Tinnitus Coaching : Managing severe tinnitus and sound sensitivity disorders

Transcription

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 audiologicalpractice, 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 Severity of Tinnitus 2 20 db SL 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) 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 db SL People with Tinnitus (50 M) Bothered by Tinnitus (16 M) Debilitating Tinnitus (2 M) 2 20 db SL 1

2 Neurophysiological Model (Jastreboff, 1990) Sympathetic Dominance The body s stress reaction ( fight, flight or freeze response) is triggered automatically. ception_files/textmostly/slide2.html Sound Sensitivity Disorders Misophonia Sound Sensitivity Disorders Hyperacusis hypersensitivity to the physical properties of sound regardless of source or situation (LDLs < db HL) Hyperacusis Phonophobia 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) Comorbidity 40% of patients with tinnitus also have hyperacusis. Hyperacusis Phonophobia & Misophonia 2/3 of patients with hyperacusis also have tinnitus. Can work on both disorders at the same time. Tinnitus Hyperacusis Overamplification of external sounds within the CANS. Strong negative emotions associated with external sounds. May need to address sound sensitivity first. 2

3 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 canbe 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 Neurophysiological Model (Jastreboff, 1999) Referrals General Wellness Recommendations Directive Counseling Sound Therapy Directive Counseling/Patient Education Sound Therapy 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 Referrals General Wellness Recommendations Sound Therapy Directive Counseling/Patient Education 3

4 Tinnitus Masking (Broadband noise) Tinnitus Retraining Therapy (TRT) (Broadband noise) Tinnitus Masking PTM (Broadband noise) CHATT (Broadband noise) Jack Vernon (1970s) & Jonathen Hazell(1980s) Sound therapy approach: Broadband sound (e.g., white noise) that is steady state and nature-like Neuromonics (Music) WZT (Fractal tones) SoundCure (S-tones) Masks/covers the tinnitus providing immediate relief TAT (Whatever works) 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 andpromotes long-term habituation TINNITUS TINNITUS TINNITUS TINNITUS TINNITUS TINNITUS TINNITUS 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 Background Sound Soothing Sound Interesting Sound 4

5 Progressive Tinnitus Management Progressively more severe problems caused by tinnitus Cognitive Habituation Tinnitus Treatment (CHaTT) NatanBauman, 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 SoundCure Serenade Reavisand 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 Sleep Concentration 5

6 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 ). Combination Hearing Instruments ReSound Tinnitus Solution adjustable, modulated noise WidexZen adjustable noise; fractal tones Siemens micon adjustable noise Phonak Quest adjustable noise Starkey Xino adjustable noise OticonTinnitus Support adjustable, modulated noise and preset ocean-like sounds Selection Considerations 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 Traditional Approaches to Intervention Referrals General Wellness Recommendations Sound Therapy Directive Counseling/Patient Education 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 time Me Home Hobbies Family Health Work Spiritual 6

7 Mindfulness-based Tinnitus Stress Reduction 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 The Ins and Outs of Breathing Afferent Pathways > Efferent Pathways Quick and Dirty Pathway to Amygdala Sympathetic Nervous System Fight or Flight Heart Increased/Decreased Rate Parasympathetic Nervous System Rest and Digest Lungs Inflation/Constriction Somatic Nervous System 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 Diaphragm Muscle Contraction/Flexion Autonomic Nervous System Traditional Approaches to Intervention Referrals General Wellness Recommendations Sound Therapy Directive Counseling/Patient Education 7

8 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 ideation because of their tinnitus. It is important to have a safety plan that provides patients with resources (e.g., suicide prevention lifeline: TALK) 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 complyfor 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? 8

9 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 supportthe 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 withthe client in addition to being for the client. Health Coaching Coach serves as the patient s allyor guide Helps patient establish his/her own personal goalsand 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. ( 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 Coaching Referrals General Wellness Recommendations Sound Therapy Directive Counseling/Patient Education 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 Tenants of 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 devolopinghis/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. 9

10 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 you will 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? ) 10

11 Helpful tool: The Wheel of Life Helpful tool: The ruler On a scale of 1 10, how important is it for you to. On a scale of 1 10, how confidentare 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 mustlearn to live with it ). Rather, learning to integrate tinnitus requires the patient to accept it on his own terms ( I canlive with tinnitus it is part of me ). 11

12 Take-home Message There is no one size fits all management approach. The bestapproach 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. 12