Course preview

Module 1

Module name: Introduction to tinnitus and related factors

Content:

2 hours and 18 minutes lecture

Aim: The aim of this module is to review the latest outcomes of clinical research on tinnitus and factors related to it. The focus is on providing students with information that assist them in their day-to-day clinical situations with regard to identifying the need for amplification, medical interventions, psychological treatments or onward referrals to other appropriate health and social care professionals. Tinnitus patients often ask about various physical symptoms and how treatment might be helpful to them. This module aims to equip students with a broad knowledge of tinnitus and related factors that can be used at various stages of treatment.

Learning objectives:

By the end of this module students should be able to:

• Make appropriate onward referrals to ENT for medical examination and treatment.
• Make appropriate onward referrals to mental health services for psychological assessment and treatment.
• Categorise different types of tinnitus and factors related to them.
• Differentiate distressing tinnitus or tinnitus disorder from non-distressing tinnitus.
• Identify persistent tinnitus.
• Critically examine the relationship between hearing loss and tinnitus.
• Synthesise physiological research evidence with clinical studies in order to help patients to understand the possible underlying mechanisms that can give rise to tinnitus.
• Distinguish and categorise a wide range of medical and environmental factors that can give rise to tinnitus combined with hearing loss.
• Explain the mechanism in which the changes in hearing thresholds across the frequency range can impact tinnitus loudness and how therapy can help with this.
• Differentiate tinnitus-related distress with a distress linked with decreased sound tolerance, auditory processing disorders or distorted hearing.
• Identify the physical sensations caused by tinnitus-distress and differentiate them from other disorders that might have caused tinnitus or co-exist with it.
• Analyse the relationship between tinnitus and hyperacusis.
• Predict the risk of comorbid anxiety and mood disorders based on assessing severity of tinnitus and hyperacusis symptoms.
• Explain the mechanism in which tinnitus can relate to depression and how therapy can help that.
• Appraise a wide range of psychological questionnaires which can be utilised for screening of mental health illness and select appropriate tools based on clinical research evidence.
• Integrate research evidence in order to explain the mechanism in which tinnitus can cause sleep disturbances and how therapy can help with that.
• Adapt the findings from clinical research in order to predict the risk of suicidal and self-harm ideations among tinnitus sufferers.
• Estimate the extent of tinnitus- and hyperacusis-related handicap and their consequential mental health disturbances based on the presence and breadth of adverse childhood experiences.

Module 2

Module name: Introduction to hyperacusis & misophonia

Content:

4 hours and 20 minutes lecture

Aim: The aim of this module is to review neuro-psycho-audiological research evidence and theoretical conceptualisations with regard to hyperacusis and misophonia. Evidence-based assessment methods with the use of validated psychometric instruments, physiological and audiological examinations are reviewed. Evidence-base for CBT treatment for hyperacusis and misophonia is discussed.

Learning objectives:

By the end of this module students should be able to:

• Differentiate hyperacusis and misophonia.
• List medical conditions that can have hyperacusis as symptom.
• Categorise different forms of hyperacusis.
• Differentiate between hyperacusis and loudness recruitment.
• Make a chart of ULLs to contrast the effect of hyperacusis from loudness recruitment.
• Compare physiological theories and research evidence with regard to loudness perception and their relevance to the experience of hyperacusis and misophonia.
• Critically analyse findings from human brain imaging studies and their relevance to the experience of hyperacusis and misophonia.
• Contrast the key psychological theories and models about the source of emotional disturbances and their relevance to the experience of hyperacusis and misophonia.
• Use the principles of cognitive theory in developing generic case conceptualisation models for hyperacusis and misophonia-related distress.
• Compare the differences and similarities between patient’s experience/impact of hyperacusis and misophonia based on research evidence.
• Differentiate the trigger sounds for hyperacusis and misophonia.
• Differentiate the emotional, cognitive and behavioural aspects of hyperacusis and misophonia based on research evidence.
• Interpret the results of ULLs in order to assess characteristics of hyperacusis.
• Predict severity of hyperacusis based on variations of ULLs across the frequency range and differences in average ULLs between ears.
• Critically discuss the central gain theory and contrast its assumptions with clinical research results on the relationship between hearing thresholds and ULLs.
• Draw an evidence-based model explaining the relationship between ULLmin and depression symptoms and explain how this can be helped with the use of CBT treatment.
• Differentiate the factors related to hyperacusis between geriatric and adult populations.
• Use the research evidence in order to predict severity of hyperacusis handicap based on past history of childhood adverse events and list such events.
• Make a diagnosis for pain hyperacusis with the use of ULLmin criterion.
• Compare medical, psychological, and audiological characteristics of patients with pain hyperacusis/severe hyperacusis and other forms of hyperacusis.
• Differentiate the factors related to hyperacusis between children and adult populations.
• Compare the AMC diagnostic criteria for misophonia with self-report measures.
• Critically analyse the research findings on psychological comorbidities and discuss the possibility of Axis I and II psychological diagnoses among patients with misophonia and sign post them to the appropriate mental health professionals for further assessment and treatment if needed.
• Draw a generic case conceptualisation model for misophonia distress using the research findings on the most common misophonia triggers, emotional, cognitive and behavioural misophonic reactions.
• Critically discuss the advantages and disadvantages of diagnosing hyperacusis and misophonia with different methods i.e., ULL, self-report questionnaires and clinical interview.
• Choose a criterion for diagnosing hyperacusis based on the outcomes of the measurements of ULLs which is consistent with the scores for the hyperacusis questionnaire.
• Critically examine the ULLmin and HQ diagnostic criteria against the neurobiological and modern psychoacoustic research findings.
• Critically compare the evidence-base for different cut-off values as criteria for hyperacusis diagnosis on Inventory of Hyperacusis Symptoms.
• Critically analyse the shortcomings of the HQ and IHS and select a combination of tools in order to reliably assess the impact of hyperacusis on patient’s life.
• Utilise validated psychometric instruments in assessment of misophonia.
• Critically analyse the shortcomings of the current misophonia questionnaires and select a combination of tools in order to reliably distinguish misophonia which is of clinical significance.

Module 3

Module name: Introduction to CBT for tinnitus, hyperacusis and misophonia

Content:

60 minutes lecture

17 minutes discussion session

Aim: The aim is to discuss the theoretical underpinnings of CBT and its relevance to the rehabilitation programme for tinnitus, hyperacusis and misophonia. Research evidence for CBT in population of interest will be reviewed.

Learning objectives:

By the end of this module students should be able to:

• Explain the cognitive theory’s ABC model and its relevance to the experience of tinnitus/hyperacusis/misophonia-distress.
• Link the theoretical aspects of cognitive theory with the mechanism in which tinnitus/hyperacusis/misophonia-related distress is produced and maintained.
• Explore how the relationship between negative automatic thoughts (NATs) and dysfunctional rules of life (RoL) can lead to tinnitus/hyperacusis/misophonia-related distress.
• Utilise the latest research evidence in choosing the effective clinical intervention for tinnitus/hyperacusis/misophonia management.
• Categorise patient’s characteristics that are key in being considered as clinically significant tinnitus/hyperacusis following the initial assessment and to be offered at least one CBT session.
• Categorise patient’s characteristics that are key in being considered as having tinnitus/hyperacusis-related distress following the first CBT session and to be offered full treatment.
• Predict and plan to minimise non-adherence and drop outs based on the research findings about the characteristics of patients who are likely to decline the treatment or drop out at different stages of their care.
• Use the clinical research findings in creating realistic patient’s expectations from CBT for tinnitus, hyperacusis and misophonia.

Module 4

Module name: Psycho-audiological assessment

Content:

48 minutes lecture

53 minutes discussions

50 minutes demonstration of an assessment session using role play

Aim: The aim of this module is to equip students with the knowledge and skills required for clinical application of psycho-audiological assessment procedures and interpretation of their results in patients seeking help for tinnitus, hyperacusis and misophonia.

Learning objectives:

By the end of this module students should be able to:

• Apply Tinnitus Handicap Inventory for assessment of tinnitus and interpret its results.
• Apply Visual Analogue Scale in order to assess self-report tinnitus loudness, annoyance and effect on life and interpret its results.
• Interpret the results of Hyperacusis Questionnaire (HQ) and the Inventory of Hyperacusis Symptoms (IHS).
• Apply Insomnia Severity Index (ISI) to assess sleep disturbances and interpret its results.
• Apply standardised measures for screening of psychological comorbidities (GAD-7, PHQ-9, PSWQ-AR, PDSS-SR, OCI-R, sHAI and MINI-SPIN) and make appropriate onward referrals to mental health professionals.
• Critically analyse the shortcomings of the common psychometric tools for assessment of tinnitus and hyperacusis impact.
• Utilise modern questionnaires for assessment of the impact of tinnitus, hyperacusis, and misophonia on patient’s life (TIQ, HIQ, MIQ) and interpret their results.
• Utilise proxy parent versions of TIQ, MIQ, HIQ for assessment of the impact of tinnitus, hyperacusis and misophonia on children’s life.
• Apply Sound Sensitivity Symptoms (SSS) questionnaire and its parent version in order to differentiate different types of sound intolerance disorders.
• Screen for symptoms of anxiety, depression, and suicidal and self-harm ideations with the use of SAD-T questionnaire and make appropriate onward referrals when indicated.
• Select items from ESIT-SQ in order to use for history taking.
• Evaluate history of ear and hearing disorders, previous diagnostic tests and treatments
• Evaluate history of noise exposure, ototoxic drugs, and hearing aid use.
• Pinpoint the onset of the tinnitus and gather information about its localization, pitch, quality, and loudness.
• Explore the effect of noise exposure on tinnitus and hyperacusis and physical sensations related to them.
• Evaluate use of ear protection and use of distraction methods
• Evaluate effect of tinnitus on concentration, hearing, sleep, social life, relationship, and work.
• Explore patient’s past medical history and identify relevant and key information.
• Explore if the patient hears their tinnitus in their dreams and symptoms of exploding head syndrome when indicated.
• Explore history of mental health illness/treatment and identify key relevant information.
• Explore family history of mental health illness, parental mental health, and history of ASD in the family.
• Assess if they have symptoms of hyperacusis and misophonia
• Explore onset of hyperacusis/misophonia, trigger noises, emotional and behavioural reactions.
• Modify the procedure for pure tone audiometry (PTA) in order to avoid experience of discomfort for patients with tinnitus and hyperacusis.
• Modify ULL procedure in order to avoid experience of discomfort for patients with tinnitus and hyperacusis.
• Predict the risk of discomfort during PTA and ULL tests based on patient’s characteristics.
• Utilise appropriate/evidence-based instructions to patients prior to conducting PTA and ULL tests.
• Calculate ULLmin and assess it against the ULL criteria for diagnosing hyperacusis.
• Prepare an assessment report giving details of the main complaint, severity of symptoms, the extent to which tinnitus/hyperacusis/misophonia impacts on patient’s life, comorbid psychological and medical disorders with recommendations for rehabilitation programme based on specialised CBT approach and the need for onward referrals (when indicated).

Module 5

Module name: CBT session 1

Content:

12 minutes lecture

86 minute demonstration of CBT session 1, using role play

19 minutes discussions on role play

17 minutes discussions on the clinical notes for CBT session 1

Aim: The aim is to enable students to perform the first CBT session for management of tinnitus, hyperacusis and misophonia. The key tasks in the first session comprise: rapport building, distinguish distress linked with tinnitus, hyperacusis and misophonia from the distress linked with other underlying psychosocial or medical factors, and case conceptualisation.

Learning objectives:

By the end of this module students should be able to:

• Build a rapport with patient by applying basic counselling skills and getting to know them better.
• Communicate that patient has authority and autonomy throughout these sessions.
• Elicit the need for information prior to offering information by the use of “ask-inform-ask” technique.
• Devise a “typical day strategy” in order to assess tinnitus/hyperacusis/misophonia-related distress
• Elaborate on the way that the patient is currently managing their tinnitus/hyperacusis/misophonia and identify areas for improvement.
• Conduct an in-depth interview in order to explore different aspects of the impact of tinnitus/hyperacusis/misophonia on the patient’s life and to distinguish these from the impact of other underlying mental-physical-social complications.
• Incorporate principles of guided discovery.
• Strategically use Socratic questioning style in order to help the patient to explore their thoughts, emotional reactions, physical sensations, and safety-seeking behaviours (SSBs) in relation to tinnitus/hyperacusis/misophonia.
• Create an individualised cognitive behavioural formulation to explain the distress caused by tinnitus/hyperacusis/misophonia.
• Explain the formulation to patient and discuss how CBT can help.
• Carry out 4C methodology in order to encourage patient to reflect on what they have achieved so far and enhance their confidence in their own ability to cope with tinnitus/hyperacusis/misophonia.
• Combine the explanations about the formulation with a counselling style based on motivational interviewing in order to encourage the patient to explore the advantages and disadvantages of continuing with the CBT versus the status quo.

Module 6

Module name: CBT session 2

Content:

49 minutes lecture on transferrable counselling skills

13 minutes lecture on CBT session 2

14 minutes discussions on CBT session 2

1 hour demonstration of CBT session 2, using role play

16 minutes discussions on role play

Aim: The aim of this module is to enable students to perform CBT session 2 as a part of the specialist rehabilitation programme for tinnitus, hyperacusis, and misophonia management. The key task in the second CBT session is to design a behavioural experiment. This module also includes a review of transferrable counselling skills which need to be used throughout the therapy programme.

Learning objectives:

By the end of this module students should be able to:

• Discuss options of therapeutic self-management.
• Create a suitable environment for ‘‘therapeutic self-management’’ in a way that the patient becomes psychologically engaged in the therapy process.
• Effectively communicate with patients through application of a wide range of counselling skills as necessary.
• Develop an empathic conversation by the use of certain counselling skills i.e., attending, affirmations, and reflections.
• Differentiate between open and closed questions and utilise them strategically.
• Distinguish different forms of affirmations and use them.
• Formulate simple and complex reflections.
• Devise appropriate reflections and questions in order to maintain focus of the session.
• Devise appropriate reflections, affirmations and questions in order to help the patient to move forward when they feel stuck.
• Develop a conversation based on motivational interviewing approach.
• Critically discuss the shortcomings of common self-report questionnaires for tinnitus/hyperacusis/misophonia and explain how 4C tool can overcome these shortcomings.
• Critically discuss the differences between behavioural experiment and exposure techniques.
• Test patient’s understanding of experiment concept.
• Explain to patient what a behavioural experiment is.
• Use open questions and reflective listening skills in order to encourage the patient to think of real-life scenarios that they would expect to be affected by their tinnitus or hyperacusis/misophonia.
• In a collaborative client-centred style of conversation, identify and distinguish the key troublesome thoughts and assumptions to be tested during the experiment.
• Critically analyse the thoughts and decide if they are relevant to the topic of the rehabilitation programme which is addressing distress related to tinnitus/hyperacusis/misophonia.
• Explore hidden meanings behind the automatic thoughts.
• Rate the probability or strength of the identified negative thoughts.
• Instruct the patient with regard to the practical aspects of conducting a behavioural experiment.
• Use techniques of motivational interviewing in order to enhance patient’s commitment to therapy.

Module 7

Module name: CBT session 3

Content:

28 minutes lecture on CBT session 3

55 minutes demonstration of CBT session 3, using role play

30 minutes discussions on role play

Aim: The aim is to enable students to deliver the 3rd CBT session as a part of the specialist rehabilitation programme for tinnitus, hyperacusis, and misophonia management. The key task in this session is to review the results of the behavioural experiment, teach the patient how to challenge their irrational thoughts, create counter-statements, and issue diary of thoughts, errors and counters.

Learning objectives:

By the end of this module students should be able to:

• Review the results of the behavioural experiment
• Evaluate what the patient has learned as the results of the experiment.
• Critically analysis patient’s evaluation of the collected data.
• Combine empathic listening skills with Socratic questioning in order to help the patient to compare the advantages and disadvantages of their irrational thoughts and help them to decide if they wish to modify them.
• Teach their patient how to create effective counter statements.
• Appraise the counter-statements created by the patient against the criteria for effective counter-statements.
• Construct effective counter-statements as example for their patient to follow.
• Instruct the patient about the use of counter-statements and the CBT process.
• Apply 4C methodology in order to enhance patient’s confidence in creating and using counter-statements
• Teach the patient about the common errors of judgment and how to identify them.
• Apply counselling and teaching skills in order to help the patient to understand the mechanism in which errors of judgment are produced and their characteristics.
• Issue and explain the diary of thoughts, errors, and counter-statements for patient to complete as the between sessions task.
• Apply SEL (Stop avoidance/rituals, Expose, Learn) technique when behavioural experiment is deemed to be less effective.

Module 8

Module name: CBT session 4

Content:

19:30 minutes lecture on CBT session 4

14 minutes discussions

80 minutes demonstration of CBT session 4, using role play

25 minutes discussions on role play

Aim: The aim is to enable students to deliver the 4th CBT session as a part of the specialist rehabilitation programme for tinnitus, hyperacusis, and misophonia management. The key tasks in this session comprise: reviewing patient’s remaining counter-statements from the behavioural experiment task, review the diary for thoughts, errors and counter-statements, identify hot thoughts, use the continuum technique to challenge core beliefs.

Learning objectives:

By the end of this module students should be able to:

• Strategically, use a wide range of counselling skills in order to provide an atmosphere of support that encourages the patient to use the therapy techniques.
• Review the diary of thoughts, errors, and counter-statements.
• Evaluate patient’s understanding about distinguishing thoughts, events and emotions induced by tinnitus and noise (in the case of hyperacusis/misophonia).
• Assess patient’s understanding about the common thought distortions and make sure they appreciate that these are part of the normal experience as a human being.
• Use Socratic questioning style in order to encourage the patient to identify and challenge their own irrational thoughts.
• Identify and challenge hot thoughts.
• Guide the patient to construct relevant counter-statements for the identified hot thoughts.
• Use downward arrow technique in order to identify core beliefs.
• Use a continuum the technique in order to construct adaptive and rational core beliefs.
• Set tasks/ assignments for the patient in order to strengthen their new rational core beliefs.
• Set between session assignments.

Module 9

Module name: CBT session 5

Content:

30 minutes lecture on CBT session 5

10 minutes discussions

62 minutes demonstration of CBT session 5, using role play

30 minutes discussions on role play

Aim: The aim is to enable students to deliver the 5th CBT session as a part of the specialist rehabilitation programme for tinnitus, hyperacusis, and misophonia management. The key tasks in session five are to teach patient the use of counter-statements, strengthen the counter-statements by challenging dysfunctional rules of life, and reviewing practical aspects of using CBT skills for managing tinnitus, hyperacusis, and misophonia-related distress.

Learning objectives:

By the end of this module students should be able to:

• Evaluate patient’s understanding about when and how to use the CBT skills for tinnitus, hyperacusis and misophonia.
• Explore the practical challenges that the patient might have experienced in using CBT skills and offer solutions and further instructions (when needed).
• Teach the patient on how to distribute their resources in dealing with tinnitus-distress in real-life scenarios using the “who is your opponent” technique.
• Discuss the metaphors relevant to acceptance.
• Use Socratic questioning style in order to guide the patient to analysis and modify common dysfunctional rules of life.
• Teach patients how to combine the counter-statements for hot thoughts and rules of lives in order to create double impact statements.
• Teach the patient the KKIS process (Know when to do CBT, Keep on with negative emotions, Identify irrational thoughts, Substitute them with rational thoughts).
• Teach how to use “Dark cloud and Sunshine” worksheet.
• Set the between sessions assignment.

Module 10

Module name: CBT session 6/ End of treatment

Content:

17 minutes lecture on CBT session 6

22 minutes discussions

Aim: The aim is to enable students to deliver the 6th CBT session to end treatment. The key tasks in this session are to discuss self-assessment, managing setbacks and integrating CBT into lifestyle.

Learning objectives:

By the end of this module students should be able to:

• Evaluate patient’s understanding about the whole process.
• Problem solving.
• Use a wide range of psychometric and audiological tests in order to assess treatment effect.
• Interpret the results of the self-assessment tools.
• Decide if the patient is ready to move on to the maintenance stage of treatment.
• Decide if the patient needs to be referred to other professionals for further investigations and/or treatment.
• Assess patient’s satisfaction.
• Create final progress report for patient.
• Prepare the patient for dealing with setbacks.
vTeach the concept of Cbstyle! Integrating CBT into life style.

Module 11

Module name: CBT for children

Content:

21 minutes lecture on CBT for children

8 minutes discussions

Aim: The aim is to enable students to adjust their treatment and the method in which it is delivered to the cognitive developmental age of their patient. The focus is on using specialised CBT techniques in helping children to manage tinnitus/hyperacusis/misophonia distress.

Learning objectives:

By the end of this module students should be able to:

• Select appropriate educational tools based on the child’s cognitive development.
• Create puzzles and educational tools to convey principles of cognitive theory in simple language and its relevance to the experience of tinnitus/hyperacusis/misophonia.
• Apply SEL to help patients test the validity of their thoughts and improve their tolerance.
• Evaluate factors related to tinnitus/hyperacusis/misophonia-related distress using the reaction source worksheet.
• Modify “Who is your opponent” tool for children.
• Design an individualised rehabilitation programme for tinnitus, hyperacusis/misophonia for children based on CBT approach.
• Discuss principles of therapy with parents
• Apply a wide range of counselling skills in order to actively engage parents in treatment of their children.

Module 12

Module name: Service development

Content:

11 minutes lecture on service development

22 minutes discussions

Aim: The aim is to guide students in developing their own clinical protocols, design and conduct clinical audits and service evaluation surveys, and identify additional training needs. Other topics relevant to developing and managing a tinnitus and hyperacusis/misophonia rehabilitation specialist service will be discussed.

Learning objectives:

By the end of this module students should be able to:

• Plan for specialist staff training.
• Create network of support for staff members joining the tinnitus team. This includes technical and emotional support.
• Arrange for ongoing supervision for specialist clinicians.
• Plan for ongoing scientific updates.
• Develop policies and procedures for their tinnitus service.
• Create patient-clinician agreement setting out matters related to confidentiality, consent and professional boundaries.
• Scope the mental health support available to patients and how these services can be accessed when needed. This includes telehealth services.
• Design and conduct clinical audits and service evaluations.
• Apply iCBT for basic support when needed.