tinnitus coaching final...tinnitus “coaching”: managing severe tinnitus and sound sensitivity...
TRANSCRIPT
9/19/2014
1
Tinnitus “Coaching”: Managing severe tinnitus and sound sensitivity
disorders
Lisa G. Fox-Thomas, Ph.D., CCC-A
AP Associate Professor, Audiology
The University of North Carolina at Greensboro
Disclosures
• The presenter has no relevant financial and
nonfinancial disclosures.
• The content presented is for informational purposes
and is not intended to support one management
approach above all others.
• The clinical experiences of the presenter inform and
guide her audiological practice, which is in a constant
state of evolution.
Learning Objectives
1) Identify management approaches for tinnitus and
sound sensitivity disorders
2) Discuss barriers for managing severe tinnitus and
sound sensitivity disorders
3) Describe how tinnitus “coaching” compares to
traditional management strategies
Prevalence of Tinnitus
• Transient Tinnitus
• Chronic Tinnitus
▫ “People with tinnitus”
• Severe Tinnitus
▫ “Tinnitus patients”
People with
Tinnitus (50 M)
Bothered by
Tinnitus (16 M)
Debilitating
Tinnitus
(2 M)
Severity of Tinnitus
• Disturbance is not directly
related with tinnitus
loudness, pitch, or other
attribute.
• Rather, the importance
assigned to the tinnitus,
and its negative associations,
determines its severity.
People with
Tinnitus (50 M)
Bothered by
Tinnitus (16 M)
Debilitating
Tinnitus
(2 M)
2 – 20 dB SL
2 – 20 dB SL2 – 20 dB SL
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Neurophysiological Model(Jastreboff, 1990)
The body’s stress reaction (“fight, flight or freeze” response)
is triggered automatically.
Sympathetic Dominance
http://faculty.pasadena.edu/dkwon/PNS%20and%20propioception/peripheral%20nervous%20system%20and%20propio
ception_files/textmostly/slide2.html
Sound Sensitivity Disorders
Hyperacusis Phonophobia
Misophonia
Sound Sensitivity Disorders
• Hyperacusis – hypersensitivity to the physical
properties of sound regardless of source or situation
(LDLs < 70-90 dB HL)
• Phonophobia – fear of sound and/or what it represents
(e.g., sounds that hurt; sounds that may damage
hearing or make tinnitus worse)
• Misophonia – strong dislike of sound and/or what it
represents (e.g., selective sound sensitivity syndrome
or 4S)
Neurophysiological Model(Jastreboff, 1990)
Hyperacusis Phonophobia
& Misophonia
Overamplification of external sounds within the CANS.Strong negative emotions associated with external sounds.
Comorbidity
• 40% of patients with tinnitus
also have hyperacusis.
• 2/3 of patients with
hyperacusis also have tinnitus.
• Can work on both disorders
at the same time.
• May need to address sound
sensitivity first.
Tinnitus
Hyperacusis
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Management of Tinnitus
• To date, there is no medical “cure” or treatment for
tinnitus.
• The goal is to habituate the
conditioned emotional
responses and stress reaction
to the perception of an internal
stimulus (tinnitus).
• Tinnitus patient � Person with tinnitus
People with
Tinnitus (50 M)
Bothered by
Tinnitus (16 M)
Debilitating
Tinnitus
(2 M)
Treatment of Sound Sensitivity
Disorders
• Sound sensitivity disorders can be treated effectively using
a combination of counseling and daily sound therapy.
• Desensitization occurs gradually over time.
• LDLs are shifted upward as sound tolerance improves
(hyperacusis and phonophobia).
• Triggers are gradually reduced and/or the responses to
triggers become more manageable over time
(misophonia).
Traditional Approaches to
Intervention
Directive Counseling/Patient
Education
Sound Therapy
General Wellness
Recommendations
Referrals
Neurophysiological Model(Jastreboff, 1999)
Sound
Therapy
Directive
Counseling
Referral for Ancillary Services
General
Wellness Rx
Directive Counseling/Patient
Education• Demystification and neutralization of tinnitus and sound
sensitivity
• Role of limbic system and autonomic nervous system in
creating vicious cycle of disturbance
• Principles of selective attention
and habituation
• Use of sound therapy for short-term
relief and control
Vicious
Cycle
Traditional Approaches to
Intervention
Directive Counseling/Patient
Education
Sound Therapy
General Wellness
Recommendations
Referrals
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Tinnitus Retraining Therapy (TRT)
(Broadband noise)
SoundCure
(S-tones)
WZT
(Fractal tones)
PTM
(Broadband
noise)
CHATT
(Broadband
noise)
TAT
(Whatever
works)
Neuromonics
(Music)
Tinnitus Masking
(Broadband noise) Tinnitus Masking
• Jack Vernon (1970s) & Jonathen Hazell (1980s)
• Sound therapy approach:
▫ Broadband sound (e.g., white noise) that is steady state
and nature-like
▫ Masks/covers the tinnitus providing
immediate relief
• Residual inhibition – temporary suppression
of tinnitus after masking sound is
removed
Tinnitus Retraining Therapy (TRT)
• Pawel and Margaret Jastreboff (1990s)
• Sound therapy approach:
▫ Partial masking approach using broadband noise at “mixing
point”
▫ Keeps sound level below level of annoyance
and/or LDL
▫ Avoid silence (”more is better”)
• Provides short-term relief and promotes
long-term habituation.
0110 01 10 1 00 1 11 011 0
1000 1111 101 1111 11 00 101 001
00 TINNITUS
11 001 0000 11001001 00 1
10 1
001 001 1 0001 11 1 100000
1 00 111 101
00 100001
1 11 1 001 00 1111
00 TINNITUS 101 0000 1
10 0 110 0 11111 110001 0
110 0010 00
11 010 0001 100
101 1001 00
10 10 0000 TINNITUS
101000010 010 000
00101 01010 01 11
1000101010101010000111111111110100101111111111100010101010101000000
0000000000000101000101010100010101010101010111110101010000010
001010001010000111101011101001010001000101010100001010101010001
010100010001011110101010101001010001000001010101001010101001001
000101010100101010000001110101TINNITUS0000111111100101010101010
010101010001000010100101010100001000100001001111111100101010100
1001010100100010100100111111101011101010101010101000101000100101
0001010010101000000111101001010010101010001010111110101010101010
1000101010100100101010011110011101011010101010010101010100101000
101010010101010001010100010101001001010010101001000101011100101
010101001010001111101010101010101001001010100010101001010010010
0111111010101100010100101001010100101111101011111010110TINNITUS101
010001000001010100101010101010010000101010101010001011111010101
0101010100101000011111101010100101010100101010100101001010100010
1110010101010100100010101001011111101010010100100100001010100100
00000000001010100101111110001111101011111010000000011111101010111
001010001000001100010100010011110000010000010100100010100100
1000101010010TINNITUS010101001010101001010000001111111101010101
01010101010101000101000101010101010100000101000000101010100100
10100101010010010011111000100100101001011111110001111111101111111100
00011101010000011110100010101010TINNITUS10000011111100101010101
0100010101010101010101011010101000010101010101010101010100001111
10000010101010111010101010101010101010101010100001111010101001011
Progressive Tinnitus Management
• Developed for the VA by Jim Henry and colleagues (2008)
• Sound therapy approach: “Personal sound plan” using
(1) Environmental sound
(2) Music
(3) Speech
• Self-help workbook also covers relaxation exercises, behavior modification, and attitudes toward tinnitus
Soothing
Sound
Background
Sound
Interesting
Sound
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Progressive Tinnitus Management
http://www.ncrar.research.va.gov/education/documents/tinnitusdocuments/index.asp
Progressively
more severe
problems caused
by tinnitus
Cognitive Habituation Tinnitus
Treatment (CHaTT)
• Natan Bauman, founder of TPA
• Sound therapy approach: partial masking with broadband noise
• Combines principles of TRT and Cognitive Behavioral Therapy (CBT) to change attitudes toward tinnitus.
� All or Nothing: “My life with tinnitus is totally ruined.”
� Tunnel Vision: “If I could only find the cause of my tinnitus, I could make it go away.”
• Also incorporates relaxation strategies (de-stress) and distraction techniques.
Neuromonics®
• Paul Davis (1998)
• Sound therapy approach:
▫ Acoustically modified music at the
resting heart rate
▫ Frequency response up to 12.5 kHz
▫ Can use at a lower volume
▫ Dosed approach (2 – 4 hours per day)
during most disturbing times
• Promotes systematic desensitization over time.
Widex Zen Therapy (WZT)
• Francis Kuk (2008) and Robert Sweetow (2010, 2012)
• Sound therapy approach:
▫ Adjustable fractal tones and broadband noise with or without amplification
▫ Frequency response is limited by hearing aid
▫ Advocates passive listening at a soft, but audible level (all day if needed)
• WZT counseling incorporates principles of CBT and relaxation
http://www.widex.com/en/products/thewidexsound/zen/
SoundCure® Serenade
• Reavis and colleagues (2010)
• Sound therapy approach: S-tones matched to the pitch
tinnitus
▫ Frequency response up to 12
kHz
▫ Slow- and Fast-modulation
(tracks 1 and 2)
▫ Narrow- and Broadband noise
(tracks 3 and 4)
Tinnitus Activities Treatment (TAT)
• Rich Tyler and audiologists at University of Iowa (2006)
• Sound therapy approach: Whatever works
• Counseling sessions available online:
▫ Thoughts & Emotions
▫ Hearing & Communication
http://www.medicine.uiowa.edu/oto/research/tinnitus/
� Sleep
� Concentration
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Sound Therapy Devices Hearing Aids
• Compensate for auditory deprivation by feeding sound to the brain.
• Amplify low-level environmental sounds to provide natural masking.
• Decrease “central gain” boost caused by straining to hear.
• Reduce load of listening and fatigue.
• Help to separate the disturbance caused by hearing loss from tinnitus disturbance (tinnitus as “scapegoat”).
• ReSound Tinnitus Solution –adjustable, modulated noise
• Widex Zen – adjustable noise; fractal
tones
• Siemens micon – adjustable noise
• Phonak Quest – adjustable noise
• Starkey Xino – adjustable noise
• Oticon Tinnitus Support – adjustable,
modulated noise and preset ocean-like sounds
Combination Hearing Instruments
• No “one size fits all” management approach
• Selection depends on the following:
▫ Symptoms - hearing loss, tinnitus severity,
sound sensitivity
▫ Life variables – lifestyle; time of day
disturbed
▫ Personal preferences – interaction and
relief provided by sound stimulus;
goals and expectations
Selection Considerations
Traditional Approaches to
Intervention
Directive Counseling/Patient
Education
Sound Therapy
General Wellness
Recommendations
Referrals
General Wellness Recommendations
• Diet
• Exercise
• Alcohol/drug use
• Sleep hygiene
• Stress reduction
(good and bad stress)
• Pleasurable activities
(hobbies)
• Carving out “me” time
vs. treatment timeWork
Family
Home
HobbiesMe Spiritual
Health
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Mindfulness-based Tinnitus Stress
Reduction
http://mindfultinnitusrelief.com/
Mindfulness-based Tinnitus Stress
Reduction• Jennifer Gans (2012)
• 8 week online course using mindfulness training for tinnitus
• “Mindfulness is paying special attention
▫ on purpose
▫ in the present
▫ without (clinging to) judgments
to the unfolding experience, moment by moment.”
~Jon Kabat-Zinn
Full Catastrophe Living
Sympathetic Sympathetic Sympathetic Sympathetic
Nervous SystemNervous SystemNervous SystemNervous SystemFight or FlightFight or FlightFight or FlightFight or Flight
ParasympatheticParasympatheticParasympatheticParasympathetic
Nervous SystemNervous SystemNervous SystemNervous SystemRest and DigestRest and DigestRest and DigestRest and Digest
HeartHeartHeartHeartIncreased/Decreased Increased/Decreased Increased/Decreased Increased/Decreased
RateRateRateRate
LungsLungsLungsLungsInflation/ConstrictionInflation/ConstrictionInflation/ConstrictionInflation/Constriction
DiaphragmDiaphragmDiaphragmDiaphragmMuscle Muscle Muscle Muscle
Contraction/FlexionContraction/FlexionContraction/FlexionContraction/Flexion
Somatic N
ervous System
Somatic N
ervous System
Somatic N
ervous System
Somatic N
ervous System
Quick and Dirty Pathway to Amygdala
Quick and Dirty Pathway to Amygdala
Quick and Dirty Pathway to Amygdala
Quick and Dirty Pathway to Amygdala
Afferent Pathways > Efferent Pathways
Afferent Pathways > Efferent Pathways
Afferent Pathways > Efferent Pathways
Afferent Pathways > Efferent Pathways
The Ins and Outs of Breathing
• Slow, even breathing
• Equal count of 4-5 on
inhale and exhale (6
breaths per minute)
• Expand the diaphragm
and breathe deeply into
the belly
Autonomic Nervous SystemTraditional Approaches to
Intervention
Directive Counseling/Patient
Education
Sound Therapy
General Wellness
Recommendations
Referrals
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Referrals for Ancillary Services
• Otolaryngologist
• Neurologist
• Vascular specialist
• Dentist
• Sleep specialist
• Physical therapist
• Mental health professional
The Vulnerable Tinnitus Patient
• Patients who lack resilience, or the ability to “bounce back” in the face of adversity.
• Some patients may even report suicidal ideationbecause of their tinnitus.
• It is important to have a safety plan that provides patients with resources (e.g., suicide prevention lifeline: 1-800-273-TALK)
http://www.sprc.org/sites/sprc.org/files/SafetyPlanTemplate.pdf
The Severe Tinnitus Patient
• Something extra is needed for patients who are:
▫ “Difficult”
▫ “Complex”
▫ “Complicated”
▫ “Challenging”
▫ “Needy”
▫ “Noncompliant”
The Severe Tinnitus Patient
• Complex tinnitus cases: I’ve tried it all,
Now what? (March 2014)
• The “non-compliant” patient may be
unable to comply for reasons known or
unknown to them.
• “Challenging” patients often have
challenges that serve as barriers to
intervention.
Barriers to Intervention
• Cognitive Distortions
• Emotional Disturbance
• Health Problems
• Work/Family Stress
• Financial/Legal Problems
• Trauma
• Lack of Support
• Social Stigma
• Denial
• Untreated Hearing Loss
• Unrealistic Expectations (e.g., Search for the “cure”)
Now What?
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Person-Centered Tinnitus Therapy
• Anne-Mette Mohr (2006)
• For some patients, there is a “connection between the suffering from tinnitus and the way the person with tinnitus approaches life.”
• “The objectives of therapy will be to support the client to understand, learn from, and integrate tinnitus into his or her life. The person owns the tinnitus instead of being owned (victimized) by it.”
• The clinician serves to be with the client in addition to being for the client.
Health Coaching
• Coach serves as the patient’s ally or guide
• Helps patient establish his/her own personal goals and
identify barriers to success
• Coach is different than a counselor in that the focus is
not on solving past problems, but on changing future
behaviors.
• Patient is in charge of his/her own plan of care.
(http://hhs.uncg.edu/wordpress/health-coaching/)
“Tinnitus Coaching”
• A novel approach to working with tinnitus patients
that applies principles of health coaching.
• The purpose is to provide guidance and
encouragement for patients who need extra
support.
• Helps patient recognize barriers to intervention.
• Can be added to existing management approaches.
Tinnitus Coaching Approach to
Intervention
Directive Counseling/Patient
Education
Sound Therapy
General Wellness
Recommendations
Referrals
Coaching
Mindset Shift
Approach Diagnostician Educator Coach/Ally
Assumption Treat what is wrong Knowledge = Change Client is capable
Style Do as I say Let me tell you I am your advocate
Outcome Low adherence Information overload Self-efficacy
Application Tinnitus Evaluation Tinnitus Consultation Tinnitus Coaching
• Patient is more than a set of ears and disturbance
(typically) is about more than just tinnitus.
• Patient should take an active role in devoloping his/her
own treatment plan.
▫ He knows himself better than anyone else.
▫ He should set own personal goals.
▫ He can identify barriers to his own success.
▫ He is accountable for adhering to plan.
▫ He ultimately gets all the credit for success/failure of plan.
Tenants of Tinnitus Coaching
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Motivational Interviewing
• Open-ended questions allow for free response.
▫ “Tell me what you hope to accomplish.”
▫ “How much support do you think you need moving forward?”
• Set aside the “why?” to avoid placing blame on the patient.
▫ “ “Why aren’t you using your sound therapy every day?”
versus
▫ “I wonder when you can incorporate sound therapy into your daily life?”
Motivational Interviewing
• Reflections repeat and/or summarize what the patient
has said.
▫ “What I heard you say was…”
▫ “You are not sure if you are ready for hearing aids.”
▫ “Your tinnitus negatively impacts your quality of life.”
(amplified reflection + pause)
▫ “You know you have hearing loss, but you are not ready to
get hearing aids.”
(two part reflection)
Motivational Interviewing
• Affirmations acknowledge the patient’s effort,
accomplishments, and emotions.
▫ “You have tried lots of different ways of coping with your
tinnitus.”
▫ “You really care how about what your children think about
your tinnitus.”
▫ “You are ready to do something about your tinnitus.”
Motivational Interviewing
• Challenge the patients to come up with own solutions.
For example:
• “What would you like to start working on first?“
• “You have said that your tinnitus is worse when you are
stressed. What could you do to reduce your stress?”
• “What would it take for you to wear your hearing devices
more consistently?”
• Patients are more likely to following through with their
own ideas.
“I” versus “You” Statements
• Avoid “I” statements to shift responsibility of treatment outcome to the patient:
▫ “I am happy for you!”
▫ “I am proud of you.”
▫ “I want you to do X for me.”
▫ “I think you should do X by next visit.”
• Use “you” statements to recognize patient’s accomplishments and autonomy:
▫ “You did it!”
▫ “Good for you!”
▫ “You have worked hard.”
▫ “What do you think youwill do?”
▫ “How do you feel about that?”
Value Judgments
• Avoid assigning judgments on behaviors, experiences, and/or outcomes.
▫ “That is discouraging”
▫ “You must feel terrible.”
▫ “You did a good job.”
• Your interpretations may be based on your own values and experiences (e.g., smoking is not good for your health), which can create barriers between you and the patient.
• Allow the patient to consider his/her own value judgments (e.g., “What do you think about that?”)
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Helpful tool: The Wheel of Life
http://www.timstringer.com/wp-content/uploads/2010/10/Wheel-of-Life.png
Helpful tool: The ruler
• On a scale of 1 – 10, how important is it for you to….
• On a scale of 1 – 10, how confident are you that you can…”
• On a scale of 1 – 10, how ready are you to make this
change?
What would it take for you to go from a # to #?
Ditching the “All or None”
Mentality
• Patients often make a black and white
judgment regarding intervention as
either a “success” or “failure”.
• Often they don’t recognize the gradual
improvements and/or forget where they
started.
• Patients may forget to reward
themselves along the way.
The “Treatment” Journey
• Coaching helps patients celebrate
small successes along their treatment
journey.
• As a result, patients are reminded of
their destination and can better
appreciate how far they have come.
• Ultimately, this results in better
adherence to the intervention.
Regaining Control
• “When tinnitus is the filter by which you live your life
and it prevents you from doing the things that you
enjoy, tinnitus becomes very powerful and important.
Thus, the goal of intervention is to reclaim your life
from tinnitus.”
• Tinnitus coaching helps patient regain control.
▫ Patient controls tinnitus disturbance
▫ Patient controls plan of care
▫ Patient controls end destination / goals
▫ Patient gains confidence (I did it myself!)
Relinquishing Control
• Patient also learns to re-conceptualize his life with tinnitus and/or sound sensitivity.
• The fight against tinnitus (and sound sensitivity) can be the primary source of disturbance.
• Acceptance of tinnitus cannot be imposed upon the patient (e.g., “You must learn to live with it”).
• Rather, learning to integrate tinnitus requires the patient to accept it on his own terms (“I can live with tinnitus…it is part of me”).
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Take-home Message
• There is no “one size fits all” management approach.
• The best approach for an individual patient is the one
that she chooses as being the most likely to help her
achieve her own treatment goals.
• The role of the clinician is to guide and encourage the
patient as she travels down the path she as chosen.
• Tinnitus coaching supports the patient during her
journey and helps her to reach her destination.