Leitthema HNO 2015 · 63:302–306 DOI 10.1007/s00106-014-2978-2 Published online: 10. April 2015 © Springer-Verlag Berlin Heidelberg 2015
N. Dauman1 · S. Erlandsson2 · L. Lundlin2 · R. Dauman3 1 CAPS-EA4050, Department of Psychology, University of Poitiers, Poitiers 2 Department of Social and Behavioural Studies, University West, Trollhättan 3 Tinnitus Clinic, Department of ORL-HNS, University of Bordeaux and CHU of Bordeaux,
CNRS-UMR 5287, Bordeaux
Intra-individual variability in tinnitus patients Current thoughts and perspectives
Introduction Most tinnitus studies have attempted to compare groups of individuals, thus revealing inter-individuals differences, i.e., variations between compared subjects. Despite the pertinence of such studies, their view on tinnitus is intrinsically static, being comparisons of subjects at a specified time, regardless of the fact that changes may well occur in the individual’s experience of tinnitus with time. For methodological reasons, inter-individual studies cannot take into account the variability of tinnitus experience, which has been known for decades to be relevant in daily practice with tinnitus patients [15]. Suffering from tinnitus, hyperacusis, and hearing impairments should be considered as being related to the individual’s perception of time, and as chronic conditions that subjects will have to integrate into their entire life—not for a specified time only. The concept of intra-individual variability has been promoted in the research literature in order to shed light on this aspect of individual perception. For instance, moment-to-moment intra-individual variability may refer to relatively rapid fluctuations in, e.g., cognitive task performance [7, 9]. In more basic fields of neuroscience, intra-individual variability also designates the variation of intervals between the impulses discharged by optic nerve fibers under steady conditions, thus showing the influence of environment (light/ darkness) on the functioning of the visual
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system [13]. More recently, manipulation of the environment in an experimental setting applied to healthy subjects showed the extent to which underwater hearing thresholds through bone conduction can be modified [11]. In these studies, the concept of intra-individual variability implies inclusion of the environment (i.e., physical and social interactions) as a factor of individual performance. In tinnitus research, we believe that the concept of variability (within a person) could find a place beside the concept of variation (between groups of subjects). From our collaboration at a workshop during the International Tinnitus Seminar, Berlin 2014, we wish to stimulate further interest in the issue of intraindividual variability, gathering four perspectives of experiences from the clinical and research fields: (1) ENT consultation; (2) short-term group psychotherapy; (3) psychodynamic psychotherapy; and (4) clinical psychological research.
Intra-individual variability in ENT consultation Two kinds of circumstances have been encountered in which intra-individual variability could be identified. The first relates to when an individual is asked to which extent a given activity—such as reading, falling asleep, ability to concentrate, ability to relax—is made more difficult by the presence of tinnitus. Confronted with such questioning, the tinnitus patient may be inclined to respond, “It depends … on the
loudness of the tinnitus, my state of tiredness, or stress” etc. This was found in a comprehensive investigation in one of the most widely used tinnitus questionnaires, the Tinnitus Handicap Questionnaire of Iowa [10], administered to a French population of tinnitus-affected outpatients [1]. The second circumstance in which intraindividual variability is regularly experienced is when hearing amplification is suggested to a patient seeking help for tinnitus with some level of hearing disability. While the amount of annoyance was sufficiently high to lead the subject to a tinnitus specialist, the problem may be minimized once the subject realizes that an improvement of his/her disorder can only be achieved by wearing a hearing aid. Beside these two levels of ENT clinical experience, intra-individual variability was recently encountered in a double-blind crossover study on neurosurgical chronic epidural electric stimulation for disabling tinnitus [5]. Most of the nine study subjects reported questionnaire-based improvement of their tinnitus while being in a wash-out period or a period of intentionally non-effective functioning of the device. Although the exact mechanism of these questionnaire-based improvements in tinnitus handicap is still under debate, they concretely exemplify intra-individual variability. These observations support the need for further research on the expectations and disappointments of patients in the ENT consultation. Variability may imply alterna-
Leitthema tive methods in the investigation of tinnitus suffering. There is also a need for the patient’s own appraisal of what suffering and relief means to him or her, for example, by the use of longitudinal semistructured interviews (see [8]).
Intra-individual variability in short-term group psychotherapy In rehabilitation of patients with tinnitus, it is possible to explore changes on an intra-individual level of suffering. The group therapy approach can facilitate change, and we know that those who find support and understanding from their group report more improvements. However, benefits from taking part in a group can also be explained by the interaction of a number of forces, such as group structure, group processes, as well as patient and therapist characteristics. Interpersonal theory governed us when planning the group intervention, i.e., that the patients’ emotional problems in combination with tinnitus suffering could make it difficult to build and maintain satisfactory interpersonal relationships. Narratives are social constructions developed in everyday social interaction. We create ourselves through narratives and make our world meaningful. Numerous authors have defined psychotherapy as an “exercise in story repair” ([14]; see also [8]). In line with this, Spense [14] argues that the focus of psychotherapy is on meanings, which is communicated and changed through language. It means that the psychotherapist works with the construction of meanings through narratives rather than discovering meanings in the minds of the client. The therapist also plays a role as collaborator in the production of the narrative. Here, the intention was that the patients with the help of the group led by two psychotherapists would be able to bring sense to something as strange as the experience of tinnitus. We assumed, in agreement with Yalom [16], that the group therapy approach would contribute to the imbuing of hope, corrective emotional experience, modeling, and promotion of self-awareness. Zöger et al. [17] reported examples of intra-individual variability in a study including 37 patients (20–56 years of age)
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presenting with severe refractory tinnitus. Important inclusion criteria were the willingness of patients to share their experiences within a group format and also ability to imagine tinnitus distress from viewpoints other than strict medical and/or physical ones. Four groups, each including eight patients (in one group, seven) participated in eight 1.5-h weekly sessions over a 3-month period that took place at the department of psychology. Our assumption that emotional stress makes it difficult for the patients to build and maintain satisfactory relationships seemed to be confirmed. The most common desire articulated by group members was a change in their own attitudes leading to more agreeable relationships with people around them. It proves that relationships play a crucial role in the lives of the patients, here expressed as: “I would like … to be more patient— be able to control anger—be more calm—be less critical of other people—change negative thoughts into positive—to be more self-confident—to stop getting hung up about everything” ([17], pp. 68). Aspects of variability in how the patients adhered to their condition showed that some of them were able to ignore tinnitus, although it was perceived to be as loud as before. Others experienced that tinnitus varied with their emotional state. Patients who experienced that they had gained a deeper personal insight into the variability of their suffering might have a positive long-term effect as a result of their commitment. Listening carefully to the patients’ narratives can strengthen the professional role and the ability to look for variability in what has been disclosed. From a patient’s viewpoint, we can learn that transparency is mandatory for the enrolment in a group: I didn’t have such great expectations, but wanted nevertheless to be open and express what I felt in the group—otherwise there was no idea to join ([17], pp. 68).
Intra-individual variability in psychodynamic psychotherapy Psychodynamic psychotherapy has recently been promoted in tinnitus literature as a psychological frame to carry individual chronic suffering [4]. Psychodynamic psychotherapy is grounded on assumptions of
psychoanalysis, in particular that suffering is related to a lack of insight regarding the changed experience of oneself. It is a wellestablished observation that human beings need to find a meaning to their condition, otherwise it appears even more unsustainable. This is in line with our clinical experience of tinnitus patients, who suffer initially because there is no clear pattern to grasp in this unwanted condition. Broadly speaking, the process of psychodynamic psychotherapy helps the patients to improve their insight on their reactions to tinnitus and the ability to understand suffering as emanating from the individual’s history. This process can be described as a gain of awareness, which the patient can use henceforth to face circumstances associated with suffering. Intra-individual variability needs to be elucidated to a patient who suffers from tinnitus at the beginning of the psychodynamic process. Like many suffering tinnitus patients, Anna first complained about tinnitus that “never left her.” She experienced prolonged distress, in particular because of a lack of concern from professionals, who tried to convince her that she would inevitably habituate to tinnitus with time. After some time Anna complained that people around her disregarded her suffering. It was hard for her to realize that her suffering was not acknowledged even by members of her own family. A daughter-in-law advised her, “Are you still annoyed with your tinnitus? Why don’t you stop to listen to them?” However, when her son came to see her, Anna was so pleased to be trusted and listened to, that she experienced “softer” tinnitus. After being puzzled by such variability, her experience of tinnitus led her to talk about tensions in the relationship with her daughter-in-law that she had tried to ignore for years. Anna then realized that her relationship with others could contribute to the variability of tinnitus annoyance. When she became aware of this variability, Anna began to realize that her own reaction to the attitude of others also contributed to her suffering from tinnitus. This was particularly true when she recalled in psychotherapy circumstances in which she participated “reluctantly.” When riding in the car of her grandson, she understood from its noisy engine that
Abstract · Zusammenfassung she would have to suffer from “hard tinnitus” during the whole journey. Anna accepted exhausting travels regardless of her fear that tinnitus would become more intense. She kept silent and what she was afraid of actually happened, i.e., her tinnitus worsened. Although this attitude made her suffer, she never complained to others during her life. Doing things unwillingly seemed to be part of Anna’s life. She had supported her relatives until their last breath, and found it most unfair to be “rewarded by tinnitus.” But Anna understood another aspect of tinnitus variability when she realized that she also had will and desires that she could make true, although others may not see her resources. For instance, reading about tinnitus research allowed her to be involved in a pleasant activity that “left tinnitus in the background.” When she was doing something meaningful, e.g., gardening, reading, talking with the few people who care about her condition, then tinnitus was bearable. The likelihood that these moments can be reached in the future contributed to Anna’s confidence in her own ability to face tinnitus. In the frame of psychodynamic psychotherapy, awareness of intra-individual variability appears to be a positive prognostic of the relief of tinnitus suffering, as well as an insight into one’s own reaction to the fluctuation of the symptom.
Intra-individual variability in clinical psychological research Embracing the idea of human beings as complex living systems [2], we conducted a study aimed at increasing the understanding of how tinnitus interacts with unique life histories. The aim of the study described here was thus to gain more knowledge of intra-individual variability in the experience of tinnitus, i.e., unique individuals in unique contexts with several interacting factors contributing to the experience of living with tinnitus. Narrative methodology was employed in order to interpret the interviews and to give them meaning [12]. In narrative methodology, human beings are perceived as active agents in the creation of meaning. Emphasis was thus focused on the individual interpretation of tinnitus. By taking account of several interacting factors,
HNO 2015 · 63:302–306 DOI 10.1007/s00106-014-2978-2 © Springer-Verlag Berlin Heidelberg 2015 N. Dauman · S. Erlandsson · L. Lundlin · R. Dauman
Intra-individual variability in tinnitus patients. Current thoughts and perspectives Abstract Most tinnitus studies have attempted to compare groups of individuals, thus revealing inter-individuals differences, i.e., variations between compared subjects. For methodological reasons, inter-individual studies cannot take into account the variability of tinnitus experience, which has been known for decades to be relevant in daily practice with tinnitus patients. The concept of intra-individual variability has been promoted in the research literature, in order to shed light on this aspect of individual perception. In previous studies, unrelated to hearing, the concept of intra-individual variability implied inclusion of the environment (i.e., physical and social interactions) as a factor of individual performance. In tinnitus research, we believe that the concept of variability (within a person) could find a place beside the concept of variation (between groups of subjects). In this paper, four
perspectives of tinnitus experiences from the clinical and research fields are described: (1) ENT consultation; (2) short-term group psychotherapy; (3) psychodynamic psychotherapy; and (4) clinical psychological research. Intra-individual variability stresses the importance of defining tinnitus in a dynamic way, contrary to the current definition of tinnitus as the perception of sound(s). In clinical practice, it is useful to embrace the perspective of the perceiver of tinnitus, and to include social and cultural circumstances as well as audiological/physical changes. Keywords Tinnitus · Inter-individual variability · Intra-individual variability · Psychotherapy · Sociocultural factors
Intraindividuelle Variabilität bei Tinnituspatienten. Aktuelle Gedanken und Perspektiven Zusammenfassung Die meisten Tinnitusstudien haben versucht, Gruppen von Tinnituspatienten zu vergleichen und somit interindividuelle Variabilität, d. h. Unterschiede zwischen den Patienten, zu vergleichen. Aus methodischen Gründen können interindividuelle Studien leider keine Variabilität in der Tinnituserfahrung, die seit Jahrzehnten als relevant im täglichen Umgang mit Tinnituspatienten bekannt ist, berücksichtigen. Das Konzept der intraindividuellen Variabilität (intra-IV) wurde in der Forschungsliteratur gefördert, um diese konkreten Aspekte der individuellen Tinnituswahrnehmung zu klären. In den bisherigen, nicht in der Hörforschung durchgeführten Studien wurde im Rahmen des Konzepts intra-IV die Einbeziehung der Umgebung (d. h. physische und soziale Interaktionen) als Faktor der individuellen Leistung vorgeschlagen. Das Konzept der intraindividuellen Variabilität sollte unserer Meinung gleichwertig zu der interindividuellen Variabilität für die Tinnitusforschung in Betracht gezogen werden.
care was taken not to detach an individual from his or her own context. We set out to achieve this by asking questions about participants’ backgrounds, for example, questions about childhood, fami-
In diesem Artikel werden 4 Perspektiven von Tinnituserfahrungen aus dem klinischen und dem Forschungsfeld beschrieben: i) HNOKonsultation; ii) kurzfristige Gruppenpsychotherapie; iii) psychodynamische Psychotherapie und iv) klinisch-psychologische Forschung. Fazit: 1) Intraindividuelle Variabilität unterstreicht die Wichtigkeit, Tinnitus in einer dynamischen Art und Weise zu definieren, im Gegensatz zu der aktuellen Definition von Tinnitus als die Wahrnehmung von Phantomgeräuschen. 2) In der klinischen Praxis ist es sinnvoll, die Perspektive des Tinnituspatienten selbst ebenso miteinzubeziehen wie soziale und kulturelle Bedingungen sowie audiologische und physikalische Veränderungen. Schlüsselwörter Tinnitus · Interindividuelle Variabilität · Intraindividuelle Variabilität · Psychotherapie · Soziokulturelle Faktoren
ly situation, working life, and sociocultural context. Questions about tinnitus were also asked, for example, how they reacted when they first understood that they had tinnitus, how they had dealt with the HNO 4 · 2015
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Leitthema symptoms of tinnitus, what type of support they felt that they had received etc. Through these questions, an inside perspective was gained in which each participant’s life situation and previous life circumstances were regarded in relation to reactions and feelings toward tinnitus. How an individual perceives tinnitus and deals with tinnitus can thus depend on current and past circumstances. There is thus intra-individual variability in the experience of tinnitus due to several interacting factors. When we started analyzing the material, five interacting factors were found to stand out. These factors were termed: 1. External factors 2. Internal factors 3. Previous experiences and sociocultural context 4. Personality 5. Strategies External factors were associated with environmental factors. Examples were external factors in the working environment. Some participants described their working environments as very noisy and therefore detrimental to their tinnitus. Internal factors were instead particularly related to participants’ subjective experiences. All participants mentioned that feeling stressed enhanced the symptoms of tinnitus: “When life is tough, tinnitus gets worse.” Previous experiences and sociocultural context also impacted on how tinnitus was experienced and dealt with. One participant was, for example, brought up in a working class environment where he had personal ideals of working hard, of taking responsibility, of helping others etc. It was also clear from this narrative that he had male relatives who had worked in the heavy industry field and several relatives had developed tinnitus as a result of a noisy working environment: “Most of my male relatives have tinnitus so it is no big deal.” Personality also shone through in the narratives. One person, for instance, described herself as very social, outgoing, and a bit impulsive. Before she was faced with tinnitus she was able to enjoy just popping in for a chat with friends on the spur of the moment. With tinnitus, she found it difficult to enjoy social activities because it was painful for her to be in environments where many people talk simultaneously and it was
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also difficult for her to follow a conversation because of tinnitus. She felt that tinnitus had robbed her of her personality. Strategies were another factor that influenced how tinnitus was perceived. Some participants displayed more problem-solving approaches to tinnitus than others did. One participant was very active and adopted various strategies such as relaxation techniques and he also described adapting the strategies to suit him. Several interacting factors thus shaped each person’s narrative and gave it a structure that revealed intraindividual variability.
Conclusion Intra-individual variability stresses the importance of defining tinnitus in a dynamic way, contrary to the current definition of tinnitus as the perception of sound(s) [6]. In clinical practice, it is useful to embrace the perspective of the perceiver of tinnitus, and to include social and cultural circumstances, as well as audiological/physical changes. While habituation to tinnitus is a process that sets in over time, the sole focus on variation between groups of subjects may have little to offer in describing a process that would lead to an individual progress [3]. The clinical research that has been presented here on intra-individual variability can contribute toward enlightening the complexity of tinnitus by including the perspective of the suffering patients.
Corresponding address R. Dauman Tinnitus Clinic, Department of ORL-HNS, University of Bordeaux and CHU of Bordeaux, CNRS-UMR 5287 Bordeaux France [email protected]
Compliance with ethical guidelines Conflict of interest. N. Dauman, S. Erlandsson, L. Lundlin, and R. Dauman state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.
References 1. Bouscau-Faure F, Keller P, Dauman R (2003) Further validation of the Iowa tinnitus handicap questionnaire. Acta Otolaryngol 123:227–231 2. Crossley M (2000) Introducing narrative psychology. Self, trauma and the construct of meaning. Open University Press, Philadelphia 3. Dauman N, Erlandsson SI, Carlsson SG (2013) Habituation theories in current models of chronic tinnitus: evidence and criticism. In: Buskirk A (ed) Habituation: theories, characteristics and biological mechanisms. Nova Publisher, New York, pp 55–90 4. Dauman N, Erlandsson SI (2012) Learning from tinnitus patients’ narratives. A case study in the psychodynamic approach. Int J Qualitative Stud Health Well-being 7:19540. http://dx.doi. org/10.3402/qhw.v7i0.19540 5. Engelhardt J, Dauman R, Arné P et al (2014) Effect of chronic cortical stimulation on chronic severe tinnitus: a prospective randomized double-blind cross-over trial and long-term follow up. Brain Stimul 7:694–700 6. Erlandsson SI, Dauman N (2013) Categorisation of tinnitus in view of history and medical discourse. Int J Qualitative Stud Health Well-being 8:23530. http://dx.doi.org/10.3402/qhw.v8i0.23530 7. Garett DD, McDonald SWS, Craik FIM (2012) Intraindividual reaction time variability is malleable: feedback- and education-related reductions in variability with age. Front Human Neurosci 6:1–10 8. Holloway W, Jefferson T (2001) Doing qualitative research differently; free association, narrative and the interview method. SAGE, London 9. Hultsch DE, McDonald SWS, Hunter MA et al (2000) Intraindividual variability in cognitive performance in older adults: comparison of adults with mild dementia, adults with arthritis, and healthy adults. Neuropsychology 14:588–598 10. Kuk FK, Tyler RS, Russell D, Jordan H (1990) The psychometric properties of a tinnitus handicap questionnaire. Ear Hear 11:434–445 11. Pau HW, Warkentin M, Specht O et al (2011) Experiments on the mechanism of underwater hearing. Acta Otolaryngol 131:1279–1285 12. Polkinghorne DP (1988) Narrative knowing and the human sciences. SUNY Press, Albany 13. Ratliff F, Hartline HK, Lange D (1968) Variability of interspike intervals in optic nerve fibers of limulus: effect of light and dark adaptation. Proc Natl Acad Sci 60:464–469 14. Spense D (1982) Narrative truth and historical truth. Norton, New York 15. Stouffer JL, Tyler RS (1990) Characterization of tinnitus by tinnitus patients. J Speech Hear Disord 55:439–453 16. Yalom ID (1995) The theory and practice of group psychotherapy, 4th edn. Basic Books, New York 17. Zöger S, Erlandsson S, Svedlund J, Holgers K-M (2008) Benefits from group psychotherapy in the treatment of severe refractory tinnitus. Audiol Med 6(1):62–72
N. Dauman1 · S. Erlandsson2 · L. Lundlin2 · R. Dauman3 1 CAPS-EA4050, Department of Psychology, University of Poitiers, Poitiers 2 Department of Social and Behavioural Studies, University West, Trollhättan 3 Tinnitus Clinic, Department of ORL-HNS, University of Bordeaux and CHU of Bordeaux,
CNRS-UMR 5287, Bordeaux
Intra-individual variability in tinnitus patients Current thoughts and perspectives
Introduction Most tinnitus studies have attempted to compare groups of individuals, thus revealing inter-individuals differences, i.e., variations between compared subjects. Despite the pertinence of such studies, their view on tinnitus is intrinsically static, being comparisons of subjects at a specified time, regardless of the fact that changes may well occur in the individual’s experience of tinnitus with time. For methodological reasons, inter-individual studies cannot take into account the variability of tinnitus experience, which has been known for decades to be relevant in daily practice with tinnitus patients [15]. Suffering from tinnitus, hyperacusis, and hearing impairments should be considered as being related to the individual’s perception of time, and as chronic conditions that subjects will have to integrate into their entire life—not for a specified time only. The concept of intra-individual variability has been promoted in the research literature in order to shed light on this aspect of individual perception. For instance, moment-to-moment intra-individual variability may refer to relatively rapid fluctuations in, e.g., cognitive task performance [7, 9]. In more basic fields of neuroscience, intra-individual variability also designates the variation of intervals between the impulses discharged by optic nerve fibers under steady conditions, thus showing the influence of environment (light/ darkness) on the functioning of the visual
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system [13]. More recently, manipulation of the environment in an experimental setting applied to healthy subjects showed the extent to which underwater hearing thresholds through bone conduction can be modified [11]. In these studies, the concept of intra-individual variability implies inclusion of the environment (i.e., physical and social interactions) as a factor of individual performance. In tinnitus research, we believe that the concept of variability (within a person) could find a place beside the concept of variation (between groups of subjects). From our collaboration at a workshop during the International Tinnitus Seminar, Berlin 2014, we wish to stimulate further interest in the issue of intraindividual variability, gathering four perspectives of experiences from the clinical and research fields: (1) ENT consultation; (2) short-term group psychotherapy; (3) psychodynamic psychotherapy; and (4) clinical psychological research.
Intra-individual variability in ENT consultation Two kinds of circumstances have been encountered in which intra-individual variability could be identified. The first relates to when an individual is asked to which extent a given activity—such as reading, falling asleep, ability to concentrate, ability to relax—is made more difficult by the presence of tinnitus. Confronted with such questioning, the tinnitus patient may be inclined to respond, “It depends … on the
loudness of the tinnitus, my state of tiredness, or stress” etc. This was found in a comprehensive investigation in one of the most widely used tinnitus questionnaires, the Tinnitus Handicap Questionnaire of Iowa [10], administered to a French population of tinnitus-affected outpatients [1]. The second circumstance in which intraindividual variability is regularly experienced is when hearing amplification is suggested to a patient seeking help for tinnitus with some level of hearing disability. While the amount of annoyance was sufficiently high to lead the subject to a tinnitus specialist, the problem may be minimized once the subject realizes that an improvement of his/her disorder can only be achieved by wearing a hearing aid. Beside these two levels of ENT clinical experience, intra-individual variability was recently encountered in a double-blind crossover study on neurosurgical chronic epidural electric stimulation for disabling tinnitus [5]. Most of the nine study subjects reported questionnaire-based improvement of their tinnitus while being in a wash-out period or a period of intentionally non-effective functioning of the device. Although the exact mechanism of these questionnaire-based improvements in tinnitus handicap is still under debate, they concretely exemplify intra-individual variability. These observations support the need for further research on the expectations and disappointments of patients in the ENT consultation. Variability may imply alterna-
Leitthema tive methods in the investigation of tinnitus suffering. There is also a need for the patient’s own appraisal of what suffering and relief means to him or her, for example, by the use of longitudinal semistructured interviews (see [8]).
Intra-individual variability in short-term group psychotherapy In rehabilitation of patients with tinnitus, it is possible to explore changes on an intra-individual level of suffering. The group therapy approach can facilitate change, and we know that those who find support and understanding from their group report more improvements. However, benefits from taking part in a group can also be explained by the interaction of a number of forces, such as group structure, group processes, as well as patient and therapist characteristics. Interpersonal theory governed us when planning the group intervention, i.e., that the patients’ emotional problems in combination with tinnitus suffering could make it difficult to build and maintain satisfactory interpersonal relationships. Narratives are social constructions developed in everyday social interaction. We create ourselves through narratives and make our world meaningful. Numerous authors have defined psychotherapy as an “exercise in story repair” ([14]; see also [8]). In line with this, Spense [14] argues that the focus of psychotherapy is on meanings, which is communicated and changed through language. It means that the psychotherapist works with the construction of meanings through narratives rather than discovering meanings in the minds of the client. The therapist also plays a role as collaborator in the production of the narrative. Here, the intention was that the patients with the help of the group led by two psychotherapists would be able to bring sense to something as strange as the experience of tinnitus. We assumed, in agreement with Yalom [16], that the group therapy approach would contribute to the imbuing of hope, corrective emotional experience, modeling, and promotion of self-awareness. Zöger et al. [17] reported examples of intra-individual variability in a study including 37 patients (20–56 years of age)
304 |
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presenting with severe refractory tinnitus. Important inclusion criteria were the willingness of patients to share their experiences within a group format and also ability to imagine tinnitus distress from viewpoints other than strict medical and/or physical ones. Four groups, each including eight patients (in one group, seven) participated in eight 1.5-h weekly sessions over a 3-month period that took place at the department of psychology. Our assumption that emotional stress makes it difficult for the patients to build and maintain satisfactory relationships seemed to be confirmed. The most common desire articulated by group members was a change in their own attitudes leading to more agreeable relationships with people around them. It proves that relationships play a crucial role in the lives of the patients, here expressed as: “I would like … to be more patient— be able to control anger—be more calm—be less critical of other people—change negative thoughts into positive—to be more self-confident—to stop getting hung up about everything” ([17], pp. 68). Aspects of variability in how the patients adhered to their condition showed that some of them were able to ignore tinnitus, although it was perceived to be as loud as before. Others experienced that tinnitus varied with their emotional state. Patients who experienced that they had gained a deeper personal insight into the variability of their suffering might have a positive long-term effect as a result of their commitment. Listening carefully to the patients’ narratives can strengthen the professional role and the ability to look for variability in what has been disclosed. From a patient’s viewpoint, we can learn that transparency is mandatory for the enrolment in a group: I didn’t have such great expectations, but wanted nevertheless to be open and express what I felt in the group—otherwise there was no idea to join ([17], pp. 68).
Intra-individual variability in psychodynamic psychotherapy Psychodynamic psychotherapy has recently been promoted in tinnitus literature as a psychological frame to carry individual chronic suffering [4]. Psychodynamic psychotherapy is grounded on assumptions of
psychoanalysis, in particular that suffering is related to a lack of insight regarding the changed experience of oneself. It is a wellestablished observation that human beings need to find a meaning to their condition, otherwise it appears even more unsustainable. This is in line with our clinical experience of tinnitus patients, who suffer initially because there is no clear pattern to grasp in this unwanted condition. Broadly speaking, the process of psychodynamic psychotherapy helps the patients to improve their insight on their reactions to tinnitus and the ability to understand suffering as emanating from the individual’s history. This process can be described as a gain of awareness, which the patient can use henceforth to face circumstances associated with suffering. Intra-individual variability needs to be elucidated to a patient who suffers from tinnitus at the beginning of the psychodynamic process. Like many suffering tinnitus patients, Anna first complained about tinnitus that “never left her.” She experienced prolonged distress, in particular because of a lack of concern from professionals, who tried to convince her that she would inevitably habituate to tinnitus with time. After some time Anna complained that people around her disregarded her suffering. It was hard for her to realize that her suffering was not acknowledged even by members of her own family. A daughter-in-law advised her, “Are you still annoyed with your tinnitus? Why don’t you stop to listen to them?” However, when her son came to see her, Anna was so pleased to be trusted and listened to, that she experienced “softer” tinnitus. After being puzzled by such variability, her experience of tinnitus led her to talk about tensions in the relationship with her daughter-in-law that she had tried to ignore for years. Anna then realized that her relationship with others could contribute to the variability of tinnitus annoyance. When she became aware of this variability, Anna began to realize that her own reaction to the attitude of others also contributed to her suffering from tinnitus. This was particularly true when she recalled in psychotherapy circumstances in which she participated “reluctantly.” When riding in the car of her grandson, she understood from its noisy engine that
Abstract · Zusammenfassung she would have to suffer from “hard tinnitus” during the whole journey. Anna accepted exhausting travels regardless of her fear that tinnitus would become more intense. She kept silent and what she was afraid of actually happened, i.e., her tinnitus worsened. Although this attitude made her suffer, she never complained to others during her life. Doing things unwillingly seemed to be part of Anna’s life. She had supported her relatives until their last breath, and found it most unfair to be “rewarded by tinnitus.” But Anna understood another aspect of tinnitus variability when she realized that she also had will and desires that she could make true, although others may not see her resources. For instance, reading about tinnitus research allowed her to be involved in a pleasant activity that “left tinnitus in the background.” When she was doing something meaningful, e.g., gardening, reading, talking with the few people who care about her condition, then tinnitus was bearable. The likelihood that these moments can be reached in the future contributed to Anna’s confidence in her own ability to face tinnitus. In the frame of psychodynamic psychotherapy, awareness of intra-individual variability appears to be a positive prognostic of the relief of tinnitus suffering, as well as an insight into one’s own reaction to the fluctuation of the symptom.
Intra-individual variability in clinical psychological research Embracing the idea of human beings as complex living systems [2], we conducted a study aimed at increasing the understanding of how tinnitus interacts with unique life histories. The aim of the study described here was thus to gain more knowledge of intra-individual variability in the experience of tinnitus, i.e., unique individuals in unique contexts with several interacting factors contributing to the experience of living with tinnitus. Narrative methodology was employed in order to interpret the interviews and to give them meaning [12]. In narrative methodology, human beings are perceived as active agents in the creation of meaning. Emphasis was thus focused on the individual interpretation of tinnitus. By taking account of several interacting factors,
HNO 2015 · 63:302–306 DOI 10.1007/s00106-014-2978-2 © Springer-Verlag Berlin Heidelberg 2015 N. Dauman · S. Erlandsson · L. Lundlin · R. Dauman
Intra-individual variability in tinnitus patients. Current thoughts and perspectives Abstract Most tinnitus studies have attempted to compare groups of individuals, thus revealing inter-individuals differences, i.e., variations between compared subjects. For methodological reasons, inter-individual studies cannot take into account the variability of tinnitus experience, which has been known for decades to be relevant in daily practice with tinnitus patients. The concept of intra-individual variability has been promoted in the research literature, in order to shed light on this aspect of individual perception. In previous studies, unrelated to hearing, the concept of intra-individual variability implied inclusion of the environment (i.e., physical and social interactions) as a factor of individual performance. In tinnitus research, we believe that the concept of variability (within a person) could find a place beside the concept of variation (between groups of subjects). In this paper, four
perspectives of tinnitus experiences from the clinical and research fields are described: (1) ENT consultation; (2) short-term group psychotherapy; (3) psychodynamic psychotherapy; and (4) clinical psychological research. Intra-individual variability stresses the importance of defining tinnitus in a dynamic way, contrary to the current definition of tinnitus as the perception of sound(s). In clinical practice, it is useful to embrace the perspective of the perceiver of tinnitus, and to include social and cultural circumstances as well as audiological/physical changes. Keywords Tinnitus · Inter-individual variability · Intra-individual variability · Psychotherapy · Sociocultural factors
Intraindividuelle Variabilität bei Tinnituspatienten. Aktuelle Gedanken und Perspektiven Zusammenfassung Die meisten Tinnitusstudien haben versucht, Gruppen von Tinnituspatienten zu vergleichen und somit interindividuelle Variabilität, d. h. Unterschiede zwischen den Patienten, zu vergleichen. Aus methodischen Gründen können interindividuelle Studien leider keine Variabilität in der Tinnituserfahrung, die seit Jahrzehnten als relevant im täglichen Umgang mit Tinnituspatienten bekannt ist, berücksichtigen. Das Konzept der intraindividuellen Variabilität (intra-IV) wurde in der Forschungsliteratur gefördert, um diese konkreten Aspekte der individuellen Tinnituswahrnehmung zu klären. In den bisherigen, nicht in der Hörforschung durchgeführten Studien wurde im Rahmen des Konzepts intra-IV die Einbeziehung der Umgebung (d. h. physische und soziale Interaktionen) als Faktor der individuellen Leistung vorgeschlagen. Das Konzept der intraindividuellen Variabilität sollte unserer Meinung gleichwertig zu der interindividuellen Variabilität für die Tinnitusforschung in Betracht gezogen werden.
care was taken not to detach an individual from his or her own context. We set out to achieve this by asking questions about participants’ backgrounds, for example, questions about childhood, fami-
In diesem Artikel werden 4 Perspektiven von Tinnituserfahrungen aus dem klinischen und dem Forschungsfeld beschrieben: i) HNOKonsultation; ii) kurzfristige Gruppenpsychotherapie; iii) psychodynamische Psychotherapie und iv) klinisch-psychologische Forschung. Fazit: 1) Intraindividuelle Variabilität unterstreicht die Wichtigkeit, Tinnitus in einer dynamischen Art und Weise zu definieren, im Gegensatz zu der aktuellen Definition von Tinnitus als die Wahrnehmung von Phantomgeräuschen. 2) In der klinischen Praxis ist es sinnvoll, die Perspektive des Tinnituspatienten selbst ebenso miteinzubeziehen wie soziale und kulturelle Bedingungen sowie audiologische und physikalische Veränderungen. Schlüsselwörter Tinnitus · Interindividuelle Variabilität · Intraindividuelle Variabilität · Psychotherapie · Soziokulturelle Faktoren
ly situation, working life, and sociocultural context. Questions about tinnitus were also asked, for example, how they reacted when they first understood that they had tinnitus, how they had dealt with the HNO 4 · 2015
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Leitthema symptoms of tinnitus, what type of support they felt that they had received etc. Through these questions, an inside perspective was gained in which each participant’s life situation and previous life circumstances were regarded in relation to reactions and feelings toward tinnitus. How an individual perceives tinnitus and deals with tinnitus can thus depend on current and past circumstances. There is thus intra-individual variability in the experience of tinnitus due to several interacting factors. When we started analyzing the material, five interacting factors were found to stand out. These factors were termed: 1. External factors 2. Internal factors 3. Previous experiences and sociocultural context 4. Personality 5. Strategies External factors were associated with environmental factors. Examples were external factors in the working environment. Some participants described their working environments as very noisy and therefore detrimental to their tinnitus. Internal factors were instead particularly related to participants’ subjective experiences. All participants mentioned that feeling stressed enhanced the symptoms of tinnitus: “When life is tough, tinnitus gets worse.” Previous experiences and sociocultural context also impacted on how tinnitus was experienced and dealt with. One participant was, for example, brought up in a working class environment where he had personal ideals of working hard, of taking responsibility, of helping others etc. It was also clear from this narrative that he had male relatives who had worked in the heavy industry field and several relatives had developed tinnitus as a result of a noisy working environment: “Most of my male relatives have tinnitus so it is no big deal.” Personality also shone through in the narratives. One person, for instance, described herself as very social, outgoing, and a bit impulsive. Before she was faced with tinnitus she was able to enjoy just popping in for a chat with friends on the spur of the moment. With tinnitus, she found it difficult to enjoy social activities because it was painful for her to be in environments where many people talk simultaneously and it was
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also difficult for her to follow a conversation because of tinnitus. She felt that tinnitus had robbed her of her personality. Strategies were another factor that influenced how tinnitus was perceived. Some participants displayed more problem-solving approaches to tinnitus than others did. One participant was very active and adopted various strategies such as relaxation techniques and he also described adapting the strategies to suit him. Several interacting factors thus shaped each person’s narrative and gave it a structure that revealed intraindividual variability.
Conclusion Intra-individual variability stresses the importance of defining tinnitus in a dynamic way, contrary to the current definition of tinnitus as the perception of sound(s) [6]. In clinical practice, it is useful to embrace the perspective of the perceiver of tinnitus, and to include social and cultural circumstances, as well as audiological/physical changes. While habituation to tinnitus is a process that sets in over time, the sole focus on variation between groups of subjects may have little to offer in describing a process that would lead to an individual progress [3]. The clinical research that has been presented here on intra-individual variability can contribute toward enlightening the complexity of tinnitus by including the perspective of the suffering patients.
Corresponding address R. Dauman Tinnitus Clinic, Department of ORL-HNS, University of Bordeaux and CHU of Bordeaux, CNRS-UMR 5287 Bordeaux France [email protected]
Compliance with ethical guidelines Conflict of interest. N. Dauman, S. Erlandsson, L. Lundlin, and R. Dauman state that there are no conflicts of interest. All studies on humans described in the present manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration of 1975 (in its current, revised form). Informed consent was obtained from all patients included in studies.
References 1. Bouscau-Faure F, Keller P, Dauman R (2003) Further validation of the Iowa tinnitus handicap questionnaire. Acta Otolaryngol 123:227–231 2. Crossley M (2000) Introducing narrative psychology. Self, trauma and the construct of meaning. Open University Press, Philadelphia 3. Dauman N, Erlandsson SI, Carlsson SG (2013) Habituation theories in current models of chronic tinnitus: evidence and criticism. In: Buskirk A (ed) Habituation: theories, characteristics and biological mechanisms. Nova Publisher, New York, pp 55–90 4. Dauman N, Erlandsson SI (2012) Learning from tinnitus patients’ narratives. A case study in the psychodynamic approach. Int J Qualitative Stud Health Well-being 7:19540. http://dx.doi. org/10.3402/qhw.v7i0.19540 5. Engelhardt J, Dauman R, Arné P et al (2014) Effect of chronic cortical stimulation on chronic severe tinnitus: a prospective randomized double-blind cross-over trial and long-term follow up. Brain Stimul 7:694–700 6. Erlandsson SI, Dauman N (2013) Categorisation of tinnitus in view of history and medical discourse. Int J Qualitative Stud Health Well-being 8:23530. http://dx.doi.org/10.3402/qhw.v8i0.23530 7. Garett DD, McDonald SWS, Craik FIM (2012) Intraindividual reaction time variability is malleable: feedback- and education-related reductions in variability with age. Front Human Neurosci 6:1–10 8. Holloway W, Jefferson T (2001) Doing qualitative research differently; free association, narrative and the interview method. SAGE, London 9. Hultsch DE, McDonald SWS, Hunter MA et al (2000) Intraindividual variability in cognitive performance in older adults: comparison of adults with mild dementia, adults with arthritis, and healthy adults. Neuropsychology 14:588–598 10. Kuk FK, Tyler RS, Russell D, Jordan H (1990) The psychometric properties of a tinnitus handicap questionnaire. Ear Hear 11:434–445 11. Pau HW, Warkentin M, Specht O et al (2011) Experiments on the mechanism of underwater hearing. Acta Otolaryngol 131:1279–1285 12. Polkinghorne DP (1988) Narrative knowing and the human sciences. SUNY Press, Albany 13. Ratliff F, Hartline HK, Lange D (1968) Variability of interspike intervals in optic nerve fibers of limulus: effect of light and dark adaptation. Proc Natl Acad Sci 60:464–469 14. Spense D (1982) Narrative truth and historical truth. Norton, New York 15. Stouffer JL, Tyler RS (1990) Characterization of tinnitus by tinnitus patients. J Speech Hear Disord 55:439–453 16. Yalom ID (1995) The theory and practice of group psychotherapy, 4th edn. Basic Books, New York 17. Zöger S, Erlandsson S, Svedlund J, Holgers K-M (2008) Benefits from group psychotherapy in the treatment of severe refractory tinnitus. Audiol Med 6(1):62–72
