Cornelia Weise

A systematic review and meta-analysis of randomized controlled trials of cognitive-behavioral therapy for tinnitus distress

Tinnitus is defined as a sound in the ear(s) and/or head without external origin and is a serious health concern for millions worldwide. The aim of the present study was to determine whether Cognitive Behavior Therapy (CBT) is effective in reducing distress associated with tinnitus. Randomized, controlled trials that assessed the efficacy of CBT for tinnitus-related distress in adults were identified by searching electronic databases (PsychINFO, PubMed, the Cochrane Library), and by manual searches. Fifteen studies (total of 1091 participants) were included in the meta-analysis. CBT compared with a passive and active control at post-assessment yielded statistically significant mean effect sizes for tinnitus-specific measures (Hedgess g=0.70, and Hedgess g=0.44, respectively). The average weighted pre-to-follow-up effect size for the CBT group suggested that these effects were maintained over time. Smaller but yet statistically significant effects of CBT were found for mood outcome measures. Characteristics of the studies were unrelated to effect sizes. Methodological rigor, publication bias, and a series of sensitivity analyses did not influence the findings. The results suggest that CBT is an effective treatment of tinnitus distress. However, caution is warranted given that few large-scale, well-controlled trials were identified.

Psychophysiologic treatment of chronic tinnitus : A randomized clinical trial

Background: Tinnitus seems to be associated with psychophysiological over-activation (e.g., of head and shoulder muscles). Therefore we aimed to develop and evaluate a new intervention program including a psychophysiological approach. Methods: Forty-three tinnitus sufferers were randomized to 2 groups, one receiving a psychophysiologically oriented intervention lasting 7 intervention sessions (plus 2 assessment sessions), whereas the other group waited for a comparable time period. Afterward, patients on the waiting list also received the intervention. Physiological variables were muscle activity of head and shoulders and electrodermal activity. Psychological assessments took place at pretreatment, post-treatment, and 6 months later. Follow-up data were available from 95% of participants. Major outcome variables were self-rating scales (e.g., tinnitus annoyance assessed by the Tinnitus Questionnaire), and diary data (self-control, daily time of perceiving the tinnitus). Results: On most tinnitus specific variables, patients in the treatment group improved significantly more than patients on the waiting list. Main effect sizes for tinnitus-specific variables were up to 0.89. Muscle reactivity of head muscles at the beginning predicted significant treatment effects. Conclusion: Compared with meta-analytical reviews of psychological interventions for tinnitus sufferers, the presented treatment is brief and in the upper range of effectiveness. ES = effect size; GSI = General Symptomatic Index (mean score of Brief Symptom Inventory); IG = intervention group; MG = merged group; SCL-90R = symptom check list; TQ = Tinnitus Questionnaire; WLG = waiting list group.

Biofeedback-Based Behavioral Treatment for Chronic Tinnitus: Results of a Randomized Controlled Trial

Many tinnitus sufferers believe that their tinnitus has an organic basis and thus seek medical rather than psychological treatments. Tinnitus has been found to be associated with negative appraisal, dysfunctional attention shift, and heightened psychophysiological arousal, so cognitive-behavioral interventions and biofeedback are commonly suggested as treatments. This study developed and investigated the efficacy of a biofeedback-based cognitive-behavioral treatment for tinnitus. In total, 130 tinnitus patients were randomly assigned to an intervention or a wait-list control group. Treatment consisted of 12 sessions of a biofeedback-based behavioral intervention over a 3-month period. Patients in the wait-list group participated in the treatment after the intervention group had completed the treatment. Results showed clear improvements regarding tinnitus annoyance, diary ratings of loudness, and feelings of controllability. Furthermore, changes in coping cognitions as well as changes in depressive symptoms were found. Improvements were maintained over a 6-month follow-up period in which medium-to-large effect sizes were observed. The treatment developed and investigated in this study is well accepted and leads to clear and stable improvements. Through demonstration of psychophysiological interrelationships, the treatment enables patients to change their somatic illness perceptions to a more psychosomatic point of view.

Internet-delivered treatment to promote health.

Purpose of review The aim of this paper is to provide an updated review of recent controlled trials of Internet interventions for health conditions and how the Internet is used to promote health. Recent findings We identified 18 published trials including studies on diabetes, cancer, pain conditions, obesity, irritable bowel syndrome, stress management, hypertension, metabolic syndrome, cerebral palsy, infertility, HIV infection, and fruit/vegetable consumption. Of the 18 trials, one-third targeted children and adolescents. Two cancer studies investigated the role of peer support in an online environment that failed to result in any major improvements. Overall, several trials did not result in any substantial significant improvements, but there are exceptions, such as treatment of irritable bowel syndrome, headache, and chronic pain. Although a few of the reviewed studies had sufficient sample sizes, the majority were small and underpowered. In particular, this was the case for the studies on children and adolescents. Summary This review suggests that Internet interventions hold some promise as a complement to other treatments such as cognitive behavior therapy. The benefits from participating in online peer support groups are not clear. Although studies on children and adolescents have emerged, there is a lack of studies on older adults with health problems.

Internet-based guided self-help versus group cognitive behavioral therapy for chronic tinnitus: A randomized controlled trial

Background: The aim of this randomized controlled trial was to investigate the effects of conventional face-to-face group cognitive behavioral therapy (GCBT) and an Internet-delivered guided self-help treatment (Internet-based CBT, ICBT) on tinnitus distress. Methods: A total of 128 adults with at least mild levels of chronic tinnitus distress were randomly assigned to GCBT (n = 43), ICBT (n = 41), or a web-based discussion forum (DF) that served as a control condition (n = 44). Standardized self-report measures [the Tinnitus Handicap Inventory (THI), Mini-Tinnitus Questionnaire (Mini-TQ), Hospital Anxiety and Depression Scale, Insomnia Severity Index and Tinnitus Acceptance Questionnaire] were completed at the pre- and post-assessments and at the 6-month follow-up. Results: Repeated-measures ANOVAs revealed significant time × group interaction effects on the primary outcomes (THI and Mini-TQ scores) in favor of both CBT interventions compared with the DF at post-assessment (0.56 ≤ g ≤ 0.93; all p ≤ 0.001). There were no significant differences between GCBT and ICBT (all p > 0.05) and the treatment effects remained stable at the 6-month follow-up. Conclusions: This study provides evidence that ICBT might be an equally effective alternative to conventional CBT in the management of chronic tinnitus. Despite encouraging results, further research is necessary to determine the actual potential of ICBT as a viable alternative to CBT, and under which circumstances it is effective.

Physiological and psychological stress reactivity in chronic tinnitus

Several models of tinnitus maintenance emphasize the importance of cognitive, emotional and psychophysiological processes. These factors contribute to distress in patients with decompensated tinnitus symptoms. We investigated whether tinnitus patients show increased physiological levels of arousal, more intense stress reactivity patterns and exaggerated psychological strain compared to healthy controls. Seventy tinnitus patients and 55 healthy controls underwent various stress tests. Muscular reactivity and peripheral arousal as well as strain ratings were assessed. Tinnitus patients reported significantly more strain during stress tests compared to healthy controls. Few physiological reactivity patterns differed significantly between the two groups. The physiological data thus only partly supported a hyperreactivity hypothesis. Strain reports and physiological data were only marginally correlated. Tinnitus patients show maladaptive appraisal processes during stress exposure, yet physiological reactivity is only slightly affected. Treatment programs for patients with decompensated tinnitus symptoms should account for appraisal processes and coping mechanisms in stressful situations.

The Role of Fear-Avoidance Cognitions and Behaviors in Patients with Chronic Tinnitus

The current study investigated the role of fear-avoidance—a concept from chronic pain research—in chronic tinnitus. A self-report measure the “Tinnitus Fear-Avoidance Cognitions and Behaviors Scale (T-FAS)” was developed and validated. Furthermore, the role of fear-avoidance behavior as mediator of the relationship between anxiety sensitivity and tinnitus handicap was investigated. From a clinical setting, N = 373 patients with chronic tinnitus completed questionnaires assessing tinnitus handicap (Tinnitus Handicap Inventory), anxiety, depression (Hospital Anxiety and Depression Scale), anxiety sensitivity (Anxiety Sensitivity Index-3), personality factors (Big Five Inventory-10), and fear-avoidance. To analyze the psychometric properties, principal component analysis with parallel component extraction and correlational analyses were used. To examine a possible mediating effect, hierarchical regression analysis was applied. The principal component analysis resulted in a three-factor solution: Fear-avoidance Cognitions, Tinnitus-related Fear-Avoidance Behavior, and Ear-related Fear-Avoidance Behavior. Internal consistency was satisfactory for the total scale and all subscales. High correlations between tinnitus-related handicap scales, depressive and anxiety symptoms, and the T-FAS were found, whereas associations with personality factors were low. Moreover, results indicate a significant partial mediation of fear-avoidance behaviors in the relationship between anxiety sensitivity and the cognitive dimension of tinnitus handicap. Results show that fear-avoidance behavior plays an important role in tinnitus handicap. More attention should be paid to this concept in research and clinical practice of psychotherapy for chronic tinnitus.

Acceptance of Tinnitus: Validation of the Tinnitus Acceptance Questionnaire

The concept of acceptance has recently received growing attention within tinnitus research due to the fact that tinnitus acceptance is one of the major targets of psychotherapeutic treatments. Accordingly, acceptance-based treatments will most likely be increasingly offered to tinnitus patients and assessments of acceptance-related behaviours will thus be needed. The current study investigated the factorial structure of the Tinnitus Acceptance Questionnaire (TAQ) and the role of tinnitus acceptance as mediating link between sound perception (i.e. subjective loudness of tinnitus) and tinnitus distress. In total, 424 patients with chronic tinnitus completed the TAQ and validated measures of tinnitus distress, anxiety, and depression online. Confirmatory factor analysis provided support to a good fit of the data to the hypothesised bifactor model (root-mean-square-error of approximation = .065; Comparative Fit Index = .974; Tucker–Lewis Index = .958; standardised root mean square residual = .032). In addition, mediation analysis, using a non-parametric joint coefficient approach, revealed that tinnitus-specific acceptance partially mediated the relation between subjective tinnitus loudness and tinnitus distress (path ab = 5.96; 95% CI: 4.49, 7.69). In a multiple mediator model, tinnitus acceptance had a significantly stronger indirect effect than anxiety. The results confirm the factorial structure of the TAQ and suggest the importance of a general acceptance factor that contributes important unique variance beyond that of the first-order factors activity engagement and tinnitus suppression. Tinnitus acceptance as measured with the TAQ is proposed to be a key construct in tinnitus research and should be further implemented into treatment concepts to reduce tinnitus distress.

The Efficacy of Minimal Contact Interventions for Acute Tinnitus: A Randomised Controlled Study

Acute tinnitus can lead to substantial distress and eventually result in long-lasting impairment. The aim of this study was to compare the efficacy of a cognitive-behavioural intervention (delivered as Internet self-management, bibliotherapy or group training) to the information-only control condition. Applicants suffered from subjective tinnitus for up to six months, were between 18 and 75 years old and received no other tinnitus-related psychological treatment. A total of 304 participants were randomly assigned to one of the four study arms. Tinnitus distress, depressive symptoms, psychosomatic discomfort and treatment satisfaction were assessed. At the post-assessment tinnitus distress was significantly lower in the Internet and the group training conditions compared to the control condition. Inter-group effect sizes were moderate to large. At follow-up, all active training conditions showed significantly reduced tinnitus distress compared to the control condition (intention-to-treat analysis). An additional completer analysis showed a significant reduction in tinnitus distress only for the group condition. All effect sizes were moderate. There were no differences regarding psychosomatic discomfort, but depressive symptoms were reduced in the group condition at the post-assessment (intention-to-treat analysis). Treatment satisfaction was significantly higher in the training conditions. The dropout rate was 39%. The present study shows that distress can be reduced as early as the acute stadium and that minimal-contact interventions are a promising way to do this. In particular, the Internet and group conditions led to a large, immediate decrease in distress, and the participants were highly satisfied with the training.

Internet-Delivered Cognitive-Behavior Therapy for Tinnitus: A Randomized Controlled Trial.

Objectives Tinnitus has a substantially negative impact on quality of life in up to 5% of the general population. Internet-based cognitive-behavioral treatment (iCBT) has been shown to be effective in a few trials. The aim of our study was to investigate iCBT for tinnitus by using a randomized controlled trial. Methods Patients with severe tinnitus-related distress were randomly assigned to therapist-guided iCBT (n = 62) or to a moderated online discussion forum (n = 62). Standardized self-report measures for tinnitus-related distress (Tinnitus Handicap Inventory, Mini-Tinnitus Questionnaire) and associated symptoms (tinnitus acceptance, anxiety, depression, and insomnia) were assessed at pretreatment and posttreatment, 6-month-, and 1-year follow-up. Clinical significance was assessed with the Reliable Change Index. Results Multivariate analyses of variance revealed significant main effects for time, group, and interaction in favor of the iCBT group. With regard to tinnitus-related distress, the significant univariate interaction effects (time by group) were supported by large effect sizes (Tinnitus Handicap Inventory: g = 0.83, 95% confidence interval = 0.47–1.20; Mini-Tinnitus Questionnaire: g = 1.08, 95% confidence interval = 0.71–1.64). For the secondary outcomes, significant interactions with small to medium effect sizes were found. Within-group effects for the iCBT, from pretreatment to follow-up, were substantial in regard to tinnitus-related distress (1.38 ⩽ d ⩽ 1.81) and small to large for secondary outcomes (0.39 ⩽ d ⩽ 1.04). Conclusions Using a randomized controlled trial design, we replicated prior findings regarding positive effects of Internet-delivered CBT on tinnitus-related distress and associated symptoms. Implementing iCBT for tinnitus into regular health care will be an important next step to increase access to treatment for patients with tinnitus. Trial Registration: ClinicalTrials.gov, Identifier: NCT01205919.