Tinnitus & Hyperacusis Therapy Masterclass

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tinnitustherapy.org.uk

Specialist course for management of tinnitus and hyperacusis in children and adults

 








Provisional programme

11-15 September 2017, Guildford, UK

 

 

Monday 11 September 2017  

Time

Topic

Presenter

“Synopsis”

8:30-9:00

Registration & refreshments  

9:00-11:00

Cognitive Behavioural Therapy (CBT) in Tinnitus and Hyperacusis Rehabilitation  

Dr. Hashir Aazh, Head of Tinnitus & Hyperacusis Therapy Specialist Clinic, Royal Surrey County Hospital, Guildford     

“This is an introductory and interactive session which gives an overview of specialist cognitive behavioural therapy focused on tinnitus and hyperacusis management and briefly discusses the limitations and evidence-base for this method.”

11:00-11:30

Break

11:30-12:30

Neuro-anatomical and neuro-functional correlates of tinnitus assessed with imaging

Professor Deborah A Hall, National Institute for Health Research (NIHR) Nottingham Hearing Biomedical Research Unit, United Kingdom

“Over the past few decades, researchers have been chasing the neural correlates of the tinnitus percept on the understanding that chronic subjective tinnitus is the result of an ‘abnormality’ somewhere in the brain. To search for such abnormalities they have used a range of different brain imaging methods; primarily magnetic resonance imaging (MRI), electroencephalography (EEG) and magnetoencephalography (MEG). fMRI is able to detect localised transient changes in neural activity or networks of sustained baseline activity that can be associated with chronic tinnitus. MEG and EEG on the other hand have strengths in measuring the time signatures of brain activity in terms of power at different oscillatory frequencies, and coherence in oscillatory responses across regions. Anatomical brain changes are believed to arise from neuroplasticity and reorganisation. Analysis of high resolution MRI anatomical data of the brain thus complements functional imaging. In addition, magnetic resonance spectroscopy (MRS) offers a novel window on the cortical neurochemistry and recently this technique has been used to measure the chemical makeup of the tinnitus brain. In my talk, I will attempt to review and summarise this vast body of research into some clear “take home” messages about the strengths of these methods to give us insight on the human mind and some understanding of the challenges which have yet to be resolved.” 

12:30-13:30

Lunch

13:30-15:00

Application of CBT and client-centred counselling skills in exploring tinnitus/hyperacusis-related distress

 Dr. Hashir Aazh, Head of Tinnitus & Hyperacusis Therapy Specialist Clinic, Royal Surrey County Hospital, Guildford     

“How use reflective listening skills and Socratic questioning in exploring and pinpointing tinnitus/hyperacusis-related distress. This session introduces the concept of distinguishing tinnitus/hyperacusis-related distress from distress caused by other psychopathologies in a patient who happen to also experience tinnitus/hyperacusis. Professional boundaries and onward referral guideline to mental health will be discussed.” 

15:00-15:30

Break 

15:30-17:00

History taking and psychometric assessment of tinnitus

Hashir Aazh

“By the end of this session participants will be able to take a clinical case history for their tinnitus patients. This talk focuses on reviewing the clinical application of a wide range of self-report questionnaires in assessment of tinnitus handicap, self-report tinnitus loudness, annoyance and effect on life, severity of insomnia, and symptoms of anxiety and depression. In addition, by the end of this session, participants should be able to select and apply a wide range of specialist self-report tools for screening of underlying panic disorder, phobia, obsessive compulsive disorder, generalised anxiety, suicidal ideations, health anxiety and depression and make appropriate onward referral to mental health services for further investigations and treatment.”

 

 

Tuesday 12th September 2017

Time

Topic

Presenter(s)

“Synopsis”

9:00-10:00

Tinnitus and hyperacusis in children: Audio-vestibular assessment and management  

Dr. Veronica Kennedy, Consultant audio-vestibular physician, Bolton NHS Foundation Trust   

“This lecture reviews evidence-base for various medical investigations and treatments for tinnitus and hyperacusis in children.”

10:00-10:30

Break

10:30-13:00

Audiologist-led  specialised CBT in Tinnitus and Hyperacusis Rehabilitation

Dr. Hashir Aazh, Head of Tinnitus & Hyperacusis Therapy Specialist Clinic, Royal Surrey County Hospital, Guildford     

“This is an interactive session which gives an overview of the specific interventions used in audiologist-led specialised CBT for tinnitus and hyperacusis. These comprise: (1) Establish relationship using client-centred counselling skills, (2) Enhance patient’s motivation for CBT, (3) Formulation: Guided discovery, (4)Sharing formulation, (5) Agenda setting, (6) Goal setting and prioritising, (7) Check patient’s mood and symptoms, (8) DTF as an assignment for identification of thoughts, (9) DTF as an assignment for challenging thoughts, (10) ABC (non-related to tinnitus/hyperacusis) assignment, (11) Reviewing DTF for identification of thoughts, (12) Reviewing DTF for challenging thoughts, (13) Creating counter-statements, (14) Psycho-education: ABC presentation, (15) Psycho-education: hearing-related information, (16) Psycho-education: cognitive distortions presentation, (17) Behavioural experiment: identify thoughts, (18) Behavioural experiments: challenging thoughts, (19) Socratic questioning to explore different way of thinking, (20)Discuss progress of therapy and termination.”

13:00-14:00

Lunch

14:00-15:00

Cognitive Behavioural Therapy (CBT) for tinnitus & hyperacusis: review of research evidence  

Hashir Aazh

“By the end of this session participants should be able to analyse and critically discuss the relevance and evidence-base for psychological models and the key CBT theories to development and maintenance of troublesome tinnitus and hyperacusis. CBT conceptualises patients’ reported adverse emotional response to sound or tinnitus as catastrophic misinterpretation of sound or tinnitus, rather than merely a consequence of hypersensitivity or loudness of tinnitus. The Cognitive-behavioural conceptualisation posits that patients hold beliefs that environmental noises (in the case of hyperacusis) or tinnitus will lead to catastrophic consequences for their daily life. These so called negative automatic thoughts (NAT) occur when patients face situations that violate underlying rules and assumptions they have established during their early years “in order to survive I should always be at my peak efficiency”. These rules are assumed to reflect an individual’s core belief. The onset of hyperacusis or tinnitus can precipitate a perceived threat to these life rules and some people therefore direct their behaviour at reducing this threat (e.g. avoiding noise at work, using tinnitus maskers, worry). The paradoxical effect of this is a heightened awareness of the source of threat (i.e. sound) and limiting their life. CBT aims to enable the patient to live a more fulfilled life by identifying and modifying NATs, maladaptive rules for living, negative core beliefs and reducing safety seeking behaviour.”

15:00-15:30

Break

15:30-17:00

Hyperacusis, misophonia and phonophobia in adults and children 

Hashir Aazh

“By the end of this presentation participants should be able to demonstrate an understanding of physiological and psychological aspects of hyperacusis. Hyperacusis is a term that is used to describe the experience of intolerance to ordinary sounds in a way that they cause significant distress and impairment in the sufferer’s social, occupational, recreational, and other day-to-day activities. Hyperacusis can lead to a high level of disability for some leading to joblessness, an overrepresentation of emotional disorders and relationship difficulties. Substantial discomfort, total sense of dissatisfaction from health care professionals, inability to access public services, health and education, suicidal ideations and violence on people or animals have been reported among hyperacusis sufferers in internet patient’s forums in the UK and USA.

Cognitive behavioural model for hyperacusis asserts that the noise-induced distress in individuals with hyperacusis arises from the meanings they give to their experiences. For example catastrophic misinterpretation of physical symptoms (e.g., “my ears will explode when I listen to loud noises”, “I will faint”) is central to experience of panic in noisy

places, while exaggerated sense of guilt due to intrusive thoughts is central to anger reaction in respond to noise (e.g., “I will smash his face if he continue to make this noise”, “My reaction to noises that others make is rude”).”

 

 

 

Wednesday 13th September  2017

Time

Topic

Presenter(s)

“Synopsis”

9:00-10:00

The psychoacoustics of tinnitus: pitch, loudness, masking, and residual inhibition

Professor Brian Moore, University of Cambridge, Cambridge

“This lecture focuses on perceptual measurements of the characteristics of tinnitus and their applications in understanding the causes and origins of tinnitus. Topics covered include estimating the loudness and pitch of tinnitus, relationship of tinnitus pitch and tinnitus spectrum to the audiogram, the masking of tinnitus and the effectiveness of different types of maskers, and residual inhibition.”

10:00-10:30

Break

10:30-11:30

Loudness Hyperacusis: mechanisms of normal loudness and their breakdown

Professor Brian Moore, University of Cambridge, Cambridge

“By the end of this lecture participants should be able to demonstrate an understanding of loudness perception theories and their relevance in development and maintenance of the loudness hyperacusis. There appear to be many different forms of hyperacusis (Tyler et al., 2014). This presentation is concerned with “loudness hyperacusis”, which is a form of hyperacusis where sounds with medium and high levels appear to be louder than normal.”

11:30-13:00

Establish relationship using client-centred counselling skills

Hashir Aazh

“By the end of this practical session participants should be able to demonstrate an understanding of the theoretical and empirical underpinnings of client-centred counselling model of Carl Rogers. To apply a wide range of basic counselling skills within a clinical context for patients experiencing troublesome tinnitus and hyperacusis. Client-centred counselling was developed by Carl Rogers and emphasises on respecting and trusting the patient’s capacity for growth, development and creativity (Rogers 1951). According to Carl Rogers, a non-authoritarian and non-directive approach by the clinician which encompasses the core counselling conditions facilitates the change process. The core conditions of client-centred counselling comprise: (1) the therapist is congruent in the relationship (In client-centred counselling, congruence means realness in a way that the counsellor is willing to be who he is), (2) the therapist is experiencing unconditional positive regard towards the client, and (3) the therapist experiences an empathic understanding of the patient’s internal frame of mind (Rogers 1951; Merry 2002). A wide range of counselling micro-skills will be used throughout the process in order to (1) help the patient in establishing priorities and developing action plans, (2) explore various options and strategies as well as understand barriers and facilitators to change, and (3) improve confidence and helping the patient to mobilise their resources and develop an achievable timetable (Egan 2013; Egan & Thompson 1975). A summary of the micro-skills used in client-centred counselling comprise: open-ended questions, silence, focusing, empathy, paraphrasing, reflecting meaning, reflecting feelings, structuring, summarising, recognising patterns & themes, self-disclosure, immediacy, challenging, timing & pacing, goal setting, decision making, and problem solving (Egan 2013; Egan & Thompson 1975; Jenkins et al. 2000).” 

13:00-14:00

Lunch

14:00-15:00

Overview  of CBT: application and principles of  Diary of Thoughts and Feelings (DTF) and Guided Discovery

Hashir Aazh

“CBT is a psychological intervention that aims to help the patient to modify their unhelpful, erroneous cognitions and safety-seeking behaviours (Beck, 1976; Clark et al, 1999). The CBT approach is collaborative, with a strong emphasis on the clinician and patient working on a problem together. One goal is to test reality through ‘collaborative empiricism’, whereby the clinician and patient work together to test a range of hypotheses. Throughout, the principle of guided discovery is employed, in that the patient makes discoveries with some guidance from the clinician rather than the clinician pointing out maladaptive behaviour or errors in thinking. CBT involves helping the patient to identify, challenge and modify their unhelpful thoughts in response to tinnitus or environmental sounds.

By the end of this practical session, participants should be able to use DTF for identification of tinnitus/hyperacusis-related events, thoughts and emotions. Principles of guided discovery and Socratic questioning will be used in order to explore patient’s thoughts about the effects of tinnitus/hyperacusis on their life.”

15:00-15:30

Break

15:30-17:00

Explore and enhance patient’s motivation for CBT

Hashir Aazh

“This practical session provides an opportunity for participants to practice principles of motivational interviewing (MI; Miller 1996; Miller 1983) in the context of tinnitus and hyperacusis rehabilitation. MI is “a collaborative conversation style for strengthening a person’s own motivation and commitment to change”(Miller & Rollnick 2012, p.12). MI is rooted in the client-centred counselling method of Carl Rogers (Rogers 1959) and gives great importance to understanding of patient’s internal frame of mind and exhibiting unconditional positive regard (Miller & Rose 2009). However, unlike Rogerian client-centred style where the counsellor follows the patient’s lead in a truly non-directive form, MI applies a guiding style of counselling where direction of the session is influenced by both patient and therapist in a collaborative way (Miller & Rollnick 2012). In MI it is important to encourage the patient to explore and verbalise their own reasons to change an attitude (e.g., accepting tinnitus) or the need to take an action (e.g., committing to a therapy programme which doesn’t cure tinnitus but would help in management of the symptoms), as opposed to lecturing and giving them information and advice about benefits of CBT, or arguing about the negative consequences of doing nothing (Miller & Rollnick 2002).”

 

 

 

Thursday 14th September 2017

Time

Topic

Presenter(s)

“Synopsis”

9:00-10:30

Audiologist-led CBT: Practical

 

10:30-11:00

Break

11:00- 12:00

Case conceptualization (formulation) and treatment plan  

Hashir Aazh

By the end of this session, participants should be able to develop a CBT formulation explaining the development and maintenance of troublesome tinnitus or hyperacusis.”  

12:00-13:00

Identifying and modifying automatic thoughts: Application of Socratic questioning and other CBT techniques   

Hashir Aazh

“By the end of this session, participants should be able to use the cognitive distortions presentation and Socratic questioning style in order to help their patients to explore different way of thinking and attitudes.”         

13:00

Group Photo 

13:00-14:00

Lunch

14:00-15:00

Teaching patients to identify automatic thoughts and distinguish them from emotions

Hashir Aazh

“By the end of this session, participants should be able to explain the CBT model and its relevance to tinnitus/hyperacusis. They should be able to use the ABC presentation to assist patients to learn how to distinguish between events, thoughts and emotions. In this session participants will be provided with a counseling tool that can help them in offering an overview of the ABC model of human mental disturbance to their patient. In ABC model, A represents activating events, B underlying thoughts, and C emotional and behavioral consequences to their patients (Ellis 1962; Beck 1976). Patient will be encouraged to think about various ABC combinations and to decide whether CBT would be beneficial for them or not.”    

15:00-15:30

Break

15:30-17:00

The value of Behavioural Experiments in management of tinnitus & hyperacusis  

Hashir Aazh

“In CBT, behavioural experiments are defined as planned experiential activities undertaken by patients which are designed directly from a cognitive formulation of a problem and are aimed to (1) test the validity of patients’ existing beliefs, (2) construct more adaptive beliefs,

and (3) contribute to development and verification of cognitive formulation (Bennett-Levy et al. 2004). Behavioural experiments in the context of CBT are different from approaches which are rooted from behaviour psychotherapy (i.e., Tinnitus/Hyperacusis Retraining Therapy (TRT; Jastreboff & Jastreboff 2014) which aim to facilitate habituation through gradual, repeated, and prolonged exposure to feared stimulus. The main aim of behavioural experiments is to change perspective. If the troublesome thought and safety behaviours are accurately captured and examined in the experiment, then the change is likely to happen even after one single key behavioural experiment.”

 

 

 

Friday 15th September 2017

Time

Topic

Presenter(s)

“Synopsis”

9:00-10:00

Syndromic Tinnitus

Mr. Don McFerran, Consultant Ear, Nose and Throat Surgeon,

Colchester Hospital University NHS Foundation Trust, Colchester, Essex

“This lecture reviews Syndromic tinnitus and evidence-base for various medical treatments. Most cases of tinnitus are associated with pathological changes within the temporal bone, though for most people this pathology is simply the wear and tear of presbyacusis or noise induced hearing loss. There are, however, some examples of tinnitus that are associated with particular medical syndromes. Examples that commonly include tinnitus as a symptom and are characterised by conductive hearing loss include otosclerosis and chronic otitis media. There is good evidence of the tinnitus outcome after stapedectomy for otosclerosis and generally this seems helpful. There is less information regarding chronic otitis media. Syndromes that feature tinnitus and sensorineural hearing loss include Ménière's disease and vestibular schwannoma. Information regarding the tinnitus outcome after treatment of these conditions is sparse and where evidence is available it is generally disappointing. Rhythmical or pulsatile tinnitus can be divided into tinnitus that is synchronous with the heartbeat in which case a vascular aetiology is likely and tinnitus that is asynchronous with the heartbeat. In the latter case, muscular causes are likely, particularly myoclonus of the middle ear muscles; palatal myoclonus is a rarer example. A form of tinnitus can be generated by an abnormally open, or patulous, Eustachian tube. Temporomandibular joint dysfunction is sometimes seen in conjunction with tinnitus though whether this link is causal or coincidental remains contentious.”

10:00-11:00

Management of complex cases with other psychiatric co-morbidities

Hashir Aazh

“How to provide an effective specialist intervention focused on tinnitus and hyperacusis in patients with complex needs. Professional boundaries, confidentiality and medical ethics will be discussed.”    

       

11:00-11:30

Break

11:30-13:00

How to design suitable Behavioural Experiments in management of hyperacusis in children and adults      

Hashir Aazh

“This practical session focuses on the design and delivery of behavioural experiments in an audiologist-led Tinnitus and Hyperacusis Rehabilitation service.”

13:00-14:00

Lunch

14:00-15:30

Service Development and Clinical Guidelines for Tinnitus and Hyperacusis Management 

Hashir Aazh

“This presentation reviews policies, protocols, audit tools, risk management, additional training, report writing, and other relevant topics to management of a tinnitus and hyperacusis rehabilitation service.”

15:30-16:00

Break

16:00-17:00

·          Group Discussions

·          Setting out the Assignments