Treatment of Tinnitus Using Cognitive Behavioral Therapy (CBT)

Treatment of tinnitus is challenging. 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.

Treatment of tinnitus using Cognitive behavioral therapy (CBT)

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.

Treatment of tinnitus using Cognitive behavioral therapy (CBT): The Components of Treatment

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.

How Your Smartphone Is Making You and Your Teenager Dumb and Depressed!

smartphone making you dumber

Your smartphone. Smartphones are very cool devices. You can text, Snapchat, or email from anywhere. You can find your way through traffic using Google Maps or Waze. Find a good restaurant with Tripadvisor or Yelp. Take pictures and send them to all of your friends and family instantly. Nothing but upside right?

Wrong! Multiple research studies show that our smartphones are actually making us dumber, and maybe more depressed as well. Let’s look at some interesting facts. I’ve written previously about smartphone use and happiness but wanted to revisit the subject with more data.

Fact One: The average smartphone user looks at their phone 80 times a day, according to Apple.

Other reports suggest that people look at their phone 130 times a day. That means 30,000 to 47,000 times a year! Each of those glances distracts you from your current circumstances, and if you are trying to do something complex, or learn something, you are getting dumber 30,000 to 47,000 times a year! That’s a lot of time to lose. And since studies show it takes 25 minutes and 15 seconds to recover from distraction, that means you are losing 526 days a year, which is more than a year, which means that you are basically distracted and dumber all the time.

Fact Two: The closer your phone is to you, the dumber you get.

The University of California, San Diego conducted a study of 520 undergraduate students. The students took two tests of intellectual functioning. The main variable in the study was where student put their phones. Some students put the phones in front of them on the desk, others put the phone in their pockets or purses, and others left their phones in an adjoining room.

The results: the closer the phone was, the dumber the person based on the test results. Phone in front of you, bad, phone in your pocket or purse, a little better, and phone in the next room, best results. And remember, this was with participants never checking their phones!

Fact Three: We don’t realize how much our phones impair our performance.

All of the participants in the UC study later said their phone was not a distraction, and that they never thought about their phones during the experiment. This shows we don’t even recognize the damage our phones are doing to our minds.

Fact Four: Smartphones bring down college grades by one whole letter grade when brought to class!

Researchers at the University of Arkansas found that those students who left their phones at home scored a full grade higher on material presented in the classroom than those who had their phones in class. It did not matter whether the students used their phones or not. In another study from the U.K. found that when schools ban smartphones, test scores go up a lot, with the worst students benefiting the most.

Fact Five: Your smartphone makes you worse at relationships as well.

Another study from the U.K. had 142 people divided into pairs and asked to talk in private. Half had a phone in the room, while the other half had no phone. The pairs then rated each other for affinity, trust, and empathy. “The mere presence of mobile phones,” the researchers reported in 2013 in the Journal of Social and Personal Relationships, “inhibited the development of interpersonal closeness and trust” and diminished “the extent to which individuals felt empathy and understanding from their partners.”

Fact Six: It Is Worse For Teenagers

According to Neilson, teenagers send and receive 3,339 texts per month, which is about 7 texts per hour, or one text every 8.5 minutes. Actually, it is worse. Let’s assume that most teens don’t text during classes. That means outside of class, they are texting about 12 times an hour, or once every 6 minutes.

iphone woman

This can’t be good for learning or memory. Imagine you are trying to learn something hard, and every 6 minutes someone asks you a question and you have to respond. How’s your performance? And since we know that distraction lasts 25 minutes, that basically means that all teenagers are distracted every minute that they are awake and not in class.

What’s even worse is that smartphone usage also affects happiness. The Monitoring The Future Survey, which is funded by the National Institute on Drug Abuse, has collected data on 10th graders and 12th graders for decades. They asked teens how happy they are and how much time they spend on various activities including non-screen activities like socializing and exercise, and screen activities such as social media, browsing the web, or texting.

The results? All screen activities are linked to less happiness, and all non-screen activities are linked to more happiness! Eighth graders who spent 10 or more hours a week on social media were 56% more likely to say they’re unhappy. Even those who spent six hours a week on social media were still 47% more likely to say that they were unhappy. And even more ominously, the more time that teenagers spent looking at screens the more likely they were to report symptoms of depression. Teens who spent three hours a day or more on electronic devices were 35% more likely to have at least one risk factor for suicide.

Here are a few somewhat radical suggestions:

  1. This one teenagers will really hate. What if parents took away smartphones from their kids, and gave them flip phones, for phone calls only? Turned off texting on the phone. I suspect the average teenager’s grades would go up a grade. Not to mention better learning and memory. Flip phones would allow teenagers to call their parents for a ride, thus having much of the convenience factor without any of the negative smartphone factors.
  2. If this is not practical then I would recommend that parents take smartphones from their children when they arrive home from school, put them in a locked drawer, and only give them back the next morning. Certainly, there should be no access to smartphones while studying or doing homework. When children have finished their homework and are in relaxation mode, they can have limited access to their smartphone, but only until a reasonable hour because the use of smartphones before bedtime is very disruptive to sleep.
  3. For adults, leave your phone in your car trunk when having dinner out. You’ll connect with your dinner partner much better.
  4. For families, all smartphones, tablets, laptop computers go away before every family meal. Unless you are a physician on call, nothing is so important that you can’t put away your smartphone and have a nice family dinner.
  5. Finally, consider a digital device Sabbath. Orthodox Jews do not use any digital devices during Sabbath, which starts Friday night and ends Saturday night. All of us should emulate this, and pick a day on the weekend which is a digital-free day.

I am reminded of the first time I met my friend Fred Luskin, a psychologist who studies stress and forgiveness. I was attending a workshop he led. At the beginning, he asked everyone to take out their smartphones and turn them off. Not “turn off the ringer” or “set to vibrate” but actually power down the phones. Participants were shocked and resistant. It took a few minutes for him to get people to actually turn off their phones. At the time I wondered about this, but now I can see that it makes a big difference. When your phone is powered down, you are not anticipating anything from it, so that little bit of attention that is always focused on the phone is freed up for other purposes.

Now I’m going to turn off my computer and my phone, go outside, and take a walk…

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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 Deal with Teenage Depression: A New Study of Adolescent Depression and its Treatment

A new study reported in the Journal of the American Academy of Child and Adolescent Psychiatry found some interesting results of a study of teenage depression and its treatment.

This study of 439 teenage children with major depression, done at the University of Texas Southwestern Medical Center at Dallas tested anti-depressant medication (fluoxetine or Prozac), cognitive behavioral therapy (CBT), and a combination of both (COMB). They found that only 23% of the patients had their depression cured by 12 weeks of therapy. But 9 months of therapy was much more effective, with 60 percent going into remission.

The bad news though is that this means that almost half of the teenagers (40%) were still depressed after 9 months of therapy.

The good news is in terms of relapse. Of those who responded quickly to treatment, two-thirds retained the benefits of treatment over 9 months. The same was true of those who took longer to respond.

Which treatment was better? That is an interesting picture.

It depends at which time point you are looking at. At 12 weeks, the results for percentage fully remitted (cured) of depression were: combined drug and CBT therapy (37%), drug therapy only (23%), and CBT therapy only (16%). The combined therapy was significantly better than the other therapies. But note that overall, only 23% of the teenagers had recovered at 12 weeks, which means that 77% were still suffering!

But at nine months the outcomes look quite different. The combination therapy is still the best, but by less of a margin. The results for remission at at 9 months were: combination, 60%; drug, 55%; cognitive-behavioral therapy, 64%; and overall, 60%. By 24 weeks all the treatments were working well. But a full 40% of the teenagers were still depressed.

So the right answer to the question of which treatment works better is neither. Both drugs and cognitive behavioral therapy were equally effective, over the long term. But the combination of both was worked more quickly. As the researchers said, “choosing just one therapy might delay many teenagers’ recovery by 2 or 3 months.” As the saying goes, candy is dandy, but liquor is quicker, and we might conclude that drugs or CBT are dandy, but combined therapy is quicker.

So what does this mean to parents of depressed teenagers? Here are my takeaway messages:

  1. Don’t expect treatment for depression to work quickly. It may take more than 9 months of weekly treatment before your teenager responds to therapy. This means at least 40 sessions of therapy.
  2. Be patient, and set reasonable expectations for both yourself and for your child. Tell them that therapy will help, but it may take a while. Let support networks such as school counselors or trusted teachers know to be patient.
  3. Although medications and cognitive behavioral therapy were equally effective in the long run, the combination of both tended to work much more quickly. So if you can afford it, and have access to good practitioners who do cognitive behavioral therapy, use both.
  4. Be aware that in other studies, the relapse rate for medication treatment of depression was significantly higher than for cognitive behavioral therapy, once the medications are discontinued. So choosing medications only may increase the risk that your teenager will relapse into depression.
  5. Be aware that much teenage depression can be a reaction to social environments. This includes the family, the school, and peers. Be sure that your teen’s therapist is attuned to family, school, and peer issues. They should meet with the whole family at least several times.
  6. Take teenage depression seriously. It’s not just a phase. Teenage depression, when serious, can greatly increase the risk of suicide. All suspected depression should be evaluated by a professional and treated if present.

Copyright © 2009 Andrew Gottlieb, Ph.D. /The Psychology Lounge/TPL Productions

SOURCE: Journal of the American Academy of Child and Adolescent Psychiatry, February 2009 . And December 2006 issue too .

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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.