Aug 1, 1994 - A cognitive behavioural tinnitus coping training (TCT) was developed and compared to yoga and a self-monitoring control condition. Forty-three.
Journul cd P.~yr’ho.romal;c Research. Vol. 39, No. 2, pp. 153-165, I995 Coovneht 0 1995 Elsevm Scmcc Ltd Prmted 1, &ear Britam. All rights rcscrved 0022 3999195 $9.50 + 00
Pergamon
0022-3999(94)0009W
THE MANAGEMENT OF CHRONIC TINNITUS-COMPARISON OF A COGNITIVE-BEHAVIOURAL GROUP TRAINING YOGA B. KRijNER-HERWIG*, A. FRENZEL*,
WITH
G. HEBING*, U. VAN RIJN-KALKMANN*, G. SCHILKOWSKY* and G. ESSERt (Received
I 1 August 1994)
Abstract-Two non-medical treatment strategies for chronic idiopathic tinnitus were evaluated in a randomized control group design. A cognitive behavioural tinnitus coping training (TCT) was developed and compared to yoga and a self-monitoring control condition. Forty-three chronic tinnitus patients, were assessed at baseline, directly after therapy, and at 3 months follow-up. For evaluation, differential psychoacoustic variables were registered, a tinnitus diary as well as the Tinnitus Questionnaire and different measures of general well-being were used. Statistical analyses showed effects favouring the TCT treatment in comparison to the control and yoga treatment. The TCT-treated patients reported more satisfaction with the training than the yoga group. Participants in the self-monitoring control group were treated either by TCT or yoga after a waiting period. The outcome in this group was even better than in the experimental groups while yoga again showed rather poor effects. Keywords:
Tinnitus,
Yoga, Management
training,
Controlled,
Group
design,
Coping.
INTRODUCTION
Tinnitus is a sensation of sound, mostly of a hissing or ringing quality, not stimulated by a simultaneous mechano-acoustical or electrical signal (International Ciba Foundation Symposium on Tinnitus, 1981). Epidemiological data suggests that 3545% of the adult population experiences tinnitus at least once in a while. Up to 1% of the population suffers from chronic tinnitus and is severely distressed by the symptom [l-4]. These patients report frequent states of depressed mood, feelings of hopelessness and helplessness, and complain of irritability and insomnia. They experience tinnitus as interfering with their daily lives and suffer from difficulties with cognitive processing and communication. Subjective loss of control seems to be a core variable in the syndrome [5]. In many, if not most, cases no definite etiology for the tinnitus can be discovered [6]. Its onset is often associated with sudden hearing loss. At this stage medical treatment can be helpful. Once tinnitus has become a persistent symptom, effective medical relief is no longer available [7]. Technical aid by exteroceptive stimulation
* Clinical Psychology, Heinrich-Heine-University, Duesseldorf, t Medical, Acoustics and Audiology, Heinrich-Heine-University,
1.53
Germany. Duesseldorf,
Germany
154
(tinnitus
B. KRONER-HERWIG
masking)
rt ~1.
is useful only for a very small proportion
of tinnitus
sufferers
[S,
91. The lack of effective medical help has motivated the search for alternative treatment strategies in chronic tinnitus. Furthermore, the observation that tinnitus intensity does not determine the extent of individual distress but that cognitive appraisal and attentional processes are main factors [lo, 111 and that stress seems to play an important role in complex tinnitus, encouraged the application of psychologically based interventions. Initially studies on progressive relaxation [12] and thermal or EMG biofeedback [ 133151 seemed to promise a high efficacy in the amelioration of tinnitus symptoms. But further research with randomized group designs did not support these findings [16, 171 and new concepts of treatment were developed within a cognitive-behavioural framework. Scott et al. [18] were the first to evaluate an outpatient treatment of tinnitus including relaxation, attention diversion techniques and desensitization in a controlled group design at the Swedish University in Uppsala. This program was extended and refined by Lindberg et al. [19-211, whose well-controlled studies demonstrated that subjective tinnitus loudness and the discomfort of tinnitus could be markedly decreased by treatment. An inpatient cognitiveebehavioural treatment program was evaluated by Goebel et al. [22] with encouraging positive results. This study attempts to differentiate the efficacy of a non-specific (yoga) vs. a specific problem-targeted program (tinnitus coping training) and to examine of the pattern of efficacy by using a wide range of outcome variables (psychoacoustic/diary/ psychometric/global self report). We designed a cognitiveebehavioural outpatient treatment program for groups, since we consider this delivery of treatment to be potentially time-efficient and cost-effective. The program included interventions shown to be beneficial in the Swedish study but at the same time put a special emphasis on cognitive interventions. Encouraged by the positive clinical experience of one of the authors, yoga was included as a second treatment format. It was used as a non-specific strategy improving the ability to relax and build up a more positive body-mind relationship.
METHOD Tinnitus patients were recruited through a newspaper announcement which informed potential subjects of the opportunity to take part in a research study on non-medical treatment approaches to chronic tinnitus. Patients were included in the study using the following selection criteria: duration of tinnitus ~6 months; impairment due to tinnitus >4 on a IO-point rating scale; hearing ability good enough to allow communication in a group setting; no treatable organic pathology; no psychophathologic disorder; no current psychotherapy; medical examination completed; willingness to participate in the assessment and in at least 8 of 10 treatment sessions. If there were doubts regarding medical aspects of the disorder the patients were referred to the Department of Audiology for further examination. After this selection procedure 52 of the 120 patients taking part in the first screening session remained in the study. Patients were randomly assigned to four groups. Two groups received ‘tinnitus coping training’ (TCTI, TCT2), to control for the therapist effect. One group received yoga training and the final group was a waiting-control condition (WLC) of double the size of the other groups (Table I). After completion of the experimental assessment subjects of the control group were randomly assigned to either TCT or yoga, so as to enlarge the sample of treated patients.
Each training
group
(TCTI,
TCT2,
yoga) participated
in ten 2 hr sessions.
The TCT was performed
The management
of chronic
Table I.-Patient
155
tinnitus
characteristics
Variables
TCTl
TCT2
Yoga
WLC
No. of patients age (x, s)
Vl=l 44.7 (7.8) 43% 29.3 (22.7) 1.7 (2.1) 6.7 (1.8) n=3
n=8 48.4 (10.3) 50% 46.1 (39.5) 6.8 (2.1) 5.9 (2.3) n=2
n=9 47.6 (14.6) 33% 60.2 (69.1) 6.3 (2.0) 5.8 (1.9) n=l
n= 19 48.4 (10.7) 37”/;1 63.7 (63.9) 7.3 (2.0) 7.2 (1.8) n=3
Gender female Duration of tinnitus (months) Impairment by tinnitus (O-10) Subjective loudness of tinnitus (O-10) Drop out
by two different female graduate students of clinical psychology. In every group the first session focused on patient education (morphological and functional characteristics of the hearing system; illness model of tinnitus as disorganized spontaneous activity in the hearing system; importance of stress I ways of controlling tinnitus; coping not ‘healing’ as the goal of training). In the cognitive-behavioural training groups progressive relaxation was one main element in sessions 2-10 [23]. Sessions 336 focused on analysing stressful events and their effect on tinnitus. At the same time tinnitus was conceptualized as a main stressor. From sessions 5510 directing attention to and from tinnitus was demonstrated as a means of coping with tinnitus. Sessions 5510 focused on cognition, i.e. trying to change dysfunctional irrational self-statements, catastrophizing thoughts and beliefs relating to tinnitus. In session 10 the maintenance of acquired coping skills after training was a topic of discussion. Yoga (Hathayoga) was presented by an experienced yoga trainer (a female grddudte student of clinical psychology) and comprised special yogic exercises to foster relaxation and adequate body perception. Furthermore the attainment of a relaxed contemplative state of consciousness was induced by breathing exercises, special body positions (asanas) and other exercises.
All participants of the study underwent a series of audiometric test procedures. Tinnitus sensation level (TSL) was determined by asking the patient to match the level of intensity of a sound, most similar in pitch to the tinnitus sensation, to the loudness of tinnitus. The sound level (dB) was related to the hearing thresholds in the specific frequency spectrum. Tinnitus masking level (TML) was determined for both ears, using a procedure proposed by Feldmann [24]. A pitch spectrum between 125 Hz and 10,000 Hz was presented to each ear. One single parameter of TML was used for each individual by computing the median of all recorded masking levels. After a 1-wk trial of the tinnitus diary a self-monitoring period of 2 wk was introduced for each patient in every treatment condition. Three times a day the patient assessed and recorded the following main diary variables ‘subjective loudness’ of tinnitus, ‘tinnitus discomfort’, ‘sleep disturbance’, ‘interference with activity’, ‘control of tinnitus’ and ‘hours per day of tinnitus ignored’. Numeric rating scales (O-10) were used. Medication for tinnitus was assessed also, but was not evaluated quantitatively because very few patients adhered to it. The Tinnitus Questionnaire (TQ) developed by Hallam et ul. [25] was used in its German version [26] containing five factors (‘psychological impairment’, ‘penetrating quality’, ‘hearing problems’, ‘sleeping problems’ and somatic complaints’; 5-point rating scale). As general measures of well-being the ‘Befindlichkeits-Skala’ assessing the actual mood, the ‘Beschwerden-Liste’ assessing various symptoms and the ‘Depressivitats Skala’ [27729] were used. The complete assessment procedure was performed at baseline (pre-therapy), after the end of therapy (post-therapy) and at a 3-month follow-up (except for audiometric procedures). At the post-therapy period and follow-up a general outcome questionnaire on benefits and problems of the training was answered by the participants. Evaluation of the post therapy effects of the control group followed the same line.
156
et nl.
B. KRONER-HERWIG Table II.-
Tinnitus
sensation and tinnitus after therapy
masking
TSL J? TCTl
pre post pre post
TCT2 YOgd
pre
post WLC
*p I
pre post 0.05 **p
8.3 4.6 14.2 2.9 9.8 6.7 7.1 3.9
level before and
TML s (4.1) (2.6) (12.7) (2.8) (5.9) (4.2) (5.9) (3.2)
P
*
.ic 45.7 25.4 58.9 57.1 56. I 54.2 60.7 51.5
s (18.2) (8.9) (27.9) (20.8) (25.6) (30.6) (21.8) (22.5)
P
**
2 0.01; results of paired t-tests (2-tailed).
RESULTS
Patient
characteristics
Mean duration of tinnitus in the participants of the study was 4.5 yr with a range of 6 months to 20 yr (Table I). Mean tinnitus impairment on a IO-point rating-scale was 7.21 (range 410). Tinnitus was continuous in most cases (86%) and located in both ears in 38% of cases. More than half of the participants had hearing deficits (56%). Mean age was 48 yr ranging from 24465 yr. Sixty point five per cent of the patients were men. Nine patients dropped out of the study after having been assigned to a treatment condition. Psychoacoustic
variables
TCTl was the only group which showed a significantly decreased level of tinnitus masking level after therapy, however, the tinnitus sensation level was only slightly reduced (Table II). Suprisingly the only significant decrease in tinnitus sensation level was seen in the waiting list-control group, the observable reduction in all other groups was not corroborated statistically. A wide range of interindividual variation in individual parameters was apparent in every set of audiometric variables. Analysis using MANOVA (4 x 2 analysis of variance with repeated measures) showed a nearly significant group by time effect in TML (F= 2.57; df = 3,37; ~~0.69). This effect reflected the greater reduction in the TCTl group in comparison to all other groups. Diary variables In two of the six diary variables the TCTl group showed a significant improvement from baseline to the period directly after therapy (Table III). Discomfort due to tinnitus was significantly reduced (Fig 1) and control over tinnitus was distinctly increased (Fig 2). The TCT2 group also showed a significant gain in control over tinnitus. There was no positive change of these variables for the yoga or the control group. Analysis using MANOVA showed a highly significant interaction effect in the ‘control’ variable which indicated definite gains in the TCT groups compared to the yoga and the control group (group x time, F = 9.48; df = 3,37; pdf8Cc =3P fL6.L =S) %I!u!w~ 30 pua ayl IIT snlruug icq paqmls!p ssa[ ycrtur ][a3 sdnoJB 13~ ay) dn0.G’ ??!SoAput? dnoA3 [O_I$UOCJ lsg %I~TZMay$01pa_wduroa .au![asaq 01 pa.reduroD am% ayl ssa[ .IO alow aq 01 huanbaq SJ! puz snlruug J!ayl30 ssaupno[ ay) palw sluaged [[v ‘(10’0 5 d : [z‘z = 3p fp9.8 = 9) [??.taua8 u! ssaw ql!~ ados 01 pue (so’0 5 d : [z ‘z = 3p :LL’E = d) sn$!uug .yy~ aDuangy 01 ,Q![!q’? .t!ayl30 sluagvd palea ~A?olcayl ueq~ pawyuo3 alow aJaM sdnoS paleall 13~ yloa ‘( [oo’o > d : [z‘z = 3p is [ ‘o[ = +J IDaga dno.Ci) [wgda3s alow yDnur aJaM sluaped paleall e2ioL ayl sealaym sn)!uup ~I!Ma[doad %!d[ay 30 a[qvdw SSM Bug?.~~ayllrq paAa![aq sluedpgled 13~ .( [ 00’0 5 d : IZ‘Z = 3p : 1E’E[ = d) dnoS eS?oA ayl p!p ueyl palago ~U!U~RI) ayl Y)!M uop3~3syzs aJotu passaldxa ICpea[3 (8[‘[ = s ‘EE’P = e80LXfE8.0 = s ‘z[‘z = zx f~s.0 = s ‘LS’Z = 1~ :a[ws 2h1y1 lu!od-xfs) sdno.@ 13~ yloq luauIleaJl30 pua ayl 1~
8u~uy.g Jo uoynpna
anpa&ns
‘(I\ a[qEl) uorssaldap u! asr?alDap I? parnoys s)uagzd &oL put? dnol8 11~31 ay) Aq pauyuy_u SBMpootu 30 $uawaaoJdwy ayl L[uo ‘dn-Mo[[o3 1~ .sdno.G luaurleag ayl palnoAe3 y3q~ (soyj 5 d fi--‘[ =3p :Es’P =J) pun03 sv~ uopcwa~u~
#Comparison
symptoms
mood
depression
Variables well-being
to baseline
**
*
TCT 1 p#
70.0 (19.5) 73.4 (15.7) 68.9 (18.1)
post 74.9 (27.5) 54.6 (26.8) 73.4 (15.2)
fu
*
p#
*p I 0.05 **p I 0.01;results of paired
82.9 (15.3) 73.1 (17.4) 78.4 (17.1)
pre
pre
t-tests (2-tailed).
62.7 (29.0) 25.8 (27.8) 56.3 (25.3)
fu
p 78.3 (19.1) 65.2 (29.8) 65.2 (26.3)
pre
before and after therapy
TCT 2 p
63.8 (27.5) 58.8 (25.8) 63.8 (26.0)
post
of well-being
66.0 (31.7) 61.1 (27.9) 69.3 (18.0)
Table V--Parameters
72.2 (26.7) 53.0 (37.0) 59.4 (25.6)
post
Yoga p
66.8 (29.8) 48.9 (37.3) 58.5 (25.0)
fu
*
p
76.4 (22.7) 77.2 (21.4) 78.4 (17.3)
pre
76.4 (22.7) 78.4 (17.3) 77.2 (21.4)
WLC post
P
g < 5 2 R
E k
FJ g
yz
The management Table VI.PResult
of the Control
163
tinnitus
Group Treated by TCT or Yoga before training post period) and after training
Variables
WLCPTCT
pre
Diary subjective
loudness
4.6
(1.8) discomfort
3.9 (1.7) 2.3 (2.7) 2.2 (2.0) 1.6
sleep disturbance interference control
(1.8) 4.1 (3.9)
ignoring Tinnitus Questionnaire psych. impairment penetrating
quality
hearing problems sleeping problems somatic
of chronic
complaints
Well-being depression mood symptoms
# Comparison
to pre-therapy;
post 4.0 (1.7) 2.6 (1.6) 1.6 (1.8) 1.3 (1.6) 5.1 (2.8) 6.7 (2.2)
1.8 (0.7) 2.7 (1.0) 1.9 (0.9) 1.3 (1.2) 1.4 (1.1)
1.1 (0.5) 1.8 (1.0) 1.6
83.5 (16.3) 81.7 (16.2) 83.4 (14.2)
71.6 (17.1) 67.1 (23.8) 50.0 (28.6)
results of paired
(1.0) 0.8 (1.0) 1.1 (1.2)
(at the experimental
WLC-YOgd
P# ** **
* * ** **
*
*
**
w 5.7 (1.8) 2.8 (1.3) 1.0 (1.6) 1.8 (2.2) 0.4 (0.7) 3.6 (3.8)
post 5.1 (1.5) 2.5 (1.3) 1.5 (1.8) 2.1
P *
(1.9) 1.2 (1.3) 4.6 (4.2)
1.0 (0.7) 2.7 (0.9) I.0 (0.7) 1.0 (1.4) 1.2 (1.3)
1.7 (1.1) 2.6
68.6 (32.5) 67.9 (25.9) 68.8 (25.2)
53.4 (39.6) 65.2 (27.8) 76.6 (18.3)
(0.8) 1.0 (0.9) I.1 (1.3) 0.8 (1.3)
t-tests (2.tailed).
and also more effective than yoga training. TCT clearly enhanced the patients’ conviction that they can have control over tinnitus, whereas this effect is not seen in the patients treated by yoga. Interestingly, the enhancement of a self-efficacy belief was the variable most closely correlated to satisfaction with treatment as measured by the ‘end-of-therapy questionnaire’ (1. 0.45, p I 0.02). No other interaction effect demonstrated a distinct efficacy of TCT or yoga compared to the waiting list control. Psychological impairment, as measured by the TQ, was the only variable which showed a decrease in all treatment groups. This effect was most distinct in the TCT groups at post-therapy assessment, but faded somewhat at follow-up. The more perceptual or sensory parameters of evaluation like tinnitus loudness, frequency of tinnitus and hearing problems were not reliably modified by the treatments. The reductions observed in the psychoacoustic variables probably rellect a general familiarity with the procedure rather than therapy effects. Furthermore it should be noted that TSL is not a reliable parameter. Correlation between both assessments vary from r = 0.30 to - 0.46(!) in the four groups. In comparison TML is a more reliable parameter (0.88 I ~20.68).
164
B. KRONER-HERWIG
et al.
Changes due to tinnitus coping training, were mainly due to improvements in selfefficacy and a reduction in worry over tinnitus. TCT, more than yoga, gave the patient a feeling of control over the symptom. Tinnitus was rated as less emotionally disturbing, annoying and interfering with life, and could even be ignored for some time. Although, in general, both TCT groups tended to behave in a similar way the differences found between them underline the fact that additional factors other than the treatment protocol influenced outcome. The efficacy of the TC programme and its superiority to yoga were replicated, when analysing the results of the treated control group patients. The effects of the TCT treated control group were more pronounced than in the experimental TCT groups. It is possible that this reflects an increase in competence of the trainer in this second treatment period, especially as the chronicity and severity of tinnitus was relatively high in this group. The tinnitus patients treated by TCT were generally more satisfied with the treatment offered to them than the yoga-treated participants, who did not consider the training to be helpful. Cultural stereotypes might have had an important influence on why yoga was more or less rejected by the patients. Yoga was developed on the basis of eastern philosophy and was very unfamiliar to some patients. If patients had been allowed to select the treatment format more positive results might have been achieved using yoga training, on the other hand it may be, that yogic exercises are not specifically suited for coping with the problem of tinnitus. The overall degree of efficacy in the experimental TCT groups can be described as moderate. Reasons for this may lie in the relative inexperience of the therapists, all of whom were training tinnitus patients as a group for the first time. Furthermore there is a deep rooted medical model of illness in many tinnitus patients (requiring the result of treatment to be a total cure and expecting help from experts, medicine or technical instruments but not from themselves) an attitude which prevents them from benifiting from the treatment. Therefore, patient education should be directed towards strengthening the ‘self-relatedness’ of the patients, what Orlinsky and Howard [30] call the ability of patients to absorb the impact of therapeutic interventions which seems to be one of the most important factors in therapy. The management approach promises to be as worthwhile in tinnitus treatment as it has already proven to be in other fields of chronic illness, for example in chronic pain. In the absence of a medical cure for chronic tinnitus, training patients to actively cope with their symptoms is definitely preferabe to procedures designed to ‘mask’ tinnitus [31]. But a closer tailoring of the proposed, standardized group programme to the needs of chronic tinnitus sufferers seems to be necessary.
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