Tinnitus and Sound Sensitivity Casebook

1 Internet-Based Tinnitus Intervention

Eldre Beukes

1.1 Clinical History/Description

Patient A attended his local tinnitus clinic due to distressing tinnitus. He had a mild hearing loss and was not using hearing aids. An initial tinnitus therapy session provided explanations about tinnitus and sleep hygiene. Practically arranging appointments was difficult as he was employed abroad and was not able to attend his local clinic frequently. The clinic suggested registering for a study looking at the effects of an Internet-based tinnitus intervention as this was prior to teleaudiology being frequently used. The patient registered and completed the screening questionnaire. This indicated that he was aged between 40 and 50 years. He had experienced tinnitus constantly for 2 years in both ears. The tinnitus was described as a complex presentation of ringing, buzzing, low and high pitched sounds, pulsating, clicking, music, voices, and humming. He attributed his tinnitus to long periods of exposure to noise without adequate hearing protection. He described being generally grumpy and irritable as a result of the tinnitus. Specific difficulties included trouble getting to sleep, concentrating, and hearing on his mobile phone and the television. Loud noises were annoying and aggravated the tinnitus. Hyperacusis together with tinnitus resulted in him being unable to do the things he previously enjoyed. Although he was struggling to hear, he did not want hearing aids. He explained that he hated anything in his ears.

Both the Tinnitus Functional Index1 and the Tinnitus Handicap Inventory2 were administered and indicated a moderate impact of tinnitus with scores of 44/100 and 48/100, respectively. Mild levels of anxiety and depression were identified (8/21 on the Generalized Anxiety Disorder Questionnaire3; 5/28 on the Patient Health Questionnaire4). The Insomnia Severity Index5 showed subthreshold insomnia at 10/28. There was mild hearing concerns (14/40 on the Hearing Handicap Inventory6). Strong hyperacusis was present (28/40 on the Hyperacusis Questionnaire7).

1.2 Questions for the Reader

1.With this level of tinnitus severity, should an Internet-based intervention be considered?

2.By what means should we be evaluating the presence of comorbid conditions for individuals with tinnitus?

3.Beyond those relating to co-occurring conditions, which outcome domains should we be assessing?

4.Which outcome measures should be used to assess intervention-related changes in tinnitus severity?

5.Which other specific outcome measures should we consider for those with tinnitus?

1.3 Discussion of Questions

1.With this level of tinnitus severity, should an Internet-based intervention be considered?
Internet-based interventions have predefined inclusion and exclusion criteria. Generally, a minimum cut-off score for inclusion ensures that participants have the potential to observe benefit from the study intervention; no maximum cut-off score was specified. Internet intervention studies tend to exclude people who have other serious additional health or mental health problems or those who are undertaking additional interventions. A complex range of factors contribute to a successful outcome; however, the factors may not be clear before commencing the intervention. The patient in this case had difficulty attending his local clinic and although he met all inclusionary criteria, he presented with mild levels of anxiety and depression. Such patients require careful monitoring to ensure their ability to complete the intervention, and to determine whether any additional services are required.

2.By what means should we be evaluating the presence of comorbid conditions?
Good justification is required for each assessment measure administered. In an Internet-based intervention there is a greater possibility of not detecting problems as there is no face-to-face interaction with the patient. Although a thorough investigation of symptoms is required, there is also a fine balance between a thorough case history and overloading the patient. If many assessment measures are required, then their selection should consider the effort and fatigue of the patient completing the forms. Very high levels of anxiety and depression should be identified and may need attending to before the patient is able to focus on addressing the tinnitus (see Table 1.2 for examples of intake forms).

Table 1.3 Comments about the intervention undertaken

Questions asked Comments What was the best aspect of your treatment? Having a structure and positive feedback and advice from the personal messages. It helped me understand and enabled me to adjust and accept the tinnitus and be more relaxed about it How has it helped? Thank you for your support throughout, it has helped tremendously and I have such a better understanding, feeling and approach to my tinnitus, these last few weeks it has reduced enormously, with minor flare-ups. I successfully attended to Pantos this year and my tinnitus did not prevent me from having a wonderful time. The stress and relaxing techniques have been wonderful and these will remain part of my daily and weekly routine wherever I may be in the world. The program has helped me relax and reflect differently on tinnitus. I now feel I can cope a lot better with tinnitus Which modules were the most helpful? I have found the relaxation technique program very informative and some elements I felt I have really benefited from. Shifting Focus was a hard concept and this I did not get on well with. Whereas positive imagery and the relaxation steps provided me with excellent results. To the extent that I have had a few weeks where my tinnitus has virtually been non-existent. Trying to look at negative thoughts from a different angle has also helped. In general the more relaxed less stressful I am the less my tinnitus flares up What will you continue using? I will keep the techniques going as I have seen the benefit of them. I have found over the last month that by trying to keep less stressed has had a huge impact on my tinnitus. I will continue to incorporate all the relaxation techniques, from the deep to the rapid, into my everyday life. By making situations less stressful then it's easier to cope and makes one feel in a better place. Sleep hygiene and routine is a real benefit although extremely difficult when working away, but this is where the rapid techniques help, just before and after a meal. With deeper techniques at bedtimes. I have learned to break my worries down. This makes it much more manageable and achievable, that way I still feel in control and this helps me manage my tinnitus

3.Beyond those relating to co-occurring conditions, which outcome domains should we be assessing?
This is an important question. There are many possibilities. Some research has looked at specific outcomes that tinnitus patients find are most relevant to them. A Delphi study indicated domains such as concentration, quality of sleep, sense of control, mood, negative thoughts are important to stakeholders.8 Ideally, a core set of domains assessed across clinics would be ideal. Further work is required to establish the most appropriate and psychometrically robust measures for a tinnitus population. In view of these limitations, work is currently underway to identify a core set of outcome measures for tinnitus.9,?10

4.Which outcome measures should be used to assess intervention-related changes in tinnitus severity?
Both the TFI and THI were used here for comparative purposes. The measures selected should address various factors such as the purpose of testing (diagnostics/responsiveness to treatment). It is also important to consider whether the questionnaire is validated psychometrically for the population being tested. The TFI was specifically designed and validated to assess responsiveness to treatment, where many other tinnitus measures were designed for diagnostic purposes only.

5.Which other specific outcome measures should we consider for those with tinnitus?
Table 1.2 lists some suggestions. These are not the only options. The considerations mentioned above apply to selecting other questionnaires as well. These have generally been considered as secondary outcome measures. Thus short outcome measures may be preferred.

1.4 Final Diagnosis and Recommended Treatmen

The patient was randomized to receive 8 weeks of Internet-based cognitive behavioral therapy (CBT) principles for tinnitus. This intervention consisted of the following key elements11,?12:

?The intervention was provided on a purpose-built secure web-based platform. It had the required security features in place for data protection.

?The content was based on CBT principles as these presently have the most robust evidence of effectiveness in minimizing the effects of tinnitus, particularly longer-term.13 Audiological principles formed from clinical experience and research found to be effective for tinnitus also informed the theoretical base of the intervention.

?The content was divided into different modules. Two to three modules were...