Tinnitus Retraining Therapy

I have taken note of what you written to me @Bartoli and previously said, I have no wish to engage in debates such as yours as they often lead to arguments because what one says often doesn't sit will with other peoples opinions and beliefs. I am not here for that. All I will say tinnitus can be an extremely complex condition and when hyperacusis present more so. I have had my fair share of difficulty with it taking 4 years to habituate for the 2nd time.

I do have my opinions on the post you wrote but prefer to keep them to myself.

I wish you well.
Michael

 

Treatment fidelity in the Tinnitus Retraining Therapy Trial

Background
Treatment fidelity, defined as ensuring that the recipient receives the intended intervention, is a critical component for accurate estimation of treatment efficacy. Ensuring fidelity and protocol adherence in behavioral trials requires careful planning during the design phase and implementation during the trial. The Tinnitus Retraining Therapy Trial (TRTT) randomized individuals with severe tinnitus to tinnitus retraining therapy (TRT, comprised of tinnitus-specific educational counseling (TC) and sound therapy (ST) using conventional sound generators (SGs)); Partial TRT (TC and placebo SGs); or standard of care (SOC), using a patient-centered care approach. Study audiologists administered both types of counseling in the TRTT, creating a challenge for managing protocol adherence.

Methods
We developed methods to enhance treatment fidelity including training, competency assessment, scripts, visual aids, and fidelity monitoring. Protocol monitors identified critical topics and content to be addressed for each type of counseling session, prepared corresponding scripts, and developed training aids and treatment-specific checklists covering those topics. Study audiologists’ competency assessment required submission and review by the protocol monitors of an audiotape of one TC and one SOC counseling session. Treatment-specific aids included scripts, a 3-D model of the ear, handouts, and for TC, an illustrated flip-chart with talking points that followed the scripted content. During the trial, audiologists completed treatment-specific checklists during each counseling session, indicating topics covered/discussed and submitted audiotapes of counseling sessions. Protocol monitors reviewed audiotapes using corresponding treatment-specific checklists. Results for individual checklist items were tabulated and proportions calculated.

Results
Twenty-five audiologists were certified for TC and/or SOC counseling and 24 completed at least one counseling session. Adherence to each of 33 critical items on the TC checklist as assessed by the protocol monitor ranged from 70 to 100% across 37 counseling sessions (median 97%), with no difference between adherence for TRT (median, 97%) and partial TRT (median, 100%). Adherence to each of 44 critical items on the SOC checklist across 30 SOC counseling sessions ranged from 42 to 100% (median, 87.5%).

Conclusion
The TRTT used multiple methods to address treatment fidelity. The close adherence to each treatment type was critical for evaluating the efficacy of the study interventions in this randomized trial.

Full article: https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-020-04530-9

 

Bimodal Therapy for Chronic Subjective Tinnitus: A Randomized Controlled Trial of EMDR and TRT Versus CBT and TRT

Introduction: To date, guidelines recommend the use of a stepped care approach to treat tinnitus. The current clinical management of tinnitus frequently consists of audiologic interventions and tinnitus retraining therapy (TRT) or cognitive behavioral therapy (CBT). Due to the high heterogeneity of the tinnitus population and comorbidity of tinnitus with insomnia, anxiety, and depression, these interventions may not be sufficient for every patient. The current study aims to determine whether a bimodal therapy for chronic, subjective tinnitus consisting of the combination of TRT and eye movement desensitization reprocessing (EMDR) results in a clinically significant different efficacy in comparison with the prevailing bimodal TRT and CBT therapy.

Methods: Patients were randomized in two treatment groups. The experimental group received the bimodal therapy TRT/EMDR and the active control group received the bimodal therapy TRT/CBT. Evaluations took place at baseline (T0), at the end of the treatment (T1), and 3 months after therapy (T2). The tinnitus functional index (TFI) was used as primary outcome measurement. Secondary outcome measurements were the visual analog scale of tinnitus loudness (VASLoudness), tinnitus questionnaire (TQ), hospital anxiety and depression scale (HADS), hyperacusis questionnaire (HQ), global perceived effect (GPE), and psychoacoustic measurements.

Findings: The TFI showed clinically significant improvement in both bimodal therapies (mean decrease 15.1 in TRT/CBT; p < 0.001 vs. 16.2 in TRT/EMDR; p < 0.001). The total score on the TQ, HADS, HQ, and VASLoudness all demonstrated significant decrease after treatment and follow-up (p < 0.001) in the experimental and the active control group. GPE-measurements revealed that more than 80% (i.e., 84% in TRT/CBT vs. 80% in TRT/EMDR) of the patients experienced substantial improvement of tinnitus at follow up. Treatment outcome remained stable after 3 month follow-up and no adverse events were observed.

Conclusion: Both psychotherapeutic protocols result in a clinically significant improvement for patients with chronic subjective tinnitus. No significant different efficacy was found for the TRT/EMDR treatment compared to the combination of TRT and CBT.

Full article: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.02048/full

 

I actually found a therapist that does TRT properly i.e. counseling & possible sound therapy if needed. My wife's insurance plan has audiology coverage, therefore I am going to check it out.

 

@Michael Leigh.

Michael, you appear to be well respected on the forum and knowledgeable and as I also live in Brighton I thought I would try and reach out to you. My tinnitus started in March 2018 and I went to see an acupuncturist for help. He told me lots of people approached him at that time with ear problems and he thought it was something to do with the air pressure. The acupuncturist couldn't fix it so I went to Brighton hospital to see an audiologist for advice.

I have high pitch ringing in my left ear which I have had very faintly since I was 19 following difficulties equalising whilst diving (I am 46 now). Three years ago it suddenly got louder. I am now really struggling with my mental health as its so exhausting trying to ignore it and get on with life. This has not been helped by my finding out that my friend's husband is now in a mental hospital after becoming suicidal over his severe tinnitus. Of course, I am really worried mine will just get louder as I get older and I don't know if I can cope. I would say its about a 5/10 at the moment as I can hear it all times of day whatever I am doing.

The doctor found nothing physically wrong with my ear other than mild hearing loss. I had an MRI which ruled out anything serious. My hearing is worse in my right ear but the ringing is all in my left. The doctor told me I would just have to live with it and gave me a BTA leaflet. I called BTA but found them as useful as a chocolate teapot.

I then tried Vitamin D supplements and they seemed to lessen the noise but it came back.

So my question is this, how did you, Michael, get TRT from Brighton NHS Trust or did you get it elsewhere? If I don't qualify for TRT for whatever reason, is there anything else Brighton NHS Trust offers?

Also, your posts indicate that you are habituated but you still get spikes which bother you. Is that right? I thought TRT produces full habituation meaning that although you still hear the noise, it doesn't bother you.

Finally, I know this is a bit out there but as you live in Brighton, you may be more familiar with alternative treatments (!); what do you think about Julian Cowan Hill's take on all this? Do you think cranial sacral therapy could cure it?

Any advice greatly appreciated.

Sam

 

HI @Sam,

Tank you for your post is was interesting read and hopefully I may be able to help you. It is nice to meet a fellow Brightonian and I've lived here the 6 year and loving it. Although I was born and bred in London. I am still registered with my London hospital as an out patient for tinnitus and prefer it to remain this way.

TRT may not be available at Royal Sussex university hospital but I believe it is still practiced at the hospital I attend in London which I don't want to divulge the name in this open forum. Many things can cause tinnitus but typically it is exposure to loud noise. Headphone and earbud use at high volumes and for long durations. You need to see an Audiologist or Hearing Therapist that is experienced in noise induced tinnitus.

If you use headphone or earbuds I advise you to stop using them even at low volume. Please find the link below and read my post: New to tinnitus what to do.

Julian Cowan Hill might be able to help some foms of tinnitus but I don't think he can help noise induced tinitus since JCH's tinnitus was not noise induced, he therefore knows nothing about it or hyperacusis.

All the best
Michael

New to Tinnitus, What to Do? | Tinnitus Talk Support Forum

 

@Michael Leigh Do you believe TRT can help someone if their biggest issue is not the sound of tinnitus but all the physical sensations that come with it (headaches, fullness in ears, tingling sensations, brain zaps, etc.)?

Is there a point in doing TRT in that case?

 

@cjbhab I have taken the liberty of perusing some of your previous posts including the ones you have posted on your "started threads". I believe this is important to do, that way I can get an idea the type of person that you are and your approach to dealing and coping with tinnitus. This condition can be a frustrating and debilitating at times and I think you have a a lot of built up stress and anger inside you because of it and I'm sorry to know that you feel this way because I have been there.

Unfortunately when someone find themselves in this situation because of tinnitus, all they tend to see is problems in their life and this is quite understandable. Mixing with like minded people which are not difficult to find in tinnitus forums because of the nature of the condition and what it can do to a their mindset, they can become entrapped in a vortex of confusion and despair. They feel no one outside the realms of the forum (family members, loved ones) understands their predicament and what they are going through in life and thus, the forum and other social media platforms becomes their soapbox to vent their despair in discontent with the world and medical profession. if additional problems not related to tinnitus or hyperacusis are present, such as unemployment or housing issues especially with what's going on around the world with COVID-19 and lockdowns these things become intensified the end result being stress.

TRT can certainly help but one must understand it is not a cure and a person has to be prepared to try and help themselves, for the treatment cannot do it all. The first thing a person has to do to incorporate and accentuate the positive things in their life and this will help to eliminate the negative. If you enter into any tinnitus treatment with a negative mindset it will not work. This is different from feeling down, despondent or even despair. It is the belief: "That I will try it anyway but know it won't work". This type of thinking is negative and the person has convinced themselves from the outset that any form of treatment is doomed for failure .

To get an idea what I mean please click on the links below and read my post: Tinnitus and the Negative Mindset. Acquiring a Positive Mindset. Read other posts on my started thread too: The Habituation Process, TRT articles.

I wish you well.

Tinnitus and the Negative Mindset | Tinnitus Talk Support Forum
Acquiring a Positive Mindset | Tinnitus Talk Support Forum

 

Thanks for responding, I appreciate you taking the time.

I don't think it's so much a negative attitude rather than trying to evaluate the facts and be realistic.

My biggest problem is when there is no input to my brain - my head tenses up and pressure builds and it's very hard to describe, it's like the brain is panicking looking for input, and I can feel that process happening.

I am purchasing ear level noise generators. I am picking them up Friday, I think they will provide relief during certain activities. I'm considering TRT, but I just don't see how it will help the physical symptoms which are my problem.

 

@cjbhab

Try not to do too much evaluating an analysing because this can lead to negative thinking when results a person is looking for are not realized. White noise generators are good but it is important they are used in conjunction with good quality counselling, with an Audiologist trained in tinnitus and hyperacusis management. These health professionals often have tinnitus. They were either born with it or acquired it at some time in their life. Good quality counselling can help remove and demystify the negative thinking that is often associated with tinnitus.

With the greatest respect you have said and I quote "I just don't see how it will help the physical symptoms which are the problem". What you may not realise tinnnitus/hyperacusis although mental when they become problematic over a period of time and this is sustained, they can start to cause physical problems due to stress something a lot of people are not aware of. If the person has additional problems because life is problematic, especially what's going on with Covid and how it's affecting people in one way or another, these problems intensify .

Please see an Audiologist specialising in tinnitus counselling.

All the best
Michael

 

I think the counseling part helps reframe what you are going through. It doesn't make it go away but if it changes your understanding of the perception of sound, it can help change your reaction to it.

 

You make a valid point.

Good quality tinnitus counselling administered by a therapist that has the condition can help a patient, by removing and demystifying the negative reaction that many people have towards it. It is not a quick fix and takes time but a lot can be achieved. As you rightly say, once a person has more understanding about the condition their perception of it changes. Primarily, they no longer fear the noise and thus the tinnitus is pushed further into the background which is also helped by the use of white noise generators. The brain habituates to the white noise generators and pushes the tinnitus into the background over time making it less noticeable. This is the reason white noise generators should be used with tinnitus counselling. They also help to treat hyperacusis if it is present, by desensitizing the auditory system.

Michael

 

Hi Michael Leigh,

I contacted a TRT specialist here in NYC and they charge $5500 for 6 months. I have asked you this before... Is 6 months a short time frame? I am going to contact other specialists here in the city but there are not many.

Best,
Denis

 

HI @DCM.

I think 6 months is a short time frame. Proper TRT takes a minimum of 12 months, preferably up to 2 years. You have had tinnitus since 2017. How severe is your tinnitus at the moment and do you have hyperacusis? Some clinics say they practice TRT but this may not be the case.

Please read my post on my started threads titled: What is TRT and when should it be started?

Michael

 

I'd like to second Michael on what he said, but would like to add my own two cents of the physical symptoms you describe, ones that I too experience sometimes, are our limbic system's reaction to the perception of sound. For me, and I have tinnitus that is pretty awful, I have better days and worse days, but on those worse days there are times that I react very little to the sound, it's still not great but I just don't really react to it. There are other days that the same level and type of sounds drive a physical pain and a kind of involuntary cringing in my ears, head and body similar to how I would physiologically respond to the threat of getting cut or burned, except of course you can't get away and it just goes on forever. I feel like when I stop my completely involuntary reaction to the sound that I am experiencing some level of the habituation.

My point is I think the point of TRT or other sound therapies is to decrease that physiological response to the noise. Even when the noise is at its worst if I'm not reacting to it, it is not nearly as bad. Still isn't great, mind you.

I'm doing sound therapy, not proper TRT - I understand there are studies that indicate similar levels of success - so far I've been using these for 5 or 6 months and can't say it has helped me any more than my natural habitation process would have. On the other hand, if one has access, the money, and a willingness to try, what do you have to lose and having access to tinnitus based counseling while going through this difficult period can only be a positive. Sitting around doing nothing in the face of such pain is such a helpless feeling, even if TRT/sound therapy does nothing it gives me an action I can take to try to go further down my recovery road, which is something.

 

Hi Sam,

I have fully habituated to tinnitus. I do not experience tinnitus spikes, although my tinnitus is variable in intensity and changed to this in 2008 after a second noise trauma. I have written about it in my post: My Experience with Tinnitus. It is available on my started threads. My tinnitus can be completely silent, mild, moderate, severe or very severe. This is different from a tinnitus spike which most (not all) are caused by hyperacusis that hasn't been treated.

Habituation doesn't mean the tinnitus will not bother you although for many people it doesn't. To understand my interpretation it, please click on the link below and read my post: The Habituation Process.

Michael

The Habituation Process | Tinnitus Talk Support Forum

 

There is a confusion between habituation, and not reacting to your tinnitus.
I think if you don't react to your tinnitus, but you still hear it, you have not habituated. I'm pretty sure it still bothers you.

Habituation means you truly don't react to tinnitus and, as a result you don't hear it in the sense that you're not aware of it, even if it's still there.

This is what I experienced during 5 years, when my tinnitus was moderate in volume. It took me almost 2 years to habituate, and during the following 5 years, I was never aware of my tinnitus. This is habituation.

People who take pills, use masking to sleep or to distract themselves from tinnitus are just coping. If you have to take drugs when your tinnitus spikes, you have not habituated.

And of course, if your tinnitus is loud, unmaskable, I don't think habituation is possible. When I'm in restaurants, I always hear the 75-80 decibel background noise even though it's not threatening and bothersome.

I live near a train station in France, Grenoble. I do hear the train passing, it's not bothersome, but I do hear them.

This is why I don't understand TRT practitioners' comparisons with loud daily life background noise, because I do hear them, my brain doesn't filter these sounds.

 

Habituation means to live with tinnitus, that is all. TRT (Tinnitus Retraining Therapy) is exactly what it implies. To help retrain the way a person thinks about their tinnitus and not let negative thinking adversely affect mental and emotional wellbeing. To be more positive even in the downtimes. It is a process that takes time to learn and not achieved overnight or within a few weeks. It can take many months and one has to work at it. Some people require professional help.

I have explained this in many of my posts in addition to the Habituation Process. They are available on my started threads. These are a few: Tinnitus and the Negative Mindset. Acquiring a Positive Mindset. Positivity and Tinnitus. The Complexities of Tinnitus and Hyperacusis. Tinnitus and Mental Health. Look at What You Can Do, Not What You Can't.

Michael

 

Hi Michael,

Further details to above about this NYC TRT clinic.

The cost breakdown is $2500.00 for 6 months and $3000.00 for the hearing aids (noise generators) that the client owns. The course can continue but $250.00 for each visit.

Best,
DCM

 

Thank you for the information. TRT is expensive and you will have to decide whether to try it or not. I believe it can help people to manage the condition better as it helped me and cured my hyperacusis using the white noise generators.

Saying that, I am a little concerned as you've had tinnitus since 2017. This is the reason I asked you, how does your tinnitus affect you at the moment and do you have hyperacusis?

Please read my post: What is TRT and when should it be started, to see what it involves.

What Is TRT and When Should It Be Started? | Tinnitus Talk Support Forum

 

Up until 5 weeks ago I was doing OK. I had a good run for 8 months. I had tinnitus some days but had quiet days too. I had hyperacusis for certain sounds but livable. Now my hyperacusis is a little better this week. I think within the next 4 weeks there should be some improvement?

Thinking of using a sound machine for night as I have always slept in a quiet room.

Best,
DCM

P.S. I really thank you for your advice!

 

You are welcome @DCM.

The advice that I give in this forum is just my opinion based on personal experience and corresponding with many people, that have noise induced tinnitus. However, it is not absolute. Unless you are experiencing a lot of stress, the tinnitus is very intrusive most days without relenting, I don't think you need TRT at this time. You have had it for three years and coped thus far. You have said that you had a good run for 8 months until 5 weeks ago. Ruling out an underlying medical condition within your auditory system causing the tinnitus to increase. Usually, three things are responsible. Stress, exposure to loud sounds, headphones, earbud or headset use.

If it's stress and there's a lot of it around due to COVID-19, this will subside in time, you could also have a talk with your family doctor. If it's exposure to loud noise, hopefully the tinnitus will settle down in time and it's something you need to be careful of in future. If you have been using headphones, earbuds or headset even at low volumes, then I advise you never to use any of these devices again.

I think you can do a lot to help yourself and I advise to start using sound enrichment, particularly at night and during the day. Remember, the idea is to use low level sound enrichment not to mask or cover up the tinnitus so it can't be heard. Give it time and see how you get on at least 3 months. If you don't see a marked improvement and want to try TRT then this might help.

Please read my post: Hyperacusis, As I See It, for suggestions on using sound enrichment and try to engage in things you like to do to direct your thoughts away from the tinnitus. Read my posts that are on my started threads, mentioned above. This will help to reinforce positive thinking.

All the best
Michael

Hyperacusis, As I See It | Tinnitus Talk Support Forum

 

Taking meds to help sleep or reduce anxiety are helping me habituate. Your statement that taking meds means your are not habituated is false. Meds can help habituate. People with already existing anxiety disorder should not stop taking meds to habituate.

 

I haven't found counseling helpful in a CBT context. I don't know about a TRT context, but they were basically pulling out printouts from the neurophysiological model by Jastreboff. It's kind of tough to hear a counselor who hasn't got tinnitus talk you through the whole TRT-doctrine over and over, shoving aside every proper argument about loudness and intrusiveness, saying these are shown not to make a difference. Also, I shouldn't fear noise under 85dB according to her, even if it led to a spike.

Then again, the audiologist had mild tinnitus coupled with a superhero-complex. That was arguably even worse...

 

Medical professionals with non-problematic tinnitus are the absolute worst.

 

Yeah my ENT (who is probably in his late 50s/early 60s) said that he had ringing and shrugged it off like it was nothing. Clearly his isn't that bad if he's telling his own patients that it's nothing to worry about.

 

I do not want to get into discussion about the effectiveness of TRT. I have been doing it since July.

The question I am trying to get a straight answer on is if benzos really make it difficult or impossible to habituate.

Other than Jastreboff’s video where he says you can’t be on benzos, is there any evidence at all if this is really a fact?

I have been on .5mg a day of Klonopin since this all started almost a year ago and I had been on 1.5mg a day in the past for IBS and had no problems tapering off.

My tinnitus I believe is noise induced in the left ear only, and I have had sinus surgery in October. ENT thinks allergies might be making it worse because when the tinnitus flares up, I also feel pressure in my head. Going to start immunotherapy soon.

 

Sorry to hear about the difficulties that you have been going through with noise induced tinnitus. It is a complex condition, the same as other types of tinnitus that isn't noise induced. No two people will experience them the same. In addition to this you have had sinus surgery. Because the Ear, Nose and Throat are linked, your ENT doctor is probably correct in thinking your allergies are contributing to making the tinnitus worse. Hopefully this will improve with time.

I have been taking Clonazepam periodically over ten years. Usually, once or twice a month for 1 or 2 days and then stop. I was informed by my ENT doctor it shouldn't be taken regularly as this medication can be addictive. It can make habituation difficult if taken regularly as the body will become dependent on it. Whilst it may reduce or completely silence the tinnitus for some people, as in my case, as soon as the person stops taking Clonazepam it is likely the tinnitus will return, allowing the brain to focus on it more and it can seem more intrusive. Therefore, habituation is harder to achieve.

Clonazepam is usually meant for short term use. Certainly not for long duration, for reasons I've mentioned in this post and previous posts on this thread.

Hope you start to feel better soon.

Michael

 

So I'm not doing TRT proper as none is available where I live but I'm doing a sound therapy on hearing aids set up by my audiologist and self education on CBT and general tinnitus knowledge.

The sound therapy doesn't do much for me to the point that I would really rather not do it at all; maybe I've been using it for 6 months with no particular positive effect.

I am 95% functional except for my worst days, but still have almost 24/7 intrusive tinnitus, which is apparent even over shower, traffic, basically I can hear it everywhere. I'm somewhat habituated to it and probably actively notice it 30% of the time. Unless I'm having a spike I don't really have stress or problems because of it. I continue to go on a trajectory of little change in symptoms but a continual progressive improvement in my ability to function in the face of those symptoms. All that being said I'd still rather not have it at all, have it quieter, or get to that magical point where I don't notice it for a day at a time.

So @Michael Leigh or others that may have an opinion, should I still use the maskers/sound therapy thing or am I basically already experiencing whatever likely therapeutic effects I would expect to have received from the treatment?