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Sound treatment tinnitus, holistic medicine for ringing in ears - Test Out

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Tinnitus, a condition that causes people to hear sounds such as ringing in the ears even when all is quiet, afflicts at least 10 percent of American adults.
Tinnitus is the perception of sound within the human ear in the absence of corresponding external sound. Tinnitus is not itself a disease but a symptom resulting from a range of underlying causes.
As there are no easy cures for tinnitus, the tinnitus patient has to adjust to not only the perception of internal noise but also to the often negative beliefs and consequences that accompany it (Psychological aspects of tinnitus, in Contributions to medical psychology. Some of the difficulties that tinnitus patients encounter include high levels of emotional distress, sleep difficulties, loss of concentration, attention problems, and disruption to their personal, occupational, and social lives (J Speech Hear Disord 48:150–154, 1983). The need to address these “psychological” aspects of tinnitus has been known for many years (Lancet 36:828–829, 1841) but has only recently been given adequate consideration.
Fundamentally, the goal of tinnitus treatment is to reduce the negative impact this condition has on the patient’s life. Providing patients with education about what their tinnitus is, and what it is not, helps to demystify the condition, which can greatly change how they perceive and respond to their tinnitus. To help people cope with their tinnitus and its consequences, counselling is recognized as a vital component of virtually all tinnitus management options [6]. With regard to its role in tinnitus, it has been said that counselling is the single most important component in the management of tinnitus [6].
One of the early attempts to investigate the problems experienced by tinnitus patients was undertaken by Tyler and Baker [4], who asked tinnitus sufferers in a self-help group to list the difficulties they experienced as a consequence of their tinnitus. When considering how people react to tinnitus, people with tinnitus generally fall within two distinct groups: those who have marked distress or handicap associated with their tinnitus and those who do not [22].
Of those who experience distress and disability related to their tinnitus, there is considerable variability regarding the nature and extent of the psychological distress they experience [4, 25].
Although tinnitus is a sensory experience, how individuals respond to their tinnitus tends to be more multidimensional, involving their perceptual, attentional, and emotional processes [29]. The treatment of tinnitus patients can be further complicated by a delay in patients seeking medical attention from the onset of their tinnitus.
The negative consequences of tinnitus may include emotional states such as depression, anger, and anxiety, resulting in sleep disturbance, concentration difficulties, and interference with personal and social activities [4, 29, 30, 31]. The goal of tinnitus management is the reduction of either the tinnitus itself or the patient’s perception of the annoyance related to the tinnitus [7].
There is an opinion that interventions involving psychological therapy for tinnitus should include qualified psychologists [39].
Due to the chronic and distressing nature of the condition, tinnitus patients require engagement at a greater level than many other otologic or audiologic problems; as a consequence, clinicians should be prepared for an ongoing relationship with the patient.
As a chronic condition, a primary focus in counselling and psychological approaches to the management of tinnitus is to reduce the distress caused by the tinnitus and the impact the condition has on the person’s life.
Tinnitus treatments use either group or individual sessions, but sometimes both have been applied. A technique commonly used in counselling of chronic conditions such as tinnitus is goal setting, as it is an important skill to help patients work toward, achieve, and maintain treatment success [12]. The purpose of using a goal setting technique is to help the patient focus on ways to move themselves forward, thereby reducing their focus on the negative and distressing aspects of their tinnitus. Specialists demonstrate and say to patients: Although swallowing is louder than your tinnitus, it is not perceived.
Specialists say to patients: Tinnitus sound can be “stored” and become longer lasting the more you are focused on it.
It is thought that tinnitus becomes magnified because of how the brain analyses tinnitus and how we think about it. The first step in the evaluation of tinnitus, and then its management, is a comprehensive case history including questions of onset, description of the tinnitus “sound,” location, possible cause (noise, medications, stress), and severity. In our daily activities we are able to listen to one sound of interest, such as a friends voice buried in a background of competing noise. Feldmann [68] eloquently described that the natural reaction of people to tinnitus onset is to search for it and place it in context of a sound in the environment. One of the reasons tinnitus is so annoying is that we hear it, but can’t see it or find where it is coming from. The above examples help to relate the tinnitus sufferer’s experiences within a simple philosophical framework that can be adjusted to suit the patient and the therapeutic approaches described in the following sections. A decline in behavioral responses to a sound signal due to repeated exposure is known as auditory habituation [69].
Attention may play a large role in tinnitus annoyance and should be addressed in counselling [12].
Attention control techniques aim to help listeners learn strategies to switch focus of attention from one thing to another, so that attention can be brought under voluntary control to direct thought to and from one’s tinnitus.
We need to teach your hearing system to pay less attention to the unnatural sound of tinnitus and instead listen more to other “real” sounds. The different treatment types can be discussed in lay person’s terms to facilitate the patient’s understanding of their tinnitus and the role that different treatment approaches can play in the management process. It is likely that tinnitus is the response of the hearing system to altered output of the inner ear following hearing loss.
Masking is the process of covering, usually partially, the tinnitus with an external sound.
If the patient has no reason to attend to tinnitus, they should get used (habituate) to it. It has been shown that a person vulnerable to stress is more likely to experience tinnitus distress, whereas a more stress-tolerant or resilient person might be able to handle a greater degree of tinnitus before seeking help [70].
A very common complaint amongst tinnitus sufferers is difficulty in sleeping [4, 12, 15, 27].
Sleep hygiene is a treatment tool for insomnia which involves behavioral practices that promote good sleep [45]. One easily implemented self-help sound therapy measure is the use of low-level music played in the background in quiet situations to draw attention away from the tinnitus. For short-term relief, when tinnitus is severe, attention capturing music can be beneficial. For long-term tinnitus, habituation music which induces relaxation while reducing tinnitus audibility. Extra stimulation could be provided at night by a bedside sound generator or compact discs (CDs) designed to interfere with tinnitus detection [77]. On the basis of cost-effectiveness, it is proposed that combining education and self-help advice should produce significant tinnitus reducing benefits when used as routine treatment. Once made aware of potential triggers and means to manage them, the patient should be able to identify signs that a previously compensated tinnitus may re-emerge. Although this chapter focuses on counselling for tinnitus, the underlying counselling principles can be applied to other symptoms of auditory injury such as hyperacusis. The benefits of the inclusion of homework assignments into therapies can be seen through such effects as significantly improving treatment outcomes [84] and modifying behavior without supervision of a clinician [90].
Tinnitus may result in a withdrawal from work and social activities that might normally provide a sense of achievement and enjoyment.
For an example of a measurable goal, let us say your goal is to read in the evening without becoming annoyed by tinnitus.
For example, setting a goal of reading an entire book without being annoyed by the tinnitus may not be feasible, whereas reading several chapters may be. By relaxing and becoming more calm, the stress driving your tinnitus, or resulting from tinnitus, may be reduced. People may experience tinnitus as intrusive, constantly on their mind and in their thoughts. Learning this skill of attention control means you will be able to give less consideration to your tinnitus. With tinnitus (or anything else really!) it is impossible to simply choose not to think about it anymore. But now the Neuromonics Tinnitus Treatment lets you relieve these symptoms and reclaim your life.
To facilitate this, counselling helps individuals understand their tinnitus, which can reduce the occurrence and level of distress. Yet despite the important role that counselling plays, it can be difficult to ensure that this aspect of tinnitus management is undertaken. To help patients understand tinnitus and facilitate their coping with the condition, clinical approaches to the management of tinnitus include the use of education, psychological interventions, and counselling approaches. Tinnitus is experienced as an occasional slight irritation by the majority of the population [8, 14].
In describing the impact of psychological factors on tinnitus, Hallam and colleagues [3] proposed a psychological model based on the process of habituation. It is not always clear why the person has not sought help for their tinnitus earlier and why their tinnitus has now become distressing [18].
Accordingly, psychological treatments aim to reduce the negative impact of tinnitus; often through the use of cognitive behavioral therapy (CBT see Chap. As reactions to tinnitus and the ability to cope with this condition vary from person to person, tinnitus is a complex condition to treat.

It is also argued that an complicated by a considerable delay in patients audiologist may be satisfactorily skilled to provide the CBT for patients with problematic tinnitus [34].
That is to say that tinnitus is a persistent condition with no easy cure and the focus of interventions therefore are to alter any negative thoughts the person has about the condition and its impact on their life, as this will decrease the role that tinnitus plays in their life.
In so doing, the aims are to provide knowledge of the processes occurring in the generation of tinnitus and eliminate unfounded fears or presumptions as to the underlying causes [46].
Outer and middle ear are responsible for conduction and amplification of sounds to the inner ear. Brainstem: reaction to sound when detecting danger and provoking a strong and subconscious reaction. Midbrain and cortex: addition of emotions and complex association of the sound to templates of normal sounds and depending on the subconscious evaluation we may focus even more on the tinnitus sound.
Tinnitus usually begins following ear injury, even small amounts of damage can start tinnitus (we relate the patient’s tinnitus to audiometry and discuss different measures such as otoacoustic emissions (OAEs)).
If the tinnitus is objective, pulsatile, unilateral, or associated with a tempromandibular joint complaint, referral to an otolaryngologist or other specialist is recommended to the patient.
With true sounds, we can localize them to something we can see, touch, and sometimes even smell. It appears that habituation is not caused just by the repetition of the sound but by the meaning or association the stimulus holds in the particular situation [69]. Tinnitus can often become the main focus in a person’s life, consuming their attention resources and ability to concentrate in other tasks. Henry and Wilson [2] suggest that by exerting control over attention, tinnitus-related distress will be reduced.
One treatment approach is to identify any underlying reasons for the hearing system being overly active and to interfere with how the brain analyses the tinnitus. The sound used does not appear to be crucial, but should be less bothersome than the tinnitus.
Even loud sounds can be habituated to if they are non-threatening, for example, people living near railroad tracks seem unaware of the sound of trains passing. Although tinnitus and its associated symptoms can be a frequent source of stress and distress, stress in return can often exacerbate the existing effects of tinnitus. Although homework assignments are not commonly applied as part of a tinnitus intervention plan, research on home work in other disorders has demonstrated improved treatment outcomes [84].
Due to the complexity and multiple factors which impact upon the emotional well-being of an individual, a multidisciplinary team approach is best when treating a patient with complex tinnitus [52, 94]. The loss of these positive feelings, along with isolation, may lead to the person strongly attending to their tinnitus. Relaxation is one strategy toward overcoming the negative consequences of stress and alleviating some tinnitus effects. The answer is quite likely “Too much!” One of the most common complaints amongst those with bothersome tinnitus is that it is always on their mind.
Henry J and P Wilson (2001) The psychological management of chronic tinnitus: a cognitive-behavioral approach. Hallam R, S Rachman and R Hinchcliffe, (1984) Psychological aspects of tinnitus, in Contributions to medical psychology, S Rachman, Editor. Searchfield G (2006) Hearing aids and tinnitus, in Tinnitus treatment: Clinical protocols, R Tyler, Editor.
Jastreboff PJ (2000) Tinnitus habituation therapy (THT) and tinnitus retraining therapy (TRT), in Tinnitus Handbook, R Tyler, Editor. Henry JA, MA Schechter, SM Nagler et al (2002) Comparison of tinnitus masking and tinnitus retraining therapy.
Andersson G (2002) Psychological aspects of tinnitus and the application of cognitive-behavioral therapy.
Tyler R, W Noble, JP Preece et al (2004) Psychological treatments for tinnitus, in Tinnitus: theory and management, JB Snow, Editor. Aazh H, B Moore and B Glasberg (2008) Simplified form of tinnitus retraining therapy in adults: a retrospective study. Lindberg P and B Scott (1999) The use and predictive value of psychological profiles in helpseeking and nonhelpseeking tinnitus sufferers, in Proceedings of the Sixth International Tinnitus Seminar, Cambridge UK.
Holgers KM, S Erlandsson and M-L Barrenas (1999) Early identification of therapy resistant tinnitus, in Proceedings of the Sixth International Tinnitus Seminar, Cambridge UK. Jakes S, R Hallam, C Chambers et al (1985) A factor analytical study of tinnitus complaint behaviour. Henry J and PH Wilson (2001) The psychological management of chronic tinnitus: a cognitive-behavioural approach. One of the latest is a sound-therapy device designed to produce unique tones that distract the wearer's brain from more irritating sounds.
Tinnitus is also a side-effect of some oral medications, such as aspirin, and may also result from an abnormally low level of serotonin activity. Non-psychologists often feel uncomfortable in their role as a patient’s counsellor, frequently feeling uncertain as to how far their counselling efforts should patients’ efforts to reduce tinnitus distress.
As the term “counselling” has many connotations and is used by many professionals, it is important to be clear what “counselling” refers to, what role it has in the management of tinnitus, and who should be providing the counselling. These treatments include the use of hearing aids [8] tinnitus retraining therapy [9], tinnitus masking [10], and cognitive behavioral therapy [11]. Between 6 and 17% of the population have tinnitus to a significant degree, with 0.5–2% reporting tinnitus that produces sufficient annoyance to interfere with day-to-day activities and quality of life [15–17].
For example, vulnerable people exposed to significant stressful events, such as war and accidents, may suffer tinnitus related to post traumatic stress disorder [23].
When assessing the impact of tinnitus on the patient’s life, it is important to realize that how, and why, a person experiences distress is variable and may not relate to the more “obvious” elements of their condition. They suggested that the distress caused by tinnitus is due to an individual’s inability to habituate to the signal, which should occur as it does to any other constant stimulus that does not present as something harmful to the individual [30]. The delay in seeking assistance may be due to people’s developing strategies to distract themselves from their tinnitus to help them cope with the condition [18]. Which psychological approaches are incorporated into the treatment of tinnitus will reflect a variety of factors, including the resources available to provide the patient and the training of the clinician. There are differences across country borders as to whom and how tinnitus management is provided.
The professional also needs to provide a clear therapy plan and express their belief in the chosen treatment [13]. These approaches include masking and partial masking [2], tinnitus retraining therapy [46], tinnitus activities treatment [47], and audiological tinnitus management [48].
Providing information is considered by many to be a critical part of tinnitus management [29, 40, 51].
It is also vital that misconceptions are corrected and patients are given sufficient reassurance that tinnitus is not a life-threatening injury or a psychiatric disease.
Multisensory recognition of objects is normal, tinnitus lacks this sense of reality, making it difficult to ignore. When hearing loss accompanies tinnitus, this would involve the fitting of hearing aids to the injured ears in an attempt to normalize activity. Masking often allows the tinnitus sufferer to gain control over their tinnitus by determining when they do not wish to hear it.
The difference between a person who experiences tinnitus and one who “suffers” from it may be the person’s ability to habituate to the tinnitus. Therefore, managing stress and learning to relax helps reduce the effects of tinnitus and prevent further aggravation. It is possible that tinnitus seems louder and more noticeable at bedtime due to the decrease in ambient noise at night [72].
If these are not available, purchase of a purpose-built bedside sound generator or tinnitus reduction CD could be considered (the clinic could have these available or a source for clients to obtain them).
A common reason why tinnitus becomes stressful and disabling relates to the persons’ perception of the auditory stimuli in terms of what could be causing the sensation and their ability to cope with it.
Reassurance that the re-emerged tinnitus is likely a consequence of these events and that management of these issues should again reduce the salience of tinnitus is important. Kong [56] investigated the effectiveness of two CBT-based homework exercises alongside group-based information sessions to manage tinnitus. We can redirect the focus of our attention from the tinnitus to something else; with practice this can become nearly second nature!
We can work this to your advantage, with tinnitus becoming less the center of attention and receding into the background of your awareness. The importance of counselling was emphasized by Tyler [12], who encouraged all sound-based therapies to go hand-in-hand with counselling. Further demonstrating the distress that tinnitus can cause the patient, 6.9% of the respondents in Tyler and Baker’s [4] study had considered suicide.
For example, it may appear obvious that the loudness of the tinnitus is the factor most likely to influence the degree of distress experienced by a person with tinnitus [2], yet this is not always the case. Alternatively it may be that their resources to endure and manage their tinnitus become weakened over time, and as the condition persists, they require assistance in adapting or strengthening their resources.
CBT attempts to address the negative or unhelpful thought patterns and consequential behavioral problems accompanying tinnitus.

To facilitate the treatment of tinnitus, the practitioner must work toward establishing as in-depth an assessment of the individual’s complaints as possible, including a thorough tinnitus interview as well as assessment measures. Common elements of a management approach include providing education and means to cope with the tinnitus and its effects. It has been suggested that an educational approach be the first step in tinnitus treatment before additional intervention is ventured into [39].
A slight modification of this scale can also be applied to help determine needs and set goals for tinnitus management [8]. Most of the “wiring” of the auditory system is involved in the development and appearance of tinnitus itself (see Picture 3 below for illustration of the nonauditory centers, which explains that the limbic and autonomic nervous systems are primarily responsible to a large extent for tinnitus annoyance).
Specialists also explain that while there is currently no objective measure of tinnitus, psychoacoustical assessments of tinnitus qualities (pitch and loudness) and psychometric evaluations of tinnitus severity are often used by clinicians to characterize tinnitus. One reason for the annoyance and “strangeness” of tinnitus could be its conflict with normal Auditory Scene Analysis (ASA) [66, 67] (Picture 4 below). Contrast this with tinnitus perception where no auditory object is present but a similar process of constructing the image of sound must occur. By shifting attention from the faces to the vase, the patient can be informed about the use of attention strategies to focus less on tinnitus than background sound.
The acquisition of attention control skills, such as distraction, allows a person to shift their attention to and from tinnitus during stressful situations [13, 43]. Long-term use of partial masking, along with counselling, may lead to tinnitus habituation. By minimizing the impact of unhelpful or negative thoughts about tinnitus, through challenging and changing responses, tinnitus annoyance can be reduced. As a stress-reduction technique, relaxation training enables an individual to become calmer and less reactive, hopefully reducing tinnitus perception [40]. Improving the quality and ability of individuals to sleep may reduce the adverse effects of tinnitus.
Psychological therapy is therefore an appropriate treatment approach for tinnitus, as psychological techniques, including CBT, aim to change how a person thinks about something that will then impact how they react to that situation, stimulus, or event.
Pubmed is a great source for up-to-date information on tinnitus, while hearing aid manufacturers often have excellent anatomy charts.
Simple attention control exercises can be useful to shift attention from tinnitus to more useful perceptions.
It is therefore the intent of this chapter to clarify the need to provide counselling for tinnitus patients, the role of counselling, and who should deliver this very important component of a tinnitus treatment program.
The rationale and the form of counselling may differ across treatments [13], but regardless of which strategy is employed, it is necessary to help the patient understand and learn to cope with their tinnitus [6]. For those working with tinnitus, it is important to appreciate the influence of factors that can impact on the experience of tinnitus, as these factors can increase the level of distress caused by the tinnitus as well as the patient’s ability to benefit from treatment (see Picture 1). Several studies have considered features of tinnitus such as loudness and unpleasantness and have found that the loudness of tinnitus (either self-rated or determined by loudness matching) was unrelated to complaint dimensions [26–28]. Furthermore, patients often report difficulties in accessing appropriate information and referral to specialist services for tinnitus.
The assessment allows better understanding of the person’s experience of their tinnitus, the impact it has on their life, and their ability to cope [12].
This helps with correcting the maladaptive thoughts and behaviors that can develop from false beliefs about tinnitus, which would be counterproductive to any accompanying management strategy [13]. Topics usually covered include: the hearing system and hearing loss, the epidemiology and causes of tinnitus, perception (including habituation and attention), and treatment options [13].
Sound (1) travels from the cochlea (2) (discuss using analogy with light switch), auditory nerve (wiring) via auditory nuclei (3) (junction boxes) to auditory cortex (4) (light bulb – light goes on – we hear). Use this to explain the unusual nature of tinnitus and how it differs from sound, with regard to tinnitus assessment and attempts to interfere with the tinnitus using sound. Habituation has become a common feature of most counselling and sound therapy practice [46, 47]. These techniques may provide the individual with some sense of control over their tinnitus and the related distressing experiences [29, 44]. When you were listening for the sound – were you aware of the tinnitus – possibly not as the other sound was competing for attention against the tinnitus, we can’t hear everything around us all at once, we must pick and choose. Some idea of the potential benefit of masking can be assessed in the clinic by listening to an assortment of sounds over headphones. Hearing aids, broadband noise generators, and devices combining both amplification and generation of sound (combination aids) are used to reduce tinnitus audibility to facilitate the habituation of tinnitus. Within a tinnitus management program, the intent is therefore to change how the person perceives and responds to their tinnitus, so that they are not as negatively impacted by the condition.
In addition, clinicians have offered helpful counselling tools in print [92] and on the internet Patients should be guided in how to undertake internet searches for tinnitus information and informed of the frequency of poor quality information and misinformation on the World Wide Web.
We have found the education approach a very useful counselling method to empower patients to de-attend and habituate to tinnitus.
The tones are customized for each patient based on that person's specific level of tinnitus, although the reprieve is temporary, experienced only when the Serenade is in use.Reports of tinnitus are rising because of widespread use of personal entertainment and communication devices, particularly in children, according to researchers at the University of California at Irvine's Hearing Research Center, where Serenade was first developed. While today it is accepted that tinnitus can impact the patient’s life in many ways, awareness of the broad-ranging consequences and potential contributors to distress caused by tinnitus was facilitated by studies designed to assess how tinnitus patients experienced this condition. Clearly, tinnitus has widespread effects on the lives of those with this condition, which would normally require a multidisciplinary approach to manage it. This highlights the importance of understanding that the perception of tinnitus is only one dimension of tinnitus and it is the psychological dimension that leads to the emergence of tinnitus related distress [2]. Such persons may perceive the tinnitus as distressing, harmful, and something that they will be unable to cope with. While CBT has been shown to be an effective treatment approach for tinnitus, some of the techniques are considered beyond the scope of practice for non-psychologists; a more general approach is required for those who are working with tinnitus patients, but are not trained in CBT.
Patient’s perception of their tinnitus, their ability to cope with their tinnitus, their overall level of disability, and their ability to benefit from treatment interventions should be evaluated. For those that do not have access to a multidimensional team approach, there is still a great deal that can be offered to the tinnitus patient in terms of tools to help them to understand and cope with their tinnitus.
Educating the patient about tinnitus and peoples’ responses to this condition enables both the patient and the clinician to explore the problem and clarify the purpose and expected outcomes of subsequent interventions [41]. At stages throughout the tinnitus rehabilitation process, the problems identified using the COSIT are re-examined and in each situation, the degree of tinnitus improvement is determined. Apparently, it is the assumed uncontrollability of the tinnitus sensation which plays a key role in tinnitus being aversively interpreted [27, 68].
The sound therapy is thought to help by allowing the patient to become used to tinnitus as the sound fades into the background.
All participants were given information sheets with general instructions to carry out the homework tasks that were meant to help in areas of difficulty caused by tinnitus.
In a paper published online in April by the Journal of the Association for Research in Otolaryngology, the researchers, who describe tinnitus as a "brain disorder," said their device was most effective when the volume was set at a level just softer than the sounds produced by tinnitus (pdf). Effective counselling on this basis requires that the clinician has good working knowledge of the physiology of the auditory system, as well as the mechanism and management of tinnitus and be able to convey this information in layman’s terms to de-medicalize the condition. The use of sleep hygiene alone has produced variable success; however, when applied with other forms of intervention (for instance, relaxation exercises or cognitive behavioral treatment) greater improvement in tinnitus symptoms has been observed [75]. Tinnitus is also the most common disability among Afghanistan and Iraq war veterans, according to the U.S.
Relate this to tinnitus by explaining that the white lines depict activity – normal hearing, while the black squares depict absent activity – hearing loss.
An over emphasis on hearing protection may lead to an auditory deprivation effect – potentially reactive plasticity and tinnitus [79] and hyperacusis.
With practice, it is possible to take that same control over the attention that you give to your tinnitus. While it is ideal for tinnitus patients to have access to a professional trained in the psychological management of this condition, it is not always possible or practical, as many practices do not have the resources or funding to provide such treatment.
At the same time, patients should be made aware of dangerous sounds and how to avoid further injury [80]. A slightly greater reduction in tinnitus effect was recorded for the ACTIVE group participants at the end of this study when compared to the participants in the PASSIVE group. The idea is that you will learn how to direct your attention, to and from, the tinnitus under your own control. It is, however, possible to provide tinnitus patients with effective approaches to manage their condition, as audiologists or other tinnitus specialists can provide professional counselling [18] by familiarizing themselves with general counselling skills and principles (good basic texts exist for this purpose [7]).
One method to avoid resumption of annoying tinnitus is for the individual to be equipped to manage any re-emergence. It was concluded that group-based information sessions including specific “active” homework assignments have the potential to be used alongside audiological management to reduce tinnitus impact [56]. Written materials to refer to can be useful, “The Consumer Handbook of Tinnitus” [81] and “Tinnitus.
The decision for the weekly topics was based on areas of difficulty frequently experienced by people with tinnitus, which were identified in previous research [4, 11, 30].

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