CBT for tinnitus: research and clinical practice

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1 CBT for tinnitus: research and clinical practice Gerhard Andersson, professor Department of Behavioural Sciences and Learning

2 What is CBT? Basic principles Evidence Internet treatment Structure of talk

3 CBT Psychological treatment Structured Home-work Based on cognitive and behavioural change Collaboration between patient and therapist (both are are active) A range of techniques, administration formats, and target problems

4 CBT II Strong links with basic research on information processing and behavioural psychology Use of models, for example lack of positive reinforcement and depression Open in the sense that education is an important part

5 CBT III The basic idea is to adjust the treatment according to the problems the patient has Then, check if you are correct (use research) Much in common with rehabilitation as conducted by related professionals Multidisciplinary, evidence-based

6 For tinnitus Rationale presented Manualised with some tailoring Will target annoyance and not the sound

7 Treatment tools Applied relaxation Cf. Andersson & Kaldo, 2006 in Tinnitus Treatments (red R.Tyler).

8 More on applied relaxation Progressive Brief progressive + positive image Conditioned relaxation Rapid relaxation Major difference lies in the application and function

9 Cognitive tools Attention skills Positive image Shift of focus Focus on tinnitus Advice regarding concentration

10 Cognitive tools II Negative thoughts and beliefs. Automatic and unrealistic First detection, then handling Situation Thought Reaction

11 Sleep management Sleep hygiene Smooth transitions Stimulus control (time management)

12 Use of sound enrichment As in Tinnitus Retraining Therapy Habituation Hearing loss vs. External sounds How do the patients behave? What are they thinking? CBT-principles apply

13 Conditions for which CBT has been applied Numerous (anxiety, depression, pain, cancer, eating disorders etc) In audiology: tinnitus, hearing loss, dizziness, hyperacusis Probably for other conditions as well, but in research mainly tinnitus

15 15 studies (total 1091 participants) CBT vs passive control posttreatment Hedges's g = 0.70 CBT vs active control posttreatment g = 0.44 Cima, R. F., Maes, I. H., Joore, M. A., Scheyen, D. J., El Refaie, A., Baguley, D. M., Anteunis, L. J., van Breukelen, G. J., & Vlaeyen, J. W. (2012). Specialised treatment based on cognitive behaviour therapy versus usual care for tinnitus: a randomised controlled trial. Lancet 379,

16 Tinnitus team Audiologist, counsellor, physician, psychologist Multidisciplinary Running since 2004 Stepped care

17 All patients after referral Assessment by ENT or Audiologist Questionnaire Tinnitus information (half-day) Questionnaire Group CBT Team meetings Individual treatment (various professionals)

50 * p<.001 45 40 35 30 25 20 15 10 * p<.

18 50 * p< * p< Tinnitusbesvär Ångest Depression Före Efter

19 Internet treatment.back in 1998 We in Sweden were among the first to develop and test internet-delivered psychological treatments The basic idea it to regard psychological treatments as a form (at least partly) of education

20 Internet treatment Text and film etc Like lessons with homework Guided by a therapist/clinician

world) We did a trial on tinnitus after our first

21 The tinnitus case Audiology clinic in Uppsala First to start with regular services using the internet (in the world) We did a trial on tinnitus after our first trial on headache in 1998 Back then technology was primitive

25 30 Tinnitus reaction questionnaire Group Internet 0 Pretreatment Posttreatment One-year

32 Tinnitus Handicap Inventory Titus trial ,44 53,38 45, ,83 intervention wait-list 20 pre Astitel post MANOVA: F(1,117)=48.60, p<.0001; Hedges' g=0.88 Weise et al. 2017, Psychosomatic Medicine 32

33 Tinnitus Handicap Inventory ICBT Group CBT Discussion forum Pre Post 6-m German trial MINT N=128; Jasper et al Psychotherapy and Psychosomatics 33

34 THI Support No support Pre Post

Study name Comparison Statistics for each study Hedges's g and 95% CI Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-value Andersson et al.

2012a ICBT vs control 0,608 0,257 0,066 0,104 1,111 2,367 0,018 Hesser et al. 2012b IACT vs control 1,161 0,265 0,070 0,640 1,681 4,373 0,000 Nyenhuis et al.

36 Study name Comparison Statistics for each study Hedges's g and 95% CI Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-value Andersson et al ICBT vs waitlist 0,256 0,256 0,065-0,244 0,757 1,003 0,316 Abbot et al ICBT vs control 0,235 0,278 0,077-0,310 0,780 0,847 0,397 Hesser et al. 2012a ICBT vs control 0,608 0,257 0,066 0,104 1,111 2,367 0,018 Hesser et al. 2012b IACT vs control 1,161 0,265 0,070 0,640 1,681 4,373 0,000 Nyenhuis et al. 2013a ICBT vs control 0,619 0,194 0,038 0,238 1,000 3,188 0,001 Jasper et al. 2014a ICBT vs control 0,546 0,225 0,050 0,105 0,986 2,429 0,015 0,574 0,125 0,016 0,328 0,820 4,579 0,000-2,00-1,00 0,00 1,00 2,00 Favours Control Favours Treatment Meta Analysis Andersson, G. (2015). Clinician-supported internet-delivered psychological treatment of tinnitus. American Journal of Audiology, 24,

37 UK trials Eldré Beukes, Vinaya Manchaiah, David Baguley, Peter Allen Pilot trial with very promising results RCT published Updated program

38 Suggested modules Intervention outline Tinnitus overview Progressive relaxation in six phases Positive imagery Reinterpretation of tinnitus Focus exercise Identifying negative thoughts Cognitive restructuring Exposure to tinnitus Summary Future planning Optional modules Sound enrichment Sleep guidelines Concentration tips Sensitivity to sound Hearing tactics

46 Tinnitus Functional Index Pre Post

47 TFI PRE TFI POST THIs PRE THIs POST EXPERIMENTAL CONTROL

48 Conclusions CBT is promising but few practice Internet treatment could be a complement Further innovation is possible The challenge now is dissemination

WIDEX ZEN THERAPY. Introduction

WIDEX ZEN THERAPY. Introduction WIDEX ZEN THERAPY Introduction WIDEX TINNITUS COUNSELLING 2 WHAT IS WIDEX ZEN THERAPY? Widex Zen Therapy provides systematic guidelines for tinnitus management by hearing care professionals, using Widex