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Surprisingly in this day and age relatively little is certain about the causes of tinnitus. In our ignorance we further exacerbate the problem by enjoying our music at extreme volume. The onset of tinnitus can on rare occasions be an indicator of more pressing issues of health. Especially when other symptoms are noticed with the start of tinnitus it is very important to see your doctor.
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Cognitive behavioral interventions are the most widely used psychological strategies for coping with tinnitus. The goal of the therapy is to alter maladaptive cognitive, emotional, and behavioral responses to tinnitus and not to abolish the sound itself.
There are two main components to this approach: (a) Cognitive restructuring and (b) Behavioral modification. Treatment programs comprise of techniques like relaxation training, cognitive restructuring, attention control techniques, imagery training, and exposure to difficult situations. The combined approach assists patients in identifying and modifying maladaptive behavior and promotes habituation to tinnitus.
The collaboration of patient and therapist is a prerequisite for a positive outcome of therapy. In the history of tinnitus research and treatment, many attempts have been directed toward abolishing or minimizing tinnitus. Most interventions in reducing tinnitus-related distress are predicated on cognitive theories of behavior regulation. A general cognitive framework as shown in Picture 1 asserts that the emotional and behavioral consequences of an event or situation experienced by a person are modified by the way a person thinks about it.
A comprehensive model for the chronification of tinnitus, including various dysfunctional cognition and behavior, is described by Kroener-Herwig [4] based on the assumptions regarding tinnitus tolerance made by Hallam and Jakes [5]. This model describes the vicious cycle of tinnitus distress and demonstrates how different cognitive, emotional, and behavioral factors interact and create positive feedback loops generating and maintaining tinnitus-related annoyance and discomfort. The origin of cognitive behavioral therapy goes back to the 1950s and 1960s when Wolpe and Lazarus [6] developed new techniques for changing behavior – in particular in patients with anxiety disorders – based on experimental psychology. Cognitive behavioral therapy was developed mainly as a treatment for affective disorders such as depression and anxiety.
Treatment programs comprise of techniques like relaxation training, cognitive restructuring, attention control, imagery training, and exposure to difficult situations.
Relaxation methods were one of the earliest psychological treatments applied to patients with tinnitus [20]. Despite the popularity of relaxation training in clinical practice, research shows that relaxation seems to be of limited value for most tinnitus patients when used as the sole treatment [21].
In general, cognitive therapy involves the identification of dysfunctional beliefs and negative thoughts, which occur in response to life events or sources of distress. The therapist helps the clients to challenge and test the validity of their automatic thoughts and to learn ways to substitute them with more constructive ones. Imagery techniques are used to change the negative associations related to tinnitus either by “masking” the noises or by integrating them into positive scenes. In clinical practice, these approaches are rarely used as sole therapeutic methods, but are incorporated into relaxation training or cognitive restructuring interventions. Fifteen neuro-otological patients have been investigated for post-traumatic vertigo, hearing loss and tinnitus. The neurotological clinical manifestations of posttraumatic vestibular lesions demonstrate variation. Accidental head injury and its sequelae constitute major medical problems in Europe and America.
The Glasgow Coma Scale has reported data from 1248 patients: 21% had severe head trauma, 24% moderate, and 55% minor head injuries. Craniocorpography (CCG) is a simple and more rapid method for the evaluation of vestibular function than Computerized Electronystagmography (CNG).4,5,6 Both techniques were performed in a group of 15 patients with post-traumatic vertigo in an attempt to establish the value of each test for the identification of the site of lesion. The clinical charts of all patients with a diagnosis of posttraumatic vertigo between 1990 - 1995 seen at the Audiologic and Otoneurology Clinic were reviewed. Sex, age, type and degree of head trauma, time interval that elapsed between the onset of head trauma and the complaints of hearing loss, tinnitus and vertigo, results of audiologic and otoneurologic studies were recorded.
The history included questions to elicit complaints reflecting involvement of other cranial nerves. CCG is a test initially developed as a screening procedure in occupational medicine for patients with the chief complaint of vertigo.
CNG was performed with both horizontal and vertical leads to record extra-ocular eye movements.
Fifteen neurotological patients with a diagnosis of posttraumatic vertigo were selected for this study. All completed the neurologic examination including the history form NODEC IV (Germany) and Neurophysiology Otoophthalmologic (Argentina) ENT examination, CCG, and ENG tests. The incidence of occurrence of head trauma and post traumatic vertigo was found to be greater in male patients by a ratio of 2 to 1.


Evaluation of the Craniocorpography (CCG) and Computerized Electronystagmography (ENG) revealed an association between both. Fifteen patients with the diagnosis of post-traumatic vertigo completed a neurotologic examination which included audiometry and equilibriometry tests.
CCG is considered a useful test in the diagnosis of central and peripheral lesions of the vestibular system secondary to head trauma.
The incidence of occurrence of head trauma and posttraumatic vertigo was found to be greater in male patients by a ratio of 2 to 1. CCG and the Butterfly Calorigram are considered significant tests to establish the diagnosis of central and peripheral lesions of the vestibular system secondary to head trauma. Despite all these efforts, until now no treatment has been found to successfully eliminate tinnitus permanently.
In other words, emotions and behavioral reactions are the result of appraisals of an event and are not the result of the event itself. It is made clear that mainly the thoughts, beliefs, and expectations about tinnitus are creating the problem. They are convinced that the tinnitus is “making” them depressed, anxious, and worried and that their ways of dealing with tinnitus are of no account. Regardless of the cause of tinnitus, “suffering” is a function of how the patient reacts to tinnitus – how he or she copes with it.
In the early phases, therapy (then called behavior therapy) was dominated by techniques like operant conditioning [7], systematic desensitization [8], or aversion therapy [9], which were directed at overt behavior change. Patients are taught methods of challenging those thoughts and substituting their catastrophic, unrealistic thoughts with more constructive ones (cognitive restructuring). Furthermore, strategies to specifically manipulate the acoustical environment are recommended. In imagery exercises, a patient may be asked to imagine that the tinnitus is masked by the sound of a waterfall or the waves of the sea. Tinnitus for them is an acceptable solution or “a legitimate excuse” for avoiding these situations. The meta-analysis of Anderson and Lytthens [21] showed that psychological treatments are very effective regarding the reduction of tinnitus-related distress.
Kroener-Herwig, B, Biesinger, E, Gerhards, F, Goebel, G, Greimel, KV and Hiller, W (2000) Retraining therapy for chronic tinnitus A critical analysis of its status. Hallam, RS and Jakes SC (1987) An evaluation of relaxation training in chronic tinnitus sufferers In: Proceedings of the Third International Tinnitus Seminar.
Wolpe, J and Lazarus, AA (1966) Behavior therapy techniques: a guide to the treatment of neuroses.
Hallam, RS (1984) Psychological aspects of tinnitus In: Contributions to medical psychology pp. Andersson, G, and Lyttkens, L (1999) A meta-analytic review of psychological treatments for tinnitus. Jastreboff, PJ and Hazell J (1993) A neurophysiological approach tinnitus: clinical implication. Wilson, PH, Henry, JL, Anderson, G, Lindberg, P and Hallam RS (1998) A critical analysis of directive counselling as a component of tinnitus retraining therapy.
Martinez Devesa, P, Waddell, A, Perera, R and Theodoulou M (2009) Cognitive behavioral therapy for tinnitus.
Clinical examination and laboratory tests included audiometry and equilibriometry in all patients.
Correlations for vertigo with the type of head trauma, nystagmus frequency, Slow Phase Velocity (SPV), and associated complaints of hearing loss and tinnitus were analyzed.
A detailed questionnaire (NO DEC IV (Germany); and Neurophysiology Otoophthalmologic (Argentina) ENTexamination was completed for each patient.
The past history was explored to identify underlying disease with emphasis on past or recent post-traumatic vertigo.
The test is simple to perform, less time consuming, objective, and a quantitative equilibriometric test. The polygraphic Electronystagmogram was analyzed for coordinated or dissociated eye movements. Localization of peripheral vestibular disease can be easily differentiated from central states of dysequilibrium.
The correlation of SPY and frequency of 40ºC left ear with LD right suggests an indirect response of the site of lesion and a central lesion. On the other hand the SPY right 40ºC showed a direct response suggesting a peripheral lesion.
Claussen CF, De Sa J: Clinical Study of Human Equilibrium by Electronystagmography and Allied Tests.
Hickey SA, Ford GR, Buckley JG, Fitzerald O-Connor: Unterberger stepping test: a useful indicator of peri pheral vestibular dysfunction?
Claussen CF, Schneider D, Marcondes LG, Patil NP: A computer analysis of typical CCG Patterns in 1021 Neuro-otological Patients.
As a consequence, increasing efforts have been undertaken by behavioral scientists and psychologists to eliminate or at least ameliorate psychological symptoms associated with tinnitus. Furthermore, if the patient thinks that there is nothing that can be done to alleviate the symptoms, he or she will likely become hopeless and depressed. Focusing attention on tinnitus, accompanied by specific dysfunctional cognitive processes of appraisal like catastrophic thoughts and rumination, leads to negative emotional consequences.
In the 1970s, increasingly cognition-centered theories of behavior regulation were established and, consequently, cognitive interventions were implemented into therapy.


A cognitive behavioral approach was first applied in the treatment of patients with tinnitus in the 1980s [13–16].
Cognitive restructuring helps patients think differently and adopt a different attitude about their problem. Cognitive behavioral therapy (CBT) encourages patients to expose themselves to those situations in order to realize that they can cope without major negative consequences. It is more frequent in men than women with a ratio of 2 to 1; and was found of increased incidence of occurrence in patients age 20 and above. Vertigo was categorized to be of five sub-groups: tilting, lift, rotation, falling, and blackouts.
The methods of statistical analysis included Chi Square and Pearson's for dependence or independent variable; and Spearman correlation for association. In our series a significant associated complaint in patients with post-traumatic vertigo was identified.
The aim of psychological interventions is not to “cure” or to eliminate the inner noise but to reduce tinnitus-related distress and increase quality of life. This assumption can be illustrated by the fact that the majority of individuals permanently afflicted by tinnitus – even if they describe it as loud – do not feel distressed by it. Blaming a situation or person for the onset of tinnitus will create anger and hostility (see Picture 2). The goal of the therapy is to alter maladaptive cognitive, emotional, and behavioral responses to tinnitus and not the sound itself. Beck [2] has been most influential in introducing cognitive interventions into therapeutic strategies. Nowadays, it is one of the most widely used and accepted psychological strategies for coping with intractable disorders [17–19]. In this technique, a person is shown how to decrease muscular tension and to achieve states of relaxation in a very brief period of time after detecting tension. It is used as a method to guide patients recognize and subsequently abandon rigid, unhelpful thinking patterns and replace them with constructive cognitions and thoughts.
These behavioral “experiments” must be well prepared and these new skills should be frequently practiced.
In these cases, patients have to become aware of the underlying problem and are assisted in finding adaptive problem solutions. Correlations for vertigo with the type of head trauma, nystagmus frequency Slow Phase Velocity (SPV) and associated complaints of hearing loss and tinnitus were analyzed. Neurootological symptoms like vertigo and tinnitus were subjectively difficult to describe and to classify; and frequently varied over time and following treatment.
It provides a photographic, quantifiable record using a video-camera and a computer that receives, analyzes, and prints physiologic graphic significant data of the response of the patient to stimulation by stepping and standing.
If patients are no longer bothered by their inner noises and the question of how tinnitus can be removed, they might become secondary. Nevertheless, the therapist should make it explicitly clear that he or she knows that the tinnitus is real, not imagined, and that the patient’s response to the abnormal tinnitus perception can be well understood.
In accordance with this trend, Ellis [10] introduced Rational-Emotive Therapy (RET) based on his A-B-C model. The therapist instructs patients how to sequentially tense and relax various muscle groups, moving from practice in comfortable settings to practice in real-life situations such as sitting at a desk, watching television, etc. This is different from simple “positive thinking” or from “directive counseling,” a treatment component of tinnitus retraining therapy [22], because in cognitive restructuring the therapist and patient collaborate in identifying, testing, and challenging dysfunctional thoughts, beliefs, attitudes, or attributions [4, 23].
Some authors consider vertigo to be a consequence of the concussion and not due to alteration only of the ear.
As long as tinnitus itself cannot be eliminated, the main intention of all therapeutic interventions is to alleviate suffering from tinnitus.
Meichenbaum [11] introduced the notion of the specific importance of self-talk and self-instructions for behavior regulation. Relaxation techniques may be helpful in assisting people in learning a way of coping with tension and anxiety related to tinnitus. It is theorized that for patients with tinnitus, the source of distress is not the sound itself, but the way in which the person evaluates and interprets the sound.
Patients might be instructed to imagine walking through a landscape by listening to the singing of birds or lying on a blooming field and hearing the noises of bumblebees, cicadas, and other insects. Head trauma is well recognized as a cause of vertigo and is a common disturbance of the nervous system. Bandura [12] states in his social learning theory that self-efficacy beliefs play a most important role in guiding behavior.
Furthermore, it is commonly reported by patients that stress exacerbates tinnitus or causes a person to experience the tinnitus more intensely, and that a reduction in stress levels may reduce loudness and annoyance. Alternatively, a patient may imagine a cold and snowy winter day, sitting comfortably in front of the fire place, hearing the sizzling of a teakettle, and looking forward to enjoying a cup of hot tea. Also, listening to one’s tinnitus in a relaxed state can foster habituation and retain serenity in the presence of tinnitus.



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