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.

Suffer From Insomnia? Best Insomnia Drug Is Not A Drug, But Rather Cognitive Behavioral Therapy According to Consumer Reports

Do you suffer from insomnia? Have you tried sleeping pills? When a major consumer ratings agency such as Consumer Reports endorses cognitive behavioral therapy over drug treatment for insomnia, it is big news.sleeping dog

In the May 2017 issue of Consumer Reports (CR), there is an article entitled Why the Best Insomnia Treatment Is Not a Drug.  In earlier versions of their articles on sleep and medications for sleep they had reviewed various different sleeping agents but in this updated article they conclude that at best, the newer sleep medications add only between eight and 20 minutes of sleep time, and don’t improve how people feel or operate the next day.

They also reviewed a recent systematic research study by the federal Agency for Healthcare Research and Quality (AHRQ) that compared multiple treatments for sleep problems including drugs, cognitive behavioral therapy, and alternative therapies. This study concluded that cognitive behavioral therapy (CBT) is a safe and effective way to treat insomnia, and is more effective and safer than other treatments.

So Consumer Reports’ Best Buy drug pick is actually not a drug at all! It is Cognitive Behavioral Therapy (CBT). They recommend at least one session and optimally suggest three to six  sessions of CBT with a psychologist.

They also have a good description of how CBT works for insomnia. They explain how you meet with a psychologist and work on changing your beliefs about sleep, as well as changing certain behaviors that may contribute to insomnia. CR also includes a concise chart about bad sleep habits and how to fix them. They have an excellent description of CBT for insomnia here.  If CBT was a sleep medication, promoted by a powerful drug company, it would be a multibillion-dollar product!

insomnia slide

I have previously written about CBT for the treatment of insomnia in the article Cognitive Behavioral Therapy for Insomnia (CBT-I) Outperforms Drugs for Insomnia,   Want to Sleep Better? Get Brief CBT-I Therapy for Sleep Instead of Sleeping Pills, and Good News! You May Be Getting More Sleep Than You Think, Especially If You Suffer Insomnia! so I will just summarize some of the conclusions from those articles.

The bottom line for these articles was that Cognitive Behavioral Therapy for insomnia was safe, effective and long-lasting in its effects. What is clear from virtually every study of sleep treatments is that CBT may be the only treatment for sleep problems that doesn’t have side effects and negative impacts into the next day. According to a 2015 Consumer Report survey, 36% of people who took a sleeping pill felt drowsy the next day. They also report a study of 410,000 adults published in the American Journal of Public health which found that those who took sleeping pills were twice as likely to be in automobile crashes. The researchers in this study concluded that people taking sleep medications were as likely to have car accidents as people with blood-alcohol levels above the legal limit!

So what are the recommendations and interventions used in CBT for insomnia?

  1. Spend only seven or eight hours in bed, and don’t compensate for insomnia by lying in bed for ten or eleven hours, as that just teaches you to be an inefficient sleeper.
  2. Go to bed and get up at the same time every day.
  3. Don’t go to bed unless you actually feel sleepy. If you can’t fall asleep get out of bed and do something peaceful and relaxing until you are sleepy, and then go back to bed.
  4. Try to get regular exercise but don’t exercise in the evening.
  5. Use your bed only for sleeping (or sex), don’t read or watch TV or look at your smartphone in bed.
  6. Don’t nap.
  7. Reduce your intake of caffeine, nicotine, and alcohol, especially later in the day.

Now it’s time for my nap—no, my mid-day exercise!

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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 Anger Works: The SAP Model ™ (Part 1)

In this article I will give you a simple cognitive behavioral explanation of how we get angry, and how you can use this knowledge to short-circuit and defuse your own anger. Anger is probably the most cognitive of all of the emotions. We can’t get angry without thinking. And most anger directly stems from our distorted thoughts.

There are three cognitive steps to getting angry. The first two are absolutely necessary for anger, and the third is like gasoline on fire, it intensifies anger. The acronym for remembering these three steps is SAP(tm), which is what anger will make you if you think these thoughts.

To help illustrate this lets consider a common situation where a person might get angry. You are driving on the freeway and a car cuts you off. You instantly react with anger. You steam all the way to work.

STEP ONE: VIOLATION OF SHOULDS or “SHOULDY THINKING”

The first step to getting angry is that you must have a set of shoulds or expectations that have been violated. Without this there is no anger. In the driving example what are your expectations? You tell yourself that the other driver shouldn’t have cut you off. He or she should have looked first and seen you. Obviously this should has been violated. This is what some cognitive therapists call “shouldy” thinking!

STEP TWO: AWFULIZING

But just having a set of shoulds or expectations is not enough to generate anger. The second step is necessary. In this step you exaggerate the negative consequences of the violation of the shoulds. You tell yourself it is awful and terrible that this event has happened. In our driving example your self talk is “Wow, the idiot could have killed me. It’s awful and terrible that they allow people like that to drive. Grrrrrr!” This step is called Awfulizing. Or Terribilizing, if you prefer. The key distortion is that you blow the event out of proportion. After all, if you are able to have these thoughts, then obviously no serious accident has ensued.

STEP THREE: PERSONALIZING

The first two steps will get you mad, but the third step of Personalizing or Blaming will make you crazy angry. If you tell yourself that the person didn’t see you, and it was an accident that they cut you off, you may still get angry. But if you tell yourself they did see you and purposely chose to cut you off anyway, then your anger spirals out of control. Blaming thoughts are like pouring gasoline on the fire of anger. They are responsible for such things as road rage.

So this how anger works. Let’s consider another example. This time we will use one closer to home. It’s early Saturday morning, and you are sleeping in after a long hard work week. Suddenly you are awoken by the loud noise of a lawn mower. It’s your neighbor George, who for some unknown reason, has decided that Saturday at 7:30am is a good time to mow his lawn. You are furious.

Let’s analyze this. What are the shoulds? Basically that your neighbor shouldn’t do noisy activities until 10 or 11 am on a weekend day. This should has been violated by George. What is the awfulizing? You are thinking that now you will be tired all day, and you’ll be cranky and irritable, and won’t have any fun. Is there a personalizing statement? Yes, you think, “George knows I work late, and knows I like to sleep in, so mowing his lawn so early is a direct insult to me!” And so you explode with anger.

So there you have it, a simple cognitive model of anger, the SAP model: Shoulds, Awfulizing, and Personalizing. Try an experiment. For a week, write down each anger incident you have by identifying the three Anger Thought Steps. This will help you to increase your awareness of how anger works, and prepare you for the next step, learning to defuse and eliminate your anger, which I will discuss in Part 2 of this article,  How to Stop Anger in its Tracks.

Copyright 2007 The Psychology Lounge/ TPL Productions All Rights Reserved

 

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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.