linked to tinnitus, hyperacusis and misophonia
Benefits and shortcomings of self-report questionnaires
Recent study conducted by Dr. Aazh’s tinnitus
team which was published in the International Journal of Audiology showed that the use of questionnaires can help audiologists to screen for
underlying psychological disorders in patients with tinnitus and hyperacusis
and make appropriate onward referral to mental health services (Aazh &
Moore 2017). In addition, psychometric
instruments maybe used to quantify the effect of tinnitus and/or hyperacusis on
patients’ life and monitor treatment outcome (Aazh et al.
2013; Aazh et al. 2014). However, abnormal scores on the
questionnaires do not always mean that the patient is currently experiencing
distress related to their tinnitus and/or hyperacusis (Aazh et al.
2018). Specialized version of cognitive
behavioural therapy (CBT) for tinnitus and/or hyperacusis rehabilitation which
is taught in this masterclass is only needed if the patient experiences current
tinnitus and/or hyperacusis-related distress, in the other words if their
day-to-day activities or mood are affected due to their tinnitus or sound
intolerance. A pioneering study by Dr. Aazh and his tinnitus team showed that about
70% of patients with abnormal scores on the hyperacusis questionnaire (HQ) and/or
tinnitus handicap inventory (THI) presented with tinnitus- and/or
hyperacusis-related distress warranting specialized CBT (Aazh &
Moore 2018b). For 30% of patients there was no
current tinnitus and/or hyperacusis-related distress, although approximately
half of them were experiencing some form of emotional distress which they
assumed was due to their tinnitus. For these patients (15% of the total) it was
agreed that the emotional disturbances they were experiencing did not seem to
be related to their tinnitus and/or hyperacusis and were more likely to be
related to an underlying psychological disorder. Hence, they were referred for
further psychological evaluations and treatment.
The interesting point is that there was no
statistically significant difference in the scores on the questionnaires
between the patients who shown to have current tinnitus and/or
hyperacusis-related distress (as established based on the in-depth interview,
see details the section below) and patients whose tinnitus did not interrupt
their day-to-day activities or affect their mood. Therefore, use of
questionnaires does not help to accurately identify patients who
might benefit from specialized CBT and in-depth interview is needed.
The methodology for identifying the distress linked to tinnitus,
hyperacusis and misophonia
Dr. Aazh proposed
that in-depth interviews should be
used to explore the impact of tinnitus and/or hyperacusis on the patient’s life
(Aazh et al.
2018; Aazh & Moore 2018b; Aazh & Moore 2018a). In-depth interviews are
typically used as a method of data collection in interpretivist approach of
qualitative research (Mason 2002). Interpretivist approach is consistent with pragmatism ontological and
epistemological philosophical standpoints which encourages application of a
diverse range of approaches including quantitative (e.g., questionnaires
scores, audiological results, etc.) and qualitative data collection methods (e.g.,
in-depth interview) in order to answer the questions in hand (Tashakkori & Teddlie 2010;
Cherryholmes 1992). The interpretivist
approaches considers people’s interpretations, meanings, and perceptions as the
primary data sources but at the same time such data can be combined and
triangulated with the quantitative data i.e., scores on questionnaires and
audiological measurements. The important factor about the interpretivist
approach is that it seeks people’s perceptions, the “insider view”, rather than
imposing an “outsider view” on them (Blaikie 2000) (e.g., asking open questions versus questions with fixed multiple choice
In the past, in-depth interviews have reliably been used to gather
information in various research settings (Green &
Thorogood 2009). Dr. Aazh’s approach is
unique because it encourages the use of in-depth interviews in clinical setting
in order to explore the individual’s cognitive, behavioral, and emotional
reaction to tinnitus or certain sounds (in the case of hyperacusis and
misophonia). During the in-depth interview, patients are encouraged to talk
about a typical day (e.g., tell me a bit more about how your tinnitus and/or
hyperacusis affect your activities and/or mood on a typical day?). The aim of
this strategy is to provide an opportunity for the patient to reflect on the
way that they currently manage their tinnitus and/or hyperacusis and to
identify any areas for improvement. The approach is collaborative, with a
strong emphasis on the clinician and patient exploring the problem together.
Throughout, the principle of guided discovery (Todd &
Freshwater 1999) is employed, in that the
patient is encouraged to make discoveries with careful questioning from the
clinician rather than the clinician giving information and advice. If the
tinnitus and/or hyperacusis do not interrupt the patient’s day-to-day
activities or affect their mood, it will be concluded that specialized CBT is
not needed. Such patients should be discharged. If the conclusion is that the
distress the patient experiencing is due to an underlying psychological
disorder, not necessarily to tinnitus/hyperacusis, then the patient needs to be
referred to mental health services. In
the 3rd International Conference on Hyperacusis (Guildford, 2017)
Dr. Aazh discussed a case study of a patient who was referred for hyperacusis
management for whom the in-depth interview revealed
that the main reason for the distress she was experiencing was her symptoms of
psychosis and visual hallucinations, which she felt were more likely to happen
in noisy situations. The conclusion was that although she was experiencing
intolerance to sound, the root cause of the problem was not hyperacusis. Hence,
she was referred to the Early Intervention in Psychosis Service (Aazh et al.
If in-depth interview show that tinnitus and/or hyperacusis does affect
the patient’s activities or mood in a typical day, then this should be further
explored and specialized CBT to be considered.
Aazh, H., Eghbal,
P., & Kurian, J. (2013). Outcomes Monitoring System (OMS) as a managerial
tool: reflections from application of OMS at tinnitus and hyperacusis therapy
clinic, Royal Surrey County Hospital. British
Academy of Audiology Magazine, 28,
Aazh, H., Knipper, M., Danesh, A. A., et al. (2018). Insights from
the third international conference on hyperacusis: causes, evaluation,
diagnosis, and treatment. Noise Health,
Aazh, H., McFerran, D., Salvi, R., et al. (2014). Insights from the
First International Conference on Hyperacusis: causes, evaluation, diagnosis
and treatment. Noise Health, 16, 123-6.
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.
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