A combination of counseling and sound therapy has proven effective for people with chronic tinnitus.
If you have tinnitus, you feel you have no control over it. It is never quiet. You wonder, what is causing it? Will it get worse? Am I imagining it?
For many people, a combination of counseling and sound therapy can help. Here are some techniques that we use, called Tinnitus Activities Treatment, at the University of Iowa Tinnitus and Hyperacusis Clinic.
Patients who come to the clinic bring in a variety of concerns. They are asked:
What do you think caused your tinnitus?
When did it start?
Do you have trouble with hearing loss?
Do loud sounds make your tinnitus worse?
Do moderately loud noises sound really loud to you?
What treatments have you tried?
Have you found any treatments helpful?
What kind of difficulties has your tinnitus caused?
Then patients are categorized as “curious,” “concerned,” or “distressed.” Those who seek further information are encouraged to join a group counseling session.
After the group session, patients have the option to continue with individual help. In the first session they receive an overview, through simple graphs and pictures, about causes, mechanisms, problems, and treatments. Each patient has the opportunity to ask questions and receive explanations about his or her own history while also meeting other people who have similar problems. Family members are actively encouraged to participate. Patients can sample various sound therapy devices.
In some, but not all cases, the magnitude of the tinnitus is measured in two ways. With the minimum masking level, a broadband noise is typically used. The noise threshold and amount of noise required to mask the tinnitus are determined. Using a loudness balancing procedure, the patients are asked to adjust a 1,000 hertz tone until it is equally as loud as their tinnitus.
The patients’ reactions to their tinnitus are also measured with questionnaires, such as the Tinnitus Handicap Questionnaire, which is used worldwide, and the new Tinnitus Activity Limitations Questionnaire.
Our approach focuses on treating four affected areas—sleep, hearing, emotions, and concentration—depending on the patient’s individual needs.
Sleep: The patient learns about the sleep cycle and how habits affect sleep. Effective strategies to use before and during sleep are taught, and the use of background sounds and relaxation exercises is discussed.
Hearing: Most people with tinnitus also have hearing difficulties. The patient is taught strategies to improve hearing and communication and, when appropriate, the use of hearing aids is considered.
Emotions: The patient is asked to describe fears and concerns about how tinnitus is affecting his or her life and health. Patients are taught that they can change their reactions to their tinnitus, and that we will help them.
Concentration: Patients are asked to identify situations when tinnitus interferes with concentration. They practice doing activities that require different levels of attention and, in some situations, use background sounds to help.
Most patients find the use of background sound very helpful in combination with counseling. Sound therapy, or acoustic therapy, works by making the perception of the tinnitus less noticeable in relation to background sound that is delivered through the sound therapy device. The devices can be wearable or be placed on a tabletop. (For wearable devices, see “Good to Go
The kind of sound utilized depends on each patient. The sound should be easy to ignore and not interfere with speech and everyday sound perception. The sound can be used when sleeping, when focused concentration is required, during difficult times of the day, or all day.
For Tinnitus Activities Treatment, a low-level partial masking sound is recommended, during which the patient will perceive both the tinnitus and the background sound. Many different sounds are available:
Noise: Broadband noise is most widely used, most likely because it is easy to ignore. Sounding like radio static, it includes a wide range of frequencies. (Frequency refers to the number of vibrations per second; its perceptual equivalent is pitch.) This is believed to activate a large area of auditory cortex in the brain, possibly making this type of sound more effective. The quality of the noise and its spectrum can be adjusted to maximize efficacy and comfort.
Music: Studies have found music to be effective for encouraging relaxation and reducing anxiety. Music can also help distract you from your tinnitus. Most clinicians use mild, moderate-tempo, instrumental music rather than fast-tempo music or music with vocalists, which can feel more stimulating than calming. There are many music options designed for relaxing and also specifically for tinnitus relief.
Modulated tones: In this newer type of sound therapy, amplitude and frequency can be varied, resulting in softly pulsing tones. Some patients find this a more effective, acceptable, and relaxing sound.
Notched sounds: “Notched” sounds refer to sound with a portion of the spectrum removed, or filtered out. Some approaches remove some frequencies from the frequency of the patient’s particular tinnitus pitch. Other strategies remove frequencies around the patient’s pitch match frequency. Preliminary results look promising for some patients, but more research is needed.
Sound therapy has been shown to be more effective when combined with some form of counseling. Tinnitus treatment clinics are increasingly offering this management approach.
Hyung Jin Jun, M.D., an otologist, and Eveling Rojas Roncancio, M.D., an otolaryngologist, are visiting scholars at the University of Iowa Tinnitus and Hyperacusis Clinic.
Richard S. Tyler, Ph.D., is a professor and the director of audiology in the Department of Otolaryngology–Head and Neck Surgery and a professor in the Department of Communication Sciences and Disorders, both at the University of Iowa. His scientific tinnitus work includes the quantification of tinnitus and the investigation of different treatments. He sees tinnitus patients weekly at the Tinnitus and Hyperacusis Clinic and hosts an annual tinnitus treatment workshop at the University of Iowa.
Tinnitus Activities Treatment is one of several tinnitus treatments that combine counseling with sound therapy. Two others are:
Cognitive behavioral therapy (CBT): This method of counseling has been used for depression, anxiety, post-traumatic stress disorder, and other conditions. It focuses on restructuring the negative reactions toward and regaining control over the condition. In addition to relaxation techniques, it teaches that while you can’t change the tinnitus, you can change your attitude toward it and in this way better manage it. Sound therapy, if needed, augments the counseling. A 2010 Cochrane Review of six CBT studies found that while tinnitus did not lessen, depression abated and quality of life improved.
Tinnitus Retraining Therapy (TRT): This therapy aims to achieve habituation to your tinnitus. This means you are no longer aware of your tinnitus except when you focus on it, and even when you do notice the tinnitus, it does not bother you. It is combined with low-level, broadband sound generators. A large, National Institutes of Health–funded TRT trial is currently under way with veterans as subjects. (See “A Landmark Trial
”) —Yishane Lee, Editor, Hearing Health