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Stress Management: Stress aggravates tinnitus, and stress management through relaxation techniques and therapeutic habits like physical activity, meditation, and socializing can lead to significant improvements. Smother Noise: You may find that using soothing music or a fan can smother the background noise that tinnitus creates, if they are in an otherwise tranquil environment.
Earplugs: Loud and abrupt noises can worsen tinnitus, and loud enough noises can cause more damage to the ears and contribute to related auditory problems. Earwax Removal: Depending on the underlying cause of your tinnitus, earwax removal can reduce the symptoms of tinnitus if earwax accumulation is disrupting normal hearing enough. Drugs: Drugs can reduce tinnitus symptoms, if not actually cure the condition, since it is not strictly chemical.
Vitamins and Herbs: There is little evidence that vitamin and mineral supplements have any effect on tinnitus symptoms other than a placebo effect, and you should be wary of over-consuming certain minerals. Blood Vessels and Circulation: Some tinnitus cases are related to cardiovascular or blood vessel problems, and treating those blood vessel problems would at least reduce the symptoms. Recreational Drugs: Other recreational drugs can have the same effect, especially tobacco products. Depression and Anxiety: Tinnitus remedies should be emotional as well as physical, because it will affect people on both levels.
Tinnitus remedies of all varieties can provide hope and comfort to sufferers trying to work around their tinnitus symptoms and carry on with their lives. I’ve set up this website to provide useful information and to help other tinnitus sufferers learn how to manage and live with this annoying condition. Top 3 Articles (voted by our visitors!)Tinnitus Remedies 2 CommentsTinnitus is the technical term for a persistent ringing in the ears.
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. This article focuses on one counselling approach and provides resource materials that will enable specialists and therapists to provide support for their patients’ efforts to reduce tinnitus distress. To help people cope with their tinnitus and its consequences, counselling is recognized as a vital component of virtually all tinnitus management options [6]. For the purpose of the chapter, we define counselling as the process of facilitating change by informing, advising, and empowering individuals who need support. 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.
Psycho-education is a patient-focused approach based on the premise that the more knowledgeable the patients are about their condition, the better the therapeutic outcome [50]. Tinnitus treatments use either group or individual sessions, but sometimes both have been applied. With regard to the content of the counselling, in an individual setting, it should be adjusted to suit each individual because a patient’s lack of understanding will be a barrier, thereby defeating therapeutic interventions [8].
Although for presentation purposes, the topics are presented here in a linear fashion (2 follows 1, etc.), the person providing counselling should be prepared to take a very nonlinear approach – the clinician should guide and react to patient responses, rather than follow a script.
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. Counselling based on neurophysiology will commonly attempt to explain, in some detail, the normal and abnormal physiology of the auditory system and related neural networks.
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].
If a person moves from the country to the city often they become annoyed by the noise of city traffic. 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. Homework permits the practitioner to use the time between sessions effectively by engaging the patient in tasks aimed toward the therapy goals [83]. 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]. The following homework exercises were compiled and trialled by Kong [56] on the basis of several previous studies [including: 2, 27, 92]. Tinnitus may result in a withdrawal from work and social activities that might normally provide a sense of achievement and enjoyment. Goal setting is the process of determining what your goals are, and making plans to achieve them. 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.
Take the time to look back, notice the progress you have made, and celebrate your successes!
By relaxing and becoming more calm, the stress driving your tinnitus, or resulting from tinnitus, may be reduced.
After learning the skill of relaxation, this can be quickly tapped into at times of stress.
Put both feet flat on the floor and now pull your toes back toward your face as far as possible. After a few minutes of breathing like this, as you breathe in, think of the work “relax” and as you breathe out say the words “let go”. 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. A characteristic of human behavior is that we can really only concentrate on one thing at a time. Face the person you are talking to so their gestures and facial expressions will help you understand what they’re saying. If your hearing is not the same in both ears, try turning your better side towards the person speaking to you.
If you don’t catch what someone says, don’t be afraid to ask him or her to repeat it or say it in a different way.
Please note: If you have a promotional code you'll be prompted to enter it prior to confirming your order. If you subscribe to any of our print newsletters and have never activated your online account, please activate your account below for online access. Various herbs and other supplements have been touted for their ability to improve cholesterol levels. As you've gotten older, have you noticed that you often find yourself marching around the house in a huff, searching for misplaced car keys or eyeglasses, or you just cannot remember the name of that new neighbor you met when walking the dog? The way you live, what you eat and drink, and how you treat your body can affect your memory just as much as your physical health and well-being. Hip and knee pain can keep you from the activities you love, as well as make routine tasks difficult. Watching the sugar in your diet can help you control your weight and potentially avoid serious chronic health problems — for example, heart disease and diabetes.
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PurposePosttraumatic stress disorder (PTSD) affects nearly 10% of the population, a prevalence comparable with that of tinnitus. You will receive an email whenever this article is corrected, updated, or cited in the literature. Portions of this work were presented at the 12th Annual Conference on the Management of the Tinnitus Patient, Iowa City, IA, September 2004.
For full access to this article, log in to an existing user account, purchase an annual subscription, or purchase a short-term subscription. It is usually a symptom of other problems, including damage to the ears or a cardiovascular disorder. Machines that simulate white noise, or produce white noise themselves, can work just as well depending on your preference. If you live in a noisy environment or regularly encounter too much noise you should invest in some earplugs or try to make the appropriate lifestyle adjustments. You should see a doctor about removing earwax rather than trying to do so on your own, which can worsen the problem if it is done incorrectly. Some medications can actually contribute to tinnitus symptoms, and you may need to talk to your doctor about altering your current drug regimens or finding substitutes with different side effects.
Similarly, herbal remedies have not been shown to have any statistical effects on tinnitus symptoms, although they may have other health benefits.
Smoking leads to constriction of the blood vessels and other circulation problems, so tinnitus sufferers in particular are advised to quit smoking or reduce their exposure to secondhand smoke. People who have depression or anxiety as a result of tinnitus should certainly educate themselves as much as possible about their condition. 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]. It is important that the professional be knowledgeable in their area of speciality, be sympathetic and caring for the patient, and demonstrate an understanding of the patient’s problem [13]. 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. Readers are referred to Lukens and McFarlane [50] for a review of the effectiveness of psycho-education in health care. In a group setting, the content should be broadly based to encompass the essential elements applicable to most patients. Research has shown the importance of goals in improving self-efficacy and performance; it has been reported that the enthusiasm to match performance to goals derives from an anticipated increase in self-satisfaction [57]. Many audiologists will be familiar with the Client Orientated Scale of Improvement (COSI, [65]).
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].
It is important to pitch the amount of detail to the perceived level of the patient’s understanding. Outer and middle ear are responsible for conduction and amplification of sounds to the inner ear. Auditory nerve ruling out possibility of acoustic neuroma (assuming investigation has been undertaken). 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. They also use visual analogs to explain phantom perceptions (such as lateral inhibition, Picture 5b). 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.
Sleep problems may include regularly waking during the night and difficulty in falling asleep [72]. This could involve the use of a pillow speaker in combination with a pre-existing CD or MP3 player. Those patients not profiting from the use of the minimal-contact approach could be offered CBT [78] or another psychological intervention.
Care should be taken to explain the concept of hypersensitized auditory pathways, hearing protection vs.
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].
It is important to note, however, that the benefits a person gains from the homework assigned depends on the clarity of its description and rationale, as well as the degree of patient involvement and level of compliance [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.
Specific goals have a much greater chance of being accomplished than do broad and general ones. This way you will be able to see the progress you are making, will know when your goal is reached, and will know when it is time to celebrate! The goals also need to be important for you so as to encourage you to make the commitment and put the effort in to reaching them. Setting an endpoint for your goal gives you a clear target to work towards and helps to encourage you to put in a consistent effort. Good sleep practices along with relaxation exercises may improve the amount or quality of sleep.
These strategies are commonly referred to as “sleep hygiene.” Good sleep refers not only to quantity of sleep, but also quality of sleep.
You might have your dinner, do whatever it is that you normally do, and then just go to bed for the night. Write down your worries and possible solutions before you go to bed so you don’t need to dwell on them in the middle of the night. If you find you have to, limit naps to 30 min, as daytime sleep can upset your body clock for sleeping at night. This will help to keep your mind occupied, will increase your relaxation, and help you to fall back to sleep. Don’t read or watch a stimulating TV program (as the brain receives a mixed message of having to pay attention to something and yet wanting to go to sleep). If you are frequently experiencing sleeplessness, think about going to bed later so that the time you spend in bed is spent sleeping.
A highly visible clock may cause you to focus on the time and make you feel stressed and anxious.
Twenty to thirty minutes of exercise every day can help you sleep, but be sure to exercise in the morning or afternoon, not evening. Iron deficient women tend to have more problems sleeping so if your blood is iron poor, a supplement might help your health and your ability to sleep. Relaxation is one strategy toward overcoming the negative consequences of stress and alleviating some tinnitus effects. Use a squeeze ball while doing these muscle-relaxing exercises, as it a useful aid to help a person to identify when a muscle is being tensed and when it is relaxed. Simultaneously, press your head back as far as possible and roll it in a clockwise fashion.
If you cannot feel your stomach rise under your hand keep practicing to learn the technique – you will know when it is right because you will feel your stomach rise under your hand. It can become the unwanted over riding focus of their attention and make it difficult to think about anything else. 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. As we focus on a particular thing, other things become less of the focus of our attention and recede into the background of our mind. Ask yourself “Where is my attention now?” Is it focused on a thought, a feeling, or a noise outside? Communication is such an important activity we seldom think of the detrimental effects of being unable to effectively communicate. If you become anxious or flustered, it might be harder for you to follow what’s being said. 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. Clark J and K English (2004) counselling in Audioloigic Practice: Helping Patients and Families Adjust to Hearing Loss. 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.
Andersson G (1995) A review of psychological treatment approaches for patients suffering from tinnitus. Andersson G and L Lyttkens (1999) A meta-analytic review of psychological treatments for tinnitus. Sweetow R (2000) Cognitive-behavioural modification, in Handbook of tinnitus, R Tyler, Editor. Kroner-Herwig B, E Biesinger, F Gerhards et al (2000) Retraining therapy for chronic tinnitus.
Hallam RS and L McKenna, (2005) Tinnitus habituation therapy, in Tinnitus treatment: clinical protocols, R Tyler, Editor. Henry J and PH Wilson (1996) The psychological management of tinnitus: comparison of a combined cognitive educational program, education alone and a waiting-list control.
Lindberg P, B Scott, L Melin et al (1989) The psychological treatment of tinnitus: an experimental evaluation. Jefferson CD, CL Drake, HM Scofield et al (2005) Sleep hygiene practices in a population-based sample of insomniacs. Tyler RS, AK Gehringer, W Noble et al (2006) Tinnitus activities treatment, in Tinnitus treatment: Clinical protocols, RS Tyler, Editor. Henry JA, TL Zaugg and MA Schechter (2005) Clinical guide for audiologic tinnitus management II: Treatment. McKenna L and R Irwin (2008) Sound therapy for tinnitus – Sacred cow or idol worship?: An investigation of the evidence. Lukens EP and W McFarlane (2004) Psychoeducation as evidence-based practice: considerations for practice, research, and policy. Newman CW and SA Sandridge, (2005) Incorporating group and individual sessions into a tinnitus management clinic, in Tinnitus treatment: clinical protocols, R Tyler, Editor.
McKenna L and HC Daniel (2005) Tinnitus-related insomnia treatment, in Tinnitus treatment: clinical protocols, R Tyler, Editor.
Jakes SC, RS Hallam, L McKenna et al (1992) Group cognitive therapy for medical patients: an application to tinnitus. Bandura A (1989) Self-regulation of motivation and action through internal standards and goal systems, in Goal concepts in personality and social psychology, LA Pervin, Editor. Manderlink G and JM Harackiewicz (1984) Proximal versus distal goal setting and intrinsic motivation. Dillon H, A James and J Ginis (1997) Client Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit and satisfaction provided by hearing aids. Feldmann H (1992) Tinnitus – reality or phantom?, in Proceedings of the Fourth International Tinnitus Seminar, J Aran and R Dauman, Editors. Worden FG (1973) Auditory habituation, in Habituation: Physiological substrates, HVS Peeke and MJ Herz, Editors.
Similarities between the way PTSD and tinnitus influence auditory behaviors include exaggerated startle responses and decreased loudness tolerance. Fagelson, Department of Communicative Disorders, East Tennessee State University, Box 70643, Johnson City, TN 37614. If you do not have an ASHA login, you may register with us for free by creating a new account. At present, tinnitus is treatable sometimes, but often you will have to learn to work around it. Alcohol increases blood circulation in the inner ear region, which can worsen tinnitus symptoms. There are also support groups specifically for tinnitus that have meetings in person and online.
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]. From a clinician’s perspective, group therapy is a more cost- and time-effective method; it allows for the presentation of information to more patients in less time [52].
Goal setting is said to positively impact an individual’s performance through a self-regulatory process.
It is necessary to ensure that the goals are adequately difficult to motivate, but not so difficult to discourage an individual from achieving them [61– 63].
This tool is used to determine specific hearing needs and the extent to which they are achieved following the fitting of hearing aids. 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. Starting simple is best, but allow the patient to guide you as to the depth of their understanding through questions and answers. The inner ear sends nerves (think of these as wires in an electrical circuit) to information centers in the brain.
But the parts of the brain involved in hearing and emotion are also involved downstream from the ear.
Specialists explain that the underlying cause in these cases may possibly be medically treatable, and are careful not to build expectations of a cure, nor are they pessimistic as to the potential for an effective intervention. Multisensory recognition of objects is normal, tinnitus lacks this sense of reality, making it difficult to ignore. Usually this annoyance reduces and the person becomes less and less aware of the city noise with time. 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. One of the primary benefits of using homework is that the techniques learned during the intervention are practised outside the session [83]. Kong [56] investigated the effectiveness of two CBT-based homework exercises alongside group-based information sessions to manage tinnitus. However, circumstances will determine which professionals will be providing counselling within different settings. Goal setting is about identifying and then overcoming barriers to participation and activity. While goals should challenge you slightly, it is important to set goals which you are likely to achieve. Likewise, try to keep your bedroom dark while you are sleeping so that the light will not interfere with your rest.
Exercise stimulates the body and aerobic activity before bedtime may make falling asleep more difficult. Follow the principals of holding a muscle tense for 10–20 s and releasing, then relaxing for 15–20 s before moving on to tensing the next muscle. Don’t stand up in a hurry after finishing – take a few deep breaths and stand up slowly to give your body a chance to re-orientate itself. Slow deep abdominal breathing is a useful method of reducing anxiety and causing relaxation. 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.
Reduced communication can lead to isolation and miscommunication can lead to negative consequences for relationships with family and friends.
If you drink alcohol and depending on the severity of your tinnitus, you should consider decreasing your alcohol consumption. Support from family and friends can help people cope with tinnitus and face life’s challenges in general.
Just as the term “counselling” can cover a variety of topics, those who undertake counselling can include a wide range of professionals including psychologists, audiologists, counsellors, social workers, general physicians, nurses, and medical specialists. 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 is our opinion that provision of good counselling is important no matter the professional and that all clinicians should be aware of their own limitations and establish appropriate collegial networks. It has been suggested that an educational approach be the first step in tinnitus treatment before additional intervention is ventured into [39]. Individuals in a group may be role models to each other, which helps with the realization that there are others in similar situations [52, 53]. Shorter term counselling interventions have become increasingly favorable in a variety of clinical settings and are usually designed to be part of an overall management plan [42].
These processes include enabling the individual to focus their attention, promote effort, and initiate task-related strategies [58]. Several studies [57, 61] also emphasize the need to have explicit performance levels, including concrete and quantifiable outcomes. A slight modification of this scale can also be applied to help determine needs and set goals for tinnitus management [8]. It is better that a patient leaves their consultation with a firm grasp of basic concepts, than a collection of confusing neuroanatomical nomenclature. Discuss the stria vascularis as the battery of the inner ear, outer hair cells (OHCs) as amplifiers (relate to OAE results) inner hair cells (IHCs) as switches to send information via the auditory nerve.
When damage occurs to a specific region of the ear, there is less activity from the ear; the brain reacts to this over time creating new activity. 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]. Focus on external noises in the room and outside…notice you can only focus on one thing at a time. 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. However, they all generally involve learning about sleep scheduling, attitudes and feelings that affect sleep, appropriate prebedtime activities, maintaining a good sleep environment, and the importance of daytime behavior [74]. 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. CBT [11, 29], cognitive therapies [85, 86], and rational-emotive therapy [87] have all incorporated homework as part of their therapy plans.
Simple, stand-alone take-home tasks were specifically designed, so that they could be provided to participants without needing to have a psychologist involved in their delivery. Pubmed is a great source for up-to-date information on tinnitus, while hearing aid manufacturers often have excellent anatomy charts. Each time you reach one of these mini-goals you know that you are making good progress towards your overall goal. The “going to bed” and “falling asleep” strategies may be the ones that create the biggest change in your quality of sleep, so focus on establishing these first. To help learn this technique, imagine that when you take a breath in you are inflating a balloon in your stomach – deep breathing inflates the balloon and your stomach goes out and exhaling deflates the balloon and your stomach goes in. Simple attention control exercises can be useful to shift attention from tinnitus to more useful perceptions. There are a number of strategies that can help you learn how to direct the focus of your attention. The following are two examples of attention control techniques simplified from a self-help book “Tinnitus. This report addresses physical and psychological relations between PTSD and tinnitus.MethodA chart review of veterans seen over a 4-year period for tinnitus services was conducted. 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. In this chapter, we refer to counselling in the broad psycho-educational context that can be provided by any number of health professions. 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]. For example, if the person is someone who experiences negative thinking, this can overlay all processing of incoming sensations. 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]. How these are provided to the patient varies considerably between programs and practices (again due to resources, practitioner experience, and practicality of program delivery). As the role of counselling and its definition will differ across professional groups, the varied background of participants in the counselling process will inevitably require that their expertise be used in different ways. It is important not to foster dependence on the clinician but still maintain an easy means for the parties to communicate. 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]. Another benefit of the group educational approach is its abilities to attract those who are not drawn to counselling, per se, due to the stigma and uncertainty attached to nonmedical or psychological approaches [54]. 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]. Regardless of the nature of an assignment, a person is usually advised to set shortterm goals, as this increases their motivation and expectations toward the task at hand [64].
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.
As a first step, relaxation exercises such as progressive muscular relaxation and abdominal breathing [2] are potentially helpful. Caffeine and nicotine both have stimulating effects, and intake should thus be regulated [53].
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. Anxiety disorders [88] and certain phobias [89] are examples of clinical conditions that have been aided by homework activities.
Two experimental groups, ACTIVE and PASSIVE, received identical educational sessions, once a week, for five consecutive weeks. 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. Succeeding will encourage you, help to keep you motivated, and give you confidence to set and achieve further goals. Without a time frame in which to accomplish your goals, the commitment to achieving them becomes too vague. Chest breathing is shallower and does not provide the relaxation that comes with abdominal breathing.
Although we are not always aware of it, we have some control over what we pay attention to – and we make these decisions many times a day.
A self-help management guide for the ringing in your ears” by Drs’ Henry and Wilson (2002) which you might find useful. 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. Knowledge and training will determine to some extent the amount of, and style of, counselling. 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]. However, a disadvantage of the group session is the lack of an one-on-one relationship between the patient and the clinician [52]. In the following sections, we will briefly outline the main contents of one approach to counselling and the rationale for using them.
The clinician’s role is to help patients identify the areas they want to change and then guide them in ways to achieve these goals. 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.
For a patient with a good understanding of physiology explanation of the various processes within the cochlear nucleus (CN) superior olivary complex (SOC), inferior colliculus (IC), medial geniculate body (MGB), and auditory cortex (AC) can be provided.
Have the patient stare at the center of the crosses, they should notice the emergence of gray spots at the intersections of the lines.
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. Patients can be informed about relaxation and be provided with resources for undertaking it (Appendix 1 below). As part of a SMART approach, homework need not be complex or onerous, but it should encourage participation and ownership of the problem by the patient. 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.
As you focus on your breathing, notice that you have been less aware of other parts of your body. Notice that as you focus your attention on one thing, other things fade into the background. A review of the literature related to triggers and effects of PTSD was conducted to explore potential consequences related to the presence of PTSD in the Veterans Affairs Medical Center (VAMC) tinnitus population.ResultsChart review confirmed that 34% of the first 300 patients enrolled in the VAMC Tinnitus Clinic also carried a diagnosis of PTSD. Consideration must therefore be given to both the physiological aspects of this condition and the psychological factors that can impact the experience of the disorder and, hence, the level of distress it creates for the patient. The importance of understanding how people interpret their situation is eloquently summarized by the Greek philosopher Epictetus’ quote at the beginning of this chapter. Also, unless sessions are well managed, outgoing individuals may dominate discussions to the detriment of more reserved participants.
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.
If improvement is not shown, appropriate steps (change in strategy, different techniques, or referral) are undertaken to address the problem until realistic goals are achieved. 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]. Additionally, the ACTIVE group participants received detailed and specific assignments to complete during the week.
Quillen Veterans Affairs Medical Center, who recommended source material for the study of posttraumatic stress disorder (PTSD) and provided valuable information related to the PTSD clinic’s function. Patient reports citing tinnitus severity, suddenness of tinnitus onset, sound-tolerance problems, and sound-triggered exacerbation of tinnitus were more common for patients with a PTSD diagnosis than patients with tinnitus only.ConclusionsSeveral neural mechanisms linked to both tinnitus and PTSD affect auditory behaviors.
It is, after all, the person’s perceived disability that is going to have the greatest impact on their life. The Beck Depression Inventory [35] and State-Trait Anxiety Inventory [36] have been used to assess baseline states of anxiety and depression. For example, an otolaryngologist in a small rural center may be required to undertake greater counselling across a broader scope of practice than a clinician based in a large urban hospital working as part of a multidisciplinary team. Additionally, within the group format, the observation of another group member’s success might evoke envy or confirm the uniqueness and difficulty of one’s problem [55], making the person feel more distressed.
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. The aim of all of these techniques is to learn how to control the focus of your attention – to be able to direct your attention from one thing to another at will.
Audiologists should be aware that patients with tinnitus and PTSD will require test protocols and referrals that address these powerful responses. A useful alternative measure of the presence of psychological distress is the Hospital Anxiety and Depression Scale [37], which provides an easy to administer and well-validated measure of psychological distress in physical health conditions and is suggested as a crucial first step in identifying when to refer patients for psychological assessment [38]. 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. In contrast to group therapy, individual sessions allow for specific issues pertaining to each individual patient to be addressed, which might be necessary for some. 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]). The decision to provide group or individual counselling depends on factors such as the availability of groups (this is not always feasible for some practices) and the patient’s preference [56]. 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].
Notice that you can become aware of where your attention is and that you can change the focus of your attention. Another way is to have access to homework tools that can be used independent of the clinician.
As you focus your mind on your feet, notice that you have become less aware of your breathing.

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