Facts and FAQs
1. The nature of tinnitus.
Tinnitus is a debilitating condition that affects both men and women of all ages across the world. Sufferers perceive sounds internally, and in various forms, without an external acoustical stimulus. Although some individuals can experience tinnitus without loss of hearing, usually sufferers have varying degrees of deafness, and it is for this reason that incidence increases towards old age. Although deafness is certainly a factor, it is many, not just some, who can suffer from tinnitus yet have no deafness. These sounds also vary—for example, some complain of ringing sounds, or high-pitched feedback, but there are many others forms, including cracking, distorted pitches, sounds of locusts, beeping, sizzling, engine sounds and thumping sonorities. However, tinnitus is not a disease and although, in many cases, the tinnitus is often caused by a loss of large-diameter fibres in the osseous spiral lamina of the cochlea, many patients are able to adapt to these phantom sounds. But the tinnitus becomes a problem when the individual develops a hypersensitivity to these sounds: as this condition develops, the sound intensifies and, if it is one of the main sources of a person’s attention, it can become unbearable. Nevertheless, tinnitus can be treated effectively using psychotherapy, and hypnosis as an adjunct: if treated efficiently and sensitively, patients are able to manage, reduce or even completely eliminate the tinnitus.
2. Six causes of tinnitus.
There are many causes of tinnitus. I have listed six here and make some further comments on the subject.
i. excessive loud noise—this can be one incident or a prolonged exposure to loud sounds.
ii. loss of hearing—due to old age or general hearing loss
iii. Meniere’s disease
iv. Acoustic neuroma
vi. ear infection
Tinnitus is often associated with loss of hearing. The inner ear contains thousands of tiny hair cells. These hairs oscillate quickly when sound waves enter this part of the ear. Continuous exposure to loud noises, or gradual loss of hearing over a period of time, can cause these hair cells to flatten; when different neurons are activated, the brain seems to compensate for this and produces internal sounds. There are many other causes of tinnitus including the following:
A. ear wax impaction, middle ear effusion, sensory-neural hearing loss
B. mercury or lead poisoning
C. use of analgesics, anti-inflammatory drugs, antibiotics, loop diuretics or antidepressants
D. multiple sclerosis
E. various types of head injury
F. thyroid disease
G. vitamin B 12 deficiency and anemia
H. depression, stress, anxiety, excessive tiredness, hypertension
I. fibromyalgia, vasculitis, hypertonia (muscle tension), Lyme disease
J. nasal congestion
3. How may hypnosis treatment be adapted as a result of different causes?
I think that it is important as a psychotherapist to consider using a multi-modal approach to treatment during the initial stages of treatment. For example, it is important to ascertain whether there are any medical reasons for the tinnitus before pursuing psychological treatment. During the initial history taking, one might discover that the client has been suffering from depression and that the tinnitus started around the same time as he started taking antidepressants. In this case, a simple letter to the GP might be the solution to this problem. There are certain antibiotics and have a deleterious effect on individuals’ tinnitus and this can be reduced or eliminated by reducing or changing the antibiotic. This type of investigation can be done for any other drugs that may be taken by your client. In short, it is helpful to work in conjunction with your client’s GP.
If your client is suffering from stress, as is often the case, or the tinnitus is a result of, or intensified by, unresolved unconscious conflicts, then it is helpful, through suggestion, to develop neural pathways which are nothing to do with the tinnitus, in order to shift the focus away from the unwanted sounds to more pleasant sounds (Collingwood Bell, 2012). This can be done using client-generated imagery (Williamson, 2008, 2012), special place visualization (Callow, 2003). Parts therapy (for example, Araoz, 2005), and the use of the affect bridge (Watkins, 1971) can also be used later on in treatment to help your client deal with any inner conflicts.
4. How is tinnitus generated within the brain (including information on the limbic system)?
Tinnitus is generated and/or intensified by peripheral and central mechanisms. The limbic system is the emotional centre of the brain and it is a collection of components: the hippocampus, amygdala, limbic cortex, septum, fornix and anterior thalamic nucleus. This area is also associated with long term memory (LTM), motivation, smell and behaviour. The limbic system influences the autonomic nervous system. This mechanism is extremely important when discussing tinnitus because any changes—for example, dysregulation of the hypothalamic pituitary-adrenal axis (LHPA), as a result of stress, can have an effect on the rest of the body right down to the cellular level (Calvert, 2007). This can cause mood changes, gastro-intestinal problems (including IBS), sexual dysfunction, insomnia, ADHD and depression. There are certain monoamine neurotransmitters that are helpful in the regulation of the LHPA axis. It is for this reason that serotonergic (5HT) and dopaminergic modifying agents have been applied in the treatment of IBS, insomnia and depression (Graeff, Guimarães, De Andrade & Deakin, 1996; Monti, 2010; Lembo, Olden, Ameen, Gordon, Heath, & Carter, 2004). Tinnitus is often inextrciably interconnected with depression, insomnia and other anxiety-related conditions. Mühlau et al (2006, p1283) point out that, ‘ tinnitus-evoking manipulations result in an increased activity of various structures in the auditory and limbic system, as revealed by various activity-dependent assays, such as the cytoskeleton-associated protein Arg 3.1, 2-deoxyglucose, or c-fos expression’.
And, furthermore, as the condition worsens and one experiences more hyper-sensitivity to these sounds, in one or both ears, the tinnitus worsens. Sound enters through the outer ear towards the middle ear and causes the ear drum to vibrate. From the first sounds in the womb, we all begin to categorize sounds into discrete groups and sub-groups—crying, laughing, music, language, tone, intensity, types of music, sirens and so forth. In our long term memory, we store these sounds so that we know the difference between the types of sounds. As a result, we are able to communicate effectively and we can respond to threat if necessary. When one first experiences tinnitus, one may fear that the sound might get worse, or louder, while, sometimes, one feels out of control. This stress can have an effect on the tinnitus, making it worse or more intense. And, as one focusses on the sound, it comes to the fore. Tinnitus likes attention (Collingwood Bell, 2012). However, tinnitus is a sound which is generated by electrical activity. One experiences tinnitus when the tiny hairs in the cochlea duct begin to reduce in size or when they collapse completely; however, tinnitus can also be a result of increased stress, a loud external sound or excessive ear wax.
5. What are some of the consequences of tinnitus to the sufferer and to others?
Tinnitus can have a tremendous effect on an individual’s quality of life. It can affect concentration, but can also cause irritability, mood swings, sexual dysfunction, sleeping disorders (such as insomnia, nightmares or night terrors), panic attacks, and feelings of isolation. This can also have a knock-on effect in a relationship, particularly if the partner does not understand the nature of the problem. In some extreme cases, patients are forced to leave their partners or jobs.
6. What is Habituation?
The term ‘habituation’ is one used in behaviour psychology and it refers to a decreased behavioural response to a recurring stimulus (Wolpe, 1953, 1958, 1978; Thompson, 2009). This term can be used to describe a process by which an individual ignores or responds less and less to an internal or external sound (Collingwood Bell, 2012). And the less one feels negatively about this auditory stimulus, and, perhaps, the more one re-frames it as a pleasant sound or ‘interesting signal’, the more it fades into the unconscious or, indeed, the distance.
7. What other treatment modalities might be helpful to sufferers? Explain.
In the first instance, it is important to ask one’s client whether he or she has been to the GP or had either a CT scan o MRI scan. It is important to eliminate any medical causes for the tinnitus. There are other possible treatments which include the removal of ear wax, anti-depressants or the use of tinnitus reframing (Retraining therapy or TRT)—for example using white noise as a form of re-directing one’s auditory awareness. In addition, it is possible that the tinnitus is due to temporomandibular joint dysfunction (TMJD) (Salvinelli, Casale, Paparo, Persico & Zini, 2003). In these instances, it is worth considering osteopathy or intercranial sacral therapy. However, a visit to the dentist might be a better idea. He might recommend prosthetic dentistry or massage for the jaw (Bell, Yamaguchi & Poor,1990). Acupuncture has also seen good results in this area (Ernst & White, 1999).
TRT is a fairly new treatment modality which is very helpful for individuals suffering from tinnitus. It is also helps clients who are frightened of, or overly sensitive to, external sounds. The treatment is based on the research carried out by Jastreboff (1994, 2004) who illustrated how sound therapy can be used to help tinnitus sufferers. The beginning of the therapy focuses on helping the patient understand the nature of tinnitus and what is happening in the ear. This involves careful counselling and education. Once the clients have understood that there the ear is not damaged, and that this is just ‘compensatory activity’ (Collingwood Bell, 2012, p16), the therapy begins. TRT practitioners tend to use noise generators to provide background noise: this is the process of ‘habituation’. After a number of sessions, the clients’ awareness of these internal sounds should return to an appropriate level.
8. What is the relationship of tinnitus to depression, anxiety and stress? (The answer will include references to the academic literature).
Depression, stress and anxiety are often interconnected to tinnitus for the reasons stated above (see question 4): indeed, it is often difficult to ascertain whether one or more of these ‘psychiatric disorders’ came about as a result of the tinnitus, or whether the tinnitus was exacerbated by, or was a direct cause of, the psychological disturbance. Halford and Anderson (1991) found that anxiety rates and depression ‘tendencies’ were significantly correlated with tinnitus severity. Holgers (2003), pointed out that tinnitus was, in many cases, caused by intense feelings of stress and anxiety. It has certainly been pointed out by many sufferers that anxiety and stress can worsen the condition. A few individuals point out that if they can manage their tinnitus, it only comes back at moments of stress. Some clinicians (for example, Haw, 2007; Collingwood Bell, 2012) have stressed the importance of noticing the tinnitus and then dealing with the problem by reducing unnecessary stress. In treatment, it is important to deal with the whole person: by doing so the tinnitus can reduce at the same time as the concomitant problems. Finally, as a person becomes less depressed, the internal negative dialogue, as well as the tinnitus, will reduce; and, as these positive suggestions affect levels of cortisol, and neurotransmitter activity, the body is able to interpret any internal noises in a completely different and, generally, more appropriate way.
9. The efficacy of hypnosis in the treatment of tinnitus: a talk. The following is a plan for a talk on the subject of tinnitus.
i. An introduction to the aetiology of tinnitus. The role of stress and anxiety in generating and perpetuating tinnitus.
ii. Other causes of tinnitus. Excessive loud noises, age-related hearing loss, ear wax impaction, middle ear effusion, sensory-neural hearing loss, mercury or lead poisoning, use of analgesics, anti-inflammatory drugs, antibiotics, loop diuretics or antidepressants, head injury, thyroid disease, vitamin deficiencies, iron deficiency, excessive tiredness, hypertension and nasal congestion.
iii. A brief introduction to the efficacy of hypnosis in the treatment of anxiety conditions (Waxman, 1985; Sapp, 1992; Evans & Coman, 2003; Yapko, 2003; Spiegel, 2004; Kraft & Kraft, 2007).
iv. Psychological and social consequences of tinnitus (Halford and Anderson, 1991; Dobie, 2003). Depression, impact on relationships, isolation, panic attacks, sexual dysfunction; irritability).
v. A multi-modal approach: working in conjunction with audiologists and/or general practitioners.
vi. What is habituation and how can this principle be employed in clinical practice? Utilizing pleasant sounds to reduce unwanted ones. Use of guided imagery to take an interest in sounds around us. Changing the focus of attention. Reframing tinnitus sounds. Tinnitus is a warning for the beginnings of a stressful experience. Client-generated imagery. Use of sensory rich metaphors. Use of story-telling or matching metaphors (Lankton and Lankton, 1983) with indirect suggestions. Use of naturalistic inductions. Focusing attention on the sensation around, and in, the hand; a utilization of the principles of reciprocal inhibition (Wolpe, 1958).
vii. Later therapy in the treatment of tinnitus. Affect bridge (Watkins, 1971), use of anchoring and ‘Distress/Tinnitus Diary’ (Collingwood Bell, 2012). Age regression by eliminating emotion; age regression using protective bubble (Alden, 1995), age regression by gradually reducing unwanted negative emotion through the arm and into the hand, releasing unwanted negative energy (Collingwood Bell, 2012). Parts Therapy/Ego State Therapy (Degun Mather, 2003; Aroaz, 2005).
viii. Treating the whole person. Healthy eating; family dynamics; exercise; self hypnosis; managing stress. The role of expectation. Conclusions and questions.
10. Example case study: treatment plan for Gary.
Gary has developed hearing loss and, in the first instance, he must see his GP to ask for advice. After this, I would be happy to see Gary in order to reduce his stress levels, depression and tinnitus. All individuals are different, and I never write a treatment plan. After each session, each client will make changes and benefit at different speeds. I also do not make any suggestions as to how long or short the treatment might be. However, in order to show that I am familiar with some of the techniques and principles that can be used in the treatment of tinnitus, I will formulate a hypothetical treatment plan for Gary. This is as follows:
Session1. Rapport building; psychotherapy; history taking; asking permission to write to GP; asking Gary to have a CT scan or MRI scan; answering any questions about what is hypnosis and what it is not; visualization. During the visualization, I would encourage Gary to take an interest in the sounds around him and, utilizing all the sensory modalities, open up his awareness to all the senses around him. He would be given the opportunity to develop a scene in his own way and to reduce, increase and generally manipulate the stimuli around him.
Sessions 2 and 3. Psychotherapy (presumably, complications at work and in the family context); visualization. Again, using client-generated imagery, I would encourage him to imagine a tailor-made scene so that he could enjoy the sounds around him, the sight and the feelings associated with the walk. This walk will be sensory rich. Building an understanding of what tinnitus means—the role of stress in maintaining psychosomatic problems. Re-framing of tinnitus. Lifestyle changes. Keeping a daily log of stress levels and tinnitus sounds. At this point, I would teach Gary self hypnosis so that he can utilize these skills at home.
Session 4. Using a matching metaphor to help him to enjoy other sounds, and to reduce the unwanted sounds.
Sessions 5 and 6. Regressive technique. I would encourage Gary to go back to a time when he developed the tinnitus and to help him to transfer all the unwanted stress and negative thoughts through the arms, and help him to release it out of his hand. I would do this several time and watch the changes that occur. Ego strengthening and support.
11. Treating the whole person. A response to private hospital department rationale.
It is important to remember, at all times, that when we treat someone for tinnitus we are often treating all sorts of other problems as well—depression, insomnia, anxiety, stress and other conditions. And, as the tinnitus decreases, this will have an effect on their rest of their lives. Other factors that are important to consider are the lifestyle changes that may occur: as a therapist, one needs to promote healthy living and to help them to reduce their stress at home and at work. One might consider talking about healthy eating, exercise, managing stress levels, and ways to boost the immune system generally (Collingwood Bell, 2012).
12. What medical checks should be done before a client is accepted for treatment?
The following are the medical checks that need to take place before seeing a client with tinnitus.
i. CT or MRI scan.
ii. The doctor should also check for an evidence of an ear infection or foreign object in the ear.
iii. Any evidence of inner ear imbalance or disorder (including Meniere’s Disease).
iv. Any problems with high blood pressure, anaemia, or vitamin deficiency.
v. The doctor should find out when the tinnitus started and whether it occurred as a result of taking anti-inflammatory medication, antibiotics or other medication.
DMJ Kraft, November 2012