What is CBT?
Cognitive behavioral therapy (CBT) is a psychological
intervention that aims to alleviate anxiety by helping the patient to modify
their unhelpful, erroneous cognitions and safety-seeking behaviors (Beck 1976; Clark et al. 1999).
What is the research evidence in support of CBT
Two systematic reviews have led to the conclusion that
CBT delivered by psychologists in a research setting helps patients to reduce
the effect of tinnitus on their lives (Martinez-Devesa et al. 2010; Hesser et al. 2011).
Specialized CBT for tinnitus and/or
hyperacusis rehabilitation delivered by audiologists
Audiologist-delivered CBT is focused on managing
hyperacusis/tinnitus-related distress and patients with symptoms of co-morbid
psychological disorders should be referred to mental health professionals for
assessment and appropriate management of their psychological symptoms. These
should be identified at the assessment stage prior to initiating the treatment.
Patients should undergo psychiatric/psychological assessment/treatment at the
same time or prior to their tinnitus and hyperacusis rehabilitation, when
needed. Given the high prevalence of anxiety and depression symptoms among
patients with tinnitus/hyperacusis, most patients generally have some form of
mental health treatment prior to be referred to audiology for tinnitus and
hyperacusis management. If not then this should be identified promptly and
appropriate actions to be taken.
In collaborative work
between specialists in audiology and clinical psychology, Aazh and Allott
(2016) published a protocol
for audiologist-delivered CBT for hyperacusis rehabilitation. More recent studies
published in the International Journal of Audiology and the American Journal of Audiology evaluated the feasibility and clinical effectiveness of CBT specialized on
tinnitus and/or hyperacusis rehabilitation (Aazh & Moore 2018b; Aazh & Moore 2018a). These studies
reported “medium” and “large” effect sizes (ES). The ES’s were 1.13 for
tinnitus handicap inventory scores, 0.76 for hyperacusis questionnaire scores,
0.71, 0.95 and 0.93 for tinnitus loudness, annoyance and effect on life,
respectively, measured using the visual analog scale, and 0.94 for the insomnia
severity index score. They concluded that audiologist-delivered CBT led to
significant improvements in self-report measures of tinnitus and hyperacusis
handicap and insomnia. They also suggested that methods described in these
papers should be used when designing future randomized controlled trials of
outcome evaluations in Dr.Aazh’s tinnitus team
Figure below is the results of a recent service evaluation
conducted by Dr. Aazh’s tinnitus team on over 500 patients illustrating the change in the mean of tinnitus
loudness, tinnitus handicap, insomnia and hyperacusis handicap as measured via
Visual Analogue Scale (Adamchic et al. 2012), Tinnitus Handicap Inventory
(Newman et al. 1998), Insomnia Severity Scale (Bastien et al. 2001), and the Hyperacusis
Questionnaire (Khalfa et al. 2002). All
the changes were statistically significant.
in the graph below there are considerable improvements in tinnitus-related anxiety
and depression scores as measured via Generalized Anxiety Disorder (GAD-7) (Spitzer et al. 2006), and the Patient Health
Questionnaire (PHQ-9) (Kroenke et al. 2001), respectively. All the
changes were statistically significant indicating that the anxiety and
depression symptoms in this
population were likely to be associated with tinnitus and/or hyperacusis hence
a specialised CBT focused on minimising tinnitus and/or hyperacusis-related
distress have led to improvements on GAD-7 and PHQ-9.
below summarises before- and after-treatment mean scores and standard
deviations (SD) on the questionnaires assessing anxiety disorders which are
typically prevalent among people who experience tinnitus and/or hyperacusis/misophonia-related
distress (Aazh & Moore 2017). This is on a smaller sample
of patients with tinnitus and/or hyperacusis/misophonia (n=36). The tinnitus
team has made recommendations for onward
referrals for further psychological/psychiatric evaluations and treatment to
the general practitioners (GP) of all the patients who exhibited abnormal
scores on the questionnaires listed below. Most patients who exhibited abnormal
scores on these questionnaires had already received some form of treatment for
their anxiety disorders via GP or mental health services prior to being
referred for tinnitus and/hyperacusis management.
Short Health Anxiety Inventory (Salkovskis et al. 2002)
Scores of 18 or above indicates the likely
presence of health anxiety
MINI - SOCIAL PHOBIA INVENTORY(Connor et al. 2001)
of 6 or higher indicate possible problems with social anxiety
The Obsessive–Compulsive Inventory: Short
Version (Foa et al. 2002)
Scores above 21 indicates the likely presence
of obsessive compulsive disorder
Penn State Worry Questionnaire: abbreviated
version (Crittendon & Hopko 2006)
of 23 shows symptoms of generalised anxiety disorder
The Panic Disorder Severity Scale – Self
Report Form (Houck et al. 2002)
Scores of 8 or above indicate symptoms of
Improvements in the measures of “general”, “social”,
and “health” anxieties were statistically significant which highlights that such
symptoms in this population were likely to be associated with the experience of
tinnitus and/or hyperacusis hence a specialised CBT
focused on minimising tinnitus and/or hyperacusis-related distress helped. It
is worth mentioning that all patients with abnormal scores on the psychological
questionnaires were referred to mental health services via their GP for further
evaluation and treatment if needed.
However, the changes in the measures of OCD and panic
disorder were not statistically significant. This suggests that it is unlikely
that symptoms of OCD and panic disorders to be related to tinnitus and/or
hyperacusis, therefore more specialized interventions by appropriate mental
health professionals are needed. To read the research report with regard to
those who need onward referral to psychological services see “the screening
questionnaires for tinnitus and/or hyperacusis” study conducted by Dr. Aazh’s team in collaboration
with the University of Cambridge, Department of Experimental Psychology.
Aazh, H., &
Allott, R. (2016). Cognitive behavioural therapy in management of hyperacusis:
a narrative review and clinical implementation. Auditory and Vestibular Research, 25, 63-74.
Aazh, H., & Moore, B. C. J. (2017). Usefulness of self-report
questionnaires for psychological assessment of patients with tinnitus and
hyperacusis and patients' views of the questionnaires. International Journal of Audiology, 56, 489-498.
Aazh, H., & Moore, B. C. J. (2018a). Effectiveness of
audiologist-delivered cognitive behavioral therapy for tinnitus and hyperacusis
rehabilitation: outcomes for patients treated in routine practice American
Journal of Audiolgy, [Epub ahead of
Aazh, H., & Moore, B. C. J. (2018b). Proportion and
characteristics of patients who were offered, enrolled in and completed
audiologist-delivered cognitive behavioural therapy for tinnitus and
hyperacusis rehabilitation in a specialist UK clinic. Int J Audiol, 1-11.
Adamchic, I., Langguth, B., Hauptmann, C., et al. (2012).
Psychometric evaluation of visual analog scale for the assessment of chronic
tinnitus. . American Journal of Audiolgy 21, 215-225.
Bastien, C. H., Vallieres, A., & Morin, C. M. (2001). Validation
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Crittendon, J., & Hopko, D. R. (2006). Assessing worry in older
and younger adults: Psychometric properties of an abbreviated Penn State Worry
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Hesser, H., Weise, C., Westin, V. Z., et al. (2011). A systematic
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Reliability of the self-report version of the panic disorder severity scale. Depress Anxiety, 15, 183-5.
Khalfa, S., Dubal, S., Veuillet, E., et al. (2002). Psychometric
normalization of a hyperacusis questionnaire. ORL J Otorhinolaryngol Relat Spec, 64, 436-42.
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