authored by Melehin AI*
Abstract
In the article, tinnitus is considered as a biopsychosocial disorder that leads patients to tinnitus-specific distress. Approaches and psychotherapeutic targets for reducing tinnitus distress are systematized. The protocol of clinical and psychological examination of a patient with noise/ringing in the ears, which allows you to identify the targets of therapy, track the dynamics of treatment and minimize barriers, is presented. The specifics and effectiveness of the protocols of the «first», «second» and third waves of cognitive-behavioral psychotherapy of tinnitus.
Keywords: Tinnitus; Cognitive behavioral psychotherapy; Tinnitus distress
Mini Review
Over the past few years, patients with complaints of noise/ ringing in the ears have been increasingly seeking psychological advice in Russia. The patients themselves describe sounds as «buzzing», «squeaking», «clock ticking», «hissing», «roaring». Most often, these patients turn to a clinical psychologist on the recommendation of a doctor-an otorhinolaryngologist, audiologist, or neurologist. The presence of such noise in the ears is called tinnitus (subjective tinnitus) - a subjective («phantom») auditory perception (not an auditory hallucination), which is the result solely of the activity of the nervous system, without any participation of mechanical, vibrational effects on the inner ear [1-6]. This disorder is common in 10-15% of the adult population, and due to its multifactor origin, it is accompanied by a heterogeneous course profile in each patient. For some people, the presence of tinnitus, although constantly present, is perceived as harmless, while for others it is accompanied by a strong tinnitus-specific distress (tinnitus-related distress) in the form of [4]:
• impaired concentration;
• insomnia;
• careful monitoring of sounds in the ears;
• a disastrous style of thinking;
• anxious ruminations;
• a spectrum of avoidant and problem-oriented behavior.
Up to 70-80% of patients suffering from tinnitus have mental comorbidities (depression, anxiety spectrum disorders) that affect the quality of life. The presence of tinnitus is inextricably linked to the patient’s attention disorders, which affect the process of habituation and do not inhibit the “phantom” auditory perception [2].
Similar to chronic pain, tinnitus can be viewed as a distorted perception of illness/harm, rather than as a «true» illness. The presence of disturbing tinnitus is a negative emotional and auditory experience that is perceived by the patient as carrying actual or potential physical or psychological harm. To this day, this disorder is not treated, there is no effective pharmacological, instrumental tactics. The use of psychopharmacotherapy does not directly affect tinnitus, causing a range of additional side effects in patients. For example, dizziness, the appearance of «new noises» [2,6].
To this day, both in Russia and foreign otorhinolaryngological and neurological practice, there is no standardized treatment tactics, so we are talking more about the tactics of cognitive behavioral management of symptoms due to the fact that tinnitus is mainly explained more by the psychological characteristics of the patient. For example, reactions to fear, cognitive distorted interpretations of bodily sensations, negative emotional reactivity, selective attention processes, and avoiding behavioral strategies [6]. Changes in cognitive control and a shift in attention negatively directed at oneself affect tinnitus [3].
The role of «psychosomatic» and stress responses in the development of tinnitus is confirmed by a number of modern pathogenetic models. For example, the neurophysiological model proposed by Jastreboff. (neurophysiological approach to tinnitus), according to which tinnitus becomes chronic and decompensated due to impaired functioning of the circuit in a complex neural network that includes sensory, limbic and vegetative components. There is a connection between the subjective perception of tinnitus and excessive spontaneous electrical / metabolic activity in the auditory center, limbic system, and changes in the autonomic nervous system. Thus, most often the basis of tinnitus is dysregulation in the nervous system, which can be caused by various psychological reasons. Since the updated Cochrane review of psychotherapeutic approaches to the treatment of tinnitus in 2020 was published [4], cognitive behavioral therapy for tinnitus (СBT-T) is considered the «gold standard» of treatment. The multi-disciplinary European guidelines for the treatment of tinnitus 2019 [2] considers CPR as the «first line». It can be used with pharmacotherapy (ginkgo biloba, BzD), audiological means (hearing AIDS, cochlear implants), TMS.
СBT-T is based on the following models: the habituation model of Hallam (habituation model tinnitus, R. Hallam); the neurophysiological model of tinnitus P. Jastreboff (neurophysiological model tinnitus, P. J. Jastreboff), and the cognitive behavioral model of tinnitus L. Makenna (conceptual cognitive model tinnitus, McKenna) [2,6].
In Table 1, we show that the existing models of tinnitus underlying the psychological approach can be divided into two areas with counseling psychotherapeutic targets (Table 1).
We distinguish the following tactical lines of cognitivebehavioral psychotherapy of tinnitus (CBT-T):
1) Demystification of tinnitus and ensuring maximum understanding of the patient’s own condition in order to minimize the phenomena of «doctor shopping» and «treatment in the pharmacy»;
2) Passive/active habbitation for reclassifying tinnitus into the category of neutral stimuli (like smell) and having a benign character. Restoring the threshold of auditory experiences is accomplished by masking - using any sound that provides some immediate relief for tinnitus. Also, the selection of therapeutic sound or emotional «anchor» - soothing sounds, smells, thrills. Gabbitation also includes techniques for managing attention, translating it from a scanning, problem-oriented position;
3) Reducing maladaptive responses (both cognitive and behavioral) using «de-catastrophization» techniques and exposure algorithms.
At the beginning, middle and end of CBT-T, we recommend conducting a clinical and psychological examination of a patient with tinnitus according to our proposed diagnostic protocol (table.2) to assess the dynamics of psychotherapy treatment and minimize barriers (for example, «why did I try everything but nothing worked? am I special, a loser?») (Table 2).
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