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The aim of our study was to describe a therapeutic proposal based on a stress-reaction tinnitus model (SRTM) by taking an educational approach to management of patients suffering with chronic tinnitus. In a model based on reactions induced by exposure to stress factors-the SRTM-tinnitus is an alarm signal, just like an alarm bell, at least at its onset [4]. According to the SRTM model, stress signals of a specific patient have to be identified during the alarm phase to prevent an evolution toward a resistance phase and, especially, an exhaustion phase. In chronic tinnitus, attention must be paid to behavioral and emotional reaction strategies of affected patients rather than to identifying the audiological documentation and stressors. In the resistance phase, accurate evaluation of auditory function is useful but not primarily necessary because treatment of hearing disorders rarely produces, per se, tinnitus relief; furthermore, in the resistance phase, auditory stimulation is usually more difficult and less effective.
In the exhaustion phase, identifying both audiological and stress factors is useful but not necessary. Chronic disabling tinnitus is correlated to the combination of two main phenomena: paradoxical auditory memory in common final pathway structures [2] and pathological attention to tinnitus [6]. Tinnitus school is aimed at promoting behavioral reorganization, helping affected patients to cope with tinnitus, decreasing paradoxical memory, and improving diversion and distraction of auditory attention. Counseling is carried out by the physician who visited with an affected patient and prepared treatment planning. Particular attention should be paid to diseases, disorders, or activities likely to stress an affected patient. The CAPPE questionnaire is useful to identify "objective" stress factors, but it is not sufficient to clarify patient's perceptions of their personal "value" of stressors.
Training is performed by a physiotherapist with a small class of patients (three subjects) in a gymnasium.
The first step is to prepare patients to cooperate in a complex program involving movement, thinking, and learning. After a complete audiological and stress balance test, when the 20-PSQ score totaled more then 15 despite the subscale score, tinnitus school was proposed to patients suffering from chronic disabling tinnitus. The TRQ is a self-reported scale designed to assess perceived distress associated with tinnitus. The TCQ investigates patients' approach to tinnitus, with 13 negative-thinking items (1-13) and 13 positivethinking items (14-26), rated on a 0 to 4 scale. Tinnitus school is an educational approach aimed at helping affected patients to manage their symptom and thereby to restore a normal quality of life. Decreasing TCQ, TRQ, and 20-PSQ scores represented significant improvement in the quality of life of the participants, thus suggesting that an educational approach could have an effect on the qualitative aspects of tinnitus and can contribute positively to the management of tinnitus.
This study was presented at the Thirty-Third Neurootological and Equilibriometric Society Meeting, Bad Kissingen, Germany, March 23-26, 2006. We will be provided with an authorization token (please note: passwords are not shared with us) and will sync your accounts for you. The aim of this review is to focus the attention of clinicians and basic researchers on the association between psycho-social stress and tinnitus. Stress stimulates neuroendocrine axes such as hypothalamus-pituitary-thyroid axis (Mebis and van den Berghe, 2009), hypothalamus-pituitary-gonadal axis (Whirledge and Cidlowski, 2010) and hypothalamus-pituitary-adrenal axis (HPA axis) (Lupien et al., 2007). Tinnitus is a subjective perception of sound without external acoustic signal caused by inappropriate activation of auditory cortex. In this review, we will describe some of HPA axis-mediated effects induced by stress and will discuss their possible influence on the auditory system with special focus on tinnitus.
HPA-induced steroids signal trough their respective receptors: glucocorticoid and mineralcorticoid receptors.
Glutamate is an abandoned neurotransmitter in CNS and is involved in the process of memory, learning, and also in the auditory processing. Post-synaptic neuronal plasticity can be induced by changes in the expression and trafficking of glutamate receptors AMPAR. Taken together, peripheral and central auditory systems express molecules, which are modulated by stress in the limbic, memory, and learning centers of CNS. Extended presence of stressor such as inability to escape from a stressing situation (chronic stress) or a high impact stressor (acute stress) may induce allostatic load reflected by pathological reactions or conditions.
Taken together, caution needs to be taken when designing, interpreting, and comparing experiments that use various animal stress models. In the auditory research, influence of stress on the auditory processing was often studied using physical acute stress.
Under special circumstances, the administration of corticosteroids can also have adverse effects on the auditory system. In addition to physical stress, psycho-social stress model was also used in the auditory research. Interesting for the issue tinnitus and stress is the HPA axis, which seems to be disturbed in tinnitus patients.
The link between tinnitus and negative emotional arousal was proposed many years ago by Jastreboff and Hazell to explain why is tinnitus perceived as unpleasant or even dangerous sound (Jastreboff and Hazell, 1993).
Scientists in the field currently agree that tinnitus may be triggered by an injury to the inner ear causing decreased activity of the auditory nerve and lastly in plastic changes in central auditory system (Kaltenbach, 2011).
Furthermore, information collected here, indirectly implies the requirement for psychological assessment during the diagnosis of tinnitus patients, with focus on perceived stress and psychological comorbidity. Second, stress-activated HPA corticosterone release may affect mineralcorticoid receptor function in cochlea and possibly influence the concentration of potassium secreted by stria vascularis, resulting in tinnitus.
Third, stress-induced activation of HPA axis and corticosteroid release could provoke pre- or post-synaptic neuronal plasticity of the auditory system (Figure 5).
Exploring the above models and obtaining a clear-cut animal model, which would combine an appropriate stress type and tinnitus read-out, is a challenging task.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Tinnitus School: An Educational Approach to Tinnitus Management Based on a Stress-Reaction Tinnitus Model. The auditory system is particularly sensitive to the effects of various stress factors (chemical, oxidative, emotional, etc.).
The auditory system is, in fact, particularly sensitive to the effects of various stress factors (chemical, oxidative, emotional, etc.). It informs an affected patient (and consequently, the physician) that something potentially dangerous for the subject's homeostasis is happening. These phases lead to chronic disabling tinnitus in which emotional-affective activation is dominant.
In the acute phase, an accurate audiological evaluation is important because treatment or auditory stimulation of hearing disorders (or both) can potentially interfere directly with eventual auditory tinnitus generators; furthermore, in the acute phase, early identification (where "early" does not attain to a predetermined period) of stress factors is important, too, to allow treatment of auditory or systemic disorders as soon as possible. Stressor identification is necessary, as in the acute phase, because stressor removal may still interrupt prolonged stress reaction and avoid exhaustion. The final common pathway is activated, a paradoxical auditory memory is maintained, attention is pathologically shifted toward tinnitus, behavioral modifications are evident, and emotional-affective aspects are predominant. The combination of both phenomena, and mainly the second [7], leads to significant everyday cognitive failures.
Tinnitus school is particularly directed at physical exercises to lead to a consciousness of one's own body, respiration control, and neck tension control and, in this way, to the shifting of a patient's attention away from tinnitus. The physician explains the main aspects of the auditory system, stressing the patient's attention to the phenomena involved in chronic tinnitus (paradoxical auditory memory and pathological attention to tinnitus). In our experience, a CAPPE questionnaire [11] and an accurate evaluation of the patient's general medical documentation form a useful guide.
Thus, we adopted the perceived stress questionnaire (PSQ), which is based on the perceived stress and is already used in stress evaluation in tinnitus sufferers [12]. The joy scale is scored as 1 for each negative (no) answer because all items of this scale are positively worded.
Class treatment provides comparison and cooperation between patients and improves positive enforcement. In fact, in patients suffering from chronic tinnitus, the usual procedure is to observe musculoskeletal impairments that result from increased muscle tension, fatigue, and pain in the cervical and (sometimes) the thoracolumbar region. A part of the gymnasium session is dedicated to instructing patients in how to perform home exercises correctly.
To determine individual-specific tinnitus reactions, we adopted two psychometric questionnaires: the tinnitus reaction questionnaire (TRQ) [13] and the tinnitus cognitive questionnaire (TCQ) [14]. It consists of 26 items describing some of the potential effects of tinnitus on lifestyle, general well-being, and emotional state. For each item, respondents are asked to "indicate how often they have been aware of thinking a particular thought on occasions when they have noticed the tinnitus." The negative items are scored from 0 to 4, whereas the positive items are scored from 4 to 0.
Tinnitus reaction questionnaire (TRQ, signified by 1) and tinnitus cognitive questionnaire (TCQ, signified by 2) modification after 3 months' follow-up, showing modification of mean values of a psychometric questionnaire 3 months after a tinnitus school session.
Even if amelioration regarding tension decreased (fewer positive answers) and joy increased (fewer negative answers), worries and demands remained unchanged (Fig. Chronic disabling tinnitus is due to emotional-affective involvement induced by a pathological shift of affected patients' attention to their tinnitus. Generally, in evaluating the adopted psychometrics questionnaires, the tinnitus school program resulted in a significant decrease of tinnitus disturbance (TRQ and TCQ) through a decreased perception of stress (20-PSQ).
This means that you will not need to remember your user name and password in the future and you will be able to login with the account you choose to sync, with the click of a button. This page doesn't support Internet Explorer 6, 7 and 8.Please upgrade your browser or activate Google Chrome Frame to improve your experience. Although tinnitus is an auditory symptom, its onset and progression often associates with emotional strain. Schematic representation of two main types of stress and different stress models used in basic research.
Further, stress can also activate sympathetic nervous system (Ulrich-Lai and Herman, 2009).

Most representative stress-induced pathways and hypothetical involvement in the induction of allostatic load.
This activation has been documented in tinnitus patients by using either positron emission tomography (PET) or functional magnetic resonance imagining (fMRI) (Lanting et al., 2009). Accumulating evidence suggests that changes induced by these diverse conditions may result in similar phenotype, which is inappropriate activation of the auditory cortex. In addition, we will attempt to transfer some of the in vitro knowledge into a clinical practice. HPA-induced stress hormone release and their signaling via respective receptors induce genomic (slow) and non-genomic (rapid) changes.
In contrast to ubiquitously expressed GRs, expression of mineralcorticoid receptors is restricted to selected tissues including brain, eye, intestine, kidney, mammary gland, pancreas, pituitary gland, and the inner ear.
Not surprisingly, mineralcorticoid receptor was found to be predominantly localized in stria vascularis and in the spiral ganglion neurons (Furuta et al., 1994).
Special feature of glutamate circuits is their involvement in the process of plasticity, for the reason that glutamate and glutamate receptors NMDAR (N-methyl-D-aspartate receptor) and AMPAR (α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor) regulate the strength and function of neuronal synapses. AMPAR are multimers composed of various subunits, quantity, and ratio of which influences the synaptic strength. However, the outcome of allostatic load not only depends on duration and category of stress but also on age, gender and the genetic makeup of stressed organism (Joels and Baram, 2009). Majority of stress research requiring information regarding histology, molecular or cell biology has been preformed with use of different animal stress models. Physical type of stressor (restraint) in the acute settings (4 h of duration) increased the concentration of corticosterone in blood and as a consequence, protected the animals form the noise-induced trauma.
Prenatal, long-term administration of glucocorticoids, increased the susceptibility of the of the Sprague-Dawley offspring rats to noise trauma (Canlon et al., 2003). However, little is known about the other side of this interaction—that is about stress inducing tinnitus. The first study demonstrated that the probability of developing tinnitus is approximately the same for highly stressed persons as it is for persons exposed to occupational noise (Baigi et al., 2011). Recent review of Kraus and Canlon delineates known to date anatomical connectivities between the auditory and limbic systems (reviewed in detail by Kraus and Canlon, 2012). Resulting plastic changes in central auditory activity are coupled with altered attention and negative emotions. Importantly, biomarkers and mechanisms are being indentified in a process of stress definition (Piazza et al., 2010).
Such assessment may be performed in form of a self-filled questionnaire or by a clinical psychologist. Model of stress-induced neuronal plasticity, which has been accepted in memory, learning, and emotional systems—can it also be truth to explain the induction of auditory pathologies by stress? In addition, designing and conducting large epidemiological studies, where individuals would be monitored for stress parameters and followed audiometrically for decades, would be an expensive and a time-consuming mission. Different stages of reaction (alarm, resistance, exhaustion) lead to different characteristics of tinnitus and to different therapeutic approaches.
Horner [1] described different stages of auditory pathway reaction to stress: alarm, resistance, and exhaustion. In the SRTM model, aspects concerning the danger alarm (biochemical, sensory, motor, or affective) also explain epidemiological differences between the incidence of referred tinnitus (10-15%) and that of disabling tinnitus (2%).
In the resistance and exhaustion phases, identification of primary stressors is still necessary but insufficient owing to the organization of a paradoxical auditory memory and a pathologically shifted attention to tinnitus. Attention has to be paid to eventual modification of behavior as secondary adaptation to the alarm signal. In these cases, removal of stress factors is necessary for the general health condition but useless for the course of the tinnitus, the so-called severe, disabling-type tinnitus.
These are the same principles as in kinesthetic competitive treatment as proposed by Dehler et al.
Lifestyle and drug use are investigated to identify specific stressor factors, and the possibilities of change are discussed with the patient. It is designed to represent the subjective perspective of an affected individual ("You feel .
Changes in patients' internal perception of their own sensations (pathological attention to tinnitus) can also lead to abnormal alignment of body parts with respect to one another and to the base of support.
Respondents are asked to rate, on a five-point scale (0 = not at all, 4 = almost all the time), the extent to which each of the potential effects have applied to them over the last week. Follow-up was conducted each month for 3 months to modify home-training exercise planning and to re-motivate the patients to therapy.After 6 months, we reevaluated nine patients (three had dropped out). Coping with tinnitus thus requires a modification of such patients' approach to their perception of tinnitus through modification of lifestyle, stressor removal, and diversion of that pathological attention. Cognitive tinnitus sensitization: Behavioral and neurophysiological aspects of tinnitus centralization. Concepts leading to the definition of the term cervicogenic headache: A historical overview.
The Perceived Stress Questionnaire (PSQ) reconsidered: Validation and reference values from different clinical and healthy adult samples. Tinnitus reaction questionnaire: Psychometric properties of a measure of distress associated with tinnitus. Tinnitus cognitions questionnaire: Development and psychometric properties of a measure of dysfunctional cognitions associated with tinnitus. Impact of a relaxation training on psychometric and immunologic parameters in tinnitus sufferers. GABAA-benzodiazepine-chloride receptor-targeted therapy for tinnitus control: Preliminary report.
A modified version of tinnitus retraining therapy: Observing long-term outcome and predictors.
Recent epidemiological studies have provided evidence for a direct relationship between the emotional status of subjects and tinnitus. Adaptation of neuronal system to stress-induced condition is reflected by neuronal plasticity. The results of animal and human studies have helped to determine various possible causes of inappropriate activation of auditory cortex leading to neuronal plasticity. Finally, release of ACTH to blood causes secretion of stress hormones from the adrenal glands (Lupien et al., 2007). It consists of locally produced corticotropin-releasing factor (CRF), CRF1-receptor and ACTH.
To date, mechanisms determined as responsible for the synaptic plasticity are glutamate receptors (NMDAR)—related long-term potentiation (LTP) and long-term depression (LTD). The mechanism that mediates HPA-induced changes in AMPA receptors trafficking is attributed to the genomic and non-genomic effects of glucocorticoids (Figure 4). If stress and activated HPA axis could induce plastic changes in the auditory pathway via modification of glutamate neurotransmission, remains to be established.
The goal of animal stress models is to mimic and study stress experienced by people under certain conditions. Similar protective effects had the administration of glucocorticoid-based drugs prior to acoustic trauma (reviewed in Meltser and Canlon, 2011).
However, these findings could not be reproduced by other group in Wistar rats, possibly reflecting inter-strain genetic differences in stress and corticosteroid susceptibility (Hougaard et al., 2007).
This implies that chronic, psycho-social stress may influence the function of auditory pathway.
It has been a frequent observation made by otologists and audiologists that many tinnitus patients complain of psycho-social distress prior to or during the onset and progression of tinnitus. Importantly, the authors also have noticed that psycho-social stress contributes to worsening of tinnitus symptoms. In addition, patients who had disturbing tinnitus for a longer time (on average 14.7 years) were shown to develop improper HPA responses to an experimental, psycho-social stress (Hebert and Lupien, 2007). In addition, this important work collected evidence supporting the notion of noise generating synaptic plasticity in the limbic structures.
Can stress induce such critical injury to the inner ear or induce plasticity in higher auditory structures?
This provides the researchers and clinicians not only with more basic knowledge about stress-induced processes but also with more diagnostic power. Psychological intervention with a goal of stress-management strategies appears to be an indispensable element in tinnitus treatment, especially important to use in very early stages of tinnitus, before the chronification of plastic changes has taken place. Nevertheless, step-by step understanding of how and to what degree the psycho-social or physical stress could affect our peripheral and central auditory system should become a goal in the basic and clinical auditory research. The anti-inflammatory action of glucocorticoids is mediated by cell type specific regulation of apoptosis.
Cell-specific regulation of apoptosis by glucocorticoids: implication to their anti-inflammatory action. Focal metabolic activation in the predominant left auditory cortex in patients suffering from tinnitus: a PET study with [18F]deoxyglucose. Individual characteristics of stress reaction may explain different aspects of tinnitus in various patients with different responses to treatment, despite similar audiological and etiological factors. For severe, disabling chronic tinnitus, Shul-man [2] demonstrated that a final common pathway exists in the medial temporal lobe system, the basic process of which is the establishment of a "paradoxical auditory memory." He proposed for tinnitus a stress model in which the final common pathway involves the hippocampus and the cerebellum, providing the neurochemical basis (hippocampus) and the cognitive and motor basis (cerebellum) of abnormal behavioral aspects observed in tinnitus patients. In other words, tinnitus could become a disabling symptom only in subjects chronically exposed to stress factors, when unable to switch off the alarm signal and to counteract the effect of the stressors. Such adaptation frequently evolves as a secondorder stress factor per se, with a potential risk of developing a chronic disorder. Simple exercises have to be planned, and they are generally aimed at mobilizing the pelvis, the cervical rachis, and the thoracolumbar spine.

Respondents are also asked to indicate (from not at all to always) how frequently tinnitus induces certain reactions, such as depression, anger, confusion.
A high score represents a greater tendency to engage in negative cognitions in response to tinnitus and low engagement in positive cognitions. All patients reported that their tinnitus coping was good and that lifestyle modifications (sleep and diet regulation, regular physical exercise) induced a positive increase in quality of life as documented by a lowering of TRQ and TCQ scores to 41 ± 9 and 44 ± 4, respectively (Fig. Worries and demands subscales were not modified, but tension and joy subscales were ameliorated.
The aim of a tinnitus cure, generally speaking, is to reach a golden point at which a patient is able to hear tinnitus but tinnitus does not disable the patient. In addition, studies of function, morphology, and gene and protein expression in the auditory system of animals exposed to stress support the notion that the emotional status can influence the auditory system. Generally speaking, stress is a positive reaction because it increases the chance of survival by initiating adaptation and coping with new situation (Lupien et al., 2009). These causes include changes in spontaneous firing rate, increased gamma band reflecting synchronous firing of auditory cortex and tonotopic reorganization (Nava and Roder, 2011). Stress hormones comprise glucocorticoids (corticosterone, cortisol) and mineralocorticoids (aldosterone) (de Kloet et al., 2005).
Interestingly, deletion of CRF1-receptor gene resulted in auditory impairment of knock-out animals (Graham and Vetter, 2011).
In addition, changes in AMPAR composition and density on the synapses were shown to be essential for the plasticity process.
In the prefrontal cortex, stress has been demonstrated to activate in a non-genomic way the glucocorticoid-inducible kinase SGK (Popoli et al., 2011). From the perspective of allostatic model, one could hypothesize that the acute physical stress is unable to induce allostatic load in auditory pathway. One of the earliest published observations connecting the onset of tinnitus with psycho-social distress was made by John Harrison Curtis, the surgeon of the Royal Dispensary for Diseases of the Ear in London (the first hospital in England offering specialized care for ear diseases, est. Interestingly, exposure to high level of stress and occupational noise doubles the probability of developing tinnitus. HPA axis in tinnitus patients under stress seems to be activated later and to a lesser extend than in the healthy controls, consistent with glucocorticoid inefficiency (Yehuda et al., 1996).
Induction of limbic plasticity is possible due to multi-level projections of the auditory system to the limbic structures. An important hint was recently delivered by a group studying mild stress model of depression in Sprague-Dawley rat with PET imaging technique.
Stress is no longer an undefined, sad state of mind but an important, distinct factor in precipitation and amplification of mental and mood disorders (Holsboer and Ising, 2010).
A model based on individual reactions to stress factors (stress-reaction tinnitus model, or SRTM) could explain tinnitus as an alarm signal. Furthermore, Zenner and Zalaman [3] showed that in patients with chronic tinnitus, attention is pathologically shifted toward tinnitus and, in this way, cognitive functions are disturbed.
In other individuals, the same factors or diseases could provoke tinnitus without inducing disability because these subjects are skilled to cope with tinnitus and have a real capacity to restore homeostasis.
In tinnitus school, physical exercises are integrated in an educational program, as in back school [9] and neck school [10].
In some cases, massages can be useful either to relax an affected patient or to mobilize joints.
The data provided by clinical and basic research with use of animal stress models offers valuable clues for an improvement in diagnosis and more effective treatment of tinnitus. The process of coping with conditions altered by stress is called allostasis and means a change from the usual, homeostatic status into a status, in which the organism can adapt to changes (McEwen and Gianaros, 2011). This impairment was accompanied by reduced expression of glutamine synthetase together with abnormal innervation features and was attributed to the developmental role that CRFR1 potentially plays in the inner ear. SGK1 is also expressed in stria vascularis, spiral ligament, spiral limbus, organ of Corti, Reissner's membrane and in the spiral ganglion of rats (Zhong and Liu, 2009) but role of SGK1 in the inner ear has not yet been experimentally addressed. To the physical stress models belongs between many others the immersion in cold water, restrain, cold-water restrain, electric foot shock, and food deprivation. From the perspective of allostatic model, one could postulate that chronic physical stress may induce the allostatic load in auditory pathway. On the contrary, activation of HPA axis resulting in the production of corticosteroids protects the auditory system against the noise trauma. In the second study, a self-completion questionnaire was used to inquire about work- and health-related stressors and hearing problems, such as tinnitus. Recent research has implicated that living in a city affects stress processing and may be responsible for increased incidence of anxiety disorders in the cities, as opposed to rural communities (Lederbogen et al., 2011).
Tinnitus in the general population with a focus on noise and stress: a public health study. In each patient, stressors have to be identified during the alarm phase to prevent an evolution toward the resistance and exhaustion phases. Individual capacity to counteract stress factors is, in fact, strictly specific for each subject: This means that the evolution from alarm to exhaustion is specific for each patient [5]. Stress is a result of a patient's experience of overload, with further emphasis on the experience of unpredictability and uncontrollability of events. Tinnitus school consists of three sessions per week for 2 weeks followed by two sessions per week for another 2 weeks (total, 10 sessions).
A lower score represents a slight reaction to tinnitus (alarm), whereas higher scores indicate deeply negative reactions (exhaustion).
Abuse or chronic deregulation of allostatic processes (such as prolonged or repeated stress) may lead to so-called allostatic load, which is a negative physiological and behavioral effect of stress (Figure 2) (McEwen and Wingfield, 2003). Future experiments should determine the connection between cochlear and systemic HPA systems. Lastly, there are models that mix different types of acute and chronic stress in an unpredictable way (Jaggi et al., 2011). This endogenous corticosteroid protection is comparable to the application of synthetic corticosteroids, used in therapy of acute hearing loss (Meltser and Canlon, 2011). If these projections are activated by stress and if this activation could induce plastic changes in the auditory system, remains to be determined. After 4 weeks of random mixed stressing, brain PET analysis revealed the activation of left auditory cortex and deactivation of left inferior colliculus in stressed animals.
In the exhaustion phase, chronic tinnitus is due to the organization of a paradoxical auditory memory and a pathologically shifted attention to tinnitus.
Therefore, the definition of tinnitus as acute or chronic cannot refer merely to a standardized period but must be fitted to each subject.
This implies that the existence of stress in a subject is partly inferred from information about the person's experience of lack of control. Allostatic load can affect various tissues and organs and include neuronal atrophy, impaired immunity, atherosclerosis, obesity, bone demineralization and mood disorders (McEwen, 2003). The genomic reactions occur due to the fact that both GRs and mineralcorticoid receptors are cytoplasmic, ligand-activated transcription factors (Funder, 1997).
Curtis has noticed that in two of five cases, affected patients attributed the beginning of tinnitus to a psycho-social strain caused by death in immediate family (Curtis, 1841). In addition, prevalence of sleeping problems was significantly higher in subjects with tinnitus, than in the tinnitus-free subjects. It is, however, possible that the observed changes in HPA axis of tinnitus patients may be a result and not a cause of tinnitus. Changes in the auditory system correlated significantly with the depressive symptoms of experimental animals (Hu et al., 2010).
Including stress as factor of future investigations in the auditory, tinnitus-related research seems to be a logical consequence of above observations. The aim of our study is to describe a therapeutic proposal based on the SRTM by taking an educational approach to management of chronic tinnitus. The stress experiences presented in the PSQ were intended to be abstract enough to be applicable to adults of any age, stage of life, gender, or occupation, but at the same time interpretable as specific to a variety of real-life situations. Binding of steroids to GRs or mineralcorticoid receptors induces translocation of the ligand-receptor complex to the nucleus, where the transcription of selected genes is either induced or suppressed (Datson et al., 2008).
Importantly, the authors found linear association between tinnitus and the magnitude and duration of stress, such as for instance occupational stress (Hasson et al., 2011). For example, "You feel under pressure from deadlines" could refer to anything from a bill due, to an oncoming birthday party, to a grant proposal. Both studies were performed with more than 10,000 subjects each, thus, providing statistical strength. Selection of appropriate patients and follow-up is based on psychometrics of tinnitus and stress questionnaires, including a tinnitus reaction questionnaire, a tinnitus cognitive questionnaire, and a 20-item perceived stress questionnaire.
This questionnaire asks the respondent how often certain experiences of stress occurred in the last month. Non-genomic responses induced by corticosteroids and mineralocorticoids are extremely rapid (seconds to minutes) and are not mediated by a cytoplasmic but by a minor, membrane-bound form of GRs or mineralcorticoid receptors (Groeneweg et al., 2012). The content of the items does not refer to tinnitus but focuses on a more cognitive appraisal of stress. Both receptors were shown to be localized to the lipid rafts—more precisely to caveolae on a cell surface. Caveolae are rich in signaling proteins such as G-proteins and kinases, thus, they support formation of various signalosomes. The precise signaling pathways induced by corticosteroids and mineralocorticoids remain to be confirmed but it is already apparent that the kinase pathways are predominant (Groeneweg et al., 2012).

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