The Treatment of Tinnitus Using Cognitive Behavioral Therapy (CBT)

Tinnitus is condition where the person hears a ringing in their ears or other sounds when none of these sounds are present in the environment. It is a very common problem, especially as people age. According to studies, up to 20% of people over the age of 55 report symptoms.

What causes tinnitus? There can be many causes. The most common cause is noise-induced hearing loss. Other causes include medication side effects, as well as withdrawal from benzodiazepines. In many cases no apparent cause can be found.

For many, tinnitus is a relatively minor problem that they tend to ignore. Almost everyone has momentary tinnitus symptoms. But for other people tinnitus creates a tremendous amount of psychological distress. This includes anxiety and depression. The person fears the loss of their hearing, and tends to focus intensely on their symptoms. They begin to avoid situations where their symptoms are more noticeable. This typically means avoiding quiet locations where there is no sound to mask the tinnitus sounds. Or it may involve avoiding situations where there are loud noises such as movie theaters due to the fear of further hearing loss.

Similar to some forms of obsessive compulsive disorder (OCD), the person may begin to engage in frequent checking behavior. This means that they consciously check the presence and volume of the ringing in their ears. They may also frequently check their hearing.

The person also suffers from constant thinking about causes of the tinnitus. They often blame themselves for exposure to loud noises in earlier life. They think about the music concerts they attended where they didn’t wear earplugs, or even recreational listening to music. They have strong feelings of regret that can blend into depressive symptoms.

Unfortunately there are no terribly effective physical treatments for tinnitus. This leaves psychological treatment as the primary modality for successful reduction of distress.

Cognitive behavioral therapy (CBT) conceptualizes tinnitus much like it conceptualizes the experience of chronic pain. Chronic pain consists of two components. The first component is the physical sensations. The second component is the bother or suffering caused by these physical sensations.

Tinnitus can be conceptualized in the same way. The subjective experience of sounds in the ears is the physical sensation. The interpretations of these sensations lead to the emotional reactions; suffering and bother.

Although CBT cannot directly change the physical sensations of tinnitus, it can change the reactions to these sensations. And changing the reactions can actually lead to a subjective experience of diminishing symptoms.

What are the components of the CBT treatment for tinnitus?

1. Psychoeducation. The first step is to educate the client about how tinnitus works. The model used is that the loss of certain frequencies in the hearing range leads the brain to fill in those frequencies with sounds. It is very much like phantom limb pain, where an amputee may experience pain in the removed extremity.

The nature of hearing loss is explained, and psychoeducation regarding tinnitus and the risk of further hearing loss is discussed. If needed, results of hearing tests can be discussed relative to the actual severity of hearing loss. Although in some cases of tinnitus hearing loss is quite significant and may actually impair functioning, in many cases the hearing loss is relatively minor and does not impair functioning in any way.

2. Cognitive therapy. Here the therapist helps the patient to identify the negative thoughts that are leading to anxiety and/or depression. Typical thoughts for anxiety are: “I can’t live my life anymore with this condition. I will lose my hearing entirely. The sounds will drive me crazy. I’m out of control. If I go into _____ situation I will be troubled by these sounds so I must avoid it. I need to constantly check my hearing to make sure it’s not diminishing. I need to constantly check the tinnitus sounds to make sure they are not getting worse. They are getting worse! They will get worse and worse until they drive me crazy.”

Typical thoughts for depression are: “Life has no meaning if I have these sounds in my ears. I can’t enjoy my life anymore. It’s hopeless. There’s nothing I can do about it. Doctors can’t help me. It will get worse and worse and slowly drive me crazy. I won’t be able to function.”

Once these thoughts are identified then the skills of challenging them and changing them are taught to the client. The client learns how to alter these thoughts to more healthy thoughts. This produces a large reduction in anxiety and depression.

3. Attentional strategies. Because much of the subjective perceived loudness of tinnitus is based on attention, with higher levels of attention leading to higher levels of perceived loudness, developing different attentional strategies will help very much. In this part of the treatment mindfulness training and attentional training is used to help the client learn how to shift their attention away from the tinnitus sounds onto other sounds or other sensations. Often a paradoxical strategy is first used, where the patient is asked to intensely focus only on their tinnitus sensations. This teaches them that attention to tinnitus symptoms increases the perceived severity, and helps motivate them to learn attentional strategies.

Another aspect of attentional retraining is to stop the constant checking of symptoms and hearing. Helpful techniques include thought stopping where the client may snap a rubber band against their wrist each time they notice themselves checking.

4. Behavioral strategies. Tinnitus sufferers typically develop an elaborate pattern of avoidance in their lives. They avoid situations where they perceive tinnitus sounds more loudly. This can include avoiding many quiet situations, including being in quiet natural places such as the woods, or even avoiding going to quiet classical music concerts. They also tend to avoid situations where they might be exposed to any loud noise. This includes movie theaters, concerts, and even noisy office situations.

The behavioral component of CBT encourages an exposure-based treatment whereby the client begins to deliberately go back into all of the avoided situations. In situations where there is actual loud noise exposure at a level potentially damaging to hearing, they are encouraged to use protective earplugs.

The purpose of the behavioral component is to help the person return to their normal life.

5. Emotional strategies. Sometimes it is necessary to help the client go through a short period of grieving for their normal hearing. This allows them to move forward and to accept the fact that they have hearing loss and tinnitus. Acceptance is a key factor in recovering psychologically. This often also includes forgiving themselves for any prior excessive loudness exposures.

Changing the thoughts about the tinnitus symptoms also produces emotional change and a reduction in anxiety and depression.

In summary, cognitive behavioral therapy of tinnitus seeks to reduce the psychological suffering caused by the sensations of tinnitus. Cognitive, emotional, behavioral, and attentional strategies are taught to the client to empower them to no longer suffer psychologically from their tinnitus symptoms. Successful treatment not only reduces the psychological suffering, but because it also changes the attentional focus and lowers the checking of symptoms, people who complete CBT for tinnitus often report that their perceived symptoms have reduced significantly.

Tips:

1. Traditional psychotherapy is typically NOT helpful for tinnitus.

2. Find a practitioner, typically a psychologist, with extensive training in Cognitive Behavioral Therapy. If they have experience treating tinnitus that is even better.

3. Give treatment a little time. You will have to work hard to learn new ways of thinking and reacting, and this won’t happen overnight. You should be doing therapy homework between sessions.

4. Medication treatment such as anti-anxiety or antidepressant medication is typically not very helpful, and in the case of anti-anxiety medications can actually worsen tinnitus especially during withdrawal. First line treatment should be CBT.

5. Get help. Although the actual symptoms of tinnitus have no easy fix, the suffering can be treated and alleviated. Especially if you are experiencing depression symptoms, is is important to seek therapy with a CBT expert.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

New Hope for Procrastination: Procrastinators are Trying to Repair Their Negative Moods by Avoiding Work According to the Wall Street Journal

The Wall Street Journal has an intriguing article To Stop Procrastinating, Look to Science of Mood Repair. In the article, they discuss new research that suggests that many of the avoidant behaviors procrastinators use are actually attempts to repair low moods. Procrastinators often feel anxious or worried about the task they are attempting to accomplish, so that go to Facebook, the refrigerator, or to sleep to avoid those feelings. Learning new ways of dealing with negative feelings, and using some acceptance methods so that they can better tolerate the negative emotions are both helpful strategies for overcoming procrastination.

Highly recommended article, check it out! I’d write more, but I’m trying to get to work and stop avoiding by writing about avoidance!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

How to Overcome Obsessive Compulsive Disorder (OCD) Using Exposure and Response Prevention and Cognitive Behavioral Therapy: Part One

What is Obsessive Compulsive Disorder (OCD)?

obsessive-compulsive disorder

Check? Check? Check?

OCD is a chronic psychological illness where a person has disturbing and recurring thoughts (obsessions) and compulsive behaviors that they repeat over and over.

OCD is at its core an anxiety disorder. The obsessive thoughts trigger intense anxiety, which the person attempts to ameliorate or reduce by either having compulsive behaviors or compulsive thoughts.

Typical obsessions that people have include:

  • thoughts about harming other people or being aggressive towards other people,
  • inappropriate sexual thoughts and feelings,
  • fear of germs or other types of contamination such as chemical contamination,
  • thoughts about symmetry and order,
  • taboo thoughts about religion or other “hot” issues.

Some typical examples of compulsive behaviors include:

  • Checking behaviors where the person repeatedly checks to see if the stove is turned off or a door is locked
  • Excessive cleaning, hand washing or showering
  • Counting behaviors
  • Arranging things in a particular and precise way
  • I’ve also written about hoarding, which is another type of compulsive behavior.

Some compulsive behaviors are actually thoughts, such as saying a particular prayer to yourself over and over.

There’s an excellent article on OCD at the National Institutes of Mental Health page.

A common type of OCD that I treat in my practice is germ phobia. The typical obsessive thought in these cases is that touching something such as the floor will transfer dangerous germs onto the person’s hands, which will then be transferred either to them or to someone they care about, causing great harm. These people are typically very fearful of public bathrooms and will avoid touching the doorknobs in them. In order to cope with perceived contamination, they will typically wash their hands many times a day, sometimes up to 30 to 50 times. When they cannot wash their hands they will use alcohol gel to sterilize their hands. Often the handwashing is so extreme that the person’s hands will look profoundly chapped and red.

When they feel particularly contaminated they will often take very long showers, washing and re-washing their body very carefully multiple times. These showers can take 30-60 minutes in some cases.

Exposure and Response Prevention Treatment (ERP) for Contamination OCD

OCD that is accompanied by clear rituals such as handwashing is easily and effectively treated using a Cognitive Behavioral Approach that focuses on something called Exposure and Response Prevention (ERP). Let me describe a hypothetical case. (This is a hypothetical case that may include composite aspects of clients I have treated, with all identifiable client information changed.)

Susana came to me because she had developed a very severe case of contamination OCD. Her primary fear was that by touching something that might have germs, she would transfer these germs to her children, husband, or even to strangers, and that they would sicken and die. As a result of these fears, she would wash her hands more than 50 times a day, and take showers that lasted more than an hour during which she would scrub up and wash down three or four times.

She also had developed almost complete avoidances of many situations. Public restrooms terrified her, so she could not leave the home for long periods of time. She was afraid of contaminating her car, which then might contaminate people she loved, so she avoided driving. Work was out of the question since she was spending hours a day on OCD rituals.

The first step was to thoroughly evaluate her OCD. I gave her multiple questionnaires that evaluated the frequency of obsessive thoughts, compulsive behaviors, and avoidant behaviors. The same questionnaires also evaluated the level of anxiety and distress caused by both the obsessions and the compulsions. This gave us a good baseline set of numbers that described the state of her OCD. As part of the same evaluation, I obtained detailed information about all of the things that she was avoiding doing.

The next step was to do some Cognitive Behavioral Therapy (CBT) on her belief systems about germs and contamination. This consisted primarily of a set of conversations where I asked open-ended Socratic-style questions about her beliefs. She showed a variety of common OCD distorted thoughts and beliefs.

Common Thought Distortions in Contamination OCD

  • All germs are lethal and deadly: This distortion is basically the belief that every microorganism causes serious or fatal diseases. It’s actually not true. We are surrounded by bacteria, and most of them are harmless or even beneficial. The most common kind of harmful germs or viruses are the common cold and the flu. Neither these illnesses are particularly dangerous although they are unpleasant. More dangerous germs such as HIV or tuberculosis are extremely rare in developed nations, and the virus that causes HIV is extremely fragile and cannot survive for more than a couple of minutes on most surfaces.
  • Germs live forever on any surface: This is the belief that once a germ attaches itself to a surface it will stay there forever and be capable of infecting you. In reality, most surfaces are fairly inhospitable for bacteria and viruses, and the microorganisms become inactivated fairly quickly, usually within minutes or at most an hour.
  • Things transfer at 100% potency: The law of transfer says that with each transfer the potency of what is being transferred becomes less and less. So if you touch something that has germs on it, your hand will have some germs transfer. If you then touch something, such as a computer keyboard, fewer germs will transfer. Then when someone else touches the keyboard, even fewer germs will transfer to them. The more transfers the less is transferred.
  • Humans have no immune system: This is the belief that every germ or virus that one contacts will cause illness. Humans actually have a very robust immune system. Every day our immune system kills off a variety of germs and viruses we get exposed to. Unless we are exposed to many germs or viruses, our immune system usually does a good job of resisting illness.

The Treatment: Using Exposure and Response Prevention

We did some experiments to test her beliefs. One experiment I like to do is the chalk dust experiment. I have the patient touch some chalk dust, and then they touch my hand, and then I touch my keyboard of my computer, and then I have them touch the keyboard with a clean hand. Thus they graphically see that each transfer moves less and less chalk dust to the next item.

We spent a few sessions discussing and correcting the misconceptions about germs and illness. This began the process of getting ready to start the essential part of the treatment, Exposure and Response Prevention. (ERP)

To prepare for ERP we first made a laddered list of things that would be scary for her. The list went from fairly easy tasks which were a little scary, to tasks that would be terrifying. We rated the anxiety on a 0-10 scale.

I asked her to pick a task that would be somewhat challenging but not terrifying to start with. She picked a task with moderate fear attached to it, touching the floor of my office (which is a carpeted floor.) I also told her that anything that I would ask her to do I would also do with her.

I had her rub both hands on the carpeted floor. Then I asked her to just sit with her anxiety. Initially, her level of anxiety was 10 out of 10. I asked her to narrate her thoughts. “My hands are covered with dangerous germs,” she said.

Over 15 minutes or so her anxiety began to diminish. It went down to about a 7. I noticed that she was holding her hands in the air, so I asked her to put them on her lap. This increased her anxiety briefly, but after a few minutes he anxiety came back down to a 7.

Over another 20 or 30 minutes, her anxiety came down even further. Now it was only a level 4. I asked her to describe her thoughts. “Your carpet probably isn’t really covered with very many germs, and therefore my hands probably don’t have very many germs on them,” she said.

Then I asked her to do something a little bit more challenging – to rub her hands on her face. This made her anxious, but she did it, and after a few minutes of higher anxiety the anxiety subsided again.

By the end of our official face-to-face session, her anxiety level was a 3 out of 10. I asked her if she had any alcohol gel or cleanser in her purse, which she did, and I asked her to leave that in my office. Then I asked her to spend at least another 30 minutes in my waiting room to see if the anxiety level would come down even further, without washing or cleansing her hands. At the next session, she told me that the anxiety level had come down to a level 2, which amazed her given that she had started at 10. I had asked her not to wash her hands for several hours which she did.

At the next session, we tackled another item on her list, the ATM. She was afraid to touch ATMs with her fingers, and either used the back of her knuckles or used alcohol gel after touching the ATM. So we went next door to the local banks ATM, and I had her repeatedly touch the keys with her fingertips. This brought her anxiety level up to about 7, so we kept repeating the task until the anxiety began to subside. Once again I asked her not to wash or use alcohol gel.

A few sessions later after using exposure and response prevention on a variety of other issues, we tackled the top of her list – the public restroom! For many contamination OCD patients, this is the ultimate challenge. We went next door to the building’s restroom, where I put a sign on the door, Closed for Maintenance. Next, I modeled touching the doorknob, the sink, and she did the same. We went back to my office and once again she sat with her anxiety until it came way down.

Once her anxiety had dropped we went back into the restroom and did a harder task. First I modeled touching the toilet seat, and then she touched it. Not surprisingly this raised her anxiety very high. Once again we went back to my office and she sat with that anxiety. We discussed the nature of what toilet seats are made of, and how long germs could live upon them. Gradually her anxiety diminished to about a level of 5, which was a large drop for her.

Between sessions, I asked her to practice these tasks on her own. I explained that the key was to sit with the anxiety for a long enough time for it to subside naturally without any hand cleaning or sterilization. She practiced on a daily basis and made rapid progress on the items we had done together and some other items that were also on her feared list.

By this point, she had lowered her hand washing from 40 or 50 times a day to only several specific situations. After using the toilet, before preparing food, and after preparing food. She had stopped using alcohol gel completely.

A few months later she began to look for work for the first time in several years, as her OCD was virtually completely resolved. I continued to see her intermittently over the next few years, and her OCD continued not to be a problem, although there were some other non-OCD challenges.

In Part Two of this article, I will discuss the use of medications for the treatment of OCD, Thought OCD, Checking OCD, and Health OCD.

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.