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Tinnitus cbt, tinnitus right ear only - Test Out

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Richard Tyler at the University of Iowa has developed some excellent teaching materials which are useful for psychologists working with tinnitus. 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.
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.
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. 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. 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. 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. 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. This weekend I attended part of an excellent tinnitus information day organised by the British Tinnitus Association. I was able to stay for talks by Tony Kay (Head of Audiology at Aintree Univeristy Hospital) who spoke about the basic facts of tinnitus, and Laurence McKenna (Clinical Psychologist at the Royal National Throat, Nose and Ear Hospital) who spoke about the impact of tinnitus. Tony Kay gave a great explanation of the sound perception system, and where unusual things might be happening in tinnitus on a physical level.
Dr McKenna cited Kahnemann's 2-cognitive-systems model from Thinking Fast & Slow as an explanation of components of tinnitus. Another key part of the cognitive behavioural model of tinnitus is selective attention, which seems to have both automatic and deliberate components.
There is evidence that both avoidant coping (trying to get away from tinnitus) and active coping (keeping busy) are associated with worse outcomes in tinnitus. The key components of the CBT model of tinnitus where intervention is possible are at the level of negative thinking, selective attention, beliefs, and safety behaviours. The ATM method provided specific guidelines for audiologists to implement a well-defined program of tinnitus management.
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]. 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. 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.
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. Over time tinnitus is said to disappear or at least diminish to a tolerable level in most cases. In some respects this model could be used to explain all sorts of thinking errors across a lot of clinical conditions and I'm not sure how much it added in terms of being specific to tinnitus. He cited some papers indicating that tinnitus is associated with more dysfunctional thoughts about tinnitus (e.g.
When tinnitus is measured (I think by using an external sound to mask the tinnitus) it is usually measured at <=10dB SL (this is 10 decibels above that patient's sensation level). One key message of the talk was that tinnitus patients must learn to distrust their 'system 1' (automatic, biased, faulty) impressions. 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.
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.
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. 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. 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.
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. 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. Despite tinnitus affecting up to 10% of the population not many psychologists work with the condition, which is a shame because there are real opportunities for psychological approaches to relieve distress. Key points linked to this are that although lots of people experience tinnitus not everyone has a strong emotional reaction to it - so relief of distress around tinnitus can be achieved by working with the emotional reaction directly.
We are likely to automatically attend to tinnitus - particularly if it carries a negative meaning for us (therefore if the meaning can be changed then this form of attention may be ameliorated).
A discrepancy frequently occurs when tinnitus patients report that their tinnitus "sounds louder than a jet engine". 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. 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. 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. Because of compelling theoretical reasons I've become interested in using attention training approaches to treat tinnitus where there does not seem to be a heavy 'negative thought' component (see Adrian Wells' metacognitive therapy for an example of the technique). 94% described sounds like buzzing, hissing, ringing, whistling, pulsing, and roaring - exactly the noises heard in tinnitus. This certainly fits with my clinical experience whereby tinnitus seems to be bothersome to some patients in the context of (many) complicated life issues (e.g. We might also 'monitor' to see how the tinnitus is doing (more of a deliberate process) which again is going to be unhelpful. This means that either the measurements are inaccurate, or selective attention is somehow distorting perception of the tinnitus. 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).
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. 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. Interestingly, he cited a paper indicating that catastrophising early in tinnitus experience (for example, when an uninformed healthcare provider says "you've got tinnitus forever") leads to poorer outcomes (Weisse et al, 2013). 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. Principles and application of educational counseling used in progressive audiologic tinnitus management.

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