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Managing Chronic
Tinnitus As Phantom
Auditory Pain |
Robert L. Folmer, Ph. D., Assistant Professor of
Otolaryngology, Oregon Health Sciences University,
Portland, OR
Robert L. Folmer Ph.D.
Tinnitus Clinic, Oregon Hearing Research Center,
Department of Otolaryngology, Oregon Health
Sciences University, Portland
Correspondence to:
Robert L. Folmer, Ph.D.
Oregon Hearing Research Center
Mail Code NRC04
3181 SW Sam Jackson Park Road
Portland, OR 97201-3098
email:
folmerr@ohsu.edu
Web address:
http://www.ohsu.edu/ohrc/tinnitusclinic
ABSTRACT:
Patients experiencing severe
chronic tinnitus have many characteristics in
common with chronic pain patients. This study
explored these similarities in order to formulate
treatment strategies that are likely to be
effective for patients experiencing phantom
auditory pain. Answers to questionnaires filled
out by 160 patients who visited our Tinnitus
Clinic were analyzed. Patients rated the severity
and loudness of their tinnitus; completed the
State-Trait Anxiety Inventory (STAI) and an
abbreviated version of the Beck Depression
Inventory (aBDI). Patients received counseling,
audiometric testing, and matched the loudness of
their tinnitus to sounds played through
headphones. Tinnitus severity was highly
correlated with patients degree of sleep
disturbance, STAI and aBDI scores. The reported
(on a 1-to-10 scale) -- but not the matched --
loudness of tinnitus was correlated with tinnitus
severity, sleep disturbance, STAI, and aBDI
scores. Treatment recommendations are discussed in
reference to these results.
INTRODUCTION:
Tinnitus is the sensation of
sound without external stimulation. Jastreboff 1
referred to tinnitus as phantom auditory
perception. Outside of the auditory system, the
most infamous example of phantom perception is
reported by some patients who have lost a finger,
hand, arm, toe, foot or leg. These patients
continue to perceive the presence of -- and
sometimes pain from -- appendages that have been
amputated. Missing appendages that continue to
generate sensations are known as phantom limbs;
painful sensations attributed to them are referred
to as phantom limb pains.
Similarities between the
perception of chronic tinnitus and the perception
of chronic pain were listed by Tonndorf2: both
tinnitus and pain are subjective sensations; both
are continuous events that may change in quality
and/or character over time; both have the
potential to be masked/reduced by appropriate
sensory stimulation or medications; both the
auditory and somatosensory systems possess a
well-developed network of efferent fibers that
appear to exercise some control over afferent
activity; de-afferentation (that is, a disruption
in the balance between afferent and efferent
activity) might explain both perceptions; both
perceptions are under the control of the central
nervous system; efforts to treat both sensations
peripherally have met with limited success.
To this list of similarities
Moller3 added: chronic pain and some forms of
tinnitus are characterized by hypersensitivity to
sensory stimulation; the anatomic locations of the
neural structure(s) generating the sensations of
chronic pain or tinnitus are different from the
locations of the structures to which these
symptoms are referred (the ears for tinnitus or
the peripheral location of injury for pain); the
strong psychological component that often
accompanies chronic pain or tinnitus supports the
hypothesis that brain areas (limbic/sympathetic)
other than those responsible for sensory
perception are involved; pain and tinnitus are
both heterogenous, multimodal disorders that can
have different causes and pathophysiologies;
consequently, multimodal approaches should be used
to treat these disorders.
Muhlnickel et al4 used
magnetoencephalography to compare the organization
of auditory cortex in 10 chronic tinnitus patients
with that of 15 non-tinnitus control subjects.
Results of their study demonstrated that the
organization of auditory cortex in tinnitus
patients was significantly different from the
control subjects, especially in brain areas
corresponding to perceived tinnitus frequencies.
Muhlnickel et al4 concluded that similarities
between these data and the previous demonstrations
that phantom limb pain is highly correlated with
cortical reorganization suggest that tinnitus may
be an auditory phantom phenomenon.
Jeanmonod et al5 hypothesized that
positive neurological symptoms (including
neurogenic pain and tinnitus) might be
attributable to abnormal neuronal activity in the
thalamus (specifically, low threshold calcium
spike bursts that are related to thalamic cell
hyperpolarization). A subsequent
magnetoencephalographic study by Llinas et al6
demonstrated that neurogenic pain and tinnitus are
both characterized by thalamocortical dysrhythmia
resulting from inhibitory asymmetry between high-
and low-frequency thalamocortical modules at the
cortical level. These findings support the
assertions of Jastreboff1, Tonndorf2, Moller3 and
others who contend that abnormal asymmetries of
neuronal activity are responsible for tinnitus
generation.
It is clear that the perception of
chronic tinnitus has many physiological
characteristics in common with the perception of
chronic pain. In his behavioral nosology, Briner7
used the phrase phantom auditory pain to describe
severe chronic tinnitus. The present study will
explore similarities in psychological
characteristics, reactions, and coincidental
disturbances exhibited by patients who experience
chronic tinnitus or pain. The goal is to
contribute to the development of treatment
strategies that are likely to be effective for
patients experiencing phantom auditory pain.
METHODS:
Detailed questionnaires were
mailed to patients prior to their initial
appointment at the Oregon Health Sciences
University Tinnitus Clinic. These questionnaires
requested information about patients medical,
hearing, and tinnitus histories. Appendix 1
contains twelve questions that constitute the
Tinnitus Severity Index8 which is an efficient
indicator of the negative impacts of tinnitus upon
patients. The State-Trait Anxiety Inventory
(STAI)9 and an abbreviated version of the Beck
Depression Inventory (aBDI)10 were also included.
Data relating to patient
demographics, audiometric thresholds, matched and
reported (according to the 1-to-10 scale in
Appendix 1) tinnitus loudness, tinnitus severity,
sleep difficulties, aBDI and STAI scores were
analyzed.
RESULTS:
Data from the last 160
patients (112 males, 48 females; mean age 50.912.8
years; age range 17-87 years) who visited our
clinic were analyzed. Table 1 contains the grand
averaged pure tone air conduction thresholds for
these patients. This pattern of high-frequency
sensorineural hearing loss is typical for our
patient population.
Table 2 contains mean STAI, aBDI,
tinnitus severity scores, matched and reported
tinnitus loudness values for three groups of
patients based on their response to question 12:
Does your tinnitus interfere with sleep? Note that
mean values for all of these measures tend to
increase with greater sleep interference.
Statistically significant differences exist
between the No and Often sleep interference groups
on all measures except the matched loudness of
tinnitus. Statistically significant differences
exist between the Sometimes and Often sleep
interference groups on all measures except the
matched and reported loudness of tinnitus.
Statistically significant differences exist
between the No and Sometimes sleep interference
groups on two measures: severity and reported
loudness of tinnitus.
Table 3 contains mean STAI, aBDI,
tinnitus severity scores, matched and reported
tinnitus loudness values for all of the patients
in the study. Because there were no significant
differences between male and female patients in
any of these measures, correlation analyses were
performed on mean values derived from the group as
a whole. Fifty patients (31%; 30 males, 20
females) reported that they had current
depression. Fifty nine patients (37%; 35 males, 24
females) reported a history of depression. Scores
on the aBDI ranged from 0 to 28 (maximum possible
score = 39). Thirty four patients (21%) scored 8
or higher on the aBDI which, according to Dobie &
Sullivan10, can indicate that a patient is
experiencing major depression.
Table 4 contains Pearson
Correlation coefficients and 2-tailed p values
that resulted from statistical analyses of these
measures. Note that tinnitus severity is highly
correlated with STAI and aBDI scores. The reported
-- but not the matched -- loudness of tinnitus is
correlated with tinnitus severity, STAI, and aBDI.
Both anxiety indices were highly correlated with
each other and also with the aBDI.
DISCUSSION:
Results from this and other
studies demonstrated that the severity of chronic
tinnitus is often correlated with insomnia11,
anxiety12, and depression.13 As illustrated in
Figure 1, these symptoms can form a vicious circle
and exacerbate each other. Insomnia, anxiety, and
depression are also common co-symptoms for
patients with chronic pain. In fact, the word pain
can be substituted for the word tinnitus in Figure
1 and the relationships among these symptoms will
remain the same.
What other characteristics do pain
patients have in common with tinnitus patients?
Numerous studies contributed to the following
list: hypochondriasis; obsessive-compulsive
tendencies; high degrees of self-focus/attention;
perceived lack of control over symptoms/life
events; catastrophic thinking; focusing/dwelling
on symptoms; maladaptive coping strategies;
reluctance to admit to problems other than
immediate physical symptoms; the patients
perceived severity of their condition is not
necessarily related to objective measures of
stimulus intensity; severity of symptoms can be
related to patients perceptions of attitudes or
reactions of others to their condition. Of course,
every patient does not necessarily possess any or
all of these characteristics. However, these
traits are more likely to occur in pain or
tinnitus patients who perceive their symptoms to
be severe or debilitating.
Did the onset of chronic tinnitus
cause these behaviors or co-symptoms to occur?
Dobie & Sullivan10 reported that approximately 50%
of their tinnitus patients with depression had at
least one bout of major depression before the
onset of their tinnitus. Rizzardo et al14 reported
that 50% of their patients exhibited psychological
symptoms before the onset of tinnitus; 71% of
these patients experienced greater than normal
levels of depression, anxiety, hypochondriasis,
and/or neuroticism after tinnitus began.
Rizzardo et al14 stated that there
appears to be a link between psychological
distress and tinnitus in a potential
somatopsychological and psychosomatic vicious
circle (a psychological predisposition to react
emotionally to events, tinnitus as a source of
distress that reinforces the symptom, accentuating
hypochondriac fears). Dobie & Sullivan10 agree
that some people are more predisposed to
depression than others and that tinnitus is one of
many internal and external triggers that can
precipitate major depression in susceptible
individuals. Perhaps the most logical conclusion
was stated by Halford & Anderson12: It is
considered that the causal relationship between
these psychological variables and tinnitus
severity is likely to be bi-directional.
How can this information be used
to help patients with severe chronic tinnitus?
Because tinnitus patients share many similarities
with chronic pain patients, otolaryngology
clinicians can use some of the same techniques and
strategies in tinnitus treatment that are employed
in pain management. These include the following15:
1. Treatment of depression using
medications and/or psychotherapy. Sullivan et al16
demonstrated that successful treatment of
depression can reduce the severity of tinnitus for
patients experiencing both maladies. Some
antidepressant medications will also improve sleep
patterns and reduce anxiety. Identification of
tinnitus patients who are also experiencing
depression can be accomplished by using the
complete Beck Depression Inventory17 or other
appropriate instruments (such as the aBDI10).
2. Treatment of insomnia using
medications, relaxation therapy, and/or acoustic
therapy (this includes pleasant sounds generated
in the bedroom by tabletop devices, tapes, CDs,
pillow speakers, fans, or small fountains).
3. Treatment of anxiety using
medications, relaxation therapy, psychotherapy,
biofeedback, hypnosis, massage, or any other
appropriate stress management techniques.
4. Any neuroses, psychoses, or
other maladaptive behaviors need to be assessed
and addressed during a series of
psychotherapy/counseling sessions. Many experts
agree with House18 who wrote that most tinnitus
patients can often be helped by psychological
intervention. If the physician, nurse, or
audiologist does not feel that they have the time
or training to provide the counseling personally,
the clinician should refer the patient to an
appropriate mental health professional.
Acoustic therapy is one way to
give patients some control over -- and relief from
-- their tinnitus. This can include the devices
mentioned above as well as in-the-ear sound
generators, hearing aids, or combination
instruments (hearing aids + sound generators).
Because patients with severe
tinnitus often have negative affectivity
(characterized by tendencies to be distressed,
worried, anxious, and self-critical), their
counseling should be as positive and productive as
possible. Jakes et al19 admonished clinicians:
instead of advising patients that they must learn
to live with it with no advice as to how this is
to be achieved, one could rather advise them that
distress about tinnitus is not determined by
having tinnitus, and that an intrusive,
subjectively loud tinnitus will not necessarily
produce a strong effect on the patient's social,
domestic, or economic functioning. After
appropriate tests have ruled out acoustic neuroma
or other retrocochlear etiologies for a patient's
tinnitus, clinicians should reassure the patient
that tinnitus is usually related to hearing loss20
and that it is a harmless perception of sound
generated by the auditory system. Tinnitus will
not necessarily become worse with time and it does
not portend additional hearing loss nor the
manifestation or exacerbation of any other medical
condition.
Because each tinnitus patient has
a unique medical, psychological and social
history, therapeutic interventions should be
individualized. In fact, the most successful
treatment programs employ multimodal strategies
that are designed to address the specific needs of
each patient. Hawthorne et al21 concluded that
psychiatric intervention significantly reduced the
emotional distress in a population of tinnitus
patients. This was achieved by not only dealing
with the somatic disease but also by psychiatric
management of the coincidental mental distress.
This was very time-consuming. Many of the patients
had complex difficulties; although they all had
tinnitus and most had mood disturbance, no history
was typical. The problems were protean and the
psychotherapeutic interventions had to be tailored
for each person.
How effective are individualized,
multimodal treatment programs at reducing the
severity of chronic tinnitus? We conducted a
long-term follow-up study of 174 patients (130
males, 44 females; mean age 55.9 years) who were
evaluated and treated in our clinic between
1994-1997. 22 One to four years after their
initial clinic appointment (mean = 2.3 years),
these patients reported no significant change in
self-rated loudness of tinnitus. However, there
was statistically significant improvement in nine
of the twelve measures of tinnitus severity
(including feeling irritable or nervous; feeling
tired or stressed; difficulty relaxing; difficulty
concentrating; interference with their required
activities; interference with their overall
enjoyment of life; interference with sleep; the
amount of effort to ignore tinnitus; and the
amount of discomfort usually experienced when
tinnitus is present) for the entire patient
population. A subset of 40 patients who purchased
and used in-the-ear devices (hearing aids,
maskers, or combination instruments) reported
significant improvement in all twelve measures of
tinnitus severity.
If a clinician has assessed and
treated every reasonable medical cause for a
patient's tinnitus, and the patient reports little
improvement in tinnitus severity, the clinician
should do one of two things: 1) spend the time
necessary to effectively treat the patient
according to procedures described here and
elsewhere23; or 2) refer the patient to a
comprehensive treatment center with experienced
personnel who are willing and able to spend a
substantial amount of time with each patient. For
a certain number of patients with phantom auditory
pain, only a specialized treatment program of this
type can help them to improve their condition.
Telling patients that since nothing can be done
for tinnitus they just have to learn to live with
it is both erroneous and counterproductive.
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