinnitus, changing thoughts and feelings to manage tinnitus, relaxation techniques, hearing conservation, sleep hygiene tips, and general tinnitus information. Group education has been shown to be effective as part of a hierarchical tinnitus management program at a major tinnitus clinic. Further information about managing tinnitus is then presented, and the participants revise their sound plan based on the discussion and new information. Those wishing further details are referred to the resources below that provide the basis behind the information presented herein and are the suggested readings for continued study in this area.
She has received funding from the VA Rehabilitation Research and Development Service to conduct research as a Co-Principal Investigator on studies related to tinnitus management and traumatic brain injury. She currently serves as an Education Specialist for customers as well as Siemens staff on products and services. The Tinnitus Pyramid highlights that patients who complain of tinnitus have very different needs, ranging from the provision of simple information to long-term individualized therapy. Videos of PATM Level 3 counseling and methods of relaxation and imagery based on cognitive-behavioral therapy (CBT), as well as a CD demonstrating the different ways that sound can be used to manage tinnitus, are currently under development and will be added to the workbook to provide the audiologist and patient with additional intervention tools in a multimodal format. The NCRAR completed a randomized clinical trial evaluating group education for tinnitus in almost 300 patients that showed significantly more reduction in tinnitus severity for those in the group education group as compared to control groups. By the end of the second session, the participants should have learned how to develop, implement, evaluate, and revise a sound plan to manage their most bothersome tinnitus situation. Special procedures are used to select devices for tinnitus management, including ear-level noise generators and combination instruments, and personal listening devices. Because the population with TBI can vary greatly in terms of tinnitus severity, peripheral and central function, speech perception abilities in quiet and degraded conditions, cognition, and emotional, behavioral, and physical health, there is no universal standardized approach to audiologic management or tinnitus management of persons with TBI. They are encouraged to use the Sound Plan Worksheet on an ongoing basis to write additional sound plans for other bothersome tinnitus situations. Screening for referral to mental health is required at the Level 4-Tinnitus Evaluation; however, mental health screening should always be considered at any level of management if patients' comments and discourse point to significant mental health issues. Jastreboff (1990).TRT is based on the neurophysiological model of tinnitus, described by Dr.
Principles and application of educational counseling used in progressive audiologic tinnitus management. Hearing impairment and traumatic brain injury among soldiers: Special considerations for the audiologist.
Posttraumatic stress disorder and posttraumatic disorder-like symptoms and mild traumatic brain injury.



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