REVIEW

A REVIEW OF PSYCHOLOGICAL TREATMENT APPROACHES FOR PATIENTS SUFFERING FROM TINNITUS 1

Gerhard Andersson, Ph.D., Lennart Melin, Ph.D., Christina Hiignebo, M.Sc., Befit Scott, Ph.D., and Per Lindberg, Ph.D. Uppsala University, Uppsala, Sweden

ABSTRACT

experience (e.g. after rock concerts). In hearing impaired persons, the prevalence has been estimated to be as high as 60% (8). Approximately 1-2% of the total population are severely disturbed by the condition (5,6) in the sense that tinnitus plagues them all day, and some cases of tinnitus-related suicide have been reported (9). Several symptoms have been reported together with tinnitus, like hearing loss (6), hyperacusis (i.e. increased sensitivity for noises) (10), and psychiatric comorbidity (e.g. depression and anxiety) (11). Various theories on the origin o f tinnitus have been proposed (3,12,13). Tinnitus is known to occur together with medical conditions and as a consequence o f noise exposure and certain pharmacological agents (e.g. salicylate). Tinnitus is often transitory, but can be a chronic condition that has been linked to the experience o f chronic pain (14,15). It is most likely that tinnitus originates from several different causes, in particular from damage to the organ of Corti (1). Since tinnitus can seldom be measured without the subject's active participation (16), self-reports o f loudness and annoyance are commonly used to analyze the perception o f tinnitus and to compare it with psychoacoustic and pitch matches (i.e. tinnitus matchings) (17). Many treatment strategies for tinnitus have been investigated including pharmacological (18), acupuncture (19), maskers (20), hearing aids (21), electrical stimulation with cochlear implants (22), transcutaneous nerve stimulation (23), magnets (24), and surgery (25). Typically, tinnitus treatments aim at decreasing the psychological distress and/or decreasing or eliminating the tinnitus sound. In sum, the effects of pharmacological treatment tend to be short-lived and sometimes even cause tinnitus (26), although recent studies on antidepressants seem more promising (27). The empirical support for acupuncture is weak, with a controlled study showing no effects (19) and long-term follow-ups generally being disappointing (28). Studies on tinnitus maskers (i.e. hearing aid-like devices designed to produce a noise in the ear and to cover up the tinnitus) have shown that they can help some patients (20). However, in a study by Erlandsson et al. (29), masking was found to be equal to a comparable placebo apparatus, and there is a lack of long-term follow-up studies on the effects o f masking. Melin et al. (21) found no effects of hearing aids alone on tinnitus in a controlled study, but here again a few patients benefit from hearing aids together with counseling. Electrical stimulation with cochlear implants is generally reserved for the deaf and is far from being a suitable

Disabling tinnitus (ringing or buzzing in the ear) is a condition experienced by at least 1-2% of the population. Since medical and technical treatments are only partly successful several psychological treatment approaches have been applied in the treatment of tinnitus. This article reviews 38 studies on hypnosis, biofeedback, and cognitive-behavioral approaches together with relaxation techniques. It is concluded that relaxation training together with cognitive--behavioral coping techniques is the method which so far has received the most empirical support. Still, more research is needed on the effects o f psychological treatment. Finally, five recommendations are made regarding the treatment of tinnitus patients. (Ann Behav Med

1995, 17(4):357-366)

INTRODUCTION Tinnitus is defined as the perception o f sound in the absence o f any appropriate external stimulus (1). Some patients experience tinnitus as extremely disturbing and disruptive to everyday activities and sleep (2). Since the perception is localized near the auditory cortex, it is now considered inappropriate to use the distinctions "subj ective" and "obj ective" (1), which has been the terminology used previously (2-4). Even though a small percentage of patients have objective tinnitus (i.e. somatosounds that are measurable without referring to the patients' self-reports), the sensation of "ringing or buzzing" is real and should be treated as such. The experience of and emotional reactions to the sound are always subjective. The relatively high prevalence o f tinnitus found in epidemiological studies makes it a c o m m o n medical problem; 8-17% o f the total population report some degree of tinnitus (5-7) that lasts for more than five minutes at a time and occurs not only after loud sounds. This excludes trivial cases that most people

i Preparation of this manuscript was supported in part by the Swedish Council for Social Research (Grant No. 90-0168:2 and Grant No. 910004:01).

Reprint Address: G. Andersson, Department of Clinical Psychology, Uppsala University, Box 1225, S-751 42 Uppsala, Sweden. 9 1995 by The Society of Behavioral Medicine. 357

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treatment alternative for the hearing-impaired or n o r m a l hearing tinnitus patient (22). Transcutaneous nerve stimulation can help a few patients, but it is not established that it differs from a placebo (23,30). Magnets were ineffective in the double-blind trial by Coles et al. (24). According to Hazell (25), the results o f surgery are often unpredictable and ablative surgery m a y well make the tinnitus worse. G i v e n that in most cases the physician's aim is the relief o f the disturbing s y m p t o m s that often are o f a psychological nature (3 I), several psychological treatment approaches have been tried (32). Stouffer et al. (33) stated that counselling is one o f the best available methods to treat tinnitus, since medical and surgical treatments are usually not effective. A similar conclusion was reached by Tyler et al. (34). The aim o f the present article is to review psychological treatments for the alleviation oftinnitus and related symptoms. Included under the heading o f psychological treatments in this review are hypnosis, biofeedback, relaxation training, a n d cognitive-behavioral approaches combining relaxation techniques and cognitive coping strategies. PSYCHOLOGICAL TREATMENTS In the following, each study is classified by its m o s t salient treatment, even though some involve a combination o f techniques. Studies published in scientific journals (Medline and Psychlit search) and unpublished data presented at the Fourth International Tinnitus Seminar in Bordeaux in 1991 are reviewed. As much as possible, each study will be reviewed in the order o f subjects involved, methods used, statistical analysis, and finally the results o f the treatment. For each treatment modality, we will begin by briefly reviewing the case reports and single group designs, focusing more on some o f the latter, and then review the controlled experiments with r a n d o m i z e d groups before making a conclusion about its value in the treatment o f tinnitus. The studies vary in scientific quality, and the emphasis is laid on studies using randomization, pre-post measures, follow-ups, and control groups. In our view, a high-quality study also includes daily diary measures oftinnitus annoyance. This, because of the distress caused by tinnitus and sometimes even the loudness o f tinnitus itself, varies between days and also the ability to distract oneself from the sounds.

Hypnosis Hypnosis is a form o f treatment sometimes applied in medical settings (especially pain management), but it is still viewed with suspicion by some health care personnel (35). It is described by Kihlstrom as " a social interaction in which one person, designated the subject, responds to suggestions offered by another person, designated the hypnotist, for experiences involving alterations in perception, memory, and voluntary action" (35, p. 385). In view o f the proposed similarities between tinnitus and pain (15), hypnosis has been tried as a way to treat tinnitus.

Case Reports and Single Group Designs: In one case report by Marlowe (36), treatment was reported as successful, but the study had methodological flaws. Brattberg (37) studied 32 patients in a single group design. Twenty-two o f these i m p r o v e d in that they learned to ignore their sounds, whereas ten patients showed no improvement. The methodological weaknesses o f this study make it hard to draw any conclusions. In a crossover study, Marks et al. (38) studied 14 patients with tinnitus. Hypnosis treatment was administered in three different formats. Five patients anecdotally reported that the treatments had some

A n d e r s s o n et al. beneficial effects. A strength of this study was that baseline measures were taken and the authors set out to isolate differential effects o f hypnosis. These non-experimental studies give little support for hypnosis as a treatment for tinnitus.

Controlled Experiment: In a recent study by Attias et al. (39), 36 patients (all males, age = 28-58 years) participated. The patients were matched into three groups according to their tinnitus pitch, tinnitus loudness at the frequency where tinnitus was matched, and also according to a rating of their feelings about their tinnitus. The groups were then randomized into one of three treatment formats. The first group received self-hypnosis (SH) (without the presence o f a therapist), the second group was presented with a brief auditory stimulus (BAS), and the third group served as a control group (waiting list). Treatment consisted o f four individual sessions each lasting up to 50 minutes (intervals not stated). Assessment was made by a questionnaire on which the patient rated ten tinnitus symptoms (e.g. disturbance to sleep) on a 15-digit scale divided into three degrees o f severity (mild, moderate, and severe). This was administered before treatment, one week after treatment, and at a t w o - m o n t h follow-up. On these occasions, subjects were also assessed by audiological tests. The d a t a were analyzed with the Wilcoxon rank test for two groups and one-way A N O V A s followed by post hoc Tukey tests. Results indicated a total disappearance o f tinnitus for 73% o f the patients in the SH group. The corresponding figure for the BAS group was 24%. A t the follow-up, a significant reduction in severity o f the tinnitus was found between pretreatment and follow-up assessment for the self-hypnosis group only (Wilcoxon rank test). A N O V A o f the post-treatment results across the three groups showed a significant group effect, and Tukey testings showed that the SH group had a significantly lower score. N o effects were found on the audiological tests. The study could be criticized for using only questionnaire data and not daily assessments oftinnitus severity and annoyance in the subjective assessment o f tinnitus. In a second study (40), the Israeli research group has replicated the results found for the SH treatment. Forty-five patients (all males, mean age = 47 years) were included and assigned to one o f three groups. The groups were matched as in the first study (39). The SH was c o m p a r e d with Masking (see introduction for a short description) and with giving Attention to the patient's complaint (attention control). All subjects received five weekly administrated individual treatment sessions o f 50 minutes each. The SH treatment included home practice, and in both the SH and Masking groups, patients were provided with a mini stereo cassette recorder to be able to listen to the recorded therapies between sessions. Various assessments were performed, but the final results were evaluated by the same questionnaire as in the first study. Similar statistics were applied as in the previous study, with the exception o f not using the Tukey post hoc test. Results, by means o f one-way A N O V A s performed separately for each group on separate items (prepost), showed the superiority o f the SH group which showed i m p r o v e m e n t on seven out o f t e n scales. Masking had virtually no effect, and the Attentiveness group improved in three domains (i.e. disturbance in noisy environment, restlessness, and general feeling). Analysis o f the total score for the whole scale by means o f the Wilcoxon rank test showed that only the SH group patients improved significantly. The finding that the Attention group i m p r o v e d on the i t e m level deserves further investigation, since few, if any, studies have included attention control groups when studying the effects o f a psychological treat-

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TABLE 1 Studies Using Hypnosis in the Treatment of Tinnitus. Single Case, Single Group, and Controlled Studies Presented in Order Study

N

Design

Marlowe, 1973 (36) Brattberg, 1983 (37)

2 32

Single case anecdotal Single group outcome

Marks et al., I985 (38)

14

Single group pre--post

Attias et al., 1990 (39)

36

Controlledgroup pre--post

Attias et al., 1993 (40)

45

Controlled group pre-post, attention control 40% controlled group studies

Summary

Total N 129

Assessment Verbal report Questionnaire posttreatment VAS*, tinnitus matching, interview Questionnaire, pre-post, follow-up (FU) Questionnaire

Conclusion/Outcome Improved 22 Ss learned to ignore the sound; 3 were totally improved 1 subject improved on VAS, 5 found treatment of value Self-hypnosis reduced tinnitus for 73% after treatment and was superior to control and BAS# at follow-up Self-hypnosis reduced tinnitus severity; some effects of attention Studies in favor = 4 of those 2 controlled group

* Visual analogue scales. # Brief auditory stimuli. ment of tirmitus. It could be that just attentiveness and caring could have positive effects and be part of the management of the tinnitus client. The same point of criticism as in the first study is also applicable here, since no repeated measures were applied. Also, the authors provided no clear descriptions of how SH might work in the daily life of the patients. Maybe SH worked through the relaxation provided by listening to the tapes, or by the distraction, which also has been shown in other studies. In summary, the studies reviewed in Table 1 show two controlled group studies on hypnosis. Even if the overall treatment response seems to be good in those two studies, the data presented so far is inconclusive about the benefit of hypnosis for tinnitus. Biofeedback Biofeedback procedures have been widely applied in various medical settings and also in the treatment of tinnitus. Biofeedback is a method in which awareness of physiological states (by means of monitoring) are trained with the purpose of altering their functions. The main idea is that tinnitus can be reduced by learning to control bodily tension. Another related idea is that direct control of the tinnitus sound can be obtained.

Case Reports and Single Group Designs: In anecdotal report, House et al. (41) treated 41 patients with biofeedback, consisting of feedback from the muscle groups of the frontalis and skin temperature of the fingers. The authors reported a remarkable success rate of 80% improvement. Methodological problems also characterize their follow-up study (42), where about half of the patients still were improved. In a study ineluding pretreatment assessments by Elfner et al. (43), a 16year-old patient was treated with electromyogram (EMG) and thermal biofeedback. It was reported that the patient managed to decrease EMG activity and increase finger temperature and that the treatment resulted in psychological benefits. Results were stable at a one-year follow-up. Duckro et al. (44) performed a controlled single case-study with a patient severely annoyed by his tinnitus and hospitalized for a history of mood disorder. Treatment included biofeedback, relaxation training, and treatment of accompanying psychological problems. Results of treatment were reported as successful, but since the patient was hospitalized for another condition than tinnitus, this must be regarded as a very special case. A different approach, while still falling under the heading of biofeedback, was presented by Ince et al. (45). One male and one female patient were treated using a "'matching-to-sample feedback technique." The patients were

trained how to suppress the tinnitus sound by using a matched external sound and gradually trying to decrease his/her tinnitus sound as the external sound decreased. The procedure was repeated until the two patients managed to decrease their tinnitus (45). At a follow-up interview, both patients were still able to reduce their tinnitus loudness from baseline levels. In a singlesubject double reversal experimental design, Borton and Clark (46) critically examined the use of biofeedback for tinnitus and concluded that the physiological effects of biofeedback probably are not responsible for the effects reported in earlier studies (e.g. 41). Erlandsson et al. (47) studied a 56-year-old male patient with severe tinnitus. He was treated with forehead EMG biofeedback and a relaxation tape. The results showed a significant reduction in symptom intensity. The E M G results did not show clear effects of the treatment. The conclusion was that biofeedback training should include a broader therapeutic framework in contrast to earlier conditioning paradigms. In a multiplebaseline design, Kirsch et al. (48) treated six patients with relaxation training, EMG, and thermal biofeedback. The authors concluded that degree of improvement at the end of treatment largely depends on how it is measured. Combining biofeedback with relaxation training, Carmen and Svihovec (49) treated eleven tinnitus patients. Authors reported that 90% of the patients became less negative towards their tinnitus and that 63% felt that the tinnitus sound had been reduced. One important finding was that high correlations were found between ratings oftinnitus and tension, both at pretreatment and at follow-up. Ince and coworkers did a larger study (50) with 30 patients. The treatment was similar to that presented in their previously described casestudy (45). Sessions followed the same procedure and consisted of from 10 to 15 trials of 30-second duration with an equal rest period. The patients were encouraged to practice the skills at home between sessions. Assessments were made within each session in terms of matched dB level. The results showed significant decreases in matched dB level oftinnitus. Results from their earlier study were replicated in that the patients learned to decrease their tinnitus loudness, and some even managed to eliminate their tinnitus sound completely. Since no follow-up data has been presented and no later studies have replicated these promising findings, the results must be considered with caution (4). Walsh and Gerley (51) investigated their tinnitus treatment in 32 patients. Treatment consisted of thermal biofeedback and a relaxation tape. Significant improvements were found on ratings of both loudness and annoyance. In a withinsubject design, Landis and Landis (52) did a study with seven

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patients. Three biofeedback moralities were considered of which the two best were chosen for each patient. N o effects were found on ratings o f loudness, while non-experimental subjective statements o f treatment efficacy were claimed as sufficient support for the continued use o f biofeedback in the treatment oftinnitus. Finally, using a crossover design, Erlandsson et al. (53) studied the effects o f stomatognathic treatment (the jaw using stabilization splints) and biofeedback in a group o f 32 patients. The treatment consisted o f biofeedback training, progressive relaxation as h o m e practice, and counseling. I m p r o v e m e n t s in m o o d and a decrease in tinnitus intensity were reported. The authors considered the i m p r o v e m e n t s as m i n o r regardless o f type o f treatment given. M o o d seemed to be i m p r o v e d mainly by the biofeedback treatment. Together, these studies give some support for biofeedback, but are heterogeneous and show little support for the link between treatment and decrease in tinnitus.

Controlled Experiment: In a study by White et al. (54), 44 patients (24 females, total age 39-70) participated. Treatment consisted o f frontal biofeedback and relaxation tapes. The n u m ber o f sessions was at least ten one-minute trials o f frontal biofeedback, a n d 20 minutes o f taped relaxation training were given. The subjects were randomly allocated to treatment or to a waiting-list condition before being matched according to age and sex. Assessments were based on a posttreatment telephone interview in which tinnitus was rated on a five-point scale. Resuits were evaluated with Mann-Whitney U-tests showing greater i m p r o v e m e n t for the control group. The authors also reported that 60% o f the treated subjects i m p r o v e d after therapy whereas only 5% o f the control subjects improved. Unfortunately, the study did not include pretreatment measures or daily measures o f tinnitus distress. H a r a l a m b o u s et al. (55) studied 26 patients (13 females, total m e a n age = 51 years). They were randomized into one group receiving E M G biofeedback with a "counter d e m a n d " (not to expect any effects o f treatment) instruction (N = 7), one group E M G biofeedback with a "neutral d e m a n d " instruction (N = 9), and one group serving as an untreated control group (N = 10). Treatment was given in eight weekly 1.5-hour sessions. Among the measures used were daffy tinnitus monitoring (three times per day), a tinnitus questionnaire, and measures o f depression and anxiety. Results were analyzed with Bonferronicorrected ANOVAs. N o significant effects could be ascribed to the treatments given, even if patients became less aware o f their tinnitus. These results also applied to the untreated controls. This well-controlled study seriously questions the use o f biofeedback as a treatment alternative for tinnitus and the authors conclude: " T h e results o f the present study do not support the efficacy o f E M G biofeedback as a treatment for tinnitus or its related psychological distress" (55, p. 53). More recently, Podoshin et al. (56) conducted a study with 58 patients (26 females, total mean age = 55 years). They were randomly allocated to five treatment conditions: biofeedback (N = 10), acupuncture (N = 10), Cinnarizine (i.e. a drug) (N = 10), control for the biofeedback treatment (N ~ 8), and control for the Cinnarizine treatment (N = 20). The subjects treated by E M G biofeedback and acupuncture underwent ten weekly sessions o f 30 minutes. The Cinnarizine group received 25 mg o f Cinnarizine three times daily for ten weeks. Registrations o f tinnitus were made by the patients both at rest and while being active. The statistics used were paired t-tests. Biofeedback was the superior treatment showing a significant treatment effect, especiaUy during the measures taken at rest. However, the au-

A n d e r s s o n et al. thors also presented percentages o f patients improved. In the biofeedback condition, 50% of the patients improved, whereas in the acupuncture condition 30% improved a n d in the Cinnarizine condition only 10% improved. N o improvements whatsoever were found in the control groups. A risk of inflated results (Type I error) exists, due to the use of pairwise t-tests in calculating treatment effects. Also, no pre--post measures or daily assessments were undertaken. The studies reviewed are summarized in Table 2, which shows a total o f three controlled group studies, five single group studies, and seven single case-studies. Biofeedback for tinnitus has not yet been a convincingly documented treatment approach with only two controlled group studies. In fact, the more controlled the study, the more disappointing the results (e.g. 55), even though data from some studies suggest that biofeedback may be a suitable treatment at least for some patients. The promising findings o f Ince and co-workers (45,50) have not been replicated and are unfortunately not reliable in terms o f the stability of the effects. Another important concern is the mechanism by which biofeedback m a y work to alleviate tinnitus. It could be that the procedures used in the studies showing results in favour o f biofeedback have just been another way o f implementing relaxation training. Also, some form o f relaxation training has been included in most biofeedback studies. It is likely that the annoyance associated with tinnitus can be reduced by means of an active coping technique (such as relaxation or distraction). Biofeedback could serve this function in that it could help the patient to learn how to control bodily sensations. It is more difficult to explain the effect of biofeedback on tinnitus loudness. If not attributable to distraction, this notion should be further explored.

Relaxation Training and Cognitive-Behavioral Techniques In analogy with treatments o f chronic pain, various relaxation techniques have been a treatment alternative for tinnitus patients (57). This is despite the fact that few clinical psychologists work in audiological clinics to conduct relaxation as a psychological treatment (58). By learning relaxation skills, tinnitus annoyance m a y be reduced, particularly since tension is believed to make tinnitus worse (2,3). Cognitive techniques are also believed to be helpful in learning to distract oneself from the tinnitus. These two approaches are sometimes combined. Studies of relaxation are reviewed together with approaches that have relied on behavioral assessments a n d / o r cognitive distraction.

Case Reports and Single Group Designs: MacLeod-Morgan et al. (59) combined relaxation training with a cognitive imaginative technique in three cases of tinnitus. One finding was the utility o f reinterpreting the tinnitus sound as something associated with a pleasant picture or sound (e.g. a waterfall) instead o f viewing it as an enemy. The study is i m p o r t a n t since it is one o f the first to describe a cognitive approach to tinnitus. Another case report was made by Chiodo et al. (60) who treated a severely hearing impaired 55-year-old female patient with a modified form o f relaxation training. The authors concluded that the treatment ameliorated the experience o f annoyance. Using a behavioral assessment approach in a single case design, Malesta et al. (61) treated a 32-year-old male patient. Treatment consisted of relaxation skills, exposure to music, and abstinence from coffee drinking. Relaxation was also provided. Targets for intervention were found by careful registrations o f tinnitus dur-

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TABLE 2 Studi~ ~on the Effect of Biofeedback on Tinnitus. Single Case, Single Group, and Controlled Studies Presented in Order Study

N

House et at., 1977 (41) House, 1978 (42)

41 Same

Elfner et al., 1981 (43)

Design

Assessment

Anecdotal case report Anecdotal FU

Verbal report Questionnaire, verbal report

l

Single case pre-post FU

EMG, verbal report

Duckro et at., 1984 (44)

1

Single case pre-post, 3-month FU

Ince et at., 1984 (45)

2

Borton and Clark, 1988 (46)

2

Erlandsson et al., 1989 (47)

1

Kirsch et al., 1987 (48)

6

Carmen and Svihovec, 1984 (49)

11

Ince et al., 1987 (50)

30

Walsh and Gerley, 1985 (51)

32

Erlandsson et al., 1989 (53)

33

Landis and Landis, 1992 (52)

7

White et al., 1986 (54)

44

Haralambous et al., 1987 (55)

26

Podoshin et al., 1991 (56)

58

Summary

Total N 295

Conclusion/Outcome 80% improved About 50% still improved at FU 6-12 months Psychological symptoms improved at l-year FU Decrease in tirmitus, BDI, and fear of being alone, increased skin temp

Skin temperature, tinnitus rathags, BDI, personality scales Single case pre-post Tinnitus matchings, self-reBoth Ss able to reduce loudness from ported loudness baseline levels Single case double rever- Ratings of annoyance and EMG EMG levels changed, not related to sal tinnitus Single case controlled Ratings of intensity, EMG lev- Intensity, BP reduced, EMG increased els, and blood pressure (BP) Multiple baseline across Daily diaries, global assessment No effects on diaries but on global subjects design at posttreatment scales Single group pre--post FU Self-report scales, EMG EMG reduced, tinnitus ratings not reduced, 90% reported benefit and 63% reduction of tinnitus at 18month FU Tinnitus matchings, self-reSingle group pre-post 84% reducing tinnitus 10 to 62 dB, in ported loudness some cases eliminated Single group pre--post Scales of annoyance and loud- Decreased loudness and annoyance, ness, MMPI, thermal reincreased temp, 65% stated recordings duction in tinnitus Crossover design, single Ratings of intensity, severity, Minor positive changes of intensity and mood and mood group Single group Tinnitus matchings, and VAS Loudness not decreased, subjective of loudness benefit in coping ability Controlled group Telephone interview 6 and 9 60% improved in treatment group months after Controlled group 3 x 5 Questionnaire annoyance, BDI, No effects design pre, post, FU audiological Controlled group 5 condi- Severity ratings during activity/ 50% in feedback, 30% acupuncture, tions rest 10% Cinnarizine experienced amelioration of tinnitus 20% controlled group Studies in favor = 13 of those 2 constudies trolled group

ing all phases of the day and by thorough baseline registrations. Results were reported as positive. Hallam and Jakes (62) treated a 60-year-old male patient with relaxation and cognitive-behavioral therapy. The results showed significant decrease o f t i n nitus annoyance. As expected by the authors, self-reported tinnitus loudness was not influenced by the psychological treatment. During the 1980s, a series of studies were conducted in Sweden by Scott, Lindberg, and co-workers. The first published study was a case-study (63), where a male patient in his late fifties was treated. Treatment consisted of a coping technique together with applied relaxation. Data showed a 71% drop in annoyance between pretreatment and follow-up. In another case by Lindberg (64), a deaf 26-year-old female patient was suecessfully treated. The patient was treated with sign-interpreted relaxation training during five one-hour weekly sessions. The patient made daily ratings of loudness, discomfort, and ability to control the tinnitus. The results remained at a five-month follow-up. Jakes et al. (65) treated 24 patients (12 females, total mean age = 55 years). No control group was included, but subjects were randomly assigned to either relaxation treatment only or to relaxation and a cognitive "attention switching" distraction

technique. Also compared were the effects of therapist and immediate versus delayed therapy. All patients received an information phase which preceded the treatment study. Treatment was scheduled during six weekly 30-minute sessions. There were two modes of assessment. Patients made daily ratings o f t i n n i t u s loudness and annoyance. Assessments of mood and interference with daily activities were also collected. Results were analyzed with repeated-measures MANOVAs. Annoyance was significantly decreased for all patients. The results are still ambiguous, mainly because no significant differences were found between the group receiving delayed therapy and the group receiving direct therapy. Since no control group was included, it is not certain whether the patients would have improved without any treatment. One result was that the information given to all patients had a significant effect in reducing the distress and the disturbance of activities caused by their tinnitus. In a Swedish study (66), the effectiveness of treatment was investigated in a clinical sample of 75 consecutive patients (32 females, total mean age = 54 years). They received ten onehour sessions with relaxation training and techniques aimed at controlling the tinnitus. Assessments were made pretreatment and posttreatment and at a three-month follow-up using daily

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measures o f tinnitus discomfort and mood. The results, evaluated by means of A N O V A s and post-hoc tests, showed significant reductions of discomfort from tinnitus and elevated m o o d over a three-month follow-up period. A clinical sample o f 138 patients was studied by a G e r m a n research group (67). Treatment was what the authors called " m u l t i m o d a l behavioral treatment," which included relaxation training, cognitive therapy, and analytically oriented therapy. Patients increased their ability to cope and reduced their distress. Diary recordings revealed reductions in loudness a n d annoyance and increases on ratings o f coping and mood. A oneyear follow-up o f a subset o f patients showed that the results for tinnitus annoyance were sustained. Taken together, these studies show promising results for cognitive--behavioral treatment including relaxation. However, studies are heterogeneous and somewhat unclear in the description o f the cognitive parts o f the treatments.

Controlled Experiment: In a group study by Scott and coworkers (68), 24 patients (12 females, total mean age = 52 years) participated. Treatment consisted o f ten one-hour sessions during a three-week period and included relaxation and training in self-control by distraction exercises. Daily self-recordings (four times per day and one retrospective rating for the whole day), psychoacoustic measures, and a final interview were performed. Daily visual analog scale (VAS) registrations o f loudness and annoyance were used as dependent measures. Results were analyzed with unpaired t-tests. Treatment resulted in significantly decreased annoyance, whereas loudness ratings d i d not change. In a follow-up o f this study, 20 patients were interviewed nine m o n t h s after termination o f treatment (69). By this time, all the control subjects had been treated. The authors found that some o f the skills taught in therapy remained and that discomfort from tinnitus still was reduced. The Australian research group investigated the effects o f relaxation with 30 patients (14 females, total mean age = 56 years) (70). They were r a n d o m l y assigned into three groups: relaxation with counter d e m a n d instruction (N = 10), relaxation without counter demand instruction (N = 9), and a control group (N = 10). Treatment consisted o f seven, weekly 1.5-hour sessions and was conducted in small groups. The data collected was similar to that in their previous study on biofeedback (55) (e.g. daily tinnitus monitoring). Similar to that study, results were disappointing and Ireland et al. concluded: "Results o f the present study suggest that relaxation training is not an effective treatment for tinnitus, or for depression, anxiety, and sleep difficulty experienced by tinnitus sufferers" (70, p. 428). It is important to remember that this study did not include any other cognitive or behavioral coping techniques, and it is not certain whether the relaxation given was comparable to that in the Swedish studies. In the latest published study by the Swedish research group (71), a sample o f 27 patients (13 females, total mean age = 55 years) participated. Two forms o f relaxation therapy were compared with an untreated control group. One treatment (N = 9) focused on behavioral control and exposure and the other (N = 10) focused on cognitive coping techniques and distraction (e.g. reinterpreting the sound as something more bearable). The two treatments were compared with an untreated control group (N = 8), with the number o f sessions being ten one-hour sessions. Assessments were conducted with self-recordings at home, selfrecordings in a behavioral test situation, and a questionnaire. The statistics used were A N O V A s and Mann-Whitney's U-test.

Andersson et al. The results replicated earlier findings in showing significant differences between the treatment and control conditions. However, no differential effects were found between the two types o f therapy. Based on the results o f Jakes et al. (65), Loumidis et al. (72) performed a study involving 33 patients (19 females, total mean age = 55 years). They were r a n d o m l y assigned to either a group who received an information folder about tinnitus (N = 17) or to a control group (N = 16). All subjects completed a tinnitus questionnaire, but only at posttreatment. Results were analyzed with A N O V A s and chi-square analysis. No effects were found in favour o f the folder. To our knowledge, no other study has dealt with the possible effects o f bibliotherapy on tinnitus, even though patients certainly benefit from reassurance and information. In a recently published study by Jakes et al. (73), 58 patients (18 females, total mean age = 60 years) were involved. They were r a n d o m l y assigned to five different experimental conditions that were compared: tinnitus masker (see introduction), placebo masker, waiting-list control, cognitive group therapy, and cognitive group therapy together with a tinnitus masker. After randomization, each group included eight to ten patients. The cognitive group therapy consisted o f five weekly group sessions (session length not stated). A n u m b e r o f dependent measures were included, but most o f the Results section was devoted to a questionnaire (tinnitus effect questionnaire) that had previously been used in their studies. The measures were administrated at pretreatment, posttreatment, and at a three-month follow-up. Results were analyzed by one-way A N O V A s at each assessment point. The results o f this study were disappointing in that almost no between-group differences were found, except for a modification o f irrational beliefs about tinnitus for patients who received an explanatory booklet about cognitive therapy. Also disappointing was that daily diary ratings o f loudness and annoyance had to be stopped because o f bad compliance. While being one o f the best designed studies on the effects of psychological treatment on tinnitus, no group included relaxation training. Instead, the authors attempted to test the effects of a purely cognitive approach (combined with masker). One potential implication is that it is not enough to use cognitive techniques, but that some behavioral coping techniques must be added, preferably applied relaxation. In a later series o f studies conducted by Wilson and coworkers in Australia, the cognitive part o f the treatment approach originating from the research group in Sweden was tested. Henry and Wilson (74) reported findings from a study in which 60 patients (10 females, total mean age = 65 years) participated. They were randomly allocated to three conditions: cognitive coping skills and education (iV = 20), education alone (N = 20), and a waiting list control (N = 20). Treatment consisted of six weekly 1.5-hour sessions and was conducted in small groups. The results were assessed by several self-report questionnaires, daily diary recordings, and audiological measures at pretreatment and posttreatment. A N O V A s with Bonferroni corrections were the statistics used. Reduction in general distress was found for the patients in the cognitive coping skills group. Results showing i m p r o v e m e n t were measured by the self-report scales, whereas no benefits were found on daily ratings of annoyance and loudness. The authors concluded that the benefits must be considered with caution. Davies et al. (75) compared three forms of cognitive-behavioral therapy in a study involving 30 patients (17 females,

Psychological Treatments for Tinnitus total mean age = 56 years) who were randomized into groups. One treatment form was "passive relaxation training" (N = 7), involving progressive muscle tensing/relaxing and pleasant visual imagery. The second treatment was "applied relaxation training" (N = 12), which included the former treatment but essentially added the instruction o f practising the relaxation skills taught in order to break a vicious circle o f "attention leading to greater attention leading to greater annoyance." The third treatment format was "individual cognitive therapy" (N = 11), emphasizing cognitive aspects o f tinnitus annoyance. Treatment was held in six to eight weekly one-hour sessions. Assessments included questionnaires, diary recordings, insomnia diaries, a n d a clinical rating by an independent assessor. A N O V A s were used to analyze the results at posttreatment, one-month follow-up, and at a four-month follow-up. While being rather modest and short-lived, the effects o f treatment were best for the applied relaxation group. The authors concluded that individual cognitive therapy seemed to be "less effective despite its more tailored and deeper focus." The studies reviewed are summarized in Table 3. In sum, relaxation coupled with cognitive coping techniques seems to be better than either relaxation or cognitive therapy alone. Compared with the other psychological treatments, these studies have included the most subjects and have had the largest proportion o f controlled group studies, o f which four support the efficacy o f the treatment. Many o f the studies suffer from small sample sizes, and in no instance have researchers reported on the clinical significance o f their treatment. Also, it is often unclear how the cognitive components have been implemented. A distinguishing feature about the Uppsala studies is that treatment has been conducted individually, and so far it has not been shown that the results can be extended to group treatments, which probably is the most c o m m o n treatment format in clinical practice for this patient group. Still, the results from Sweden and G e r m a n y justify the use o f this treatment in clinical practice. In only one controlled study was psychological therapy compared with other treatments for tinnitus (e.g. masker) in Jakes et al. (73), and reports on long-term follow-up results have been sparse. A n o t h e r aspect is the possible variation in how relaxation has been implemented. Even i f these differences are small they could be important. The Swedish studies used an abbreviated form o f the applied relaxation technique developed by Bernstein and Borkovec (76), and it is uncertain whether other researchers have used a less elaborated format. DISCUSSION Psychological treatments o f tinnitus have received a great deal o f interest in audiological research, especially since medical treatments have been largely ineffective (34). Yet, there are few controlled comparative examinations on which to base the evidence as to whether, and in that case what, psychological treatm e n t should be recommended. Given the studies on psychological treatment reviewed in this paper, relaxation training together with cognitive-behavioral techniques could be considered the most reasonable alternative. While few controlled studies on hypnosis exist, attention should be given to the two papers from Israel on self-hypnosis (39,40). However, it seems too early to recommend this as a regular treatment, but further trials should be conducted. It is possible that self-hypnosis treatment shares c o m m o n elements with other studies in which cognitive components are included.

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For example, the cognitive distraction techniques included in the studies by Lindberg and Scott and co-workers (68,71) could be similar to the self-hypnosis techniques briefly described by Attias et at. (39,40). Another aspect shared with the Swedish studies is that in the Israeli studies, efforts were aimed at skills to be used in the patient's own environment. It is very important that the patient develops coping strategies that are effective in their home environment and that treatment be aimed at the situation outside the therapy room. Many studies exist on the effect o f biofeedback, but again, few o f them have included baseline measures and control groups. Also, sample sizes have tended to be rather small, and followup data have not been presented. As mentioned earlier, some o f the effects o f biofeedback could be attributable to relaxation. Many studies have included relaxation combined with biofeedback, but no comparative trials exist, which could single out the effective mechanisms. In the light o f the results o f Ince and co-workers (45,50) and the fact that tinnitus patients are a very heterogeneous group, it is possible that direct control o f the tinnitus could be obtained by biofeedback, at least for some patients. Judging from the data, the most successful psychological treatment approach to tinnitus appears to be the combination o f relaxation and cognitive-behavioral approaches. In an earlier review, Kirsch et at. wrote: "The goal should be to develop treatments that aim to increase coping abilities and reduce the disruptiveness o f tinnitus" (4, p. 63). Even though authors do not claim to be able to help all patients, this has been done in the Swedish studies. Ongoing clinical trials in Australia (77) seem to confirm the results from the Swedish studies and show similar outcomes. A n important finding is that relaxation or cognitive therapy alone does not seem to be enough. In a review by Jakes (2), an optimistic view was held regarding the future o f combining relaxation training and cognitive-behavioral approaches. It was therefore rather surprising that he and his coworkers d i d not include relaxation in their extensive trial o f cognitive therapy (73). Indeed, in the study by Davies et at. (75), applied relaxation seemed to be more efficient than mere cognitive techniques, suggesting that relaxation should be included in the treatment. While relaxation seems to be a m a j o r ingredient in effective tinnitus treatments, the way it is i m p l e m e n t e d is certainly important. This could explain the diverse results found in different studies. Differential effects o f instruction should be investigated, which could show that hypnosis is one way o f "selling" relaxation which works and the rationale by Ireland et at. (70) (i.e. d e m a n d versus counterdemand) is not. Unfortunately, it is seld o m clear how the authors have i m p l e m e n t e d the relaxation. Treatment manuals in which case examples are extensively described are urgently needed in the application of relaxation therapy in tinnitus patients. H o w to measure treatment efficacy still remains a controversial issue in the treatment research on tinnitus. While it would seem obvious to extend assessments into the patients' own environments, this has not always been the case. In fact, much o f the research still relies on assessments performed on single occasions. Another topic is whether researchers should strive for more objective correlates o f the tinnitus experience than self-report scales. Since tinnitus weightings are unreliable and not necessarily related to experienced annoyance (16), other correlates o f distress should be looked for. A m o n g the existing outcome measures o f treatment efficacy, the most important

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TABLE 3 Studies on the Effect of Relaxation and Cognitive-Behavioral Therapy on Tinnitus. Single Case, Single Group, and Controlled Studies Presented in Order

Study

N

Design

Assessment

MacLeod-Morgan et al., 1982 (59) Chiodo el al., 1983 (60)

3 1

Single case anecdotal Single case anecdotal

None None

Malesta et al., 1980 (61)

1

Single case controlled

Tinnitus matchings of intensity

Hallam and Jakes, 1985 (62)

1

Lindberg et al., 1984 (63)

1

Single case controlled l-year F U Single case controlled

Diary recordings of loudness and annoyance Diary recordingsof loudness and annoyance (VAS)

Lindberg, 1988 (64)

1

Single case controlled

Jakes et al., 1986 (65)

26

A B design three factor

Lindberg et al., 1988 (66)

75

Clinical trial, one group pre, post, FU Clinical trial, one group pre, post, FU Controlled group

Goebel et al., 1992 (67) Scott et al., 1985 (68) Lindberg et al., 1987 (69)

Ireland et al., 1985 (70) Lindberg el al., 1989 (71)

138 24 20 [Same as (68)] 3O 27

Diary recordings of loudness and annoyance (alAS) Diary recordings of loudness and annoyance (VAS)

Improvements in all areas assessed

Controlled group Controlled group comparison of treatments Controlled group information Controlled group, 5 conditions

Diary recordings mood, sleep Diary recordings of loudness and annoyance (VAS) TEQ*

Questionnaire, diary recordings

No effects Treated Ss improved; no difference between treatments No effects of leaflet, informed group less unfulfilled needs No group differences; irrational beliefs modified in cognitive therapy Effects on questionnaire not on diary records Applied relaxation group improved most, effects shortlived Studies in favor = 14 of those 4 controlled group

9-month FU, one group

33

Jakes et al., 1992 (73)

58

Henry and Wilson, 1992 (74)

60

Controlled group

Davies et al., 1995 (75)

30

Controlled group, 3 group TEQ*, ratings of loudness and annoyance (VAS) conditions, 4-month FU 41% controlled group studies

Total N 529

Positive Decrease in tinnitus and time for sleep onset Identification of important influencing variables Annoyance decreased

20% reduced loudness, 71% reduced annoyance Same as above + controllability Loudness, discomfort reduced; ability to control increased Diary recordings of loudness Annoyance decreased; distress and annoyance reduced after information phase Same as above + mood ratings Discomfort reduced; mood elevated Questionnaire, diary recordings Effects on all diary measures

Loumidis et al., 1991 (72)

Summary

Conclusion/Outcome

TEQ*, telephone interview at 1-5 yrs FU

Discomfort still reduced

* Tinnitus effect questionnaire. one still remains the personal experience of annoyance. A treatm e n t that permanently managed to totally eliminate the tinnitus sound would hardly need any additional assessments. Except for a few rare examples (18), up to this point, such treatment has not yet been found, neither medical, technical, or psychological. Studies are needed in which daily and within-daffy ratings of how tinnitus disturbs everyday activities such as job performance are assessed. Other problems are short- and long-term fluctuations in tinnitus (78), what determines these variations, and the adjustment to tinnitus in general (79). While self-report scales (e.g. 80,81) have their place in the assessment of patients and in prevalence estimates, it is not obvious that they are the best alternative in measuring treatment efficacy. Some investigators have focused on developing cognitive measures (82), while others have relied on symptom-oriented questions (e.g. VAS) measured on several occasions. To our knowledge, no study has empirically evaluated the differences between these assessment procedures in a clinical context. Considering the differences among the treatment studies,

the question remains what constitute the effective treatment ingredients. We would like to propose the following aspects which could be of importance in obtaining treatment success. First, all tinnitus patients should receive information and reassurance about their condition. Medical examinations as well as interviews about the psychological consequences should be included. Although not an efficacious treatment in and of itself, self-help manuals should be included in the treatment regime. Second, relaxation skills should be included in the treatment. A majority of studies in which success has been obtained seem to have included relaxation. However, relaxation alone does not seem to be enough (70). This should be further investigated before a final conclusion is made. Our third recommendation is to include some form of homework assignments to practice during the treatment. This facilitates exposure to difficult situations where tinnitus is especially troublesome and for which further coping strategies should be developed. Our fourth recommendation is to individualize treatments according to the patients' specific needs and goals. Here behav-

Psychological Treatments for Tinnitus ioral analysis of each individual patient's strengths and needs should be a useful tool (83). It remains to be determined whether treatment should be conducted individually or in groups. O u r final recommendation is that an active coping technique should be taught along with the relaxation skills. Applied relaxation tied to specific situations is one active coping technique, hut other individualized coping strategies should be ineluded i n the treatment. Research does not supply a clear-cut answer as to what should be considered the best coping technique (e.g. distraction or behavioral skills). Our impression is that self-control strategies and interpreting sounds in a more positive light are helpful treatment ingredients, but further research is definitely needed about cognitive aspects of tinnitus. CONCLUSIONS The overall evidence found in this review indicates that cognitive and relaxation techniques combined should be considered as a promising treatment for tinnitus. Two controlled experimental studies using daily measures oftinnitus annoyance give clear support for this conclusion (e.g. 68,71). Hypnosis and biofeedback treatments show some benefits, but the similarities between these and cognitive-behavioraltherapies makes it plausible that the latter are the ones that have most accurately identified the effective mechanisms (if the studies are comparable at all). However, there is still much left to be done in establishing psychological treatments for tinnitus. Assessments should be refined, in particular determining the effects of tinnitus on everyday activities, preferably using within-daily measures. While most researchers agree that tinnitus is a heterogeneous problem, few studies have tried to differentiate subgroups of patients and tailor treatments according to specific needs (e.g. 61). Finally, psychological treatments should be compared with other treatments and additive effects should be studied. In sum, much remains to be done in the study of psychological treatments for tinnitus. REFERENCES (1) Hazell JWP, Jastreboff PJ: Tinnitus I: Auditory mechanisms: A model for tinnitus and heating impairment. Journal of Otolaryngology. 1990, 19:1-5. (2) Jakes S: Otological symptoms and emotion. A review of the literature. Advances in Behaviour Research and Therapy. 1988, I0: 53-103. (3) Hallam R, Rachman S, Hincheliife R: Psychological aspects of tinnitus. In Rachman S (ed), Contributions to Medical Psychology (Vol. 3). Oxford, UK: Pergamon Press, 1984, 31-53. (4) Kirsch CA, Blanchard EB, Parries SM: A review of behavioral techniques in the treatment of subjective tinnitus. Annals of Behavioral Medicine. 1989, 11:58-65. (5) Axelsson A, Ringdahl A: Tinnitus--A study of its prevalence and characteristics. British Journal of Audiology. 1989, 23:53-62. (6) Davis A: The prevalence of hearing impairment and reported hearing disability among adults in Great Britain. International Journal of Epidemiology. 1989, 18:911-917. (7) Parring A, Hein HO, Suadieani B, Ostri B, Gyntelberg F: Epidemiology of hearing disorders. Scandinavian Audiology. 1993, 22:101-107. (8) Lindberg P, Lyttkens L, Melin L, Scott B: Tinnitus--Incideneeand handicap. Scandinavian Audiology. 1984, 13:287-291. (9) Lewis J, Stephens D, Huws D: Suicide in tinnitus. Journal of Audiological Medicine. 1992, 1:30-37. (10) Sood SK, Coles RRA: Hyperacusis and phonophobia in tinnitus patients. British Journal of Audiology. 1988, 22:228. (1 l) Halford JBS, Anderson SD: Anxiety and depression in tinnitus sufferers. Journal of Psychosomatic Research. 1991, 35:383-390.

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(62) (63)

(64)

(65)

(66)

(67)

(68)

(69)

(70)

(71)

(72)

(73)

(74)

(75)

(76) (77)

(78)

(79)

(80) (81)

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